Lance M. Dodes, M.D.

Everything you wanted to know and weren't afraid to ask.

It's time for a year-end clearance of frequent questions about addiction. I've addressed these in the past but not everyone reads the questions and answers that appear after blog posts. So, here's a compact summary.

Question: If addiction is psychological in nature, as you say, doesn't that mean it's due to something wrong with the brain?

Answer: This question usually comes from folks who don't understand what psychology is, or how it works. Human psychology is a phenomenon that emerges when a few billion brain cells function together, creating s complex system. The individual cells have no psychology. When a brand new set of phenomena emerge from a complex system, they are called "emergent" properties, and the study of this is a whole field of modern physics called "Complexity Theory". The most important part of this is that the emergent properties can neither be predicted nor understood by studying the individual elements of the system. An example from outside psychology is what happens when atoms are combined in complex ways. They form new structures (molecules) that have properties that are not present in the atoms themselves, nor are they predictable from knowledge of atoms. The field that studies the properties and interactions of these molecules is so different from the physics of atomic structure that it has its own name: Chemistry. In the same way, we are all composed of chemicals, but the nature and properties of life cannot be predicted or understood from knowledge of the chemicals that compose us (no chemicals are alive, and you could never predict life from knowledge of chemicals). To understand life, you need a new science beyond chemistry: Biology. Human psychology is an emergent phenomenon that occurs when billions of cells create a complex system. It has new properties that can only be understood through a new science: Psychology. Trying to reduce human psychology to brain function results in simplistic thinking that can never explain the new system, any more than DNA molecules can be understood by knowledge of the carbon atoms that compose it. The good news is that psychological symptoms such as addiction certainly do not mean there is something being wrong with a person's brain.

Question: I have seen a juxtaposition of two brain scans, one on drugs, the other not. Isn't that proof of the "chronic brain disease" theory of addiction?

Answer: Some people who have been exposed to drugs have an excessive brain reaction (secretion of the neurotransmitter dopamine) when they are subsequently exposed to that drug. Dopamine secretion leads to an excited reaction in rats, causing them to scurry around looking for the drug which produced the excessive dopamine response. This is the basic finding that led to the "chronic brain disease" theory. But to have evidence of this theory in humans, you would have to show that people first develop brain changes, then, as a result, become addicts. Considering that most of the country currently believes this theory, it is remarkable that there are zero cases that show this. All the "evidence" is the reverse: that people who are already addicts have changes in dopamine release, just like the rats in the original experiments. To conclude that this explains addiction is equivalent to believing that coughing produces pneumonia.

But just as important, there is an enormous body of evidence showing that the "brain disease" theory must be wrong, because it is incompatible with the evidence of human addiction. There are literally millions of people who have taken high doses of drugs like heroin or alcohol, yet never become addicts -- exactly the opposite of what the brain disease theory predicts, and impossible if the brain disease idea were true. We also know from another huge number of examples that drug addiction can be replaced by non-drug addictions that are focused on gambling or shopping or playing games on the Internet. These common examples underscore that addiction is not about responding to exposure to the same drug one took before; it has nothing to do with the same drug you took before. Then there's the fact that in human beings addictive behavior is regularly triggered not by being exposed to a drug, but by emotionally-significant stresses and traumas. On top of that, when humans make the decision to take a drink, buy a drug, or drive to a casino, they are typically reasonably calm -- sometimes for hours -- while on the way. The brain disease idea is based on the immediate response of rats to drug cues -- their tiny brains are simple matters of see-and-react. That behavior does look like the sudden release of dopamine. Finally, we know that people can stop their addictive behavior as a result of human intervention, either through psychotherapy, or through self-help group support, or even on their own (there is a substantial spontaneous recovery rate for alcoholism, for example). None of this is consistent with a theory of addiction as a "chronic brain disease."

Question: I know that AA doesn't help everyone, but why criticize it?

Answer: Almost everyone phrases this question just that way: "AA doesn't help everyone …" But this wording contains a huge error. AA has a 5-8% success rate. Therefore, the question should be rephrased: "I know that AA hardly helps anyone who goes to it … ." Seen in this realistic light, the answer to the question is obvious. By referring almost 100% of people with addictions to 12-step programs, we are failing -- and harming -- the 90% who cannot make use of this approach. When people are sent to a program that cannot work for them, it's like prescribing the wrong antibiotic to a person with pneumonia. Sure, the drug works for a small percent of people with lung infections, but if you give it to everyone then you're going to have a lot of untreated, much sicker patients. AA should be criticized for its irresponsible attitude that people who don't benefit should attend more meetings ("90 in 90"), and that those doing poorly haven't "worked the program" hard enough.

AA also deserves criticism for its failure to live up to ordinary standards of caring for people. The people we rely upon for most serious problems in our lives have carefully studied, trained, and been credentialed in a field that has standards, then kept up with changes in knowledge over the years, modifying their approach according to the results of their practice, and according to what is new. AA does none of that. Even though AA is a non-professional organization, it still must acknowledge that it is appropriate for very few of the people sent to it, and must require that every one of their groups actively advise people to try something else when AA isn't helping them. Without these assurances, we cannot trust AA to deal with addiction.

Question: How can you criticize AA unless you have fully experienced it? By full experience, I mean making the decision to work through all 12 Steps.

Answer: The questioner believes that one must go through all 12 steps before deciding to opt out, or even criticize the program. It is a restatement of the myth that "AA works if you work it." This idea is not just an obvious example of self-serving circular reasoning (wouldn't every business like to claim that its product failures are because you didn't work at it hard enough), but leads people who are unhelped to blame themselves.

Question: I belong to a great AA group. It is open-minded and thoughtful. How does that fit with criticism of AA?

Answer: This question underscores the fact that AA is intentionally unsupervised and uncontrolled. While there are groups that are composed of thoughtful and open-minded people, we know from a huge number of accounts that there are many others that are driven by fundamentalist zeal, are rigid and judgmental, often ruled by old-timers who have a stern view that what was good for them must be right for everyone, and can be unsafe. To be trustworthy, AA must have guidelines to ensure that any group calling itself "AA" lives up to minimal standards of open-mindedness, protection of all members, and knowledge of the limitations of this approach.

Question: Isn't there a big difference between serious addictions and doing things like shopping or cleaning the house too much?

Answer: The effects of a behavior do not define its cause or mechanism. When a dangerous drug addiction can be replaced by other, much less dangerous compulsive behaviors (which often occurs), it underscores the essential fact that all addictive or compulsive behaviors are fundamentally the same, and that addiction has nothing inherently to do with any one behavior.

Question: The American Society of Addiction Medicine, the American Medical Association, the National Institute of Mental Health, the National Institute of Health, the DSM IV all define addiction as a fundamental and primary brain disease. How could they possibly all be wrong?

Answer: When people are quite young, it is useful and important for them to believe that authorities, starting with their parents, are always right. Later, we learn that authorities are simply human, and they make mistakes. Anyone familiar with the history of science knows that widely accepted (and taught) theories are regularly overturned a few years later. In the case of the "chronic brain disease" theory, it's especially important to understand that all of the agencies mentioned are relying on exactly the same small set of observations and hypotheses. If they had each conducted their own studies and independently arrived at the same conclusions, their shared view would be more meaningful. But, as I've described above, there is actually no good evidence for this theory, and even more important, it is absolutely incompatible with the realities of addiction in humans. Naturally, this begs the question why so many people have climbed on this bandwagon. Some of the answer is that we all have a tendency to follow a crowd; life is easier if you go along with the currently accepted wisdom. But it is also true that the people who invented the "chronic brain disease" theory of addiction are neither knowledgeable nor interested in human psychology. They are trained in neurobiology, and with that as their hammer, the world looks like a nail.

Question: Many authorities support AA. Shouldn't that that suffice to end discussion?

Answer: This comment came in response to the publication of my book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. It is a variant on the last question, and contains the same fallacy. The fact that authorities have endorsed 12-step programs is meaningless if they base their conclusions on the same poor science. It was the fact that the science behind AA is riddled with errors that made it essential to debunk it, not ignore it. The truly shocking thing about this question is not simply that it is foolish, but that it was written by a psychiatry professor, who we'd all hope would have known better. But, personal politics has a role in most human life, and this particular professor is a consultant to a large AA-oriented treatment program, something he didn't bother to mention in his critique.

Question: How can you say that addiction is a choice, like eating peanut butter?

Answer: This question confuses "choice" with compulsion. Compulsive/addictive behaviors are driven by deeper factors. That's why we call addictions "symptoms" rather than "foolish decisions". For a few thousand years, people have mistakenly thought alcoholics were weak-willed or pleasure-seeking hedonists, believing that they drank out of pure "choice". That was wrong then and it is still wrong.

Question: Isn't addiction a spiritual problem?

Answer: This is just a year-end summary! See my next blog post for a discussion of this question.  Happy New Year everyone.