Monday, July 11, 2011

Addiction # 2

     There was an article published recently in the NY Times saying that some doctors are treating (alcohol and drug) addiction as a physical and not a mental problem, claiming, among other statements, that MRI's have shown permanent changes in the brains of addicts. They state that therefore treating addiction is a life-long treatment, much as treating diabetes mellitus is. They completely ignore the fact that any almost any part of the brain can be changed by behavioral modification, the environment, or by drugs. If the brain moved from state A to state B under the influence, say, of heroin, why do they assume that the change is a one-way process? There is no evidence that the system cannot reverse itself, with outside help, and move back to state A from state B. How do they explain the fact that some heavy cigarette smokers awake one day and decide to smoke no more? And do their brains show similar MRI changes?

     I had written a previous blog on addiction, and I refer the reader to that one for background. I would also like to mention that the line between addiction and habit is poorly drawn. Is there a permanent change in the brain of a chronic fingernail biter? Are there similarities in the MRIs of the brains of addicts and those who are persistently happy? And in what way is obsessive-compulsive behavior different from an addiction, and what do the MRI's of their brains look like? Are an addict if you enjoy using a legal drug as opposed to an illegal drug?

     All babies desire instant gratification, and cry and yell if they do not get it. The process of civilization, of being raised in a family, of going to school, and growing into "normal" adulthood is largely a process of learning to defer present pleasure for future gain. The problem, of course, is that most addictions give  instant gratification, and how do we modify the brain so that the ego does not seek this? Again, I note the curious exception of nicotine and tobacco: we cough heavily when we inhale our first cigarette, which would seem to be a  negative reinforcement,   but we persist until it feels "good". (Some people would say the same about the taste of beer.) And most drugs are either uppers or downers, in that we engage more heavily with the world, or draw into ourselves. However, pharmacology is not a prediction of social effect: alcohol is a CNS sedative, but people become much more garrulous and interactive under its effect, while heroin, also a CNS sedative, helps you to withdraw from the world and, some addicts add, achieve Nirvana (which is also sought by Buddhists).

     It would seem that almost all pleasurable activities either increase the amount of CNS endorphins ("runner's high") or transport us or insulate us from the present world. I would go so far as to say that ALL pleasurable activities (except for sex between two people who love each other) is an escape: opera, reading, movies, museums, playing Gameboy, fishing, golfing, kayaking, skiing,  bicycle riding, amusement park rides, sniffing glue,nursing your baby, doing your job if you love it, watching your child graduate, seeing your child being born,  or (Jeter's father) seeing your child get his 3000th hit in baseball with a home run, or completing the iron man marathon. I will defer  a discussion of the joys of sex (including masturbation) to a future blog.

     Freud stated that although conforming to the norms and rules of civilization and of your family are bound to make you neurotic, so  long as you possess the ability to work, to love, and to play, you are relatively normal and high-functioning. He had little to say about the use of drugs, and he himself used cocaine frequently. For that matter Halsted, the father of American surgery at Johns Hopkins, was dependent upon daily injections of morphine, but that did not prevent him from being one of America's most brilliant surgeons. I also don't know if the patients of mine who use cocaine only on weekends and whose work does not apparently suffer from this use are true addicts, and how to characterize the may patients and couples in my practice who get stoned nightly on marijuana.

     Then of course, we come to the question of other addictions : food, gambling, sex, etc. In each case, the person prefers the immediate gratification of that action to deferment of pleasure. Even Jackie Kennedy on her deathbed said that she wished she drank more champagne, and very few businessmen on their deathbeds say they wished they worked longer hours at the office. I note in passing that Tiger Woods was denoted a "sex addict" because he slept with 20 to 30 women while married, while Wilt Chamberlain, who openly boasted about having sex with over 13,500 women was not labeled a sex addict because he was not married (!?). I have one patient who feels that a night without an orgasm is a wasted night, but that is her philosophy.

     What it all boils down to is that the pleasure-pain principle rules a large part of our life: some get pleasure by deferring future pleasure, some get pleasure from their families, some get pleasure from their physical complaints (we call them "hypochondriacs), some get pleasure from other people's misfortune (we call them "sadists"), and some get pleasure from immediate escape. In fact, as a doctor, I have come to the conclusion that if an overweight diabetic does not want to lose weight, then some pleasure is derived from this lack of action. This is precisely why gastric bypass surgery is the most efficient and productive way to treat overweight diabetics.

     Since our teenagers' minds are not yet fully formed nor  capable of easily deferring immediate gratification, we fight as hard as we can to keep them from acquaintance with drugs, alcohol and sex.The problem is that their experienced high school colleagues will try to induct/indoctrinate them into this realm,so they are subject to both peer pressure and the tantalizing possibility that something unknown may make them feel better and happier. This is why I would like to reduce the drinking age to 16, especially for non-drivers, so they can learn to drink "responsibly" because they have to come home to mom and dad, rather than have their first drinking experience as an unsupervised 18-year-old college freshman. And state college campuses are even more dangerous: they tend to be strictly dry, even at the fraternity houses on campus, so the students  go off campus to drink and drive back drunk. I don't think that is an improvement.

     As an aside about sex: I tell all of my teenage female patients to always carry a condom in their purse, to never tell the boy if you are on the pill, and to tell him "if he doesn't put it on, he doesn't put it in". I find I have to be direct with the modern teenager, so there is no misunderstanding of my message. I give the boys the same message, but is is less critical for them from an STD point of view, and some of them know it. And as I've said before, if a young adult comes to me and asks for an AIDS and STD test, either because they had unprotected sex or their future sex partner requests it, I tell them to go to their local Red Cross office or hospital and donate a unit of blood, and they will be tested for AIDS, syphilis, West Nile Virus Hepatitis A,B,C, and some other diseases such as Chagas'.



  1. An article in The Sunday NY Times Magazine section (June 24, 2011) discusses the addictions of both Freud and Halsted.

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