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  1. 5-HT2A
    The narrative of addiction is familiar. A pleasure-seeking “addictive personality” spirals out of control, “enabled” by friends and family, and eventually hits “rock bottom” in the form of arrest, divorce, or homelessness. She may then succeed in a 12-step program, where she’ll embrace a “higher power,” receive “tough love,” and accept total “abstinence” from substances including antidepressants and drugs that ease withdrawal symptoms. Even if she gets clean, she’ll be an addict forever, and is more likely than not to relapse.

    A powerful new book by Maia Szalavitz, Unbroken Brain: A Revolutionary New Way of Understanding Addiction, reveals that narrative to be a literary creation, not a work of evidence-based science. Szalavitz is a journalist who in the 1980s was addicted to cocaine and heroin, charged with felony possession, and faced 15 years to life in prison under New York’s now-repealed Rockefeller drug laws. (Her case was eventually dismissed.) She has spent 30 years researching and writing about substance use disorders, and her book offers an alternate way of thinking about what addiction is: neither an illness nor a sign of an immoral personality, but a learning disorder.

    “We never get out of this ‘It’s a disease or it’s a choice’ debate,” Szalavitz tells me. “But addiction is not brain damage or a pathology like Alzheimer's. It really is misguided learning.”

    What she means is that the path to addiction—which she defines as compulsive behavior despite negative consequences—depends on learning that the problematic substance can help soothe some other problem in a person’s life, such as depression, social anxiety, physical pain, or, in Szalavitz’s case, what she believes was an undiagnosed childhood autism-spectrum disorder.

    In high school, when her parents were divorcing and the socially awkward Szalavitz was desperate to befriend a gorgeous hippie girl, she readily agreed to smoke hash with her. Later, she snorted her first lines of coke backstage at a Grateful Dead concert—with Jerry Garcia himself. She immersed herself in books about the mind-expanding qualities of various drugs. And she experienced real revelations while high, which helped her cope with an overwhelming fear of death. But she eventually became one of the 10 to 20 percent of drug users who become addicted. As a Columbia University student alert to class differences for the first time, she began to sell cocaine, which won her invites to hip rich-kid parties. After she was kicked out of school and began a toxic relationship with a fellow addict, she turned to heroin, which she learned could make her feel carefree and loved despite her boyfriend’s inattention.

    Szalavitz hit many potential “bottoms”—being suspended from college, an arrest, a short stint in jail—but didn’t get clean until she seriously considered violating her own ethical code by trading sex with a man who disgusted her for drugs. That was when she learned she was, as she writes, “a debased addict. … I looked around, and it was as if I was seeing my home, and myself in it, for the first time. The cat litter hadn’t been changed in far too long, and it gave off an evil stench. Everything was covered in a layer of grime—cat hair clotted with dust atop soiled laundry; burnt, shattered crack pipes on yellowing newspapers. The atmosphere was nauseating. I was suddenly amazed at my surroundings and unable to comprehend how I had lived in such a state for years.” That was when she freely chose to enter a 12-step rehab program and got clean.

    Szalavitz didn’t have a classic “addictive personality.” She was a good student and fearful of many novel experiences, not a thrill-seeker. In her case, anxiety drove addiction. “Fundamentally, the idea of a general addictive personality is a myth,” she writes. She notes that the negative stereotypes associated with addiction, such as irresponsibility, animalistic impulsiveness, and hypersexuality, are also those that have been applied to black Americans and have driven America’s drug war and mass incarceration of people of color (even though whites use and sell drugs at higher rates than nonwhites).

    Understanding addiction as a learning disorder calls for a different set of interventions. Though 12-step orthodoxy preaches that friends and family ought to step back and allow addicts to hit rock bottom, Szalavitz demonstrates that close, loving relationships are, in fact, key to sobriety. “[P]eople are actually more likely to recover when they still have jobs, family, and greater ties to mainstream society, not less,” she writes, because learning is more likely to take place in the context of supportive relationships.

    Although Szalavitz got clean with the help of a 12-step program, she mounts a case against the dominance of the 12-step model, especially as it has become enshrined in the criminal justice system. Contra Alcoholics Anonymous dogma, there is little evidence that an addiction to one substance means a person cannot learn to safely use another substance, she writes. But in part because of this blanket disapproval of drugs, there has been a lack of evidence-based treatment for opioid addicts. Maintenance medications that can help addicts withdraw, like Suboxone, are still not widely available.

    One-third to one-half of clients in 12-step treatment programs are compelled there by courts, and others are essentially forced to enroll by employers or family members. Yet those coerced to attend rehab are less likely to get clean than those who choose treatment on their own, as Szalavitz did. That comports with what we know from education research: Learning is more often driven by intrinsic motivation (the authentic desire of the student to succeed) than by extrinsic motivation, such as rewards and punishments from authority figures.

    Mark Kleiman of New York University is an expert on drug policy and a proponent of “swift, certain, and fair” punishments, such as short jail stays, for offenders who violate probation. But when it comes to addicts, he agrees with Szalavitz that they should not be arrested for drug possession alone, and when they are charged with more serious crimes, compelling addiction treatment often backfires. “Someone who can quit without professional attention should be allowed to do so” by the courts, he says.

    Szalavitz would like both parents and the criminal justice system to become warier of referring adolescents and young adults to group rehab. After all, not everyone who commits a low-level crime while drunk or high is an addict, and there is a real risk of “overtreating” substance problems that many people spontaneously grow out of.

    “Who do you want your kid hanging out with?” she asks. “Put them in a group, when they are smoking pot and drinking, with heroin and cocaine and meth users, who will have to repeatedly talk about how much they love those drugs? This is going to be a good influence?” Individual or family therapy with a well-trained, evidence-based practitioner is a safer bet than many formal rehab programs, Szalavitz says.

    Potentially more controversial is her application of the concept of neurodiversity to addiction. Autistic people have argued that their brain differences are not a disorder that needs to be cured, but a natural, even desirable variation in the human condition. Is it possible that addiction, too, should be seen as a potential strength?

    “When starving, when in love, and when parenting, being able to persist despite negative consequences—the essence of addictive behavior—is not a bug, but a feature,” Szalavitz writes. Perhaps addicts are wired for extra love, obsession, and creativity in ways that can be productively channeled, Szalavitz suggests, such as in the arts, or in advocating for more progressive drug policies. She notes that brain scans of recovered addicts show growth in the prefrontal cortex, which governs self-control. The learning they’ve done in overcoming addiction is visible and may make them smarter and stronger in the long run.

    “With addiction, the vast majority of people do recover,” Szalavitz says. “And that’s a really important thing for people to realize. The reason I called the book Unbroken Brain is that your brain isn’t broken. You’ve learned something that is problematic.”

    by Dana Goldstein

    April 7, 2016

    Source:
    http://www.slate.com/articles/life/education/2016/04/is_addiction_a_learning_disorder.html

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