More people than ever before see themselves as addicted to, or recovering from, addiction, whether it be alcohol or drugs, prescription meds, sex, gambling, porn, or the internet. But despite the unprecedented attention, our understanding of addiction is trapped in unfounded 20th century ideas, addiction as a crime or as brain disease, and in equally outdated treatment.
Challenging both the idea of the addict's “broken brain” and the notion of a simple “addictive personality,” Unbroken Brain offers a radical and groundbreaking new perspective, arguing that addictions are learning disorders and shows how seeing the condition this way can untangle our current debates over treatment, prevention and policy. Like autistic traits, addictive behaviors fall on a spectrum and they can be a normal response to an extreme situation. By illustrating what addiction is, and is not, the book illustrates how timing, history, family, peers, culture and chemicals come together to create both illness and recovery- and why there is no “addictive personality” or single treatment that works for all.
Combining Maia Szalavitz’s personal story with a distillation of more than 25 years of science and research, Unbroken Brain provides a paradigm-shifting approach to thinking about addiction.
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A Revolutionary New Way of Understanding Addiction
By Maia Szalavitz
St. Martin's PressCopyright © 2016 Maia Szalavitz
All rights reserved.
Heroin was the only thing that really worked, the only thing that stopped him scampering around in a hamster's wheel of unanswerable questions. Heroin was the cavalry ... [it] landed purring at the base of his skull, and wrapped itself darkly around his nervous system, like a black cat curling up on its favourite cushion.
— EDWARD ST. AUBYN, BAD NEWS
BY JULY OF 1988, MY LIFE had narrowed to the point of a needle. I was living with my boyfriend, Matt, and selling cocaine. My only daily goals were, first, to slog to a methadone program, and then, somehow, to ensure we made sufficient money to get high and pay for rent and cat supplies. That summer was simultaneously the best and the worst time of my life. It was the best because in August, I would successfully kick the cocaine and heroin addiction that had left me weighing 85 pounds, with angry tracks dotting all four limbs, my hair a thin, overbleached Madonna-trying-to-be-Marilyn blonde and my eyes distant and blank. It was also the worst because, well, I wouldn't exactly recommend active addiction and early recovery.
I was 23. I was out on bail, facing a mandatory minimum 15-to-life sentence on a 1986 cocaine charge, under New York State's Rockefeller drug laws. I had been busted with 2.5 kilos of cocaine, which made me look like a high-level dealer, but the truth was that most of it belonged to Matt's supplier, who had asked him to stash it.
Few would have predicted such a future for a child who read at three, who tried to channel her social awkwardness and became "most likely to succeed" in eighth grade, and who excelled academically enough to be admitted to Columbia in its first class of women in 1983. But Columbia was now in my past. I couldn't study while facing the stress of a felony case; in fact, I couldn't do much at all, not even tasks of basic self-care like household cleaning, bathing, and laundry.
About here's where I'm supposed to tell you that I'm different, that I wasn't your "typical addict." The American media repeatedly assures us that such an addict certainly isn't white, female, educated, or middle class. But I'm not going to do that. History demonstrates that the idea of the "typical addict" is itself a cruel stereotype forged in a period of intense racism, which has a great deal to do with why our drug treatment system and drug policies are both draconian and ineffective. The whole notion is one of the hidden obstacles that keeps us from truly understanding drug issues. To do better, we need to understand what addiction really is — and how our misguided attempts to define it have actually caused great harm.
In the 1980s, when I was addicted, great emphasis was placed on the distinction between "physical" and "psychological" addiction, and folk belief in the importance of this difference remains surprisingly common. Physical addiction was seen as medical: it was primarily a problem of dependence, of biologically coming to need a drug to function without being physically ill. Indeed, the official term for the problem in psychiatry's diagnostic manual, in the '80s and until 2013, was "substance dependence."
"Psychological" addiction, however, was seen as moral: it meant you had lost control over your mind and were weak willed, selfish, and bad. Physical addiction was real; psychological addiction was all in your head. Unfortunately, as people like me learned the hard way, the physical need for the drug to avoid withdrawal symptoms is not the core of the problem. Instead, psychology, and the learning that influences it, matters much, much more. In the summer of 1988, that psychology dominated my life.
* * *
ONE OF MATT'S favorite words was "fetid," and that aptly described our living conditions that summer. Our $750/month rental in Astoria, not far from the Triborough Bridge, was essentially a square divided into four rooms, sparsely furnished, with a bare, stained futon mattress on the floor in one bedroom, many books, comic books, records, CDs, a high-end stereo system, and a few tables and chairs.
Scattered around were the detritus of drug habits: bent, blackened spoons and bulbous glass crack pipes, some of which were broken and had charred metal screens in their bowls. A few neon-orange syringe tops could be seen atop piles of dirty laundry, mine almost entirely black. In the corner of one bedroom was a desk with an early PC and dot matrix printer, which I used to file articles I wrote for the stoner magazine High Times. (My first national column, written under the pseudonym Maura Less, was called "Piss Patrol" and covered urine testing.)
A litter box stood in another corner, and our long-haired gray tiger cat, Smeek, padded around, showing off his massive puffy tail. Smeek, at least, was well loved and perhaps a bit too well fed. But otherwise we lived in filth and disarray — and the litter certainly wasn't always clean, a situation Smeek would sometimes protest by thinking outside the box, often on the scattered papers and clothes.
Meanwhile, Matt had become grotesquely obsessed with his bodily functions and terrified of being arrested by firefighters. He thought that the men in the red trucks were somehow able to monitor and detect the fumes from the cocaine he smoked. He always kept the shades down, cautiously peeking out occasionally to see if the firefighters were on to him. This once drily witty and artistic Jewish boy from Long Island now sat indoors most days, wearing only tighty-whities and surrounded by garbage, convinced that freebasing was destroying his digestive tract but unable to stop himself.
Every morning, I'd tell myself that I wasn't going to shoot coke, knowing that it would only make me anxious, obsessive, and paranoid (though, at least not about firemen!). I'd drag myself to the fortress-like methadone program near the elevated subway lines at the base of the 59th Street Bridge. I had chosen to get this treatment; I knew being physically dependent on heroin was a problem and I wanted help detoxing from it. I thought, in fact, that doing this would be all that was needed to get me back on track.
I was thoroughly steeped in America's paradoxical view of addiction: I thought it was simultaneously a moral and a medical problem. I couldn't accept that I had the moral problem; I thought that would mean that my intelligence — the only aspect of myself that I valued — was weak and corrupted. So, I told myself I was "just physically addicted" and that methadone would fix that.
The idea was to "wean" me from an illegal opiate by providing a safe, clean, noninjectable legal one in progressively lower amounts over the course of six months. The Bridge Plaza Methadone Maintenance Treatment Program started by first "stabilizing" me on what I now know is far too low a dose. An effective dose of methadone varies from patient to patient but is typically over 60 milligrams (I was given 30) and ultimately reduces craving for heroin without producing euphoria. At such a dose, methadone also blocks your high if you relapse. I never experienced that.
But even if the program had gotten the original dose right it wouldn't have mattered much. They began "tapering" me almost immediately, decreasing the methadone in what research had already shown by that time to be a highly ineffective way of using the drug. Consequently, as that data could have predicted, I titrated up my heroin use as they ran the methadone down, rendering the entire exercise useless while sustaining my physical dependence. I felt hopeless, trapped.
So, I changed tactics. First, I convinced myself that the methadone actually made the detox process worse. The word on the street was that kicking heroin was "easier" than methadone detox because the worst of heroin withdrawal lasts around two harsh weeks, while methadone withdrawal is more protracted, lasting months (though if done right, I later learned, it should be less severe). My new plan to quit drugs became this one: I would complete the methadone detox and afterward, just do heroin for a few weeks to get the methadone out of my system. Then I'd stop for good. And yeah, I'd stop the cocaine at that point, too. Today, however, I'd just have one more shot.
Since Matt and I were selling cocaine and virtually always had it around, that one injection would soon lead to dozens. I'd dig for one of my few remaining accessible veins, awaiting the moment when I'd strike it rich, watching the blood blossom up into the barrel like a gusher of oil. But even when that happened easily, the euphoria no longer sparkled. It was contaminated with paranoia, shadowed by a looming overhang of objectless dread. What had started as a burst of excitement that opened for me a sense of endless opportunity and capacity was now fraught with fear and a feeling of being stuck, not liberated. Desire curdled into dread that only prompted more fruitless and frustrating desire for more.
Wired to the gills, shaking, unable to relax, my heart seeming to pound louder than it should, I'd then realize that the only thing that would help was heroin. That would produce an epic quest to cop in what were then dire neighborhoods in Bushwick, Brooklyn, or Manhattan's Lower East Side.
I was terrified of getting arrested while buying — not only for the usual reasons, but because I was afraid of what effect it would have on the conditions of my bail and, therefore, on both of my divorced parents' houses, which served together as collateral instead of $50,000 in cash. The high bail was set because the 2.5 kilos of cocaine I'd been charged with possessing when I got busted legally qualified me as a high-level dealer, although that was hardly the reality. It was actually my first arrest.
Consequently, to minimize rearrest risk, I wouldn't buy for myself, but I would instead ride along with friends who would score on the street for me in return for a share of the drugs. We'd drive in someone's clunker of a car to Bushwick on the Brooklyn-Queens Expressway, shivering past the acres of graveyards that divide the two boroughs. When we got close, I'd slump out of sight in the passenger seat or backseat. My race and ragged looks made it obvious why we were in the neighborhood. I'd wait anxiously as whoever had agreed to drive darted into decrepit, graffitied buildings, always taking what seemed like years to return.
The heroin, if we managed to procure decent stuff — not ineffective, adulterated dross — would win me a few blessed hours of blissful calm. When I got home, I'd heat the spoon to prepare the heroin, which I dissolved in water, adding a dash of coke when it cooled, then injecting the mixture. If the drugs were good and my tolerance wasn't too high (a rare concurrence at this stage of my addiction), the first hit would be heavenly. Like a flourish from a brass section, the cocaine would trumpet a burst of exhilaration as I pressed the plunger in; I could taste its icy flavor at the back of my throat. A few moments later, the warmer, soothing harmony of the heroin would take over. Every atom in my body felt calm, safe, fed, content, and, most of all, loved.
Unfortunately, however, before long, I'd decide that another shot of cocaine would be nice. That would start a compulsive cycle of "just one more," until the cocaine's anxious alertness blotted out the heroin's sedative effect entirely. After a sleepless night, the next day would be exactly the same, starting with the humiliations of the methadone program.
Low-slung, located in a forbidding light industrial area in the shadow of the elevated tracks of the N and 7 trains, surrounded by businesses like auto parts suppliers, the place looked like a prison. Every feature bespoke an emphasis on security and the siege mentality that comes with trying to retain valuables when you see all of your customers as criminals. Rain, snow, sleet, or hail — there was no weather extreme enough to keep a line from forming outside before the clinic's early-morning opening time so we could be medicated to stave off withdrawal. At that minute — sometimes a bit later, but never a second before — the heavy metal door would creak open and we'd be herded into a mantrap and monitored by video camera. After the first door closed, a second, equally armored and imposing portal would open to admit us.
Next, we'd line up inside. Often, you would have to provide a urine sample before you'd get your bitter cocktail of methadone and orangeade from a nurse using a precisely calibrated and heavily defended machine. This process posed a problem for me that summer: I was virtually always dehydrated from shooting drugs the night before. And if I had to give an "observed urine," the woman charged with that lovely job would usually have to stand there and wait until I was able to eke out enough pee. They could have just asked if I'd taken drugs: I don't think I ever gave the place a "clean" urine, and my using should have been a signal that I needed additional assistance. But that approach would have required them to see me as a fellow human being who was ill, not as just another junkie — and it would have required genuinely individualized therapy, not just bureaucratic rules.
This was my first personal encounter with supposedly professional "help" for addiction: a system that calls you "dirty" if you relapse; one that assumes you are a liar, a thief, or worse and responds to increasing symptoms of addiction not by offering more help but by punishment or expulsion. Indeed, as it became clear that my "detox" was failing, I asked my counselor if I could stay on methadone longer to see if I could stabilize and improve, but I was told that I hadn't used heroin for long enough to be given long-term methadone treatment. And besides, I took too much cocaine.
In other words, while it was clear that I wouldn't successfully detox, my problem was both "too bad" (the coke) and not "bad enough" (too few years on heroin) for me to get more help. The fact that I exhibited symptoms of addiction was basically why I was expelled from treatment for it. I wasn't even offered a referral for any type of additional rehab or medical care — despite the fact that it was the peak of the HIV epidemic in intravenous drug users in the United States and I was in New York City, the epicenter of that epidemic. At least half of the injection drug users in the city were already infected; among these were many of my friends, with whom I could have shared needles. In any other area of medicine during a global pandemic, such "care" would be considered malpractice.
Still, that's what I received — and what sadly is still all too common today, with at least one third of all methadone programs still failing to provide an adequate dose. But as unbelievable as it now seems even to me, despite shooting up dozens of times a day and facing felony drug charges, despite being on a methadone program for heroin addicts and having dropped out of college following my arrest, I didn't yet see myself as a real drug addict.
That would change on August 4. That was the day I recognized that I was about to cross a line and meet my own carefully designed criteria for addiction (specially created, mainly, to try to exclude myself, I must admit). While recovery stories are often told as though they result from sudden insight that prompts life-altering action, in reality, studies find that psychological breakthroughs are not the typical path to change and rarely lead directly or in any linear way to alterations in behavior. Indeed, research suggests that having an intention to do something only predicts engaging in the desired behavior about 33% of the time, even for people without drug problems. Learning a new behavior typically takes time.
My experience, however, was somewhat different. My story may be an example of a recovery path that researcher William Miller has labeled "quantum change," in which a minority of people do suddenly completely shift course — as opposed to the more typical gradual process of fits and starts. It could also be the case that my brain's natural maturation process finally reached the point where my "executive function" could begin to put the brakes on the regions that create desire — and this change allowed my epiphany to save my life.
Excerpted from Unbroken Brain by Maia Szalavitz. Copyright © 2016 Maia Szalavitz. Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
Author's Note xiii
1 Needle Point 9
2 A History of Addiction 20
3 The Nature of Addiction 32
4 Intense World 41
5 The Myth of the Addictive Personality 56
6 Labels 72
7 Hell Is Junior High School 84
8 Transitive Nightfall 94
9 On Dope and Dopamine 106
10 Set and Setting 121
11 Love and Addiction 138
12 Risky Business 155
13 Busted 167
14 The Problem with Bottom 174
15 Antisocial Behavior 191
16 The 12-Step Conundrum 207
17 Harm Reduction 224
18 The Kiwi Approach 243
19 Teaching Recovery 258
20 Neurodiversity and the Future of Addiction 272