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On the Future of Addiction

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After selecting me for their list of most influential addiction experts, yet disparaging my reputation and ideas, The Fix allowed me to present my ideas for myself. (There is some dispute about that, though; I say they encouraged me, but in a lengthy introduction to my piece, which repeats the same knocks against me, they claim that I twisted their arms.)

I took the opportunity to describe what I see as the future of addiction in the 21st century. In one kind nod by an assistant editor, the introduction notes, "To a surprising degree, many of his once-heretical beliefs have increasingly been adopted by mainstream medicine. Whether or not you agree with him, it's a safe bet that his alternative approach will be at the center of the most critical debates in the coming decades."

Here are the five points I predict about the future of addiction and how we treat it:

1. Addiction is not caused by substances.

I wrote "Love and Addiction," in which I explained that addiction is not a drug reaction, in 1975. Proposed changes in the American Psychiatric Association's diagnostic manual, scheduled for release in 2013, add to the list of addictions for the first time a non-substance-related activity: compulsive gambling (which I discussed in my 1975 work). Thinking of addiction as independent of drugs or alcohol -- as a response that can occur with any powerful involvement (think porn, video games, shopping, eating and sex) -- changes our entire conception of what addiction is. Instead of conceiving of addiction as a chemical reaction in the brain caused by specific drugs, we are now seeing that addiction is a pattern steeped in how we interpret and respond to powerful experiences of all sorts.

2. Most people recover naturally from addiction.

Although we all know that most people quit addictions on their own (think of the most difficult drug addition to quit, smoking, and all the people you know who have quit), The Fix and the DSM-5 are in the business of making addiction the object of treatment. But addiction is more accurately described as a result of deficiencies in many people's lives that, in most cases, they naturally outgrow. In fact, all research on the course of addictions, from smoking, to love, to video games, to cocaine, to alcohol dependence, paints the same picture: people tend to sober up on their own, if their lives don't become mired in the flotsam of the addiction.

3. Harm reduction is the most important 21st-century innovation in addiction policy and treatment.

The percentage of American addicts who are diagnosed and sent to treatment and who recover is minuscule, despite the fact that it's the most popular and heavily marketed trope in our addiction lexicon. So, where does that leave us? Trying to help people establish reasonable lives so that they can outgrow their addictions without irrevocably harming themselves or others in the meantime. How do you do that? By making sure that they don't become infected with AIDS or other communicable diseases, die of malnutrition, drive while intoxicated or suffer from other risky behaviors or accidents, and generally have enough support to reengage in normal life. Some don't and maintain addict lives until they die -- but that's a minority, a small minority. And even these chronic addicts deserve support.

4. Treatment is more than providing support for addicts to quit.

This new addictive scenario naturally implicates different kinds of treatment. Rather than convincing people that they have a lifelong disease and that recovery is all about abstinence, treatment needs to encourage and train people toward belief in themselves and the ability for independent living. This involves therapies that encourage self-control through skills training, emotional self-maintenance (for example, learning how to avoid and escape depression), community integration (called community reinforcement therapy), relapse prevention (not allowing a bad experience or patch of substance use to explode into full resumption of the addiction) and empowerment.

5. Empowerment vs. powerlessness.

If people don't feel that they have control over themselves and their lives, they are skunked. This is certainly far from an easy path, and many of us go back and forth on a "self-efficacy" scale depending on how our day, week and month have gone. But framing the goal of recovery as ultimately being one of self-empowerment makes us think totally differently about the image of addiction and of how to escape it. We don't tell people that they are helpless, that the addiction has its claws into them forever, that no one ever escapes its grasp -- least of all poor, debased them. It doesn't take much psychological sophistication to see that this is the wrong message to convey; think of giving a 16-year-old this image of themselves and of their powerlessness in the face of an addiction.

In other words, this had better be the century of self-empowerment, or else our level of addiction will escalate no matter how much money we spend on brain-imaging and PET scans.

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