Addiction expert Dr. Drew Pinsky answers your questions about addiction:
Q: What's a behavioral addiction? Is it different from, say, drug addiction?
A: Behavioral addiction generally refers to repetitive escalating actions unrelated to the ingestion of substances that affect one's health, work, relationships, school, finance or legal status. These actions tend to escalate or continue in spite of the consequences, causing significant distress in spite of the desire to stop. It is different from a drug addiction in that it is not specifically induced by pharmacological agents acting on the brain. However, in my experience it is often the case when a chemical addiction precedes a behavioral addiction, shall we say priming the brain towards the system to need escalating reinforcement.
The archetypal behavioral addiction is gambling and there appear to be two type of gambling addicts: those that pursue the excitement — and interestingly those people seem to enjoy more the excitement of losing money rather than winning. And those that seem to zone out during their gambling with their gambling addiction. They seem to be drawn to the video gambling machines such as poker, they will sit for long periods at these machines and dissociate to the point that they have been reported to even lose control of their bladder function.
Sexual addiction is altogether the other most addictive behavior. Now with the advent of pornography on the internet, the home computer has been like having a crack pipe in the addict's home. Some who work in the field of treating sexual addicts believe this is the most rapidly increasing diagnostic category in the country. The unfortunate reality of internet pornography addiction is that it tends to escalate, subjects tend to need increasing levels of arousal and will often graduate to more bizarre images and ultimately to accessing dangerous or even illegal activities.
The term behavioral addiction has begun to be applied to a wide variety of behaviors perhaps to the point where the meaning of behavioral addiction has lost its value and impact. A simple definition that I like to use is first assess whether or not you have a risk for addiction per se, is there genetic heritage of alcoholism, for instance is there genetic heritage of alcoholism in your family background, secondly is there evidence of escalated use in spite of deleterious consequences, and finally, is there any degree of denial here, about your behavior and its consequences. If you meet these criteria and are having significant distress or consequences in your life, it might be worth consulting with an expert.
It appears this system can become permanently disrupted, such that the motivational systems, responsible for things such as eating, drinking, reproduction and survival, become broken. The entire focus of that system becomes deployed towards the motivation to seek drugs and alcohol. It is a deep area of the brain, beneath consciousness, it does not have logic or reason or language. So the willpower or reasoning part of the brain is at the service of these broken motivational systems. If you understand this biology, it is easier to understand how people can forsake their family, friends, job, even their health. The system that is normally responsible to motivate them to survive has been subsumed by the motivation to do drugs.
Q: What causes such a strong compulsion? Meaning, how is this different from a piece of cake calling you after you've already had dessert?
A: Although this is a system that is active in eating and drinking and reproduction, it is supercharged to an extra physiological proportion. The rewards, say, someone gets from eating a piece of cake are substantial. But addiction has taken that system and heats it up, supercharging it to the point where the drugs and alcohol take over all other priorities. The only way one can experience pleasure and satisfaction now is by using drugs or alcohol.
Q: Is alcohol a drug?
A: Nicotine and alcohol are the two most abused and frequently addictive drugs in our country. Alcohol is not as rapidly addictive as some of the more addictive pharmacological agents such as opiates, OxyContin, or cocaine. These chemicals tend to induce very rapid aggression into an addictive process, while alcohol is a slowly progressive process in most cases, though some of that is determined by the amount of genetic biological burden for addiction that each individual has.
Some individuals explode with alcohol addiction very quickly; most, however, go through long periods of time where they can control their alcohol use. In fact this is something that fuels their denial later—the mistaken belief that even though they have triggered true addiction, they can still control their drinking as they had at before. What people don't understand is that there is a threshold — once somebody crosses it, they are addicted and cannot stop. And that is when they need treatment.
Q: What's the difference between uppers and downers?
Uppers and downers very simply are medications that cause stimulation, versus medications that cause sedation. Typically uppers are medications that have been referred to in the past as sympathomemetics, the paradigm being methamphetamine, but it also includes pharmacological agents like Aderol and Ritalin, it includes Ephedra and Sudo ephedrin, which, taken in sufficient quantities, will be converted by your body to methamphetamine. Cocaine can also be considered and upper.
Downers are typically the sedating medications, the valium-like drugs like Xanax, Valium, Librium, Ativan, and hypnotic sleeping medications such as Ambien, Restoril, Sonata, ProSom. Alcohol is often thought of as a downer, the class of downers ireferred to as "central nervous system depressants." But often not taken into account is that in alcoholics, alcohol gives them somewhat of a stimulant and euphoric effect. There reason is that alcoholics convert alcohol into an opiate-like substance. Witness the fact that most non-alcoholics get sleepy and drowsy after a few drinks, where an alcoholic becomes stimulated and euphoric, wants to go do their homework, go out and party or clean the house.
The central nervous system downers are very seriously addicting in that if they are cut off suddenly, the brain becomes hyper stimulated. When the depressive influence is removed, seizures and agitation are a common consequence.
Q: Are recovering drug addicts/alcoholics more likely to replace one addiction for another — i.e. gambling for drinking, or caffeine for cocaine?
A: A recovering addict by definition does not replace anything for anything. Addicts all use cross-tolerant and cross-reactive substances in order to satiate that profoundly active motivational system we call the medial forebrain bundle that is so active in addiction. All drugs of addiction have that in common. They deliver extra physiological chemicals so that just any drug can't substitute for another. That's why if you're a marijuana addict, you can't use alcohol, and if you are an alcoholic, you can't use Valium.
What you will see is that caffeine and tobacco, however, don't seem to significantly influence this. The pharmacology of activity does not seem quite sufficient to perpetuate the disease of addiction. However, some recent literature has shown that alcoholics who stop smoking at the same time they stop alcohol do tend to have slightly better outcomes. Now, an anabolic addict who is trying not to do drugs will often develop impulses to engage in behaviors that also stimulate that same area in the brain. Primarily these are extreme behaviors that include some element of thrill. So you will see people who recover that are motivated towards very dramatic relationships, sexual acting out, truancy, criminal behaviors, extreme sports, gambling, shopping and overeating. All of these behaviors when done to excess will have some degree of activity in that medial forebrain bundle which is particularly luring and particularly satisfying — especially early in their recovery.
A common behavior that I see in opium addicts who are not in recovery but are trying desperately not to use, is that they will often steal. You will see women, particularly female patients, go into a store and steal things they don't need as a way of just desperately trying to gain relief from overwhelming feelings that the drugs have left them with.
Q: What does it mean to "enable" an alcoholic or addict? And how can loved ones avoid it?
A: To enable and alcoholic or addict is to maintain a relationship which allows them to maintain their disease. It is exceedingly difficult if you are engaged with a loved one not to enable. Enabling takes different forms with different types of relationships. For instance, mothers of alcoholic children typically carry a fantasy that their child will die if they don't intervene, and literally it is their intervening that will ultimately kill the child of the addictive disease. Continuing to prevent these children from falling to the point that they have to reconcile with themselves the consequence of the behavior prevents them from getting to the point where they acknowledge the seriousness of their disease and do something about it.
And as a parent it is extremely difficult to overcome this natural instinct. In fact, whatever the nature of the relationship with the loved one, almost without exception, without some other outside supportive services such as a therapist, Twelve Steps, or co-dependency such as Alanon or AlaTeen, it is almost impossible for an individual to withstand the power of the disease in the person they love.
And I share with you that the most significant intervention a loved one can make is to go to Al-anon, to a co-dependency Twelve Steps meeting, get a sponsor and themselves work the Twelve Steps. Having done so, they will disengage from the dance that the addict so desperately counts upon in order to maintain and "enable" their disease. When that dance is finally ruptured, they feel it very deeply and become fearful of being abandoned; they feel exposed in much of their manipulation and the means by which they maintain their disease is now exposed.
That is often this one intervention, the important person going to Al-anon, to Twelve Steps co-dependency recovery, that brings the addict to treatment. The co-dependents also often have some very serious issues of their own. Typically these are boundary issues around how we identify with and experience pain in other people. Alcoholic addicts typically have a diminished capacity for experiencing empathy, while co-dependents have an exaggerated response. They see another person in pain and identify with that pain so strongly that they can't differentiate the pain that person is experiencing from their own. I wrote a book called Cracked, which is a non-fictional account exploring precisely these issues: how people with addictions get under our skin and affect us in very deep ways if we do not have extremely good boundaries.
In point of fact, what someone needs who is struggling with addiction is not rescue. If you rescue them you make them forever dependent on the need for further rescue.
