During the course of my career as a general internist, I have come to believe that 80% of illnesses are lifestyle induced and 20% are the result of bad genes, bad luck, or a bad infection. My job is to ask myself whether or not the patient sitting in front of me is an “80 percenter” or a “20 percenter”. If the patient is a 20 percenter, then the diagnostic workup will be more involved than the workup of someone with a common illness. It is my belief that 80% of those individuals with common illnesses are suffering from an addiction. I define an addiction as a pathological relationship to a mood altering substance, behavior, emotion, or relationship that results in life damaging consequences. Using this very broad definition of addiction, I can define my obese, type 2 diabetics as food addicts. These diabetic patients use food to mood-alter an uncomfortable emotional state. Indeed, food is the cheapest drug available in American society. The end result of food addiction is early death due to heart attack, heart failure, or end-stage kidney disease requiring dialysis. However, if I were to label my diabetic patients as “food addicts” they would look at me as if I were crazy. These patients do not view themselves as addicts simply because “no one ever got arrested for driving while fat.”
In other words, in order to be considered an addict a person must have violated some social norm or legal standard. Typically, addicts and alcoholics are viewed as weak willed or morally bankrupt individuals who have lost the power of choice when it comes to the use of drugs or alcohol. This mistaken notion is a byproduct of American culture. We live in the society of John Wayne; where everyone is rough, tough, and individualistic and pulls themselves up by their bootstraps. If you are an addict or an alcoholic, you have a weakness of character, an inability to deal with life, or a case of chronic “wimphood”. Given this set of circumstances, it is no wonder that denial runs rampant in the setting of these diseases. Who in their right mind, would ever admit to being an addict or an alcoholic given the social stigma that surrounds the disease. This unfortunate set of circumstances results in untold suffering in millions of people. Unfortunately, these persistent myths shame the afflicted and prevent them from getting the treatment that they need.
The truth of the matter, however, is that addiction and alcoholism are brain diseases. The brain, for the purpose of this discussion, can be divided into three major areas: the pons and medulla or “reptilian brain”; the mesolimbic system also known as the “emotional brain” or the “rat brain”; and the cortical brain or the “big brain”. The reptilian brain tells your heart how often to beat and how often you should breathe. In other words, it coordinates automatic functions within your body. The mesolimbic system, or rat brain, sits above the primitive reptilian brain– and this is where the disease of addiction resides. The cortical brain represents what we think of as characteristic of an individual human being. It is the repository for higher thinking, personality, willpower, and the capacity to judge, plan, moralize, or philosophize. The hierarchical organization of the brain is such that the reptilian brain will trump the emotional brain, which will trump the cortical brain.
What then, is the purpose of the emotional brain? From the evolutionary standpoint, the emotional brain exists for a very good reason; there are certain activities in life that are essential to survival, these include: food, sex, exercise, and drinking water when you’re thirsty. When you perform these acts, so-called pleasure chemicals are released in the emotional brain which tells you at an irrational, nonverbal, emotional level to: “keep doing this– it’s essential to your survival”. Drugs of abuse (such as alcohol, heroin, cocaine, methamphetamine, etc.) directly and reliably stimulate the production of these pleasure chemicals within the emotional brain. Each time the addict or alcoholic takes a “hit” or a “drink” they are directly stimulating the release of chemicals that tell them “keep doing this– it’s essential to your survival”. Notice that the term is “essential”, not optional. In effect, the addict’s brain is hijacked by their drug of “no choice”. Once they begin to use their drug of “no choice” they trip the switch on a self-reinforcing circuit, which perpetuates a deadly obsession and compulsion.
All of this occurs in a very primitive area of the brain. The deeper within the brain that the lesion exists, the more difficult it is to eradicate. The prevailing or stereotypical view of this disease suggests that the disease is due to a lack of willpower. Of course, this is not true. Willpower is a function of the cortical brain, which sits above the emotional brain. Willpower is ineffective in changing lower brain functions. The following example is instructive with respect to the limitations of willpower; when my youngest son was eight years old he went out on Halloween night for trick-or-treat. The next day he had a bag filled with candy. He was overindulging in the candy and I took the bag away from him, at which point he threatened to hold his breath until he died unless I gave him the candy. Of course, I said go ahead and try. By sheer force of will he attempted to hold his breath until he would die — — needless to say, this didn’t work. It didn’t work because his lower brain, i.e. the reptilian brain, overrode his desire to hold his breath. In the case of the alcoholic or drug addict, their attempts at controlling their disease through willpower are doomed to failure because they are trying to override a lower brain function by depending upon a higher brain function.
So does this mean that the addict is doomed? No, of course not. It means that he has a disease that can be arrested, but not cured. How then, is the disease arrested? First of all, the degree and severity of the disease must be assessed with respect to the need for inpatient detoxification or concurrent medical or psychiatric care. Once the patient is stabilized, the real work of recovery begins. To date, the most effective means of arresting the disease of addiction or alcoholism comes about as a result of a spiritual awakening. For some reason, as yet unknown by modern medical science, a spiritual awakening has the capacity to displace the compulsion to use drugs or drink. Of course, I am a medical doctor — — I don’t dispense spiritual awakenings. The most reliable means for attaining a spiritual awakening in the setting of alcoholism or addiction comes about as a result of working the 12 steps. The 12 steps is a spiritual technology that has the capacity to free the individual from the deadly obsession and compulsion with which he is afflicted.
The problem with the 12 steps is that many people confuse it with religion. 12 step programs focus on spirituality, not religion. In effect, spirituality represents the progressive death of self-centeredness combined with the growing awareness that the purpose of life transcends the mere gratification of instinctual drives. A key component of spirituality is the discovery of, and dependence upon, a power greater than oneself. However, the definition of that higher power is left up to each individual. The road to recovery is broad and inclusive; it is also simple, but not easy. The purpose of my practice is to use my skills as a medical doctor to facilitate the growth and eventual recovery of my patients. It is my belief that anyone can recover if they are willing to follow a few simple suggestions and to work at their own healing.