The Future of Addiction: My Predictions for the Next 40 Years
My book "Love and Addiction," published in 1975, proved prescient in the decades that followed. How optimistic should we be as we look further ahead?
In 1975, I published Love and Addiction with Archie Brodsky. Now available as an e-book, a format unimagined back then, L&A anticipated every major development in the field since. To pass the time as I await delivery of my Nobel Prize, I’ll turn my attention to making a set of predictions for the next 40 years.
But first, let’s recap what I wrote in Love and Addiction and consider how that context frames our expectations.
The primary development since 1975 is the realization that addiction is not a byproduct of drugs, but applies equally to every powerful involvement. No drug is inherently addictive; nothing in which people become enmeshed is guaranteed not to be addictive. When Love and Addiction was written, one thing—one drug—was considered to cause addiction. Everybody, including pharmacologists, imagined that some peculiarity in heroin’s chemical structure made people become addicted to it, and it alone. How quaint! Alcohol was arbitrarily placed in a different category, as being addictive for only a special population of alcoholics.
Love and Addiction instead addressed addiction as a life issue. That a love relationship could be exactly as addictive as heroin meant that addiction didn’t spring from a drug’s chemistry. Rather, an addiction is an overwhelming destructive involvement with a powerful experience that provides essential emotional rewards for the addicted person.
We know—at least we did—that destructive love can’t be a disease. Now, however, one wing of the recovery movement has decided that addictive love and sex are real—and that they’re diseases. Recognition of love and sex addiction should have transformed the way we think about addiction. But it was used instead to reinforce existing misconceptions.
For example, Love and Addiction should have forced the recognition of natural recovery: Most people outgrow immature, addictive love relationships, and don’t need to join a 12-step or other program to do so. As for harm reduction, it seems self-evident that if people become addicted to sex and love, most aren’t going to have to quit these activities altogether to get better. Instead, they need to achieve more mature relationships by focusing on their own development.
Love and Addiction changed the addiction landscape, but not the way I intended—Codependent No More was but one example of how the revolutionary thinking in L&A was funneled back through the disease/12-step meat grinder, so that the product was unrecognizable. It is thus still necessary to return to the book to describe where future developments about addiction need to go.
Love and Addiction was also a cultural commentary about how we had lost our sense of efficacy in a world grown increasingly beyond our control. No label both represented and contributed to this sense of powerlessness more than “addictive disease”—the idea that we are incapable of controlling our basic appetites and needs. Unfortunately, both this loss of personal efficacy and the power of the disease meme have grown exponentially since 1975.
Key question: Will we successfully challenge the disease meme—while reversing the constant increase in addiction?
Although it is true we are looking in more places for addiction, it is nonetheless also true that addiction is genuinely increasing. Aside from the ever-roiling heroin, painkiller, pick-your-new-drug scares, just look at people staring at their iPhones who are gaming, texting and otherwise compulsively absorbing their attention all around you.
The American Psychiatric Association publishes its bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), every decade or two to tell us what’s wrong with us. The fifth edition was released in 2013. For the first time it recognized non-substance addictions—a mere 40 years after Archie and I detailed this phenomenon in Love and Addiction.
First (are you ready?)—DSM-5 doesn’t label substances as addictive or dependence-producing. There are simply mild, moderate, and severe Substance Use Disorders (SUDs). Only activities are “addictive” in DSM-5. Actually, only a single activity, gambling, is called addictive—sex and love were notably denied this status. Still, who would have guessed in 1975 that in 2013 psychiatry would eliminate addiction regarding drug effects, but decide that there were “behavioral addictions”?
Meditate on our confusion: Addiction is a scientific term whose meaning was considered nailed down in 1975, but has been in constant flux since then. The inadequacy, inconsistency and illogic of DSM-5 were instantly apparent. Who believes that addiction doesn’t exist, except in behavioral form? Who can believe that there is one—and only one—such behavioral addiction, gambling, and not eating, sex, love, video games, etc.? To artificially distinguish one behavior amid the entire welter of human existence is patently absurd.
DSM justifies this ridiculous conclusion by playing to our neurochemical fetish. DSM-5’s authors had to make the case, however crazy, that gambling alone of all behaviors taps into the same brain reward system as drugs (which, and I repeat myself, are no longer themselves reckoned to be addictive).
Thus they cast among the shifting evidence about what exactly this reward system comprises and, voila, arbitrarily found it characterizes gambling. Without question, more such behavioral addictions will be “discovered” in the years to come. Indeed, one development over the last 30-40 years has been the official decision that one drug after another previously not considered addictive—nicotine, cocaine, amphetamines, marijuana—actually is addictive. None of the 10 types of drugs DSM-5 recognizes can be distinguished from the others because it produces, or doesn’t produce, addiction.
Our neurochemistry fetish is not new. It is only the latest version of our long, futile effort to translate addiction into biochemistry. The Harrison Act of 1914 officially declared narcotics to be singularly addictive like nothing else—and a century later, this mistake still corrupts scientific and popular thinking. We need to reverse this thinking, and the idea that neuroscience can reveal the true nature and the cure for addiction. Instead, the validity of the biochemical, now neuroscientific, approach to addiction has been disproven time and again.
Key question: Will we come to our senses, rebel against Nora Volkow of NIDA and rely on the plain sense addictive behavior patterns make?
Addiction exists and is important and is not a drug or a biochemical phenomenon. If addiction applies as a concept to gambling, then it can’t be due to specific chemical properties of drugs, nor to a specific brain-reward pathway, except in as much as any human activity can be said to involve such pathways. Addiction can only be understood at the level of human experience.
DSM-5 defines SUDs on a more-or-less scale in terms of how seriously drug use impairs users’ lives—not as an on-or-off disease. DSM-5’s SUD criteria are based on how badly a person’s life is going due to their substance use—a description of lived human experience. At some arbitrary point along the scale of dysfunction—a scale that can be applied to any involvement—we may say that someone is addicted. No brain scan or neurological measure can tell us this.
It is scientifically and clinically possible—and useful—to say that some people are addicted and to use addiction therapy techniques to address their problem. But, contrary to the constricting, self-fulfilling 12-step ideology, addiction is not a fixed personal trait. “Addicted” does not describe a person’s character in a meaningful way—it is a characteristic of an involvement that they have formed at a particular time. As Ilse Thompson and I make clear in my latest book, Recover! Stop Thinking Like an Addict:
Addiction is not who people are. Addiction manifests differently in everyone, and for different reasons. Addiction includes a wide range of involvements, whether with substances or behaviors. It can be more or less severe. It can be an acute condition, limited in time and place, or one that stretches though a longer period of a person’s life.
Key question: What characterizes the most effective treatments for addiction?
As we show in Recover!, all effective therapy techniques for addictive problems are cognitive-behavioral and address the person’s life functioning: motivational interviewing, skills training, community reinforcement approach, solution-focused therapy. All enhance people’s self-efficacy and their mindfulness and ability to manage themselves. The effort to cure addiction by intervening at the level of brain chemistry and bypassing people’s conscious control of their lives actually decreases their self-efficacy and contributes to further addiction.
What the Next 40 Years Hold for the Addiction Field
1. The concept of addiction will not disappear, and in fact will be deployed more broadly. DSM will slowly expand its conception of addictive behaviors—to start, “Internet Gaming Disorder,” already listed in the current edition as inviting further research, will be added—but, true to form, DSM will be playing catch-up on the forms addiction takes for decades to come.
2. To call a person an “addict,” meaning addiction resides in the person, is derogatory, misleading and harmful. Even the terms “substance abuse” and “substance abuser” place people in a ghetto. As the century progresses, it will become increasingly unacceptable to use these terms, and the elimination of this nomenclature will help us recognize that addiction is not a special trait that only some people are subject to. The reversal of such stigmatizing will further improve the prospects of normalizing the lives of people who become, for a time, addicted.
3. The pursuit of the neurochemical roots and cures for the “disease” of addiction spreads and prolongs the condition. Current neuroscience has produced no useful tool for diagnosing addiction—nothing that predicts outcomes, no treatments for addiction—and it never will. Moreover, it distances us from the personal and cultural forces that cause addiction, and which we need to reverse. There is no alternative to addressing live human problems.
4. However, we will still waste a great deal more money, time and effort on seeking biomedical cures, even as our long-standing failures to curtail addiction fuel our growing sense of impotence. Along with our historical biomedical fetish, the commercial interests that support the disease theory—including the rehab business, biomedical researchers like Volkow, and, most economically potent of all, the pharmaceutical industry’s marketing of chemical “remedies” for addiction—are simply too powerful for us not to see significant further medicalization of addiction over the coming decades.
5. Yet, even though they run counter to this biomedical momentum, cognitive-behavioral therapies will come to dominate the treatment marketplace, as motivational interviewing already does, at least in name, and CRAFT (community reinforcement and family therapy) promises to do. Although AA will remain prominent, its hegemony over American treatment will continue to decline as it has in recent years. In its place, the availability of treatment programs based on genuine CBT techniques will grow, gradually crowding out ersatz claims by 12-step-based programs that they are practicing motivational interviewing or community reinforcement which—given their basic powerlessness creed and mandated steps—it is impossible for them to do.
6. Harm reduction, which sees that people can modify and improve their addictive drug use without fixating on abstinence, is a far better way forward than the disease theory. There are nonetheless also pitfalls in this direction, and I will outline one dangerous sidetrack in my next article for Substance.com. Here, I’ll say that harm reduction tools like methadone and buprenorphine, while important techniques, defy the underlying values of harm reduction to the extent that they are predicated on the view of addicted people as permanently biologically predisposed to addiction. Overall, however, this burgeoning approach will establish itself more firmly and widely, with major positive implications for policy and public health.
Developments like the spread of CBT and harm reduction, simultaneous with the medicalization of addiction, create contradictory forces. How we will resolve these conflicting ways of thinking isn’t at all clear. That we are not at some end point in how we think about addiction and drugs is abundantly clear, as signaled by the tar pit DSM and American psychiatry find themselves stuck in. But I remain optimistic that the never-ending string of failures of biochemical approaches stretching before us, combined with the obvious humanity of harm reduction and the efficacy of common-sense, life-focused approaches to addiction treatment represented by CBT, will result in a rational, real-world model of addiction finally prevailing.
My only concern is that this progress will take a full 40 more years, which means I won’t be around to receive that Nobel.