The Fix
The Fix
Damian Thompson
Addictions to iphones, painkillers, cupcakes, alcohol and sex are taking over our lives.Our most casual daily habits can quickly become obsessions that move beyond our control. Damian Thompson, who has himself struggled with a range of addictions, argues that human desire is in the process of being reshaped. Shunning the concept of addiction as disease, he shows how manufacturers are producing substances like ipads, muffins and computer games that we learn to like too much and supplement tradition addictions to alcohol, drugs and gambling. He argues that addictive behaviour is becoming a substitute for family and work bonds that are being swept away by globalisation and urbanisation.This battle to control addiction will soon overshadow familiar ideological debates about how to run the economy, and as whole societies set about “fixing” themselves, the architecture of human relations will come under strain as never before.The Fix offers a truly frightening glimpse of the future and is essential reading for fans of Naomi Klein’s ‘No Logo’, Oliver James’s ‘Affluenza’ and Francis Wheen’s ‘How Mumbo-jumbo Conquered the World’.
DAMIAN THOMPSON
THE FIX
HOW ADDICTION IS INVADING OUR
LIVES AND TAKING OVER YOUR WORLD
CONTENTS
Title Page (#ue262d813-5318-5c16-b4dd-c794f0cf1afa)
1 - CUPCAKES, IPHONES AND VICODIN
2 - IS ADDICTION REALLY A ‘DISEASE’?
3 - WHAT THE BRAIN TELLS US (AND WHAT IT DOESN’T)
4 - ENTER THE FIX
5 - WHY CAKE IS THE NEW COKE
6 - HAPPY HOUR
7 - DRUGSTORE COWBOYS
8 - GAMING, THE NEW GAMBLING
9 - REDISCOVERING PORN
10 - DELIVER US FROM TEMPTATION
ACKNOWLEDGEMENTS
NOTES (#litres_trial_promo)
Copyright (#litres_trial_promo)
About the Publisher
1 (#u1b752989-d442-5211-8933-8d687b802192)
CUPCAKES, IPHONES AND VICODIN (#u1b752989-d442-5211-8933-8d687b802192)
The 21st-century cupcake is a thing of wonder: a modest base of sponge groaning under an indulgently thick layer of frosted sugar or buttercream. It’s made to look like a miniature children’s birthday cake – and, indeed, birthdays are the perfect excuse to scurry down to the local boutique bakery for a big box of them. The retro charm of cupcakes helps suppress any anxieties you might have about sugar and fat. Your mother made them! Or so the advertising suggests. Perhaps your own mother didn’t actually bake cupcakes, but the cutesy pastel-coloured icing implies that one bite will take you back to your childhood. This can’t possibly be junk food, can it?
Now let’s consider another ubiquitous presence in modern life: the iPhone, which started out as a self-conscious statement of coolness but which, thanks to Apple’s marketing genius, has now become as commonplace as a set of car keys. Millions of people own iPhones, making use of hundreds of thousands of apps, whose functions range from GPS-assisted mapping to compulsively time-wasting computer games. Your iPhone does everything you could require of a mobile phone and more, so you really don’t need the upgraded model that Apple has just released … do you?
Then there’s Vicodin. It’s the most commonly prescribed painkiller in America. In fact, it’s the most commonly prescribed drug in America: 130 million scripts for it were handed out in 2010 and 244 million for the overall class of drug, narcotic analgesics.1 (#litres_trial_promo) It’s strong stuff, a mixture of two painkillers: hydrocodone (an addictive opioid) and paracetamol (non-addictive, but causes liver damage in high doses). Vicodin is intended for the sort of pain that makes you cry out in the doctor’s waiting room – caused by twisted backs, rotting wisdom teeth and terminal cancer. If they swallow so many of those pills, it seems reasonable to conclude that Americans must be in a lot of pain. Or is it just that millions of people can’t manage without Vicodin’s deliciously soothing euphoria, even if there’s nothing much wrong with them?
A cupcake, a smartphone and a common painkiller. These three objects are so innocent-looking that you could leave them on your desk at work and no one would comment (though the cake might disappear). You can easily consume all three simultaneously: swallow the pill for your bad back with a slurp of coffee while checking your text messages and picking at that yummy frosted topping.
On the other hand, each of these mundane items can get us into trouble. They are objects of desire that can reinforce addictive behaviour – the sort that creeps up on you when your defences are down. That’s the subject of this book: a social environment in which more and more of us are being pulled towards some form of addiction, even though we may be unaware of the fact and never become full-blown addicts.
It’s not obvious to us now, but the most far-reaching social development of the early 21st century is our increasingly insistent habit of rewarding ourselves whenever we feel the need to lift our moods.
When our hand creeps out towards yet another square of organic chocolate, or when we play just one more game of Angry Birds before setting off for work, or when we check a secretly bookmarked porn site for new arrivals, we’re behaving like addicts. The activity in question can be innocent or shameful. Either way, it reinforces the addictive streak in human nature.
That streak is there because our brains have evolved to seek out immediate, short-term rewards. Our ancestors needed to stuff themselves with energy-rich berries and to respond quickly to sexual stimulation; we wouldn’t be here if they hadn’t.
Our problem is that we’ve built an environment that bombards us with rewards that our bodies don’t need and that do nothing to ensure our survival as a species. Yet, because they are rewards – that is, because they provoke specific feelings of anticipation and pleasure in the brain – we grab them anyway.
To put it another way, we reach out for a fix.
That’s a word we associate with helpless addicts. They talk about their ‘fix’ because it feels as if they’ve temporarily fixed themselves when they take their drug of choice. There’s no mystery about this. As a result of heavy exposure to the drug, they have become dependent on frequent chemical rewards. Their brains are in a state of hyper-vigilance, waiting for the blessed relief of a chemical that, once tolerance develops, merely allows the addict to feel normal, as opposed to anxious and ill.
That much is not in dispute. Many addiction specialists go further, however. They say that the brains of addicts are fundamentally different from those of non-addicts. They are forced to chase these rewards because they have ‘the disease of addiction’.
This book challenges that theory. It suggests that, if you keep eating chocolate biscuits until you feel sick, you’re indulging in a milder version of the addictive behaviour that leads heroin addicts to overdose. I’m not equating the two situations, of course. I’m suggesting that they lie at different points on a spectrum of addictive behaviour on which everyone can be located.
Also, and more importantly, many of us are being pulled towards the dangerous end of the spectrum, thanks to technological and social changes that stimulate the most fundamental of all our instincts – desire.
Never before have we had access to so many desirable things and experiences that we hope will change our moods. I know ‘things and experiences’ sounds vague, but that’s really the point. Addiction has never been confined to substance abuse, and with each passing week technology unveils a new object, process or relationship we can obsess over.
For example, these days our fixes are often delivered to us through social networking tools such as Facebook or Twitter that enable us to manipulate our circle of friends. Installing and deleting people as if they were iPhone apps offers a quick and dirty method of changing our feelings (though, needless to say, we are furious when someone deletes us). It’s a consumer experience.
In any discussion of addiction, whether of the trivial or life-threatening variety, the concept of desire is just as important as that of pleasure. Usually, it’s more important. That’s because the anticipation of the fix is more powerful than the moment of consumption, which often fails to live up to expectations. Sometimes we throw internal tantrums when this happens. The fix infantilises us so that, like children, we are constantly and annoyingly hungry for more.
Believe me, I speak from experience.
I spent many years as an addict. I was pathetically addicted to alcohol between the ages of 18 and 32. It took me a long time to acknowledge the fact, though – to realise that the act of getting drunk delighted and obsessed me to a degree that set me apart from most of my friends and colleagues. My doctor tells me I’m still an addict. I’m not exactly happy to wear that label after spending such a long time avoiding so much as a sip of alcohol, but the evidence is compelling. Since giving up drinking, my addictive desires have attached themselves to one thing, person or experience after another. I can’t swallow a Nurofen Plus for a headache without hoping that I’ll enjoy a little codeine buzz. I can obsess for ten minutes in front of a display of confectionery in a newsagent’s. And my CD-buying habit has nearly bankrupted me. Trivial stuff compared with my drinking, but my over-reactions to these stimulations don’t feel normal, exactly.
Perhaps the crucial feature of addiction is the progressive replacement of people by things. That deceptively simple statement is a brilliant insight, though I can’t claim credit for it. It comes from Craig Nakken, author of a bestselling book called The Addictive Personality, who argues that addicts form primary relationships with objects and events, not with people.
He writes: ‘Normally, we manipulate objects for our own pleasure, to make life easier. Addicts slowly transfer this style of relating to objects to their interactions with people, treating them as one-dimensional objects to manipulate as well.’
What begins as an attempt to find emotional fulfilment ends up turning in on itself. Why? Because the addict comes to judge other people simply in terms of how useful they are in delivering a fix. And, at some stage, everybody lets you down. Therefore the addict concludes that objects are more dependable than people. Objects have no wants or needs. ‘In a relationship with an object the addict can always come first,’ says Nakken.2 (#litres_trial_promo)
I felt a shiver of recognition when I first read those words. But it wasn’t just my own behaviour that came to mind, or that of people whom society can conveniently label ‘addicts’. This may come across as a presumptuous thing to say, but over the last decade I’ve been struck by the way friends and colleagues, most of them psychologically far healthier than me, have begun to display aspects of the process Nakken describes. Lifestyle accessories exert an ever greater power over them, disrupting relationships, nurturing obsessions and – as I’ve noticed in the office – dominating conversation.
Does that mean that the people around me are turning into addicts? That’s never an easy question to answer, because ‘addict’ is such a loaded term. It’s a good word to describe people whose problems are obviously out of control, as mine were, but it has to be used carefully. Not only does it carry misleading overtones of disease, but it also implies that there’s a clear dividing line between ‘addicts’ and ‘non-addicts’. That’s not true. In my experience, addiction is something that people do – to themselves and other people – rather than something that just happens to them; it’s not like developing cancer.
Addiction is easier to understand as a concept if we focus on clearly observable behaviour – that is, the search for a fix and its consequences. Almost anyone can indulge in addictive behaviour, but some of us are more prone to it than others, for reasons that scientists don’t fully understand.
In fact, let’s get this point out of the way right at the beginning of this book. In the past couple of decades, countless scientific studies have attempted to pinpoint what it is about either the brains or the upbringings of addicts that leads them to adopt self-destructive lifestyles. They have failed to do so.
No one is immune from developing addictive behaviour. If there’s a history of addiction in your family, you’re more at risk. Likewise, if you have an impulsive personality – that is, score highly for ‘impulsivity’ in psychological tests – you’re more likely to do something impulsive, such as try a new drug or drink that fatal last glass of whisky before jumping into your car. Indeed, a fashionable term for various addictions is ‘impulse control disorders’.3 (#litres_trial_promo)
For me these findings fall into the ‘No shit, Sherlock’ category of scientific discoveries. They tell us nothing very surprising. The consensus at the moment is that addiction seems to be the product of genetic inheritance and environment. In other words, the nature versus nurture question is no closer to being settled in this area of human biology than it is in any other. To repeat: we’re all at risk. That’s why the contents of this book apply to everyone, not just coke-snorting hedge fund managers, bulimic receptionists and absent fathers glued to World of Warcraft.
Psychologists talk about addictive behaviours in the plural, recognising the many different impulses that tempt people. What these behaviours tend to have in common is the replacement of people by things and events. We all develop these habits to a certain degree; the people we call addicts are those people who can’t or won’t give them up even when they cause harm to themselves and others. Again, that’s a loose definition, fuzzy at the edges. Never mind; addiction isn’t an easy phenomenon to pin down.
This isn’t to deny that addictive behaviour has important consequences for the brain. It does. Indeed, it can partly be explained by the overstimulation of the brain’s fearsomely complex reward circuitry.
Different parts of the human brain govern what some scientists call the Stop and Go impulses. More primitive sections of the brain – parts that we share with other animals – tell us to consume as much as possible in order to increase our chances of survival. They say: Go. More highly developed parts of the brain, capable of reasoning and not found in other animals, hold up a Stop sign when we’re consuming too much of something for our own good. Classic addicts keep ignoring the Stop instruction, despite the high cost to themselves and others. They require instant gratification, whatever the consequences. Indeed, they’ll often seize any opportunity to indulge in addictive behaviour even when there’s no real gratification to be extracted from it. We’ll discuss this puzzling paradox later.
The Stop and Go imagery helps us understand the growing appeal of the fix. As technologies develop and converge, the speed of delivery increases. So does the speed of our expectations. We now live in a world filled with life-enhancing objects and substances that promise ever faster and more effective gratification. It’s as if everything that tumbles off a production line is stamped with the word Go.
Temptation peeks out at us from the strangest places. Who would have guessed, 40 years ago, that a piece of electronic office equipment – the personal computer – would morph into something so desirable that people would sacrifice huge chunks of their spare time (and income) in order to play with it? Or that modifications to a telephone would generate global excitement?
Changes to our appetites don’t come about by accident. The manager of your local Starbucks didn’t wake up one morning and think: ‘I know what would brighten up my customers’ afternoons – an ice-blended cappuccino!’ As we’ll see, the Frappuccino was invented when Starbucks employed food technology to solve a specific business challenge. As a result, hundreds of thousands of their customers (including me) developed a near-obsessive relationship with something they had previously lived happily without.
The pace of technological change means we need to revise our concept of addiction. Our cultural history provides us with images of stereotypical addicts, some of them dating back centuries: the grinning harridan dropping her baby down a staircase in Hogarth’s Gin Lane; the American Indians crazed with ‘firewater’; the hollow-eyed Chinese sailor propped against the wall of an opium den; the junkie shivering in an alleyway surrounded by needles. Also, anyone who lives in a city is used to the sight of spectacular drunks and morbidly obese people whose addictions are so grotesquely out of control that we avert our eyes.
These are powerful images, but if we pay too much attention to them then we can end up with a dangerous sense of immunity. We overlook our own eagerness to self-administer fixes, those sensory experiences that temporarily lift the mood while subtly detaching us from traditional human relationships. The fix can take any number of forms. Some toy very obviously with the chemistry of the brain. Anyone with a rolled banknote up their nose knows that – so long as their dealer hasn’t ripped them off – they’re about to experience the effects of a mind-altering substance. The same goes for the guy swigging from a whisky bottle. In contrast, the tubby young man who demolishes a packet of chocolate digestives while watching the football doesn’t suspect that his eating habits have left his brain unusually sensitive to stimulation by sugar; he just knows that, once the packet’s opened, the biscuits disappear. His habit of stuffing his face with refined sugar and vegetable fat doesn’t place him very far along the addictive spectrum – but, then again, it may be enough to put him in intensive care when he has a heart attack at 50.
The most puzzling addictions are those that don’t involve the consumption of any substance. Gambling is the obvious example – we’ve known for hundreds of years that it can tear apart families as ruthlessly as hard liquor. In academic circles, these non-substance addictions are known as ‘process addictions’. It’s now clear that things you don’t eat, drink, smoke or inject can nevertheless disturb your brain in much the same way as drugs. And, in an age when so much digital entertainment – notably video games and online pornography – is designed to be as addictive as possible, their potential to do this is accelerating rapidly.
The global marketplace offers a bewildering selection of consumer experiences, simultaneously delightful and dangerous. It’s constantly modifying products and experiences that were never previously considered to be addictive – or simply didn’t exist until recently.
Also, as we’ll see, corporations have learned how to supercharge old-established intoxicants by popularising new patterns of consuming them. One vivid example is the phenomenon of recreational binge drinking, particularly by women. People have always got drunk, and a minority have always enjoyed going on binges with their friends. What no one predicted was the emergence of the binge as everyday behaviour. Ordinary drinkers, with no history of a problem with alcohol, now plan evenings to end in a messy and helpless surrender to the drug. And this is seen as normal.
It would be silly to pretend that everyone is equally threatened by this changing style of consumption. But the prospect of whole populations learning new ways of tampering with the flow of pleasure-giving chemicals in their brains is one that should make us feel very uneasy.
With that in mind, let’s take another look at the cake, the phone and the pill.
In 1996 a tiny corner shop called the Magnolia Bakery opened in Manhattan’s West Village. Its old-fashioned cakes and pies quickly became the objects of guilty fantasy for women who liked to pretend that nothing more fattening than tuna carpaccio ever passed their lips. Then, in 2000, the bakery featured in an episode of Sex and the City. This was the moment America’s cupcake craze began in earnest.
In the episode, Carrie and Miranda were filmed sitting outside the Magnolia. Carrie, played by Sarah Jessica Parker, told her friend that there was a new obsession in her life. This turned out to be a new boyfriend called Aidan – but viewers could have been forgiven for thinking it was icing sugar, judging by the way Parker was pushing the rose-coloured cupcake into her face. Viewed in slow motion, it’s a faintly disgusting spectacle. The truth is, there’s no elegant way to eat a Magnolia cupcake, which is why customers adopt self-mocking smiles as the fluorescent globules of frosting tumble down their chins.
‘When Carrie took her first bite, she left teeth marks in my neighbourhood,’ wrote Emma Forrest, a journalist living opposite the bakery. ‘Not long after the episode was broadcast, the tourists started to arrive and the bakery started charging them if they wanted to take photographs of Carrie and co’s favourite haunt. With the influx of tourists came the rats, as half-eaten cupcakes were dumped into overflowing bins outside my apartment … Riding on this extraordinary upturn in its fortunes, Magnolia changed its hours, and stayed open to midnight throughout the summer. I was kept awake each night by the hoots and hollers coming from the queue that now snakes all the way around the block.’4 (#litres_trial_promo)
In 2006 and 2007 I spent quite a lot of time in the West Village visiting my friend Harry Mount, then New York correspondent of the Daily Telegraph. By this time, Sex and the City was off the air and the cupcake craze had gone mainstream: Magnolia-style bakeries were opening all over America. Yet, on chilly autumn evenings, there was still a queue outside the original store, and it didn’t seem to consist of tourists. ‘Our local stick-thin fashion victims can’t get enough of the things,’ explained Harry. In which case, how come they were stick-thin? Was there a parking lot at the back where they threw them up?
That was a bad-taste private joke between Harry and me, but when I recently did a word search on ‘cupcakes’ and ‘bulimia’ I discovered a blog by a bulimic mother of two entitled ‘Eating Cupcakes in the Parking Lot’. Its posts appear to have been deleted, but cupcakes feature prominently in many other blogs devoted to eating disorders. After a row with her boyfriend, one bulimic girl baked cupcakes decorated with the words ‘I am sorry’. She added mournfully: ‘And now where are those cupcakes? Floating along a sewage pipe.’5 (#litres_trial_promo)
This sort of incident isn’t unusual. Abigail Natenshon, a psychotherapist who treats eating disorders, tells another horror story involving cupcakes: ‘One young woman with bulimia found herself, at a time of great stress, compelled to drive into a 7–11 convenience store where she purchased three cupcakes; she then proceeded to stuff them down her throat whole in an emotional frenzy in the dark and deserted alley behind the store. As far as she was concerned, her binge had begun at the moment when she drove her car up to the front door and did not finish until she had purged the cupcakes.’6 (#litres_trial_promo)
The disturbing subculture of ‘pro-ana’ (pro-anorexia) websites actually encourages girls to starve themselves, or ‘b/p’ (binge and purge). A recurring question on these sites is: are cupcakes easy to throw up? Answer: not as easy as ice cream, but eating them with diet soda can help.
‘It doesn’t surprise me that cupcakes are favourites with bulimics,’ the food writer Xanthe Clay told me. ‘They’re the ultimate eye-candy, primped and styled like a teen pop star, the food incarnation of many girls’ fantasies.
‘In the gossip magazine world, where shopping is the only serious rival to celebrity in terms of aspiration, cupcakes are consumer-desirable in a way a Victoria sponge isn’t. If having an eating disorder is about a desperate attempt to take control, then eating these artificial, too-perfect creations may be particularly satisfying. More likely, the huge sugar rush will feed the craving, and provide a quivering kick of hypoglycaemia. The texture – smooth, aerated, oily – may, like ice cream, be especially suitable for regurgitation.
‘And – just my prejudice this – but perhaps the ultimate emptiness of cupcakes, those empty calories, the way they never deliver on flavour what they promise in looks, is a metaphor for the hopelessness of the woman, or man, with bulimia.’
Although a high proportion of bulimics have ‘issues’ with cupcakes, clearly the overwhelming majority of people who eat them don’t throw them up. They do, however, seem obsessed with them. A chain called Crumbs sells 1.5 million cupcakes every month in 35 US stores; in June 2011, it started trading on the Nasdaq, with an opening valuation of $59 million. And market analysts predict robust growth if Crumbs moves into emerging markets such as China.
The Facebook group for Sprinkles Cupcakes had, at the time of writing, been ‘liked’ by 325,000 people and was spreading the cupcake gospel with near-hysterical enthusiasm.7 (#litres_trial_promo) For Valentine’s Day: ‘It’s back! The first 50 people to whisper “love at first bite” at each Sprinkles receive a free raspberry chocolate chip!’ For Super Sunday: ‘Whether you’re rooting for the New York Giants or New England Patriots or just tuning in for the commercials, Sprinkles Super Sunday boxes will score a touchdown at any viewing party. Each box contains 6 Red Velvet and 6 Vanilla cupcakes, adorned with football sugar decorations and your favourite team’s name. Just don’t get tackled reaching for the last one!’ There were even signs that cupcakes were trying to infiltrate the military-industrial complex: ‘Sprinkles is excited to bring freshly baked cupcakes to the Pentagon! Pentagon employees can find us in the Main Concourse …’
This is a resilient craze, as Dana Cowin, Food & Wine magazine’s editor-in-chief told Reuters in 2011. ‘I have predicted the demise of the cupcake so many times that I’m actually going to go to the dark side now and say the cupcake trend is not going to abate,’ she said.8 (#litres_trial_promo) When an earthquake struck Washington DC on 23 August 2011, someone tweeted that you could tell it had happened because there was suddenly no line outside Georgetown Cupcakes.
Could the ‘emptiness’ of the cupcakes to which Xanthe Clay refers be part of their appeal? Their overwhelming sugar hit fills the consumer with what nutritionists call ‘empty calories’, because they have no nutritional value. But that’s not to say they have no mood-altering value. Sugar triggers production of the brain’s natural opioids, according to Princeton neuroscientist Bart Hobel, who led a study into sugar dependence. He found that rats which binged on sugar went into withdrawal when the supply was cut off. ‘We think that is a key to the addiction process,’ he said. ‘The brain is getting addicted to its own opioids as it would to morphine or heroin. Drugs give a bigger effect, but it is essentially the same process.’9 (#litres_trial_promo)
Opioids are also implicated in bulimia, irrespective of whether sugar is involved. Have you ever experienced that feeling of glorious relief after you’ve just thrown up a dodgy curry? It’s not just getting rid of the food that makes you feel good; it’s a natural elation produced by chemicals in the brain. Bulimics get off on it, to put it crudely.
As Abigail Natenshon explains: ‘The bulimic cycle releases endorphins, [opioid] brain chemicals that infuse a person with a sense of numbness or euphoria. Ironically, the relief passes in short order, only to be replaced by anxiety and guilt for the bulimic behaviours.’ Again, we need to state the obvious fact that most people don’t throw up their food. But the sort of food associated with purging is also the sort of food that many of us have difficulty resisting, because its heavy concentrations of sugar, fat or salt can magnify euphoria and neediness.
It’s easy for urban sophisticates to mock American rednecks or British ‘chavs’ who stuff themselves with fast food, and easy to recognise that they’re in the grip of some sort of addiction. Just look at their waistlines. But the marketing executive who orders a cranberry muffin to go with her morning cup of coffee really ought to ask herself: why am I eating cake for breakfast?
So what about the iPhone? Isn’t it a bit much to call our love affair with this shiny gadget an ‘addiction’? Researchers at Stanford University aren’t so sure: in a survey of 200 Stanford students in 2010, 44 per cent of respondents said they were either very or completely addicted to their smartphones.10 (#litres_trial_promo) Nine per cent admitted to ‘patting’ their iPhone. Eight per cent recalled thinking that their iPods were ‘jealous’ of their iPhones. These are strange things for students at one of America’s top universities to say about their phones, even in jest. They also reveal something about how completely the iPhone has become part of these students’ identities and social frameworks. They’re not just tools that allow us to connect instantaneously and prolifically with others: they’re also being afforded identities of their own – ‘patted’, protected and cherished.
Perhaps it has something to do with how these devices are engineered. They practically force you to perform repetitive rituals of the sort associated with obsessive-compulsive behaviour: from the initial activation of the iPhone to the weekly ‘syncing’ and nightly charging, your relationship to the phone is structured for you. And because the iPhone’s battery life isn’t quite enough to last a full day’s use – and certainly not long enough to withstand hours of constant fiddling and gaming – ‘pit stop’ charges become a regular feature of the day. iPhone users can often be seen checking for power sockets in coffee shops so that, while they get their own fix of caffeine, their phones can get juiced up as well.
‘iPhone owners live in a constant state of anxiety about their battery levels,’ says Milo Yiannopoulos, editor of The Kernel, an online culture magazine. ‘To some extent, the phone ends up structuring their day. For example, they tend not to plan to be out of the office for more than six hours at a time, in case they run out of battery and have to start knocking on doors, USB cable in hand, begging for a few minutes’ worth of charge to get them through the afternoon.’
Talk about the replacement of people by things. The 4S version of the iPhone, released in October 2011, includes a virtual assistant called Siri that responds to spoken instructions and speaks back to the user. This infant technology is already so complex that you can have entire conversations with Siri. She will then execute commands, in some cases fetching very specific data from the internet. ‘Intelligent personalised assistant software is going mainstream,’ says Yiannopoulos. ‘Never in the history of mass-market consumer electronics has the line between man and machine been so blurred.’
It’s significant that a quarter of respondents in the survey above said they found iPhones ‘dangerously alluring’. They are supposed to be. Absolutely nothing is left to chance in the design of these devices. If Apple customers have an embarrassing tendency to anthropomorphise their gadgets, that is because Apple has explored the possibilities of the human mind and body more thoroughly than any of its competitors.
For example, one of the most appealing features of the MacBook laptop line has been the status light, which pulsates gently when the computer is sleeping. Early reviewers cooed over the calming effect of the light, but couldn’t put their finger on why it felt so good to watch. Later, it was revealed that Apple had filed for a patent for a sleep-mode indicator that ‘mimics the rhythm of breathing’ and was therefore ‘psychologically appealing’. As the tech blogger Jesse Young noted, while Apple’s sleep light matched the pace of breathing while we sleep, Dell’s was closer to breathing during strenuous exercise. ‘It’s interesting how a lot of companies try to copy Apple but never seem to get it right. This is yet another example of Apple’s obsessive attention to detail,’ he wrote.11 (#litres_trial_promo)
Former Apple executives – who frequently brief American technology blogs off the record about the internal culture at Apple’s headquarters in Cupertino, California – describe the lengths the organisation goes to in order to create coveted products. There’s a design-dominated power structure that results in hushed reverence when Jonathan Ive, Senior Vice President of Industrial Design, walks into the boardroom. ‘Marketing and design have been fused into a single discipline at Apple,’ says Yiannopoulos. ‘Everything, from product strategy to research and development, is subordinate to making the products as beautiful and compulsive – that is, as addictive – as possible.’
It works. To quote an extreme example, in 2010 a schoolboy in Taiwan was diagnosed with IAD – iPhone Addiction Disorder. According to Dr Tsung-tsai Yang of the Cardinal Tien Hospital, his eyes were glued to his phone screen all day and all night. Eventually, ‘the boy had to be hospitalised in a mental ward after his daily life was thrown into complete disarray by his iPhone addiction’.12 (#litres_trial_promo)
Two days after it opened in 2010, I visited the Apple Store in Covent Garden – a magnificently restored Palladian building dominated by a glass-covered courtyard. The heady aroma of addiction was unmistakable. The misery in the queue for the Genius Bar, where broken computers are diagnosed, was painful to behold. Legs were crossed and uncrossed and eyebrows twitched every time a Genius read out a name. I couldn’t help thinking that these customers looked like addicts waiting for their daily dose of methadone.
I wanted to ask a Genius what it was like dealing with people who weren’t just asking what was wrong with their laptops but pleading for (literal) fixes. But finding someone who would talk was easier said than done.
First I went down the route of asking an Apple Store manager – a friend of a friend – whether he could chat off the record about the way the company seemed to encourage addiction to its products, or put me in touch with someone who would. His first response was encouraging, but then he changed his mind. He would be in big trouble if his bosses suspected he’d put me in touch with an indiscreet ex-employee, and he’d be fired on the spot if he got caught blabbing himself.
So I tried a different route. A start-up CEO friend of mine put out a message to one of his networks. Shortly afterwards, a young man called Ben Jackson, a social media entrepreneur, emailed to say he could meet me for coffee in Soho, London, a few streets from the Apple Store where he had spent two years as a Genius.
Ben, like many former Apple employees, inhabited the cooler end of the geek spectrum, with glasses offset by a gym-honed body. He didn’t need any prompting to talk about addiction to technology: the experience of seeing the addiction every day – deliberately stimulated by the company – was one of the reasons he left the store.
‘I saw a whole range of addictive behaviours. It’s one of the things that made the Apple Store such a surreal place to work. At one end of the scale you have the total Apple obsessives who exhibit a sort of religious fanaticism that the company does nothing to discourage – it encourages it, in fact. They’re the people who will book the same tutorial again and again, being shown how to do stuff they already know.
‘When a new product is launched, it’s the same faces at the front of the line every time. They treat the staff almost like celebrities, trying to ingratiate themselves. At the Genius Bar, they’ll show you Apple products from years ago, and you’ll have to pretend you haven’t seen them before, because they need their egos massaged. It’s kind of sad. Well, it is sad.’
But it’s not only the true obsessives who are touched by addiction, according to Ben. ‘There’s a general perception that Apple is awesome in a way that other companies aren’t – a perception that’s quite at odds with the way it operates behind the scenes. Even the products are considered awesome, which is why otherwise normal people would get quite disproportionately angry and upset if anything went wrong with them. And it’s also why there’s such unease if people think they’ve fallen behind, that their stuff is out of date. But the point is that you can’t keep up to date without spending a lot of money on things you don’t need, because the products are just coming out too fast.
‘I’ve seen people burst into tears because a credit check wouldn’t allow them to stretch to the latest upgrade. That’s when I started thinking: I need to get the hell out of here.’
Admittedly, many psychiatrists don’t believe in ‘internet addiction’ as a medical condition, let alone addiction to a specific model of smartphone. They argue that obsessive users aren’t addicted to the internet so much as to the experiences it provides, such as digital porn and computer games. But few experts would deny that gadgets such as iPhones can produce behaviour that bears the hallmarks of addiction. And it’s becoming increasingly clear that the ability of manufacturers to stimulate this behaviour is racing far ahead of our ability to cope with the psychological and social problems that are created as a result.
The science of pleasure is playing a greater role in the marketing strategies of all sorts of companies: the people who waft the smell of freshly baked doughnuts at you in the shopping mall have fine-tuned their recipes in the laboratory, not the kitchen. But Apple is in a class of its own. No other company has managed to mix such a finely balanced cocktail of desire, in which the crude flavour of compulsion is disguised by a deliciously minimalist aesthetic.
‘More than any other product, the iPhone has encouraged the tech industry to concentrate on getting people hooked on things,’ says Yiannopoulos. ‘Apple’s marketing genius, and the incredible attention to detail paid to the design of their devices, filters down into the iPhone developer ecosystem.’
He cites the example of Angry Birds, a simple computer game app that, by May 2011, had been downloaded 200 million times.13 (#litres_trial_promo) The premise of Angry Birds is simple: players launch birds across the screen with a slingshot, judging the trajectory of flight and altering the force and initial direction accordingly. It sounds harmless enough. But type ‘Angry Birds addiction’ into Google and you’re presented with 3.24 million results. So many people complain about being addicted to the game that it has spawned self-help pages all over the internet. Some of these pages ask whether Angry Birds addictions are changing people’s brains. Self-described addicts say they don’t know why they can’t put the game down, and talk about compulsively tracing their fingers on tables as they subconsciously recall the catapult action of the game. These sound suspiciously like the little rituals associated with alcoholism and drug abuse.
Again, perhaps a degree of scepticism is called for: it can only be a matter of time before some opportunistic researcher diagnoses ABAD – Angry Birds Addiction Disorder (which would presumably be a particular strain of IAD, since the game is played mostly on iPhones). No doubt the Angry Birds craze will fade, as these crazes always do. But it may well leave behind a residue, in the form of the compulsive instinct to perform repetitive actions.
It’s not a conspiracy theory to suggest that the primary task of iPhone game developers is learning how to manipulate our brains’ reward circuits. They cheerfully admit as much. At the 2010 Virtual Goods Summit in London, Peter Vesterbacka, lead developer for Rovio, the company behind Angry Birds, described how they make the game so addictive. ‘We use simple A/B testing to work out what keeps people coming back,’ he said. ‘We don’t have to guess any more. With so many users, we can just run the numbers.’14 (#litres_trial_promo)
We can just run the numbers. Remember those words. Where previously advertising and marketing were more creative disciplines that involved a huge element of risk, a new generation of manufacturers doesn’t need to guess what will keep us coming back for our fix: they already know.
Viewers of House, America’s most popular medical drama – and at one time the most watched television programme in the world – are familiar with the sight of Dr Gregory House, the snide, sexy, crippled antihero, tipping back his head and tossing a couple of Vicodin into his mouth. He’s even been known to throw a pill into the air and catch it like a performing seal. The screenplays go out of their way to portray House as an addict: several times we’re shown him shivering and sweating his way through opiate withdrawal. But, in the end, the Vicodin is as integral to his charm as his twisted humour. The one fuels the other.
Although Dr House, played brilliantly by Hugh Laurie, is prescribed the drug to dull the pain of a leg injury, he also uses it to stave off boredom and stimulate his work as a diagnostic detective. Any similarity to the cocaine-injecting Sherlock Holmes is surely intentional. But only the very earliest Holmes stories actually depict drug abuse: Arthur Conan Doyle, worried that he might encourage addiction, quickly made his hero abandon the vice. Not so the makers of House, who have sustained the central character’s dependence on Vicodin despite criticism from some medical professionals (and, reportedly, the Drug Enforcement Agency).
‘Since the first episode I have been concerned with the show’s message and have attempted several times to educate the writers and producers regarding the danger of Vicodin abuse,’ wrote one physician, coincidentally named Dr John House, who specialises in hearing loss, a devastating side effect of Vicodin.15 (#litres_trial_promo) He lobbied long and hard for this symptom to be recognised in House and eventually it was, albeit in a throwaway line. (As I write, the series is coming to an end, and so far one symptom that hasn’t been mentioned, so far as I can tell, is the awful constipation it causes: a truly realistic scenario would force the good doctor to spend most of the season straining on the lavatory.) The fictional House does succeed in giving up Vicodin after suffering rather implausible hallucinations caused by the drug and completing a period of rehab, but after a couple of seasons he is shown relapsing.
Vicodin was already a fashionable recreational drug when the show first aired in 2004. It was passed around like after-dinner mints at Manhattan dinner parties. In 2001, USA Today described Vicodin as ‘the new celebrity drug of choice’. Matthew Perry, one of the stars of Friends, had already gone into rehab for his addiction to it – twice. Eminem had a Vicodin tattoo on his arm. David Spade joked about it at the Golden Globes. ‘Who isn’t doing them?’ asked Courtney Love. ‘Everyone who makes it starts popping them.’16 (#litres_trial_promo) Celebrities favoured it for the same reason other users did: it was (and is) relatively easy to persuade doctors to prescribe it. In the US, Vicodin falls into the Schedule III category, less tightly controlled than stronger opiate painkillers such as Oxycontin, classified as Schedule II. You can phone in a prescription for Vicodin to a pharmacy; for Oxycontin, you have to hand over a physical script.
So by the time the first House screenplays were being written in 2003, Vicodin was already as famous for its recreational buzz as for its painkilling properties. When the show became a hit, Associated Press writer Frazier Moore suggested that its success was thanks to the way it ‘fetishises pain’. In other words, millions of Americans on painkillers could identify with Dr House’s suffering.17 (#litres_trial_promo) If true, that’s only part of the story. The scripts often refer to Greg House’s pain, caused by the removal of leg muscles after a thigh aneurysm. But much of the sharpest humour centres around House’s schoolboy naughtiness in trying to score more pills than he has been prescribed. That isn’t the fetishisation of pain: it’s the fetishisation of Vicodin. An unofficial range of House T-shirts, still on sale in 2011, includes one that reads: ‘Wake up and smell the Vicodin’. The same logo, accompanied by a photo of Hugh Laurie looking spaced out, is also available as desktop wallpaper for your computer.
Meanwhile, the embedding of the drug in other parts of popular culture continues apace.
‘The Vicodin Song’, by singer-songwriter Terra Naomi, has been watched on YouTube more than half a million times. It’s an appropriately sleepy ballad which begins: And I’ve got Vicodin, do you wanna come over?
The most popular comment on the thread underneath the YouTube video reads: ‘When I listen to this I think of Dr House :)) This song is really cool.’18 (#litres_trial_promo) Many of the 2,000-plus comments, however, aren’t about the song or the show. They’re about how much Vicodin you can take recreationally without hurting your liver. It’s a vigorous debate:
FreeWhoopin1390: Well vicodin (aka hydrocodone) gives you a good calm high. It’s a super chill high to be honest. Now some people might try and tell you that 20–25 mg gets you high, let me start by saying those people are idiots. 20–25 mg will give you a relaxed small buzz for the first time. If you want a really good calm high that lasts for a while take 35–40 mg. I say 40 for the first time but that’s just me. Word of caution tho, do not exceed 4000 mg of tylenol [paracetamol] which is in vicodin, in 24 hours.
Thebluefus: If you get 40 mg of hydrocodone by taking vicodin you have reached the max for tylenol. You don’t need that much to get high, especially as a first time. Just two vicodin will get you the feeling. Don’t be stupid.
FreeWhoopin1390: Are you fucking stupid? The max for tylenol is 4000 mg a day. I take 50 mg of hydrocodone at once (they are 10/500). Which means they have 10 mg hydrocodone and 500 mg tylenol. Which means I am taking 2500 mg of tylenol. Which is nowhere near the max daily dosage. But thank you for sharing what you don’t know.
There are also catfights about the respective virtues of Vicodin and Oxycontin and a discussion of the regional variations in street prices. From time to time someone interrupts to say that they take Vicodin for real pain and that these junkies should be ashamed of themselves. But there are also commenters who were legitimately prescribed the drug who are now junkies themselves. They may resent being a slave to Vicodin or they may enjoy the high; perhaps a bit of both. What should we make of a comment like this?
1awareness: Bragging about pills is lame. I’m using them to make fibromyalgia feel less intense. I also have seizures which cause a lot of pain. I enjoy Vicodin.
These are commenters who describe themselves as Vicodin ‘users/abusers’, a term that neatly captures the ambiguity of prescription drug abuse. All mood-altering drugs, from Scotch whisky to crack cocaine, can be abused: you can harm yourself by taking too much of them. But the vast majority are supposed to intoxicate, even when consumed in ‘safe’ quantities. The Vicodin abuser, on the other hand, is hooked on a drug that the manufacturers insist isn’t designed to alter moods. To further complicate matters, if the abuser is in real pain, it can be hard to tell whether he or she is merely over-medicating or enjoying an extra recreational buzz on top of the pain relief – Dr Gregory House likes to keep his colleagues guessing on this point. But that sort of confusion doesn’t make Vicodin dependence any less difficult to manage; it just means that, like so many 21st-century addictions, it is difficult to categorise and therefore difficult to treat.
As if these problems weren’t bad enough, it was revealed at the beginning of 2012 that several drug companies were working on hydrocodone pills that were potentially ten times as strong as Vicodin. The new pills would be ‘safer’ than Vicodin, according to Roger Hawley, chief executive of Zogenix, because they wouldn’t contain the paracetamol that harms the liver. Maybe so; but their time-release formula would also allow abusers to crunch them up for one hell of a hit. Zohydro, as Zogenix plans to call the drug, is scheduled for release in 2013.
This is just a guess, but it wouldn’t surprise me if, all over America, clued-up Vicodin users are already telling their doctors that their pain is getting worse and maybe they could use something a little stronger …
The addictive qualities of cupcakes, iPhones and Vicodin aren’t immediately obvious. Someone encountering a cupcake for the first time since childhood doesn’t think: uh-oh, I’d better be careful not to develop a sugar addition that triggers an eating disorder and end up washing the sick out of my hair. Likewise, people buying their first smartphone don’t worry about developing an obsessive-compulsive relationship with a computer game, and until recently the recreational use of painkillers was almost unheard of. In other words, as unqualified consumers we’re increasingly tempted by products about whose effect on our brain we know virtually nothing. We may not even notice the burst of tension-relieving pleasure they provide – at least, not until we realise that we can’t live without them.
Using substances and manipulating situations to fix your mood isn’t new. It’s the pace, intensity, range and scale of this mood-fixing that is unprecedented, irrespective of whether it involves drugs, alcohol, food or sex.
Put simply, both our need and our ability to manipulate our feelings are growing. We’re always searching for new ways to change the way we feel because, to state the obvious, we’re not at ease with ourselves. That’s a very broad-brush statement, so let me try to be more specific. Our ancestors were unable to insulate themselves from fear and despair in the way that we try to: certain forms of unhappiness, such as grief at the death of children, were more familiar to them than they are to us. Nor did they possess many fixes to address those feelings – and, in any case, experiences of such intensity aren’t easily fixed, even in the short term. We, on the other hand, struggle with small but inexorable and cumulative pressures in our daily lives. These produce a free-floating anxiety that is susceptible to short-term fixes.
The hi-tech world that ratchets up the pressure on us also yields scientific discoveries that speed up the flow of pleasure-giving and performance-enhancing chemicals in our brains. Indeed, producers and consumers collude vigorously in this process, which helps us cope with commitments that we feel are beyond our control. (Note, incidentally, how the verb ‘to cope’ has invaded so many areas of human activity: sometimes it seems that we need a ‘coping strategy’ just to go to the bathroom.) The jokey phrase ‘retail therapy’ has entered the language for a good reason. We, as consumers, know that the instant gratification of a purchase goes beyond simple pleasure at acquiring something new – it can change the way we feel about everything, albeit only for a short time. Manufacturers are well aware of it, too. They know they are the purveyors of fixes, and that the moment their fixes fail is the moment they start losing market share.
The problem is that these increasingly complex interactions between producers and consumers are also increasingly unpredictable, especially in their effects on the human body. It’s not possible to predict with any accuracy the sorts of relationships that people will form with the substances and experiences thrust at them. Neuroscientists are learning new things about our reward systems all the time, but they’ll admit privately that the attempt to turn these discoveries into drugs that target specific mental disorders have been shockingly hit-and-miss. Meanwhile, the rest of us know only one thing about those reward systems: how to stimulate them.
In other words, we are sitting in front of the controls of a machine whose workings are basically a mystery to us. And someone has just handed us the ignition keys.
2 (#u1b752989-d442-5211-8933-8d687b802192)
IS ADDICTION REALLY A ‘DISEASE’? (#u1b752989-d442-5211-8933-8d687b802192)
‘When people ask why I don’t drink, I explain that I’m allergic to alcohol. But really, it’s a disease. We all have it – everyone in this room.’
The speaker was Pippa, a former actress in her sixties with dyed auburn hair and scarlet lipstick applied so thickly that her mouth looked like a clown’s. This may sound rude, but of all the AA regulars gathered round the trestle table in the church hall she was the easiest to imagine as a drunk. She had what my father used to call ‘a whisky voice’, though she hadn’t touched a drop for 15 years. ‘I behaved in a very unladylike fashion,’ she recalled. ‘And I don’t know if you agree with me, but I think there’s something particularly undignified about the sight of a drunk woman.’
This produced a sniffle of feminist disapproval from a couple of young women in the room, who looked like business executives: the meeting was hosted by one of the Wren churches in the City of London. But no one argued with Pippa’s claim that she suffered from a disease. I attended those lunchtime meetings three times a week in the shaky few months after I stopped drinking, and never once did I hear alcoholism described as anything other than a physical illness. ‘Allergy’ was one description; much more common was the phrase borrowed from the ‘Big Book’, the bible of Alcoholics Anonymous – ‘a cunning, baffling and powerful disease’.
I had no doubt that I was an alcoholic. Alcoholism is the name for addiction to alcohol, and therefore I was also an addict – a useful word to describe someone who indulges in a pursuit so excessively that it harms them. The AA fellowship kept me away from alcohol thanks to the remarkable power of peer-group moral support, and especially the support of strangers, which has its own special potency. But I never thought my alcoholism, or any form of addiction, was a disease. Wisely, though, I kept that opinion to myself at those lunchtime meetings.
Lots of the attendees, Pippa included, seemed almost proud they had this ‘disease’. They talked about it in the defensive but boastful manner in which, years later, people would discuss their recently discovered ‘food intolerances’. They also referred all the time to ‘the alcoholic personality’, as if everyone who ended up in the rooms shared deeply rooted personality traits. Again, I couldn’t see it: on the contrary, I was surprised by how little the members of the fellowship had in common. But if I’d questioned any aspect of the AA worldview, I’d have been corrected immediately: ‘Don’t you dare tell me I haven’t got a disease!’ Or I’d have been fobbed off with words of wisdom: ‘Alcoholism is the one disease that tells you that you haven’t got it’ – an infuriating AA epigram designed to close down debate rather than open it up.
Alcoholics Anonymous dates its foundation from 1935, when it changed from a specifically Christian mission to drunks into an independent fellowship of self-help groups with a strong but deliberately all-inclusive religious ethos. Since then, AA has achieved two extraordinary things. First, it has saved the lives of innumerable drunks. I’m probably one of them, so I feel a bit churlish suggesting that its other major achievement – the dissemination of the disease model – has distorted the modern world’s understanding of addiction.
The fellowship’s first medical adviser, the psychiatrist Dr William Duncan Stillworth, declared: ‘Alcoholism is not just a vice or a habit. This is a compulsion, this is pathological craving, this is disease!’1 (#litres_trial_promo)
This disease is both incurable and progressive, according to AA. The only way to keep its symptoms under control is by a programme of total abstinence based on the famous 12 steps to recovery. In Step 1, sufferers acknowledge their powerlessness over alcohol. Other steps tell them to seek help from God, examine their character defects and make amends for the harm they caused when they were drinking. But – and this is the crucial point – AA reassures them that they cannot be blamed for the wreckage of their lives, because the disease robbed them of their free will.
This raises an obvious question. What about heavy drinkers who give up alcohol of their own accord, without any help from AA or the steps? The fellowship’s answer is a masterpiece of circular logic. Since these drunks exercised free will in stopping drinking, and since the disease of addiction robs you of your free will, they cannot have had the disease and were therefore never alcoholics in the first place.
That AA formula has had an extraordinary appeal for generations of ex-drinkers. The organisation has 1.2 million members in the United States who attend 55,000 meeting groups; there are over two million members worldwide. The fellowship is sometimes described as a religious movement, but it would be more accurate to describe it as a self-help group with religious overtones. The Big Book talks explicitly about God, though it adds that ‘God’ is shorthand for ‘a power greater than yourself’. That power can be a supernatural being or (for atheists and agnostics) simply the fellowship itself.
The disease model, enshrined in the 12 steps, has spread everywhere, perhaps thanks to the fact that AA has never attempted to copyright it. It’s happy for anyone to borrow its formula. As Brendan Koerner put it in Wired magazine, the 12 steps became ‘essentially open source code that anyone was free to build on, adding whatever features they wished’.2 (#litres_trial_promo)
As a result, there are around 200 separate 12-step fellowship networks covering all sorts of addictions. Narcotics Anonymous and Gamblers Anonymous have flourished since the 1950s, Overeaters Anonymous since 1960. Marijuana, cocaine, crystal meth and nicotine have their own 12-step programmes. (In Nicotine Anonymous, being tobacco-free is referred to as being ‘smober’.) There are fellowships dedicated to sex addiction and co-dependence. Online Gamers Anonymous was founded in 2002.
These groups have their own take on the 12 steps, but they leave intact the part of the open-source code that identifies addiction as a disease. Indeed, the vast majority of professional addiction specialists also embrace it. When Alcoholics Anonymous tells its members that medical opinion overwhelmingly thinks of addiction as a disease, it is telling the truth.
But that doesn’t mean that medical opinion is right. On closer examination, many specialists derive their ideas from 12-step groups rather than the other way round. Let me illustrate why I think the disease model is flawed by telling the stories of two addicts who were friends of mine.
In the late 1990s I got to know two young men, Robin and James, who had been inseparable at university. They were in their late 20s, bright, charming and socially ambitious. Both had been to minor public schools but neither had got into Oxford or Cambridge, so when they arrived at their redbrick university they had to settle for its wannabe Brideshead drinking societies. At least once a fortnight they would dress up in black tie and perform the charming party tricks they associated with Oxbridge – climbing up scaffolding and urinating on pedestrians, that sort of thing. When their hangovers allowed, they read Evelyn Waugh, whose cruel snobbery delighted them. They were less keen on textbooks and, despite fluent pens, did badly in exams.
After university they drifted from one undemanding job to another, in the process spending more and more time in the company of ex-public school wasters who used hard drugs. Neither Robin nor James was especially rich, but both had just enough private money to feed their dealers. Eventually they replaced their office jobs with ‘freelance’ occupations that didn’t require raising their heads from the pillow until the first of the afternoon soap operas. Both sets of parents were in despair, and raided their savings to pay for expensive spells in rehab that achieved nothing.
By 2000 the two men were boringly obsessed with getting high on any psychotropic substance they could lay their hands on, ranging from heroin to painkillers. At around that time I had a wisdom tooth taken out in the dentist’s chair and was given a supply of dihydrocodeine tablets that I didn’t take because they made me nauseous. I mentioned this to James, and within half an hour Robin was on the phone. ‘I hear you’ve got some DF118s,’ he said. I checked the label. Yes, that was what it said. ‘Since they make you puke, why not let me take them off your hands?’ he asked.
Robin and James were, or seemed to be, the most irredeemable addicts I’ve ever met. I was relieved when they drifted out of my life. I once caught sight of James hovering around the wines and spirits section of a supermarket in Bristol: this was the heyday of dirt-cheap own-brand vodka, and judging by the contents of his trolley he was taking full advantage of the special offers.
And now, five years later? Robin has a steady girlfriend, a baby daughter and a job in social media that has enabled him to start paying off his mortgage. He and his family are about to move to San Francisco, where he will work for an internet start-up. He gave up drink and drugs slowly, cutting out one substance after another, without relying on the 12 steps for guidance. ‘They just remind me of the bad old days in rehab,’ he explains. ‘My home-made recovery was a long and messy business, with plenty of false starts, but it did work in the end.’
James is dead. He killed himself by jumping from the fifth floor of an apartment block in Johannesburg in 2006. It seems to have been a spur-of-the-moment thing, but who knows? He didn’t leave a suicide note.
How can we explain the difference in the fates of the two friends? The 12-step explanation would be that Robin was never a real alcoholic or addict, since he cured himself without following the principles of the programme. He did attend AA and NA meetings, both in and out of clinics, but found them useless. ‘AA members kept regaling me with these over-polished anecdotes about their miraculous recoveries, while the NA meetings seemed to be full of people who’d been clean for a couple of days and were obviously hoping to score.’
James, in contrast, met the sort of grisly fate that, according to the Big Book, awaits most untreated addicts. In the eyes of the fellowship, his leap from the balcony proved that he was the genuine article. One of the least attractive characteristics of 12-step ‘old-timers’ is the relish with which they describe disasters that befall those who stray from the true path.
But suppose that Robin and James had died at the same time, at the height of their drinking and drug-taking. (Robin did nearly kill himself with an accidental overdose, so it’s not an unlikely scenario.) Would a post-mortem on their brains have been able to establish which of them had the ‘progressive disease’ of addiction and which was just going through a phase? The answer is no.
Moreover, if Robin and James had been subjected to a battery of tests when they were still alive, it’s extremely unlikely that any of those tests would have distinguished between the ‘real’ alcoholic, doomed without 12-step treatment, from the ‘fake’ or temporary one, capable of curing himself. My guess is that the doctors would have said, correctly: both these young men are addicted to alcohol and drugs. But if the doctors were 12-step believers, as so many are, they might have added that neither of them could cure himself. Robin would have proved them wrong.
If you doubt that addiction medicine is heavily flavoured by 12-step dogma, let me point you in the direction of one of the most recent, supposedly authoritative, definitions of addiction by doctors specialising in the subject. It was published in 2011 by the American Society of Addiction Medicine (ASAM), which represents physicians who work with chemically dependent patients.
‘Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry,’ it declares. ‘Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviours.
‘Addiction is characterised by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviours and interpersonal relationships, and a dysfunctional emotional response.
‘Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.’3 (#litres_trial_promo)
This is what a definition looks like when it has been drafted by a committee. The 80 doctors who worked on it seem to have thrown everything at it but the kitchen sink. But what their definition cannot conceal – indeed, what it inadvertently reveals – is that addiction is far too complex a phenomenon for doctors to classify as a disease in the sense that cancer and tuberculosis are diseases. Hence the waffle.
Addiction specialists wouldn’t tie themselves in such knots if they had a diagnostic test for the ‘disease’ of addiction. But there is no such test.
Not only is addiction unlike cancer and diabetes, which show up in lab results. It’s also unlike brain diseases such as Alzheimer’s. That, too, lacks a simple diagnostic test: in its early stages its symptoms can be mistaken for stress or other forms of dementia. But eventually the involuntary behaviour of the patient should allow the doctor to make an accurate diagnosis, after which its progress is truly inevitable. There is no 12-step programme for Alzheimer’s to keep its symptoms under control. The end point is death, after which an autopsy will probably reveal shrinking of the brain that provides final confirmation of the diagnosis.
I’m not saying that medicine can’t identify addiction in the ordinary sense of the word: of course it can. Scientists can test for chemical dependence on a drug. They can measure a patient’s tolerance for it and predict the withdrawal symptoms. They can identify the precise damage caused by substance abuse and hazard a guess as to life expectancy. They can look at a patient and say: this person is an addict.
But what they can’t tell, even with brain-scanning technology, is whether a neurochemical ‘switch’ has been thrown which induces irreversible addiction, which is what disease-model advocates are now suggesting. We don’t even know whether such a switch exists. It’s a fashionable theory, but that’s all it is.
Post-mortems can’t identify a disease of addiction, either. A dead body may reveal organ damage caused by taking a particular drug, but it won’t necessarily tell doctors much about the behaviour that accompanied it. You can’t know from looking at the liver of someone who drank themselves to death whether their drinking followed classic addictive patterns. People develop fatal cirrhosis of the liver – a proper disease by any definition – from regular wine consumption that isn’t compulsive in character. Non-alcoholics in France die from this sort of drinking all the time. Likewise, the body of an obese person won’t tell you whether they ate addictively. Their obesity may have been caused by an illness that stopped them exercising, for example.
Why, then, is the ASAM definition of addiction so confident in its claim that addiction is a ‘primary, chronic disease’ – an assertion that it proceeds to justify with woolly and overlapping generalisations?
At the risk of sounding like a conspiracy theorist, I think the answer lies in the role of 12-step groups in devising the treatment programmes run by the doctors in ASAM.
There’s a bit of a giveaway in the definition. This says that dysfunction in the brain’s rewards circuits leads to characteristic ‘spiritual manifestations’. I’ve heard that phrase before. During my AA years, as I sat drinking powdered coffee in draughty basements, it was drummed into me that alcoholism was a spiritual disease. That is Big Book teaching; you hear it in virtually every meeting. But if you’re trying to define addiction, you run up against a problem: there is no agreed methodology for measuring ‘spiritual manifestations’. How could there be? In all my years spent studying the sociology of religion, I never came across an agreed definition of ‘spirituality’. It’s just the sort of concept that scholars fight over.
Many addiction specialists have a habit of throwing around words as if everyone agreed on their meaning. They’ll use a term like ‘compulsion’ without exploring the philosophical questions it raises about free will. They wander into other disciplines – philosophy, sociology and theology – without seeming to realise they’re doing so. Nothing must be allowed to challenge the one-size-fits-all model of the 12 steps.4 (#litres_trial_promo)
According to the psychologist Dr Stanton Peele, a long-standing critic of disease-centred definitions of addiction, ‘the American Society of Addiction Medicine was created – and is dominated – by true-believer 12-step types’.5 (#litres_trial_promo) Peele argues that AA preserved the temperance movement’s message of total abstinence – deeply rooted in American Protestant society – while relieving guilt by naming illness rather than sin as the cause of addiction. Also, 12-step advocates have proved to be expert lobbyists, persuading health institutes that theirs is the only recovery programme that works, and influencing judges and magistrates to send criminals on compulsory 12-step courses. Most substance abuse treatment in the US is based on 12-step models.6 (#litres_trial_promo)
Unfortunately, the media rarely bother to question the assumptions and allegiances that lie behind the pronouncements of addiction specialists. ‘Addiction is a brain disease, experts declare,’ said the LA Times when ASAM published its definition. ‘Addiction a brain disorder, not just bad behaviour,’ said USA Today.
But the most enthusiastic coverage came from The Fix (no relation to this book), an upmarket website aimed at recovering addicts with disposable incomes. It declared: ‘If you think addiction is all about booze, drugs, sex, gambling, food and other irresistible vices, think again. And if you believe that a person has a choice whether or not to indulge in an addictive behaviour, get over it.’ ASAM had blown the whistle on these notions, said The Fix, by revealing addiction to be a fundamental impairment in the experience of pleasure that ‘literally compels’ the addict to chase the chemical highs produced by drugs, sex, food and gambling.7 (#litres_trial_promo)
Note the finger-wagging tone of the article. If you think choice is involved in addictive behaviour, ‘get over it’. I can imagine Pippa nodding her head vigorously at that. When I showed the article to Robin, the former alcohol and heroin addict, he smiled and said: ‘That’s exactly the sort of take-it-or-leave-it message I heard every day when I was in treatment.’
Robin was in a rehab unit run by the Priory, a fashionable and expensive healthcare provider which specialises in alcohol and drug treatment and is best known for its celebrity alumni, who include Kate Moss, Robbie Williams, Courtney Love, Pete Doherty and the late Amy Winehouse. (As that list suggests, its track record is patchy at best.) Robin told me about his experience of the treatment there.
When I was in the Priory, all the doctors and counsellors emphasised the disease concept. We had lectures in the afternoons. One was from the medical director, a psychiatrist, on the disease concept. You have a disease, the disease of addiction, ‘dis-ease’, etc. When I asked him for the evidence, he said things like ‘we can see that the metabolic pathways are different in alcoholics’. Well of course they are, because the booze, not the ‘disease’, has changed them. I didn’t think he was being very intellectually honest, but he was the expert and if we had different ideas that was just evidence of the alcoholic’s arrogance.
As for the counsellors, they kept talking about ‘the illness’. Your illness, my illness. ‘My illness tells me I’m a bad person.’ The reason for this emphasis was that ‘it’s a shame-based illness’, and the whole point is to get away from the idea that you’ve been a wicked person and you should be ashamed – such ‘stinking thinking’ might cause you to fall into a ‘shame spiral’, and shame leads you to ‘pick up’ the next drink or drug.
You’d absorb the illness chat pretty quickly, but I could never bring myself to talk in terms of ‘my illness’ – it just seemed too pat and convenient to take away responsibility and turn your addiction into something outside yourself.
Addiction specialists would reply that of course they’re not saying the disease is ‘outside’ people. But the way they talk about addicts sometimes implies that sufferers are under the control of a malign puppetmaster.
There are recognised brain diseases which, like addiction, manifest themselves as behaviour – the jerking limbs of Huntingdon’s, for example. But it’s a funny sort of primary, chronic, brain disorder that makes you drive yourself to the pub, sink seven pints of beer with whisky chasers, and then drive yourself back, turning your car into a weapon of mass destruction.
In fact, there’s a world of difference between involuntary, chaotic spasms and long sequences of actions that look perfectly voluntary, if misguided, to anyone observing them. Professor John Booth Davies, director of the Centre for Applied Social Psychology at the University of Strathclyde – and one of Britain’s most prominent opponents of the disease model – makes the point that if a disease can force people to steal, to lift up glasses, or to stick needles in their arms when they’re actually trying not to, then any goal-directed behaviour could be a symptom of disease.8 (#litres_trial_promo)
The behaviour of addicts looks voluntary because it is. However intense the temptations offered by substances and experiences, there will always be people who, having given in to them, change their mind and pull themselves out of addiction.
As we’ve seen, AA brushes aside this phenomenon with unbreakable circular logic: if you cure yourself, you were never an addict. Medically qualified addiction specialists basically agree, though they usually espouse a more nuanced version of the disease theory. They don’t deny that some addicts appear to cure themselves – but they treat such cases as outliers or questionable diagnoses. The official line remains that, to quote the Sourcebook on Substance Abuse, ‘the majority of individuals who receive treatment for substance abuse relapse’.9 (#litres_trial_promo) Clinical reports that between 50 and 60 per cent of patients relapse within six months of ending treatment are accepted as evidence of the power of the disease.
There’s something wrong with this methodology, however, as Gene M. Heyman, a hospital research psychologist and lecturer at Harvard University, points out.
‘Most research is based on addicts who come to clinics,’ he says. ‘But these are a distinct minority, and they are much more likely to keep using drugs past the age of 30 – probably because they have many more health problems than non-clinic addicts. They are about twice as likely to suffer from depression, and are many times more likely to have HIV/AIDS. These problems interfere with activities that can successfully compete with drug use. Thus, experts have based their view of addiction on an unrepresentative sample of addicts.’10 (#litres_trial_promo)
Heyman went looking for large-scale studies of addiction in the US based on more representative samples of addicts in the general population, not just in clinics. He found four of them, carried out by leading researchers and funded by national health institutes.11 (#litres_trial_promo) Yet, mysteriously, the clinical texts and journal articles spreading the message of a ‘primary, chronic, relapsing disease’ fail to mention these epidemiological studies. Why?
Could it have been because none of the surveys found that most addicts eventually relapse? What they suggested, inconveniently, was that between 60 and 80 per cent of individuals who met the criteria for lifetime addiction stopped using drugs in their late twenties or early thirties. In short, high remission rates would seem to be a stable feature of addiction.12 (#litres_trial_promo)
In 1970 there was a shockingly sudden burst of heroin addiction among GIs in Vietnam. As Alfred McCoy describes in his book The Politics of Heroin, until 1969 the ‘Golden Triangle’ of south-east Asia was harvesting nearly a thousand tons of raw opium annually – but there were no laboratories capable of turning it into high-grade heroin. That changed when Chinese master chemists from Hong Kong arrived in the region. Suddenly South Vietnam was full of fine-grained No. 4 heroin instead of the impure, chunky No. 3 grade.
‘Heroin addiction spread like the plague,’ writes McCoy. ‘Fourteen-year-old girls were selling heroin at roadside stands on the main highway from Saigon to the US army base at Long Binh; Saigon street peddlers stuffed plastic vials of 95 percent pure heroin into the pockets of GIs as they strolled through downtown Saigon; and “mama-sans”, or Vietnamese barracks’ maids, started carrying a few vials to work for sale to on-duty GIs.’13 (#litres_trial_promo)
By the summer of 1970, virtually every enlisted man in Vietnam was being offered high-quality heroin. Almost half of them took it at least once; between 15 and 20 per cent of GIs in the Mekong delta were snorting heroin or smoking cigarettes laced with it. Ironically, heroin use soared after the Army cracked down on the much more easily detectable habit of smoking pungent marijuana. But the key factor, argues McCoy, is that drug manufacturers could make $88 million a year from selling heroin to soldiers; no wonder that ‘base after base was overrun by these ant-armies of heroin pushers with their identical plastic vials’. Rumours spread that the North Vietnamese were behind this intense marketing campaign – what better way to immobilise the enemy? But the truth was that South Vietnamese government officials were protecting the pushers.
In any case, combat troops avoided heroin use in the field: being stoned, especially on a drug as soporific as heroin, was more likely to get them killed. But they made up for it when they returned to base. One soldier came back from a long patrol of 13 days; his first action was to tip a vial of heroin into a shot of vodka and knock it back.14 (#litres_trial_promo)
Panicky headlines about the ‘GI epidemic’ started appearing in American newspapers. The Nixon administration was terrified of a crime wave caused by the return of thousands of desperate junkies to American cities. But it never materialised. Instead, the addicted soldiers cleaned up their act – fast.
We know this because the US government, anticipating disaster, commissioned a medical study that recruited more than 400 returning soldiers who snorted, smoked or injected heroin and described themselves as addicted (making it possibly the largest ever study of heroin users). To researchers’ surprise, back in the United States only 12 per cent of these addicts carried on using heroin at a level that met the study’s criteria for addiction.15 (#litres_trial_promo)
This is really powerful evidence that changes in social environment can dramatically affect people’s drug-taking habits. As Professor Michael Gossop, a leading researcher at the National Addiction Centre, King’s College, London, explains: ‘The young men who served in Vietnam were removed from their normal social environment and from many of its usual social and moral constraints. For many of them it was a confusing, chaotic and often extremely frightening experience and the chances of physical escape were remote except through the hazardous possibilities of self-inflicted injury.’16 (#litres_trial_promo) Gossop uses the phrase ‘inward desertion’ to describe what heroin offered the soldiers: a cheap trip to another world.
The scared, disorientated soldiers in Vietnam were being offered a chemical fix to relieve their fear. The social and psychological pressure to do something they would never dream of doing in America – take heroin – was intense: one in five slid all the way into addiction. But, once home again, they weren’t scared any more. They weren’t mixing with other users. The drug was expensive, hard to find, low-grade and highly illegal. The pressure went into reverse. In other words, the same combination of social and psychological factors that turned these men into addicts explains why they were able to stop.
True, these were remarkable circumstances. So we might expect other addicts, whose initiation into drug use was less dramatic and more gradual, to recover at a slower rate. And that’s precisely what those four big epidemiological studies show: they paint a picture of users slowly changing their behaviour when their circumstances changed. They don’t support the progressive disease model. The Vietnam statistics, meanwhile, directly undermine it. The US government went to a lot of trouble to make sure that the soldiers it was testing were addicts. Are we supposed to believe that the 88 per cent who later kicked the habit were misdiagnosed? Or that being drafted to fight in heroin-saturated Vietnam ‘doesn’t count’ because it was such an unusual situation?
The Vietnam survey identifies a key factor in addiction: availability. To quote Michael Gossop: ‘Availability is such an obvious determinant of drug taking that it is often overlooked. In its simplest form the availability hypothesis states that the greater the availability of a drug in a society, the more people are likely to use it and the more they are likely to run into problems with it [my italics].’17 (#litres_trial_promo)
This hypothesis might seem like a statement of the obvious. Actually, as Gossop says, the question of availability is often treated as a secondary factor, less important than any predisposition to a so-called ‘disease’.
Gossop identifies different dimensions of availability. There’s physical availability, obviously, but also psychological availability (whether someone’s personality, background and beliefs increases their interest in using particular drugs), economic availability (whether the drugs are affordable) and social availability (whether the social context encourages use of the drugs). In the case of Vietnam, he points out, many soldiers found that all the boxes were ticked. Troops in Thailand, by contrast, could easily get hold of heroin – but their lives were not in danger, they were free to move among a friendly population and their peers were not using it. Less than one per cent of military personnel took the drug.18 (#litres_trial_promo)
Availability doesn’t offer a comprehensive explanation for addiction, but it reminds us that we cannot hope to understand why people engage in addictive activities – be it shooting up heroin in the jungle or gorging on muffins in Starbucks – unless we take account of what that activity means in its social setting.
No one who has watched The Wire, the magnificent television epic of life in drug-saturated districts of Baltimore, can seriously propose that it depicts a black population afflicted by chronic disease. The characters in the show who smoke heroin do so, basically, because they live in districts where everyone does. If I lived there, I’d be a smack addict. Since I’m an addict, perhaps that goes without saying. But I have a sneaking feeling that even my local vicar would be hooked on the stuff.
Gossop, who has advised the British government on drug policy, is unusual among addiction experts for the bluntness with which he dismisses the disease theory. He describes addiction as a ‘habit’. That may sound less scary than an irreversible disease, but it isn’t. In a society overflowing with abundance, the implications of a habit of addiction driven by availability are every bit as alarming as those of a disease that strikes only individuals with malfunctioning brains.
This isn’t to deny that some people are naturally more vulnerable to addiction than others. And we can’t ignore recent discoveries in neuroscience, which show how the brain’s natural reward systems are being hijacked by newly available substances and gadgets. In the next chapter, we’ll look at what the brain does and doesn’t tell us about addiction.
But I want to end this chapter by stressing, yet again, the inadequacies of the disease model. If the word ‘disease’ is at all useful in this context, it’s as a metaphor for addiction, not as a diagnosis. And I can think of another vivid metaphor that works just as well. Modern consumers are like soldiers drafted to Vietnam – disorientated, fearful and relentlessly tempted by fixes that promise to make reality more bearable. You don’t have to be ill to give in; just human.
3 (#u1b752989-d442-5211-8933-8d687b802192)
WHAT THE BRAIN TELLS US (AND WHAT IT DOESN’T) (#u1b752989-d442-5211-8933-8d687b802192)
Imagine the embarrassment. You are a retired civil servant with Parkinson’s disease. You are industrious and introverted, like many sufferers from the condition. (We don’t know for sure why it often strikes people with this type of personality, but the correlation was noted as long ago as the 19th century.1 (#litres_trial_promo)) You’re a regular at your local pub, where you’re known as a modest, affable chap who orders half-pints rather than pints. Occasionally you while away 20 minutes by pushing a few coins into the slot machine, accepting your losses with a philosophical shrug.
Then something odd happens. Without warning, you develop an obsession with playing the machine. You stand in front of it from opening time until last orders, much to the bemusement of the other regulars. You know that the pub’s fruit machine is programmed to return only 80 per cent of the money you put into it, but one day you hit multiple jackpots that earn you £50. The thrill of this experience – and the possibility of it happening again – reinforces your new preoccupation. You are no longer thinking rationally.
Eventually the teasing from other patrons turns to alarm as they see you pouring away your pension. The pub landlord has ‘a quiet word’ and asks you to stop playing. You’re mortified and stop going to the pub – but, instead of finding another place to drink, you slip into your local betting shop, where the jackpots are bigger. Then a newspaper article about online gambling catches your eye and before long you are shutting yourself away in your study, steadily building up credit card bills as you accrue greater and greater losses. Your wife still doesn’t have a clue.
But your problems don’t end there. Somewhere along the line, much to your own surprise, you discover a taste for internet pornography. Under normal circumstances, porn would have no appeal – you’re 70 years old, after all. But even before you stumbled across these sites you had noticed that your sexual appetite had mysteriously reawakened.
This story sounds implausible, but something very much like it happened to several Parkinson’s patients recently. They developed gambling urges out of nowhere, and in certain cases these were accompanied by a revived sex drive. There were other permutations: patients experienced a revved-up sex drive without the gambling urges, or started binge eating. Some began shopping obsessively, perhaps combining it with other risk-taking activities. The common thread was the startling change in the behaviour of people who, until recently, had devoted most of their leisure time to tending their begonias.
But the culprit wasn’t the disease. It was the medication designed to reverse its symptoms. The medicine wasn’t supposed to produce those results, but the fact that it did so provides us with vital information about the strange, self-defeating behaviours that we call addictions.
These Parkinson’s patients had been given drugs that mimicked the action of dopamine. This is a neurotransmitter, or chemical messenger, that affects our experience of pleasure and also has the ability to map out new reward pathways in the brain – in other words, to rewire it.
That’s a trendy way of describing complex changes in the brain. This is arguably the most impenetrable subject human beings have ever tried to understand. Scientists who have devoted their careers to it admit that they have only pieced together a tiny section of the jigsaw. That’s frustrating – but bear with me, because what they have discovered has fascinating implications. Dopamine is an ancient mechanism: it’s found in lizards and every other animal along the evolutionary tree. It has been called the ‘pleasure chemical’ because it is released whenever we eat good food, enjoy sex or take pleasure-enhancing drugs.
Recently, scientists have refined their understanding of dopamine. They now think that it has more to do with desire than pleasure – or, to use the refreshingly simple terms that now loom large in scientific discussions of addiction, with wanting rather than liking.
In a series of experiments on the brains of rats, the psychologist Kent Berridge of the University of Michigan came to the conclusion that ‘wanting’ (desire) and ‘liking’ (pleasure) are separate urges controlled by different brain circuits in humans as well as animals. That is an important discovery that we need to keep at the back of our minds whenever we think about how and why we are behaving addictively.
Dopamine is involved in both brain circuits, but its main function is to stimulate wanting; liking is more affected by the opioid system, which contains endorphins, the brain’s natural morphine-like compounds.2 (#litres_trial_promo) Of the two urges, wanting is more powerful. ‘The brain seems to be more stingy with mechanisms for pleasure than for desire,’ says Berridge.3 (#litres_trial_promo)
This helps us understand another apparently simple distinction made by scientists that we came across in Chapter 1 – between the Stop and Go impulses in the brain. The Go impulse tells us to reach out for an immediate reward; it’s ancient, it’s powerful and it’s shared with animals. As you might expect, it goes into overdrive at the prospect of food and sex. Dopamine and ‘wanting’ are central to this urge – but different levels of ‘liking’ also determine the strength of the Go message.4 (#litres_trial_promo)
The Stop impulse is highly developed only in humans. It helps us manage our Go impulse by spelling out the consequences of immediate reward. You could call it the voice of reason; it comes from the frontal lobes of the human brain. These are not fully developed in adolescents, who are therefore poor at managing the Stop impulse. This will not come as a surprise to the parents of teenage children.
Let’s return to the traumatic experience of those Parkinson’s patients. Their disease drains the brain of dopamine. Indeed, it may begin to do so decades before more obvious symptoms become apparent. That could explain why Parkinson’s seems to disproportionately affect people with introverted personalities: those self-effacing traits may not be signs of natural, life-long introversion but, rather, the first symptoms of the disease, appearing years before diagnosis.
The patients who developed sudden gambling or other impulsive habits had been given dopamine agonists, which, by boosting dopamine, usually slow down the progression of the disease. They are a common treatment and can be remarkably effective. An aunt of mine with Parkinson’s was given one of these drugs. The brightening of her personality and her fresh pleasure in everyday experiences, such as looking at her garden, seemed almost miraculous. For some patients, however, the same chemical that restored my aunt’s joie de vivre was psychological poison.
Alan Burrows, a pensioner from Queensland, was one of 100 Australians who sued the drug company Pfizer after taking its dopamine agonist medication Cabaser. He claims that it caused him to start binge gambling on ‘pokies’ (Australian slang for slot machines). Eventually, he had to sell his house to pay off his $300,000 gambling debts. ‘Once I started I had to keep going, by withdrawing money every hour, until I couldn’t get any more money,’ he said. ‘It was a compulsion to do it. You became really devious, disgusting.’5 (#litres_trial_promo)
It’s probably no consolation to Mr Burrows, but what happened to him and to the other Parkinson’s sufferers who developed compulsive habits helps us to draw the boundaries of addiction. Their ordeal suggests that dopamine is a common factor in habits that society has been slow to label ‘addictions’ because they don’t involve drugs.
After the stories of bad reactions to Parkinson’s drugs surfaced, Dr Valerie Voon of the US National Institutes of Health led a study of patients given dopamine agonists. She found that 13 per cent exhibited ‘a constellation of pathological behaviours, including gambling, shopping, binge eating and hypersexuality’.6 (#litres_trial_promo) They did so because they were being over-supplied with dopamine.
The inference we can draw from this is valuable. It seems that people who don’t have Parkinson’s disease but engage in the same pathological habits are also having problems with their dopamine levels. Gambling, obsessive shopping, binge eating, hypersexuality – note how those Parkinson’s patients found themselves caught up in the sort of activities where wanting overwhelms liking. Also, they were being driven by repetitive urges. This is typical of dopamine at work, laying down new patterns in the brain as it takes effect. As the psychiatrist Norman Doidge explains: ‘The same surge of dopamine that thrills us also consolidates the neuronal connections responsible for the behaviours that led us to accomplish our goal.’7 (#litres_trial_promo)
In other words, the more we experience dopamine-induced pleasure, the more we want to repeat the experience. But, thanks to levels of tolerance that have been raised by rewiring, the harder we have to work to repeat it to our satisfaction. That is why addicts always seem to be looking for a bigger and bigger hit.
All substance abusers experience surges of dopamine, often accompanied by craving – that is, very strong feelings of wanting. Alcohol, amphetamine, cocaine, heroin, marijuana and nicotine all increase the supply of dopamine to the nucleus accumbens, a pleasure centre buried deep in the brain that has been called the final destination of the reward pathway.8 (#litres_trial_promo)
This does not mean that addicts are people born with naturally high or low levels of dopamine, nor that they have inherited cravings that force them to keep stimulating the rush of dopamine into their nucleus accumbens. If any of these things could be proved, then the study of addiction science wouldn’t involve so much infuriating guesswork.
Different recreational drugs do different things to the brain. They produce different rewards – and different punishments. You don’t have to take them to know that; you just have to observe the behaviour of their users. It’s a bit like visiting the zoo.
Coke-heads and speed freaks gabble excitedly as they are swept along on a tide of dopamine. When that tide pulls out, they experience a particular sort of come-down. ‘Coke is the drug we save for the time after we get back from clubbing,’ says Olly, 27, a graphic designer. ‘It runs out pretty quickly. Presuming we don’t order more, by 4 a.m. everyone is getting jittery and anxious. You see people’s eyes flicking around the room wondering if anyone’s got any left. A group of four chatty and gobby friends suddenly becomes four individuals chewing the insides of their cheeks. The next morning we go for brunch to cure our hangovers but everyone’s coming down off the coke, snapping at each other. Some people feel blue for days.’
Heroin users don’t inflict logorrhea on their friends: their drug is forcing the brain to over-produce endorphins, those natural euphoria-inducing and painkilling neurotransmitters. Heroin suppresses neurotransmission in the central nervous system, which can produce an exquisitely calm feeling, particularly if your nerves were shot to pieces in the first place. This can take people to the gates of paradise, but also to hell: the come-down is long and usually profoundly depressing, because the nucleus accumbens is extremely sensitive to opioid withdrawal.9 (#litres_trial_promo)
Also, the brain’s self-regulatory process means that junkies quickly need to increase their doses to slow down neurotransmission; in severe cases, they inject themselves hourly in order to maintain a state of mental paralysis. William Burroughs, writing about his last year of addiction in North Africa, said he could look at the end of his shoe for eight hours. And if a friend had visited him and died on the spot, ‘I would have sat there looking at my shoe waiting to go through his pockets’.10 (#litres_trial_promo)
Ecstasy releases serotonin, a neurotransmitter associated with happiness; hence its users’ indiscriminate declarations of affection. ‘One of the reasons I don’t do pills is seeing how fucking annoying people are when they’re “loved up”,’ says Ollie. ‘MDMA [a purer form of Ecstasy] is even worse. You see groups of heterosexual men hugging and kissing each other. There’s this idiotic bear hugging that goes on for hours, and I’m afraid it makes me laugh when I see them at work on Monday, looking sheepish and sad.’ The sheepishness is self-explanatory; the sadness is pure dopamine deprivation.
Alcohol, meanwhile, has been called the most ruthless of all brain-hijackers. Looking back on my drinking, I now have some idea of what was happening to my body; I just wish I’d known at the time, if only to avoid some hangovers of apocalyptic proportions.
Alcohol molecules are quite unlike those of other addicting drugs. They have the ability to speed up the transmission of chemicals that excite us and also, later, those that relax us, sometimes to the point of stupor. We’re talking about a fiendishly complicated neurochemical dance that releases inhibitions and twists moods over the course of an evening. I reckon my own dopamine would peak around the third glass of red wine, which was the moment when – if I was on form – I was most fun to be around. By the third bottle the flow of mood-enhancing chemicals would have slowed down and the inhibitory neurotransmitter GABA would be in the ascendant. My voice would become slurred and my thoughts confused – but I’d be chasing the vanishing high by drinking even faster. And my friends, sensibly, would have made their excuses and left.
As for the hangovers – well, if ever I feel like going back on the sauce after 18 years I have only to cast my mind back to any of the thousand or so I inflicted on myself. Perhaps it was the ability of the alcohol molecule to insinuate itself into so many different functions of the brain that produced such all-encompassing misery. But, as we’ll see later, I eventually discovered an effective but fabulously stupid pharmaceutical remedy for those feelings.
All intoxicating experiences involve a cocktail of brain chemicals that are mixed quite differently depending on the nature of the behaviour. But dopamine is still the master drug that, in the words of the research psychiatrist Morten Kringelbach, ‘appears to encode desire’ and can make us chase after something long after we’ve ceased to derive much pleasure from it.11 (#litres_trial_promo) To quote Dirk Hansen, ‘dopamine is part of the reason why we remember how much we liked getting high yesterday’.12 (#litres_trial_promo)
As this suggests, it’s good at fastening on to cues. One sensible piece of advice that 12-step groups dole out to their members is to avoid ‘people, places and things’ that were part of their old habits. ‘If you hang around barbers’ shops, sooner or later you’re going to get a haircut,’ is an AA saying – meaning, of course, that sitting around drinking orange juice in the pub is risky for an alcoholic. The more addicted you become to something, the more sensitive you become to these cues – even after years of abstinence. Significantly, these cues are often the ‘things’ that have come to replace people in your life.
But the link between cues and desire isn’t confined to addicts. It’s part of everyday existence for people situated all along the addictive spectrum – that is, all human beings.
You don’t need to ingest any substance at all to experience a rush of dopamine: the cue is enough. The smell or even just the sight of food increases dopamine in the nucleus accumbens, the region of the brain involved in reward and motivation. It’s why our mouths water. As the psychology professors Harvey Milkman and Stanley Sunderwirth explain, this is the same type of neurochemical response that occurs when a cocaine addict sees a video of people snorting a fat line of white powder: ‘The dopamine messenger impels the organism to action, an impulse that sheer willpower cannot easily overcome.’13 (#litres_trial_promo)
I know what they mean. For some reason, watching characters drink red wine on television is more tempting for me than seeing them do it in real life; it makes me long to nip to the supermarket for a bottle of Rioja. (I don’t, I hasten to add.) Why this should be I don’t know, but in AA meetings I quite often heard speakers complain of the same thing. Some people even ‘had a slip’, to use 12-step terminology, thanks to things they had seen on screen. Cues can be made more powerful by being detached from everyday networks. This is why many slips happen when alcoholics are on holiday, away from the company of people who know they have a problem, where the booze is presented in an exotic setting that somehow detoxifies it. One businessman I know found himself – to his own astonishment – accepting a rum and coke from a stewardess on a plane flight. ‘We were so high up that it didn’t seem to count,’ he said. And thus ended the decade of abstinence of which he’d been so proud.
Milkman and Sunderwirth have produced a list of activities that boost dopamine in the nucleus accumbens. They are: crime, eating, gambling, risk-taking, sex … and hugging your loved ones. With the possible exception of hugging, there’s an addiction (or, more accurately, a huge range of addictions) lurking in all of them.
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Damian Thompson
Addictions to iphones, painkillers, cupcakes, alcohol and sex are taking over our lives.Our most casual daily habits can quickly become obsessions that move beyond our control. Damian Thompson, who has himself struggled with a range of addictions, argues that human desire is in the process of being reshaped. Shunning the concept of addiction as disease, he shows how manufacturers are producing substances like ipads, muffins and computer games that we learn to like too much and supplement tradition addictions to alcohol, drugs and gambling. He argues that addictive behaviour is becoming a substitute for family and work bonds that are being swept away by globalisation and urbanisation.This battle to control addiction will soon overshadow familiar ideological debates about how to run the economy, and as whole societies set about “fixing” themselves, the architecture of human relations will come under strain as never before.The Fix offers a truly frightening glimpse of the future and is essential reading for fans of Naomi Klein’s ‘No Logo’, Oliver James’s ‘Affluenza’ and Francis Wheen’s ‘How Mumbo-jumbo Conquered the World’.
DAMIAN THOMPSON
THE FIX
HOW ADDICTION IS INVADING OUR
LIVES AND TAKING OVER YOUR WORLD
CONTENTS
Title Page (#ue262d813-5318-5c16-b4dd-c794f0cf1afa)
1 - CUPCAKES, IPHONES AND VICODIN
2 - IS ADDICTION REALLY A ‘DISEASE’?
3 - WHAT THE BRAIN TELLS US (AND WHAT IT DOESN’T)
4 - ENTER THE FIX
5 - WHY CAKE IS THE NEW COKE
6 - HAPPY HOUR
7 - DRUGSTORE COWBOYS
8 - GAMING, THE NEW GAMBLING
9 - REDISCOVERING PORN
10 - DELIVER US FROM TEMPTATION
ACKNOWLEDGEMENTS
NOTES (#litres_trial_promo)
Copyright (#litres_trial_promo)
About the Publisher
1 (#u1b752989-d442-5211-8933-8d687b802192)
CUPCAKES, IPHONES AND VICODIN (#u1b752989-d442-5211-8933-8d687b802192)
The 21st-century cupcake is a thing of wonder: a modest base of sponge groaning under an indulgently thick layer of frosted sugar or buttercream. It’s made to look like a miniature children’s birthday cake – and, indeed, birthdays are the perfect excuse to scurry down to the local boutique bakery for a big box of them. The retro charm of cupcakes helps suppress any anxieties you might have about sugar and fat. Your mother made them! Or so the advertising suggests. Perhaps your own mother didn’t actually bake cupcakes, but the cutesy pastel-coloured icing implies that one bite will take you back to your childhood. This can’t possibly be junk food, can it?
Now let’s consider another ubiquitous presence in modern life: the iPhone, which started out as a self-conscious statement of coolness but which, thanks to Apple’s marketing genius, has now become as commonplace as a set of car keys. Millions of people own iPhones, making use of hundreds of thousands of apps, whose functions range from GPS-assisted mapping to compulsively time-wasting computer games. Your iPhone does everything you could require of a mobile phone and more, so you really don’t need the upgraded model that Apple has just released … do you?
Then there’s Vicodin. It’s the most commonly prescribed painkiller in America. In fact, it’s the most commonly prescribed drug in America: 130 million scripts for it were handed out in 2010 and 244 million for the overall class of drug, narcotic analgesics.1 (#litres_trial_promo) It’s strong stuff, a mixture of two painkillers: hydrocodone (an addictive opioid) and paracetamol (non-addictive, but causes liver damage in high doses). Vicodin is intended for the sort of pain that makes you cry out in the doctor’s waiting room – caused by twisted backs, rotting wisdom teeth and terminal cancer. If they swallow so many of those pills, it seems reasonable to conclude that Americans must be in a lot of pain. Or is it just that millions of people can’t manage without Vicodin’s deliciously soothing euphoria, even if there’s nothing much wrong with them?
A cupcake, a smartphone and a common painkiller. These three objects are so innocent-looking that you could leave them on your desk at work and no one would comment (though the cake might disappear). You can easily consume all three simultaneously: swallow the pill for your bad back with a slurp of coffee while checking your text messages and picking at that yummy frosted topping.
On the other hand, each of these mundane items can get us into trouble. They are objects of desire that can reinforce addictive behaviour – the sort that creeps up on you when your defences are down. That’s the subject of this book: a social environment in which more and more of us are being pulled towards some form of addiction, even though we may be unaware of the fact and never become full-blown addicts.
It’s not obvious to us now, but the most far-reaching social development of the early 21st century is our increasingly insistent habit of rewarding ourselves whenever we feel the need to lift our moods.
When our hand creeps out towards yet another square of organic chocolate, or when we play just one more game of Angry Birds before setting off for work, or when we check a secretly bookmarked porn site for new arrivals, we’re behaving like addicts. The activity in question can be innocent or shameful. Either way, it reinforces the addictive streak in human nature.
That streak is there because our brains have evolved to seek out immediate, short-term rewards. Our ancestors needed to stuff themselves with energy-rich berries and to respond quickly to sexual stimulation; we wouldn’t be here if they hadn’t.
Our problem is that we’ve built an environment that bombards us with rewards that our bodies don’t need and that do nothing to ensure our survival as a species. Yet, because they are rewards – that is, because they provoke specific feelings of anticipation and pleasure in the brain – we grab them anyway.
To put it another way, we reach out for a fix.
That’s a word we associate with helpless addicts. They talk about their ‘fix’ because it feels as if they’ve temporarily fixed themselves when they take their drug of choice. There’s no mystery about this. As a result of heavy exposure to the drug, they have become dependent on frequent chemical rewards. Their brains are in a state of hyper-vigilance, waiting for the blessed relief of a chemical that, once tolerance develops, merely allows the addict to feel normal, as opposed to anxious and ill.
That much is not in dispute. Many addiction specialists go further, however. They say that the brains of addicts are fundamentally different from those of non-addicts. They are forced to chase these rewards because they have ‘the disease of addiction’.
This book challenges that theory. It suggests that, if you keep eating chocolate biscuits until you feel sick, you’re indulging in a milder version of the addictive behaviour that leads heroin addicts to overdose. I’m not equating the two situations, of course. I’m suggesting that they lie at different points on a spectrum of addictive behaviour on which everyone can be located.
Also, and more importantly, many of us are being pulled towards the dangerous end of the spectrum, thanks to technological and social changes that stimulate the most fundamental of all our instincts – desire.
Never before have we had access to so many desirable things and experiences that we hope will change our moods. I know ‘things and experiences’ sounds vague, but that’s really the point. Addiction has never been confined to substance abuse, and with each passing week technology unveils a new object, process or relationship we can obsess over.
For example, these days our fixes are often delivered to us through social networking tools such as Facebook or Twitter that enable us to manipulate our circle of friends. Installing and deleting people as if they were iPhone apps offers a quick and dirty method of changing our feelings (though, needless to say, we are furious when someone deletes us). It’s a consumer experience.
In any discussion of addiction, whether of the trivial or life-threatening variety, the concept of desire is just as important as that of pleasure. Usually, it’s more important. That’s because the anticipation of the fix is more powerful than the moment of consumption, which often fails to live up to expectations. Sometimes we throw internal tantrums when this happens. The fix infantilises us so that, like children, we are constantly and annoyingly hungry for more.
Believe me, I speak from experience.
I spent many years as an addict. I was pathetically addicted to alcohol between the ages of 18 and 32. It took me a long time to acknowledge the fact, though – to realise that the act of getting drunk delighted and obsessed me to a degree that set me apart from most of my friends and colleagues. My doctor tells me I’m still an addict. I’m not exactly happy to wear that label after spending such a long time avoiding so much as a sip of alcohol, but the evidence is compelling. Since giving up drinking, my addictive desires have attached themselves to one thing, person or experience after another. I can’t swallow a Nurofen Plus for a headache without hoping that I’ll enjoy a little codeine buzz. I can obsess for ten minutes in front of a display of confectionery in a newsagent’s. And my CD-buying habit has nearly bankrupted me. Trivial stuff compared with my drinking, but my over-reactions to these stimulations don’t feel normal, exactly.
Perhaps the crucial feature of addiction is the progressive replacement of people by things. That deceptively simple statement is a brilliant insight, though I can’t claim credit for it. It comes from Craig Nakken, author of a bestselling book called The Addictive Personality, who argues that addicts form primary relationships with objects and events, not with people.
He writes: ‘Normally, we manipulate objects for our own pleasure, to make life easier. Addicts slowly transfer this style of relating to objects to their interactions with people, treating them as one-dimensional objects to manipulate as well.’
What begins as an attempt to find emotional fulfilment ends up turning in on itself. Why? Because the addict comes to judge other people simply in terms of how useful they are in delivering a fix. And, at some stage, everybody lets you down. Therefore the addict concludes that objects are more dependable than people. Objects have no wants or needs. ‘In a relationship with an object the addict can always come first,’ says Nakken.2 (#litres_trial_promo)
I felt a shiver of recognition when I first read those words. But it wasn’t just my own behaviour that came to mind, or that of people whom society can conveniently label ‘addicts’. This may come across as a presumptuous thing to say, but over the last decade I’ve been struck by the way friends and colleagues, most of them psychologically far healthier than me, have begun to display aspects of the process Nakken describes. Lifestyle accessories exert an ever greater power over them, disrupting relationships, nurturing obsessions and – as I’ve noticed in the office – dominating conversation.
Does that mean that the people around me are turning into addicts? That’s never an easy question to answer, because ‘addict’ is such a loaded term. It’s a good word to describe people whose problems are obviously out of control, as mine were, but it has to be used carefully. Not only does it carry misleading overtones of disease, but it also implies that there’s a clear dividing line between ‘addicts’ and ‘non-addicts’. That’s not true. In my experience, addiction is something that people do – to themselves and other people – rather than something that just happens to them; it’s not like developing cancer.
Addiction is easier to understand as a concept if we focus on clearly observable behaviour – that is, the search for a fix and its consequences. Almost anyone can indulge in addictive behaviour, but some of us are more prone to it than others, for reasons that scientists don’t fully understand.
In fact, let’s get this point out of the way right at the beginning of this book. In the past couple of decades, countless scientific studies have attempted to pinpoint what it is about either the brains or the upbringings of addicts that leads them to adopt self-destructive lifestyles. They have failed to do so.
No one is immune from developing addictive behaviour. If there’s a history of addiction in your family, you’re more at risk. Likewise, if you have an impulsive personality – that is, score highly for ‘impulsivity’ in psychological tests – you’re more likely to do something impulsive, such as try a new drug or drink that fatal last glass of whisky before jumping into your car. Indeed, a fashionable term for various addictions is ‘impulse control disorders’.3 (#litres_trial_promo)
For me these findings fall into the ‘No shit, Sherlock’ category of scientific discoveries. They tell us nothing very surprising. The consensus at the moment is that addiction seems to be the product of genetic inheritance and environment. In other words, the nature versus nurture question is no closer to being settled in this area of human biology than it is in any other. To repeat: we’re all at risk. That’s why the contents of this book apply to everyone, not just coke-snorting hedge fund managers, bulimic receptionists and absent fathers glued to World of Warcraft.
Psychologists talk about addictive behaviours in the plural, recognising the many different impulses that tempt people. What these behaviours tend to have in common is the replacement of people by things and events. We all develop these habits to a certain degree; the people we call addicts are those people who can’t or won’t give them up even when they cause harm to themselves and others. Again, that’s a loose definition, fuzzy at the edges. Never mind; addiction isn’t an easy phenomenon to pin down.
This isn’t to deny that addictive behaviour has important consequences for the brain. It does. Indeed, it can partly be explained by the overstimulation of the brain’s fearsomely complex reward circuitry.
Different parts of the human brain govern what some scientists call the Stop and Go impulses. More primitive sections of the brain – parts that we share with other animals – tell us to consume as much as possible in order to increase our chances of survival. They say: Go. More highly developed parts of the brain, capable of reasoning and not found in other animals, hold up a Stop sign when we’re consuming too much of something for our own good. Classic addicts keep ignoring the Stop instruction, despite the high cost to themselves and others. They require instant gratification, whatever the consequences. Indeed, they’ll often seize any opportunity to indulge in addictive behaviour even when there’s no real gratification to be extracted from it. We’ll discuss this puzzling paradox later.
The Stop and Go imagery helps us understand the growing appeal of the fix. As technologies develop and converge, the speed of delivery increases. So does the speed of our expectations. We now live in a world filled with life-enhancing objects and substances that promise ever faster and more effective gratification. It’s as if everything that tumbles off a production line is stamped with the word Go.
Temptation peeks out at us from the strangest places. Who would have guessed, 40 years ago, that a piece of electronic office equipment – the personal computer – would morph into something so desirable that people would sacrifice huge chunks of their spare time (and income) in order to play with it? Or that modifications to a telephone would generate global excitement?
Changes to our appetites don’t come about by accident. The manager of your local Starbucks didn’t wake up one morning and think: ‘I know what would brighten up my customers’ afternoons – an ice-blended cappuccino!’ As we’ll see, the Frappuccino was invented when Starbucks employed food technology to solve a specific business challenge. As a result, hundreds of thousands of their customers (including me) developed a near-obsessive relationship with something they had previously lived happily without.
The pace of technological change means we need to revise our concept of addiction. Our cultural history provides us with images of stereotypical addicts, some of them dating back centuries: the grinning harridan dropping her baby down a staircase in Hogarth’s Gin Lane; the American Indians crazed with ‘firewater’; the hollow-eyed Chinese sailor propped against the wall of an opium den; the junkie shivering in an alleyway surrounded by needles. Also, anyone who lives in a city is used to the sight of spectacular drunks and morbidly obese people whose addictions are so grotesquely out of control that we avert our eyes.
These are powerful images, but if we pay too much attention to them then we can end up with a dangerous sense of immunity. We overlook our own eagerness to self-administer fixes, those sensory experiences that temporarily lift the mood while subtly detaching us from traditional human relationships. The fix can take any number of forms. Some toy very obviously with the chemistry of the brain. Anyone with a rolled banknote up their nose knows that – so long as their dealer hasn’t ripped them off – they’re about to experience the effects of a mind-altering substance. The same goes for the guy swigging from a whisky bottle. In contrast, the tubby young man who demolishes a packet of chocolate digestives while watching the football doesn’t suspect that his eating habits have left his brain unusually sensitive to stimulation by sugar; he just knows that, once the packet’s opened, the biscuits disappear. His habit of stuffing his face with refined sugar and vegetable fat doesn’t place him very far along the addictive spectrum – but, then again, it may be enough to put him in intensive care when he has a heart attack at 50.
The most puzzling addictions are those that don’t involve the consumption of any substance. Gambling is the obvious example – we’ve known for hundreds of years that it can tear apart families as ruthlessly as hard liquor. In academic circles, these non-substance addictions are known as ‘process addictions’. It’s now clear that things you don’t eat, drink, smoke or inject can nevertheless disturb your brain in much the same way as drugs. And, in an age when so much digital entertainment – notably video games and online pornography – is designed to be as addictive as possible, their potential to do this is accelerating rapidly.
The global marketplace offers a bewildering selection of consumer experiences, simultaneously delightful and dangerous. It’s constantly modifying products and experiences that were never previously considered to be addictive – or simply didn’t exist until recently.
Also, as we’ll see, corporations have learned how to supercharge old-established intoxicants by popularising new patterns of consuming them. One vivid example is the phenomenon of recreational binge drinking, particularly by women. People have always got drunk, and a minority have always enjoyed going on binges with their friends. What no one predicted was the emergence of the binge as everyday behaviour. Ordinary drinkers, with no history of a problem with alcohol, now plan evenings to end in a messy and helpless surrender to the drug. And this is seen as normal.
It would be silly to pretend that everyone is equally threatened by this changing style of consumption. But the prospect of whole populations learning new ways of tampering with the flow of pleasure-giving chemicals in their brains is one that should make us feel very uneasy.
With that in mind, let’s take another look at the cake, the phone and the pill.
In 1996 a tiny corner shop called the Magnolia Bakery opened in Manhattan’s West Village. Its old-fashioned cakes and pies quickly became the objects of guilty fantasy for women who liked to pretend that nothing more fattening than tuna carpaccio ever passed their lips. Then, in 2000, the bakery featured in an episode of Sex and the City. This was the moment America’s cupcake craze began in earnest.
In the episode, Carrie and Miranda were filmed sitting outside the Magnolia. Carrie, played by Sarah Jessica Parker, told her friend that there was a new obsession in her life. This turned out to be a new boyfriend called Aidan – but viewers could have been forgiven for thinking it was icing sugar, judging by the way Parker was pushing the rose-coloured cupcake into her face. Viewed in slow motion, it’s a faintly disgusting spectacle. The truth is, there’s no elegant way to eat a Magnolia cupcake, which is why customers adopt self-mocking smiles as the fluorescent globules of frosting tumble down their chins.
‘When Carrie took her first bite, she left teeth marks in my neighbourhood,’ wrote Emma Forrest, a journalist living opposite the bakery. ‘Not long after the episode was broadcast, the tourists started to arrive and the bakery started charging them if they wanted to take photographs of Carrie and co’s favourite haunt. With the influx of tourists came the rats, as half-eaten cupcakes were dumped into overflowing bins outside my apartment … Riding on this extraordinary upturn in its fortunes, Magnolia changed its hours, and stayed open to midnight throughout the summer. I was kept awake each night by the hoots and hollers coming from the queue that now snakes all the way around the block.’4 (#litres_trial_promo)
In 2006 and 2007 I spent quite a lot of time in the West Village visiting my friend Harry Mount, then New York correspondent of the Daily Telegraph. By this time, Sex and the City was off the air and the cupcake craze had gone mainstream: Magnolia-style bakeries were opening all over America. Yet, on chilly autumn evenings, there was still a queue outside the original store, and it didn’t seem to consist of tourists. ‘Our local stick-thin fashion victims can’t get enough of the things,’ explained Harry. In which case, how come they were stick-thin? Was there a parking lot at the back where they threw them up?
That was a bad-taste private joke between Harry and me, but when I recently did a word search on ‘cupcakes’ and ‘bulimia’ I discovered a blog by a bulimic mother of two entitled ‘Eating Cupcakes in the Parking Lot’. Its posts appear to have been deleted, but cupcakes feature prominently in many other blogs devoted to eating disorders. After a row with her boyfriend, one bulimic girl baked cupcakes decorated with the words ‘I am sorry’. She added mournfully: ‘And now where are those cupcakes? Floating along a sewage pipe.’5 (#litres_trial_promo)
This sort of incident isn’t unusual. Abigail Natenshon, a psychotherapist who treats eating disorders, tells another horror story involving cupcakes: ‘One young woman with bulimia found herself, at a time of great stress, compelled to drive into a 7–11 convenience store where she purchased three cupcakes; she then proceeded to stuff them down her throat whole in an emotional frenzy in the dark and deserted alley behind the store. As far as she was concerned, her binge had begun at the moment when she drove her car up to the front door and did not finish until she had purged the cupcakes.’6 (#litres_trial_promo)
The disturbing subculture of ‘pro-ana’ (pro-anorexia) websites actually encourages girls to starve themselves, or ‘b/p’ (binge and purge). A recurring question on these sites is: are cupcakes easy to throw up? Answer: not as easy as ice cream, but eating them with diet soda can help.
‘It doesn’t surprise me that cupcakes are favourites with bulimics,’ the food writer Xanthe Clay told me. ‘They’re the ultimate eye-candy, primped and styled like a teen pop star, the food incarnation of many girls’ fantasies.
‘In the gossip magazine world, where shopping is the only serious rival to celebrity in terms of aspiration, cupcakes are consumer-desirable in a way a Victoria sponge isn’t. If having an eating disorder is about a desperate attempt to take control, then eating these artificial, too-perfect creations may be particularly satisfying. More likely, the huge sugar rush will feed the craving, and provide a quivering kick of hypoglycaemia. The texture – smooth, aerated, oily – may, like ice cream, be especially suitable for regurgitation.
‘And – just my prejudice this – but perhaps the ultimate emptiness of cupcakes, those empty calories, the way they never deliver on flavour what they promise in looks, is a metaphor for the hopelessness of the woman, or man, with bulimia.’
Although a high proportion of bulimics have ‘issues’ with cupcakes, clearly the overwhelming majority of people who eat them don’t throw them up. They do, however, seem obsessed with them. A chain called Crumbs sells 1.5 million cupcakes every month in 35 US stores; in June 2011, it started trading on the Nasdaq, with an opening valuation of $59 million. And market analysts predict robust growth if Crumbs moves into emerging markets such as China.
The Facebook group for Sprinkles Cupcakes had, at the time of writing, been ‘liked’ by 325,000 people and was spreading the cupcake gospel with near-hysterical enthusiasm.7 (#litres_trial_promo) For Valentine’s Day: ‘It’s back! The first 50 people to whisper “love at first bite” at each Sprinkles receive a free raspberry chocolate chip!’ For Super Sunday: ‘Whether you’re rooting for the New York Giants or New England Patriots or just tuning in for the commercials, Sprinkles Super Sunday boxes will score a touchdown at any viewing party. Each box contains 6 Red Velvet and 6 Vanilla cupcakes, adorned with football sugar decorations and your favourite team’s name. Just don’t get tackled reaching for the last one!’ There were even signs that cupcakes were trying to infiltrate the military-industrial complex: ‘Sprinkles is excited to bring freshly baked cupcakes to the Pentagon! Pentagon employees can find us in the Main Concourse …’
This is a resilient craze, as Dana Cowin, Food & Wine magazine’s editor-in-chief told Reuters in 2011. ‘I have predicted the demise of the cupcake so many times that I’m actually going to go to the dark side now and say the cupcake trend is not going to abate,’ she said.8 (#litres_trial_promo) When an earthquake struck Washington DC on 23 August 2011, someone tweeted that you could tell it had happened because there was suddenly no line outside Georgetown Cupcakes.
Could the ‘emptiness’ of the cupcakes to which Xanthe Clay refers be part of their appeal? Their overwhelming sugar hit fills the consumer with what nutritionists call ‘empty calories’, because they have no nutritional value. But that’s not to say they have no mood-altering value. Sugar triggers production of the brain’s natural opioids, according to Princeton neuroscientist Bart Hobel, who led a study into sugar dependence. He found that rats which binged on sugar went into withdrawal when the supply was cut off. ‘We think that is a key to the addiction process,’ he said. ‘The brain is getting addicted to its own opioids as it would to morphine or heroin. Drugs give a bigger effect, but it is essentially the same process.’9 (#litres_trial_promo)
Opioids are also implicated in bulimia, irrespective of whether sugar is involved. Have you ever experienced that feeling of glorious relief after you’ve just thrown up a dodgy curry? It’s not just getting rid of the food that makes you feel good; it’s a natural elation produced by chemicals in the brain. Bulimics get off on it, to put it crudely.
As Abigail Natenshon explains: ‘The bulimic cycle releases endorphins, [opioid] brain chemicals that infuse a person with a sense of numbness or euphoria. Ironically, the relief passes in short order, only to be replaced by anxiety and guilt for the bulimic behaviours.’ Again, we need to state the obvious fact that most people don’t throw up their food. But the sort of food associated with purging is also the sort of food that many of us have difficulty resisting, because its heavy concentrations of sugar, fat or salt can magnify euphoria and neediness.
It’s easy for urban sophisticates to mock American rednecks or British ‘chavs’ who stuff themselves with fast food, and easy to recognise that they’re in the grip of some sort of addiction. Just look at their waistlines. But the marketing executive who orders a cranberry muffin to go with her morning cup of coffee really ought to ask herself: why am I eating cake for breakfast?
So what about the iPhone? Isn’t it a bit much to call our love affair with this shiny gadget an ‘addiction’? Researchers at Stanford University aren’t so sure: in a survey of 200 Stanford students in 2010, 44 per cent of respondents said they were either very or completely addicted to their smartphones.10 (#litres_trial_promo) Nine per cent admitted to ‘patting’ their iPhone. Eight per cent recalled thinking that their iPods were ‘jealous’ of their iPhones. These are strange things for students at one of America’s top universities to say about their phones, even in jest. They also reveal something about how completely the iPhone has become part of these students’ identities and social frameworks. They’re not just tools that allow us to connect instantaneously and prolifically with others: they’re also being afforded identities of their own – ‘patted’, protected and cherished.
Perhaps it has something to do with how these devices are engineered. They practically force you to perform repetitive rituals of the sort associated with obsessive-compulsive behaviour: from the initial activation of the iPhone to the weekly ‘syncing’ and nightly charging, your relationship to the phone is structured for you. And because the iPhone’s battery life isn’t quite enough to last a full day’s use – and certainly not long enough to withstand hours of constant fiddling and gaming – ‘pit stop’ charges become a regular feature of the day. iPhone users can often be seen checking for power sockets in coffee shops so that, while they get their own fix of caffeine, their phones can get juiced up as well.
‘iPhone owners live in a constant state of anxiety about their battery levels,’ says Milo Yiannopoulos, editor of The Kernel, an online culture magazine. ‘To some extent, the phone ends up structuring their day. For example, they tend not to plan to be out of the office for more than six hours at a time, in case they run out of battery and have to start knocking on doors, USB cable in hand, begging for a few minutes’ worth of charge to get them through the afternoon.’
Talk about the replacement of people by things. The 4S version of the iPhone, released in October 2011, includes a virtual assistant called Siri that responds to spoken instructions and speaks back to the user. This infant technology is already so complex that you can have entire conversations with Siri. She will then execute commands, in some cases fetching very specific data from the internet. ‘Intelligent personalised assistant software is going mainstream,’ says Yiannopoulos. ‘Never in the history of mass-market consumer electronics has the line between man and machine been so blurred.’
It’s significant that a quarter of respondents in the survey above said they found iPhones ‘dangerously alluring’. They are supposed to be. Absolutely nothing is left to chance in the design of these devices. If Apple customers have an embarrassing tendency to anthropomorphise their gadgets, that is because Apple has explored the possibilities of the human mind and body more thoroughly than any of its competitors.
For example, one of the most appealing features of the MacBook laptop line has been the status light, which pulsates gently when the computer is sleeping. Early reviewers cooed over the calming effect of the light, but couldn’t put their finger on why it felt so good to watch. Later, it was revealed that Apple had filed for a patent for a sleep-mode indicator that ‘mimics the rhythm of breathing’ and was therefore ‘psychologically appealing’. As the tech blogger Jesse Young noted, while Apple’s sleep light matched the pace of breathing while we sleep, Dell’s was closer to breathing during strenuous exercise. ‘It’s interesting how a lot of companies try to copy Apple but never seem to get it right. This is yet another example of Apple’s obsessive attention to detail,’ he wrote.11 (#litres_trial_promo)
Former Apple executives – who frequently brief American technology blogs off the record about the internal culture at Apple’s headquarters in Cupertino, California – describe the lengths the organisation goes to in order to create coveted products. There’s a design-dominated power structure that results in hushed reverence when Jonathan Ive, Senior Vice President of Industrial Design, walks into the boardroom. ‘Marketing and design have been fused into a single discipline at Apple,’ says Yiannopoulos. ‘Everything, from product strategy to research and development, is subordinate to making the products as beautiful and compulsive – that is, as addictive – as possible.’
It works. To quote an extreme example, in 2010 a schoolboy in Taiwan was diagnosed with IAD – iPhone Addiction Disorder. According to Dr Tsung-tsai Yang of the Cardinal Tien Hospital, his eyes were glued to his phone screen all day and all night. Eventually, ‘the boy had to be hospitalised in a mental ward after his daily life was thrown into complete disarray by his iPhone addiction’.12 (#litres_trial_promo)
Two days after it opened in 2010, I visited the Apple Store in Covent Garden – a magnificently restored Palladian building dominated by a glass-covered courtyard. The heady aroma of addiction was unmistakable. The misery in the queue for the Genius Bar, where broken computers are diagnosed, was painful to behold. Legs were crossed and uncrossed and eyebrows twitched every time a Genius read out a name. I couldn’t help thinking that these customers looked like addicts waiting for their daily dose of methadone.
I wanted to ask a Genius what it was like dealing with people who weren’t just asking what was wrong with their laptops but pleading for (literal) fixes. But finding someone who would talk was easier said than done.
First I went down the route of asking an Apple Store manager – a friend of a friend – whether he could chat off the record about the way the company seemed to encourage addiction to its products, or put me in touch with someone who would. His first response was encouraging, but then he changed his mind. He would be in big trouble if his bosses suspected he’d put me in touch with an indiscreet ex-employee, and he’d be fired on the spot if he got caught blabbing himself.
So I tried a different route. A start-up CEO friend of mine put out a message to one of his networks. Shortly afterwards, a young man called Ben Jackson, a social media entrepreneur, emailed to say he could meet me for coffee in Soho, London, a few streets from the Apple Store where he had spent two years as a Genius.
Ben, like many former Apple employees, inhabited the cooler end of the geek spectrum, with glasses offset by a gym-honed body. He didn’t need any prompting to talk about addiction to technology: the experience of seeing the addiction every day – deliberately stimulated by the company – was one of the reasons he left the store.
‘I saw a whole range of addictive behaviours. It’s one of the things that made the Apple Store such a surreal place to work. At one end of the scale you have the total Apple obsessives who exhibit a sort of religious fanaticism that the company does nothing to discourage – it encourages it, in fact. They’re the people who will book the same tutorial again and again, being shown how to do stuff they already know.
‘When a new product is launched, it’s the same faces at the front of the line every time. They treat the staff almost like celebrities, trying to ingratiate themselves. At the Genius Bar, they’ll show you Apple products from years ago, and you’ll have to pretend you haven’t seen them before, because they need their egos massaged. It’s kind of sad. Well, it is sad.’
But it’s not only the true obsessives who are touched by addiction, according to Ben. ‘There’s a general perception that Apple is awesome in a way that other companies aren’t – a perception that’s quite at odds with the way it operates behind the scenes. Even the products are considered awesome, which is why otherwise normal people would get quite disproportionately angry and upset if anything went wrong with them. And it’s also why there’s such unease if people think they’ve fallen behind, that their stuff is out of date. But the point is that you can’t keep up to date without spending a lot of money on things you don’t need, because the products are just coming out too fast.
‘I’ve seen people burst into tears because a credit check wouldn’t allow them to stretch to the latest upgrade. That’s when I started thinking: I need to get the hell out of here.’
Admittedly, many psychiatrists don’t believe in ‘internet addiction’ as a medical condition, let alone addiction to a specific model of smartphone. They argue that obsessive users aren’t addicted to the internet so much as to the experiences it provides, such as digital porn and computer games. But few experts would deny that gadgets such as iPhones can produce behaviour that bears the hallmarks of addiction. And it’s becoming increasingly clear that the ability of manufacturers to stimulate this behaviour is racing far ahead of our ability to cope with the psychological and social problems that are created as a result.
The science of pleasure is playing a greater role in the marketing strategies of all sorts of companies: the people who waft the smell of freshly baked doughnuts at you in the shopping mall have fine-tuned their recipes in the laboratory, not the kitchen. But Apple is in a class of its own. No other company has managed to mix such a finely balanced cocktail of desire, in which the crude flavour of compulsion is disguised by a deliciously minimalist aesthetic.
‘More than any other product, the iPhone has encouraged the tech industry to concentrate on getting people hooked on things,’ says Yiannopoulos. ‘Apple’s marketing genius, and the incredible attention to detail paid to the design of their devices, filters down into the iPhone developer ecosystem.’
He cites the example of Angry Birds, a simple computer game app that, by May 2011, had been downloaded 200 million times.13 (#litres_trial_promo) The premise of Angry Birds is simple: players launch birds across the screen with a slingshot, judging the trajectory of flight and altering the force and initial direction accordingly. It sounds harmless enough. But type ‘Angry Birds addiction’ into Google and you’re presented with 3.24 million results. So many people complain about being addicted to the game that it has spawned self-help pages all over the internet. Some of these pages ask whether Angry Birds addictions are changing people’s brains. Self-described addicts say they don’t know why they can’t put the game down, and talk about compulsively tracing their fingers on tables as they subconsciously recall the catapult action of the game. These sound suspiciously like the little rituals associated with alcoholism and drug abuse.
Again, perhaps a degree of scepticism is called for: it can only be a matter of time before some opportunistic researcher diagnoses ABAD – Angry Birds Addiction Disorder (which would presumably be a particular strain of IAD, since the game is played mostly on iPhones). No doubt the Angry Birds craze will fade, as these crazes always do. But it may well leave behind a residue, in the form of the compulsive instinct to perform repetitive actions.
It’s not a conspiracy theory to suggest that the primary task of iPhone game developers is learning how to manipulate our brains’ reward circuits. They cheerfully admit as much. At the 2010 Virtual Goods Summit in London, Peter Vesterbacka, lead developer for Rovio, the company behind Angry Birds, described how they make the game so addictive. ‘We use simple A/B testing to work out what keeps people coming back,’ he said. ‘We don’t have to guess any more. With so many users, we can just run the numbers.’14 (#litres_trial_promo)
We can just run the numbers. Remember those words. Where previously advertising and marketing were more creative disciplines that involved a huge element of risk, a new generation of manufacturers doesn’t need to guess what will keep us coming back for our fix: they already know.
Viewers of House, America’s most popular medical drama – and at one time the most watched television programme in the world – are familiar with the sight of Dr Gregory House, the snide, sexy, crippled antihero, tipping back his head and tossing a couple of Vicodin into his mouth. He’s even been known to throw a pill into the air and catch it like a performing seal. The screenplays go out of their way to portray House as an addict: several times we’re shown him shivering and sweating his way through opiate withdrawal. But, in the end, the Vicodin is as integral to his charm as his twisted humour. The one fuels the other.
Although Dr House, played brilliantly by Hugh Laurie, is prescribed the drug to dull the pain of a leg injury, he also uses it to stave off boredom and stimulate his work as a diagnostic detective. Any similarity to the cocaine-injecting Sherlock Holmes is surely intentional. But only the very earliest Holmes stories actually depict drug abuse: Arthur Conan Doyle, worried that he might encourage addiction, quickly made his hero abandon the vice. Not so the makers of House, who have sustained the central character’s dependence on Vicodin despite criticism from some medical professionals (and, reportedly, the Drug Enforcement Agency).
‘Since the first episode I have been concerned with the show’s message and have attempted several times to educate the writers and producers regarding the danger of Vicodin abuse,’ wrote one physician, coincidentally named Dr John House, who specialises in hearing loss, a devastating side effect of Vicodin.15 (#litres_trial_promo) He lobbied long and hard for this symptom to be recognised in House and eventually it was, albeit in a throwaway line. (As I write, the series is coming to an end, and so far one symptom that hasn’t been mentioned, so far as I can tell, is the awful constipation it causes: a truly realistic scenario would force the good doctor to spend most of the season straining on the lavatory.) The fictional House does succeed in giving up Vicodin after suffering rather implausible hallucinations caused by the drug and completing a period of rehab, but after a couple of seasons he is shown relapsing.
Vicodin was already a fashionable recreational drug when the show first aired in 2004. It was passed around like after-dinner mints at Manhattan dinner parties. In 2001, USA Today described Vicodin as ‘the new celebrity drug of choice’. Matthew Perry, one of the stars of Friends, had already gone into rehab for his addiction to it – twice. Eminem had a Vicodin tattoo on his arm. David Spade joked about it at the Golden Globes. ‘Who isn’t doing them?’ asked Courtney Love. ‘Everyone who makes it starts popping them.’16 (#litres_trial_promo) Celebrities favoured it for the same reason other users did: it was (and is) relatively easy to persuade doctors to prescribe it. In the US, Vicodin falls into the Schedule III category, less tightly controlled than stronger opiate painkillers such as Oxycontin, classified as Schedule II. You can phone in a prescription for Vicodin to a pharmacy; for Oxycontin, you have to hand over a physical script.
So by the time the first House screenplays were being written in 2003, Vicodin was already as famous for its recreational buzz as for its painkilling properties. When the show became a hit, Associated Press writer Frazier Moore suggested that its success was thanks to the way it ‘fetishises pain’. In other words, millions of Americans on painkillers could identify with Dr House’s suffering.17 (#litres_trial_promo) If true, that’s only part of the story. The scripts often refer to Greg House’s pain, caused by the removal of leg muscles after a thigh aneurysm. But much of the sharpest humour centres around House’s schoolboy naughtiness in trying to score more pills than he has been prescribed. That isn’t the fetishisation of pain: it’s the fetishisation of Vicodin. An unofficial range of House T-shirts, still on sale in 2011, includes one that reads: ‘Wake up and smell the Vicodin’. The same logo, accompanied by a photo of Hugh Laurie looking spaced out, is also available as desktop wallpaper for your computer.
Meanwhile, the embedding of the drug in other parts of popular culture continues apace.
‘The Vicodin Song’, by singer-songwriter Terra Naomi, has been watched on YouTube more than half a million times. It’s an appropriately sleepy ballad which begins: And I’ve got Vicodin, do you wanna come over?
The most popular comment on the thread underneath the YouTube video reads: ‘When I listen to this I think of Dr House :)) This song is really cool.’18 (#litres_trial_promo) Many of the 2,000-plus comments, however, aren’t about the song or the show. They’re about how much Vicodin you can take recreationally without hurting your liver. It’s a vigorous debate:
FreeWhoopin1390: Well vicodin (aka hydrocodone) gives you a good calm high. It’s a super chill high to be honest. Now some people might try and tell you that 20–25 mg gets you high, let me start by saying those people are idiots. 20–25 mg will give you a relaxed small buzz for the first time. If you want a really good calm high that lasts for a while take 35–40 mg. I say 40 for the first time but that’s just me. Word of caution tho, do not exceed 4000 mg of tylenol [paracetamol] which is in vicodin, in 24 hours.
Thebluefus: If you get 40 mg of hydrocodone by taking vicodin you have reached the max for tylenol. You don’t need that much to get high, especially as a first time. Just two vicodin will get you the feeling. Don’t be stupid.
FreeWhoopin1390: Are you fucking stupid? The max for tylenol is 4000 mg a day. I take 50 mg of hydrocodone at once (they are 10/500). Which means they have 10 mg hydrocodone and 500 mg tylenol. Which means I am taking 2500 mg of tylenol. Which is nowhere near the max daily dosage. But thank you for sharing what you don’t know.
There are also catfights about the respective virtues of Vicodin and Oxycontin and a discussion of the regional variations in street prices. From time to time someone interrupts to say that they take Vicodin for real pain and that these junkies should be ashamed of themselves. But there are also commenters who were legitimately prescribed the drug who are now junkies themselves. They may resent being a slave to Vicodin or they may enjoy the high; perhaps a bit of both. What should we make of a comment like this?
1awareness: Bragging about pills is lame. I’m using them to make fibromyalgia feel less intense. I also have seizures which cause a lot of pain. I enjoy Vicodin.
These are commenters who describe themselves as Vicodin ‘users/abusers’, a term that neatly captures the ambiguity of prescription drug abuse. All mood-altering drugs, from Scotch whisky to crack cocaine, can be abused: you can harm yourself by taking too much of them. But the vast majority are supposed to intoxicate, even when consumed in ‘safe’ quantities. The Vicodin abuser, on the other hand, is hooked on a drug that the manufacturers insist isn’t designed to alter moods. To further complicate matters, if the abuser is in real pain, it can be hard to tell whether he or she is merely over-medicating or enjoying an extra recreational buzz on top of the pain relief – Dr Gregory House likes to keep his colleagues guessing on this point. But that sort of confusion doesn’t make Vicodin dependence any less difficult to manage; it just means that, like so many 21st-century addictions, it is difficult to categorise and therefore difficult to treat.
As if these problems weren’t bad enough, it was revealed at the beginning of 2012 that several drug companies were working on hydrocodone pills that were potentially ten times as strong as Vicodin. The new pills would be ‘safer’ than Vicodin, according to Roger Hawley, chief executive of Zogenix, because they wouldn’t contain the paracetamol that harms the liver. Maybe so; but their time-release formula would also allow abusers to crunch them up for one hell of a hit. Zohydro, as Zogenix plans to call the drug, is scheduled for release in 2013.
This is just a guess, but it wouldn’t surprise me if, all over America, clued-up Vicodin users are already telling their doctors that their pain is getting worse and maybe they could use something a little stronger …
The addictive qualities of cupcakes, iPhones and Vicodin aren’t immediately obvious. Someone encountering a cupcake for the first time since childhood doesn’t think: uh-oh, I’d better be careful not to develop a sugar addition that triggers an eating disorder and end up washing the sick out of my hair. Likewise, people buying their first smartphone don’t worry about developing an obsessive-compulsive relationship with a computer game, and until recently the recreational use of painkillers was almost unheard of. In other words, as unqualified consumers we’re increasingly tempted by products about whose effect on our brain we know virtually nothing. We may not even notice the burst of tension-relieving pleasure they provide – at least, not until we realise that we can’t live without them.
Using substances and manipulating situations to fix your mood isn’t new. It’s the pace, intensity, range and scale of this mood-fixing that is unprecedented, irrespective of whether it involves drugs, alcohol, food or sex.
Put simply, both our need and our ability to manipulate our feelings are growing. We’re always searching for new ways to change the way we feel because, to state the obvious, we’re not at ease with ourselves. That’s a very broad-brush statement, so let me try to be more specific. Our ancestors were unable to insulate themselves from fear and despair in the way that we try to: certain forms of unhappiness, such as grief at the death of children, were more familiar to them than they are to us. Nor did they possess many fixes to address those feelings – and, in any case, experiences of such intensity aren’t easily fixed, even in the short term. We, on the other hand, struggle with small but inexorable and cumulative pressures in our daily lives. These produce a free-floating anxiety that is susceptible to short-term fixes.
The hi-tech world that ratchets up the pressure on us also yields scientific discoveries that speed up the flow of pleasure-giving and performance-enhancing chemicals in our brains. Indeed, producers and consumers collude vigorously in this process, which helps us cope with commitments that we feel are beyond our control. (Note, incidentally, how the verb ‘to cope’ has invaded so many areas of human activity: sometimes it seems that we need a ‘coping strategy’ just to go to the bathroom.) The jokey phrase ‘retail therapy’ has entered the language for a good reason. We, as consumers, know that the instant gratification of a purchase goes beyond simple pleasure at acquiring something new – it can change the way we feel about everything, albeit only for a short time. Manufacturers are well aware of it, too. They know they are the purveyors of fixes, and that the moment their fixes fail is the moment they start losing market share.
The problem is that these increasingly complex interactions between producers and consumers are also increasingly unpredictable, especially in their effects on the human body. It’s not possible to predict with any accuracy the sorts of relationships that people will form with the substances and experiences thrust at them. Neuroscientists are learning new things about our reward systems all the time, but they’ll admit privately that the attempt to turn these discoveries into drugs that target specific mental disorders have been shockingly hit-and-miss. Meanwhile, the rest of us know only one thing about those reward systems: how to stimulate them.
In other words, we are sitting in front of the controls of a machine whose workings are basically a mystery to us. And someone has just handed us the ignition keys.
2 (#u1b752989-d442-5211-8933-8d687b802192)
IS ADDICTION REALLY A ‘DISEASE’? (#u1b752989-d442-5211-8933-8d687b802192)
‘When people ask why I don’t drink, I explain that I’m allergic to alcohol. But really, it’s a disease. We all have it – everyone in this room.’
The speaker was Pippa, a former actress in her sixties with dyed auburn hair and scarlet lipstick applied so thickly that her mouth looked like a clown’s. This may sound rude, but of all the AA regulars gathered round the trestle table in the church hall she was the easiest to imagine as a drunk. She had what my father used to call ‘a whisky voice’, though she hadn’t touched a drop for 15 years. ‘I behaved in a very unladylike fashion,’ she recalled. ‘And I don’t know if you agree with me, but I think there’s something particularly undignified about the sight of a drunk woman.’
This produced a sniffle of feminist disapproval from a couple of young women in the room, who looked like business executives: the meeting was hosted by one of the Wren churches in the City of London. But no one argued with Pippa’s claim that she suffered from a disease. I attended those lunchtime meetings three times a week in the shaky few months after I stopped drinking, and never once did I hear alcoholism described as anything other than a physical illness. ‘Allergy’ was one description; much more common was the phrase borrowed from the ‘Big Book’, the bible of Alcoholics Anonymous – ‘a cunning, baffling and powerful disease’.
I had no doubt that I was an alcoholic. Alcoholism is the name for addiction to alcohol, and therefore I was also an addict – a useful word to describe someone who indulges in a pursuit so excessively that it harms them. The AA fellowship kept me away from alcohol thanks to the remarkable power of peer-group moral support, and especially the support of strangers, which has its own special potency. But I never thought my alcoholism, or any form of addiction, was a disease. Wisely, though, I kept that opinion to myself at those lunchtime meetings.
Lots of the attendees, Pippa included, seemed almost proud they had this ‘disease’. They talked about it in the defensive but boastful manner in which, years later, people would discuss their recently discovered ‘food intolerances’. They also referred all the time to ‘the alcoholic personality’, as if everyone who ended up in the rooms shared deeply rooted personality traits. Again, I couldn’t see it: on the contrary, I was surprised by how little the members of the fellowship had in common. But if I’d questioned any aspect of the AA worldview, I’d have been corrected immediately: ‘Don’t you dare tell me I haven’t got a disease!’ Or I’d have been fobbed off with words of wisdom: ‘Alcoholism is the one disease that tells you that you haven’t got it’ – an infuriating AA epigram designed to close down debate rather than open it up.
Alcoholics Anonymous dates its foundation from 1935, when it changed from a specifically Christian mission to drunks into an independent fellowship of self-help groups with a strong but deliberately all-inclusive religious ethos. Since then, AA has achieved two extraordinary things. First, it has saved the lives of innumerable drunks. I’m probably one of them, so I feel a bit churlish suggesting that its other major achievement – the dissemination of the disease model – has distorted the modern world’s understanding of addiction.
The fellowship’s first medical adviser, the psychiatrist Dr William Duncan Stillworth, declared: ‘Alcoholism is not just a vice or a habit. This is a compulsion, this is pathological craving, this is disease!’1 (#litres_trial_promo)
This disease is both incurable and progressive, according to AA. The only way to keep its symptoms under control is by a programme of total abstinence based on the famous 12 steps to recovery. In Step 1, sufferers acknowledge their powerlessness over alcohol. Other steps tell them to seek help from God, examine their character defects and make amends for the harm they caused when they were drinking. But – and this is the crucial point – AA reassures them that they cannot be blamed for the wreckage of their lives, because the disease robbed them of their free will.
This raises an obvious question. What about heavy drinkers who give up alcohol of their own accord, without any help from AA or the steps? The fellowship’s answer is a masterpiece of circular logic. Since these drunks exercised free will in stopping drinking, and since the disease of addiction robs you of your free will, they cannot have had the disease and were therefore never alcoholics in the first place.
That AA formula has had an extraordinary appeal for generations of ex-drinkers. The organisation has 1.2 million members in the United States who attend 55,000 meeting groups; there are over two million members worldwide. The fellowship is sometimes described as a religious movement, but it would be more accurate to describe it as a self-help group with religious overtones. The Big Book talks explicitly about God, though it adds that ‘God’ is shorthand for ‘a power greater than yourself’. That power can be a supernatural being or (for atheists and agnostics) simply the fellowship itself.
The disease model, enshrined in the 12 steps, has spread everywhere, perhaps thanks to the fact that AA has never attempted to copyright it. It’s happy for anyone to borrow its formula. As Brendan Koerner put it in Wired magazine, the 12 steps became ‘essentially open source code that anyone was free to build on, adding whatever features they wished’.2 (#litres_trial_promo)
As a result, there are around 200 separate 12-step fellowship networks covering all sorts of addictions. Narcotics Anonymous and Gamblers Anonymous have flourished since the 1950s, Overeaters Anonymous since 1960. Marijuana, cocaine, crystal meth and nicotine have their own 12-step programmes. (In Nicotine Anonymous, being tobacco-free is referred to as being ‘smober’.) There are fellowships dedicated to sex addiction and co-dependence. Online Gamers Anonymous was founded in 2002.
These groups have their own take on the 12 steps, but they leave intact the part of the open-source code that identifies addiction as a disease. Indeed, the vast majority of professional addiction specialists also embrace it. When Alcoholics Anonymous tells its members that medical opinion overwhelmingly thinks of addiction as a disease, it is telling the truth.
But that doesn’t mean that medical opinion is right. On closer examination, many specialists derive their ideas from 12-step groups rather than the other way round. Let me illustrate why I think the disease model is flawed by telling the stories of two addicts who were friends of mine.
In the late 1990s I got to know two young men, Robin and James, who had been inseparable at university. They were in their late 20s, bright, charming and socially ambitious. Both had been to minor public schools but neither had got into Oxford or Cambridge, so when they arrived at their redbrick university they had to settle for its wannabe Brideshead drinking societies. At least once a fortnight they would dress up in black tie and perform the charming party tricks they associated with Oxbridge – climbing up scaffolding and urinating on pedestrians, that sort of thing. When their hangovers allowed, they read Evelyn Waugh, whose cruel snobbery delighted them. They were less keen on textbooks and, despite fluent pens, did badly in exams.
After university they drifted from one undemanding job to another, in the process spending more and more time in the company of ex-public school wasters who used hard drugs. Neither Robin nor James was especially rich, but both had just enough private money to feed their dealers. Eventually they replaced their office jobs with ‘freelance’ occupations that didn’t require raising their heads from the pillow until the first of the afternoon soap operas. Both sets of parents were in despair, and raided their savings to pay for expensive spells in rehab that achieved nothing.
By 2000 the two men were boringly obsessed with getting high on any psychotropic substance they could lay their hands on, ranging from heroin to painkillers. At around that time I had a wisdom tooth taken out in the dentist’s chair and was given a supply of dihydrocodeine tablets that I didn’t take because they made me nauseous. I mentioned this to James, and within half an hour Robin was on the phone. ‘I hear you’ve got some DF118s,’ he said. I checked the label. Yes, that was what it said. ‘Since they make you puke, why not let me take them off your hands?’ he asked.
Robin and James were, or seemed to be, the most irredeemable addicts I’ve ever met. I was relieved when they drifted out of my life. I once caught sight of James hovering around the wines and spirits section of a supermarket in Bristol: this was the heyday of dirt-cheap own-brand vodka, and judging by the contents of his trolley he was taking full advantage of the special offers.
And now, five years later? Robin has a steady girlfriend, a baby daughter and a job in social media that has enabled him to start paying off his mortgage. He and his family are about to move to San Francisco, where he will work for an internet start-up. He gave up drink and drugs slowly, cutting out one substance after another, without relying on the 12 steps for guidance. ‘They just remind me of the bad old days in rehab,’ he explains. ‘My home-made recovery was a long and messy business, with plenty of false starts, but it did work in the end.’
James is dead. He killed himself by jumping from the fifth floor of an apartment block in Johannesburg in 2006. It seems to have been a spur-of-the-moment thing, but who knows? He didn’t leave a suicide note.
How can we explain the difference in the fates of the two friends? The 12-step explanation would be that Robin was never a real alcoholic or addict, since he cured himself without following the principles of the programme. He did attend AA and NA meetings, both in and out of clinics, but found them useless. ‘AA members kept regaling me with these over-polished anecdotes about their miraculous recoveries, while the NA meetings seemed to be full of people who’d been clean for a couple of days and were obviously hoping to score.’
James, in contrast, met the sort of grisly fate that, according to the Big Book, awaits most untreated addicts. In the eyes of the fellowship, his leap from the balcony proved that he was the genuine article. One of the least attractive characteristics of 12-step ‘old-timers’ is the relish with which they describe disasters that befall those who stray from the true path.
But suppose that Robin and James had died at the same time, at the height of their drinking and drug-taking. (Robin did nearly kill himself with an accidental overdose, so it’s not an unlikely scenario.) Would a post-mortem on their brains have been able to establish which of them had the ‘progressive disease’ of addiction and which was just going through a phase? The answer is no.
Moreover, if Robin and James had been subjected to a battery of tests when they were still alive, it’s extremely unlikely that any of those tests would have distinguished between the ‘real’ alcoholic, doomed without 12-step treatment, from the ‘fake’ or temporary one, capable of curing himself. My guess is that the doctors would have said, correctly: both these young men are addicted to alcohol and drugs. But if the doctors were 12-step believers, as so many are, they might have added that neither of them could cure himself. Robin would have proved them wrong.
If you doubt that addiction medicine is heavily flavoured by 12-step dogma, let me point you in the direction of one of the most recent, supposedly authoritative, definitions of addiction by doctors specialising in the subject. It was published in 2011 by the American Society of Addiction Medicine (ASAM), which represents physicians who work with chemically dependent patients.
‘Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry,’ it declares. ‘Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviours.
‘Addiction is characterised by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviours and interpersonal relationships, and a dysfunctional emotional response.
‘Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.’3 (#litres_trial_promo)
This is what a definition looks like when it has been drafted by a committee. The 80 doctors who worked on it seem to have thrown everything at it but the kitchen sink. But what their definition cannot conceal – indeed, what it inadvertently reveals – is that addiction is far too complex a phenomenon for doctors to classify as a disease in the sense that cancer and tuberculosis are diseases. Hence the waffle.
Addiction specialists wouldn’t tie themselves in such knots if they had a diagnostic test for the ‘disease’ of addiction. But there is no such test.
Not only is addiction unlike cancer and diabetes, which show up in lab results. It’s also unlike brain diseases such as Alzheimer’s. That, too, lacks a simple diagnostic test: in its early stages its symptoms can be mistaken for stress or other forms of dementia. But eventually the involuntary behaviour of the patient should allow the doctor to make an accurate diagnosis, after which its progress is truly inevitable. There is no 12-step programme for Alzheimer’s to keep its symptoms under control. The end point is death, after which an autopsy will probably reveal shrinking of the brain that provides final confirmation of the diagnosis.
I’m not saying that medicine can’t identify addiction in the ordinary sense of the word: of course it can. Scientists can test for chemical dependence on a drug. They can measure a patient’s tolerance for it and predict the withdrawal symptoms. They can identify the precise damage caused by substance abuse and hazard a guess as to life expectancy. They can look at a patient and say: this person is an addict.
But what they can’t tell, even with brain-scanning technology, is whether a neurochemical ‘switch’ has been thrown which induces irreversible addiction, which is what disease-model advocates are now suggesting. We don’t even know whether such a switch exists. It’s a fashionable theory, but that’s all it is.
Post-mortems can’t identify a disease of addiction, either. A dead body may reveal organ damage caused by taking a particular drug, but it won’t necessarily tell doctors much about the behaviour that accompanied it. You can’t know from looking at the liver of someone who drank themselves to death whether their drinking followed classic addictive patterns. People develop fatal cirrhosis of the liver – a proper disease by any definition – from regular wine consumption that isn’t compulsive in character. Non-alcoholics in France die from this sort of drinking all the time. Likewise, the body of an obese person won’t tell you whether they ate addictively. Their obesity may have been caused by an illness that stopped them exercising, for example.
Why, then, is the ASAM definition of addiction so confident in its claim that addiction is a ‘primary, chronic disease’ – an assertion that it proceeds to justify with woolly and overlapping generalisations?
At the risk of sounding like a conspiracy theorist, I think the answer lies in the role of 12-step groups in devising the treatment programmes run by the doctors in ASAM.
There’s a bit of a giveaway in the definition. This says that dysfunction in the brain’s rewards circuits leads to characteristic ‘spiritual manifestations’. I’ve heard that phrase before. During my AA years, as I sat drinking powdered coffee in draughty basements, it was drummed into me that alcoholism was a spiritual disease. That is Big Book teaching; you hear it in virtually every meeting. But if you’re trying to define addiction, you run up against a problem: there is no agreed methodology for measuring ‘spiritual manifestations’. How could there be? In all my years spent studying the sociology of religion, I never came across an agreed definition of ‘spirituality’. It’s just the sort of concept that scholars fight over.
Many addiction specialists have a habit of throwing around words as if everyone agreed on their meaning. They’ll use a term like ‘compulsion’ without exploring the philosophical questions it raises about free will. They wander into other disciplines – philosophy, sociology and theology – without seeming to realise they’re doing so. Nothing must be allowed to challenge the one-size-fits-all model of the 12 steps.4 (#litres_trial_promo)
According to the psychologist Dr Stanton Peele, a long-standing critic of disease-centred definitions of addiction, ‘the American Society of Addiction Medicine was created – and is dominated – by true-believer 12-step types’.5 (#litres_trial_promo) Peele argues that AA preserved the temperance movement’s message of total abstinence – deeply rooted in American Protestant society – while relieving guilt by naming illness rather than sin as the cause of addiction. Also, 12-step advocates have proved to be expert lobbyists, persuading health institutes that theirs is the only recovery programme that works, and influencing judges and magistrates to send criminals on compulsory 12-step courses. Most substance abuse treatment in the US is based on 12-step models.6 (#litres_trial_promo)
Unfortunately, the media rarely bother to question the assumptions and allegiances that lie behind the pronouncements of addiction specialists. ‘Addiction is a brain disease, experts declare,’ said the LA Times when ASAM published its definition. ‘Addiction a brain disorder, not just bad behaviour,’ said USA Today.
But the most enthusiastic coverage came from The Fix (no relation to this book), an upmarket website aimed at recovering addicts with disposable incomes. It declared: ‘If you think addiction is all about booze, drugs, sex, gambling, food and other irresistible vices, think again. And if you believe that a person has a choice whether or not to indulge in an addictive behaviour, get over it.’ ASAM had blown the whistle on these notions, said The Fix, by revealing addiction to be a fundamental impairment in the experience of pleasure that ‘literally compels’ the addict to chase the chemical highs produced by drugs, sex, food and gambling.7 (#litres_trial_promo)
Note the finger-wagging tone of the article. If you think choice is involved in addictive behaviour, ‘get over it’. I can imagine Pippa nodding her head vigorously at that. When I showed the article to Robin, the former alcohol and heroin addict, he smiled and said: ‘That’s exactly the sort of take-it-or-leave-it message I heard every day when I was in treatment.’
Robin was in a rehab unit run by the Priory, a fashionable and expensive healthcare provider which specialises in alcohol and drug treatment and is best known for its celebrity alumni, who include Kate Moss, Robbie Williams, Courtney Love, Pete Doherty and the late Amy Winehouse. (As that list suggests, its track record is patchy at best.) Robin told me about his experience of the treatment there.
When I was in the Priory, all the doctors and counsellors emphasised the disease concept. We had lectures in the afternoons. One was from the medical director, a psychiatrist, on the disease concept. You have a disease, the disease of addiction, ‘dis-ease’, etc. When I asked him for the evidence, he said things like ‘we can see that the metabolic pathways are different in alcoholics’. Well of course they are, because the booze, not the ‘disease’, has changed them. I didn’t think he was being very intellectually honest, but he was the expert and if we had different ideas that was just evidence of the alcoholic’s arrogance.
As for the counsellors, they kept talking about ‘the illness’. Your illness, my illness. ‘My illness tells me I’m a bad person.’ The reason for this emphasis was that ‘it’s a shame-based illness’, and the whole point is to get away from the idea that you’ve been a wicked person and you should be ashamed – such ‘stinking thinking’ might cause you to fall into a ‘shame spiral’, and shame leads you to ‘pick up’ the next drink or drug.
You’d absorb the illness chat pretty quickly, but I could never bring myself to talk in terms of ‘my illness’ – it just seemed too pat and convenient to take away responsibility and turn your addiction into something outside yourself.
Addiction specialists would reply that of course they’re not saying the disease is ‘outside’ people. But the way they talk about addicts sometimes implies that sufferers are under the control of a malign puppetmaster.
There are recognised brain diseases which, like addiction, manifest themselves as behaviour – the jerking limbs of Huntingdon’s, for example. But it’s a funny sort of primary, chronic, brain disorder that makes you drive yourself to the pub, sink seven pints of beer with whisky chasers, and then drive yourself back, turning your car into a weapon of mass destruction.
In fact, there’s a world of difference between involuntary, chaotic spasms and long sequences of actions that look perfectly voluntary, if misguided, to anyone observing them. Professor John Booth Davies, director of the Centre for Applied Social Psychology at the University of Strathclyde – and one of Britain’s most prominent opponents of the disease model – makes the point that if a disease can force people to steal, to lift up glasses, or to stick needles in their arms when they’re actually trying not to, then any goal-directed behaviour could be a symptom of disease.8 (#litres_trial_promo)
The behaviour of addicts looks voluntary because it is. However intense the temptations offered by substances and experiences, there will always be people who, having given in to them, change their mind and pull themselves out of addiction.
As we’ve seen, AA brushes aside this phenomenon with unbreakable circular logic: if you cure yourself, you were never an addict. Medically qualified addiction specialists basically agree, though they usually espouse a more nuanced version of the disease theory. They don’t deny that some addicts appear to cure themselves – but they treat such cases as outliers or questionable diagnoses. The official line remains that, to quote the Sourcebook on Substance Abuse, ‘the majority of individuals who receive treatment for substance abuse relapse’.9 (#litres_trial_promo) Clinical reports that between 50 and 60 per cent of patients relapse within six months of ending treatment are accepted as evidence of the power of the disease.
There’s something wrong with this methodology, however, as Gene M. Heyman, a hospital research psychologist and lecturer at Harvard University, points out.
‘Most research is based on addicts who come to clinics,’ he says. ‘But these are a distinct minority, and they are much more likely to keep using drugs past the age of 30 – probably because they have many more health problems than non-clinic addicts. They are about twice as likely to suffer from depression, and are many times more likely to have HIV/AIDS. These problems interfere with activities that can successfully compete with drug use. Thus, experts have based their view of addiction on an unrepresentative sample of addicts.’10 (#litres_trial_promo)
Heyman went looking for large-scale studies of addiction in the US based on more representative samples of addicts in the general population, not just in clinics. He found four of them, carried out by leading researchers and funded by national health institutes.11 (#litres_trial_promo) Yet, mysteriously, the clinical texts and journal articles spreading the message of a ‘primary, chronic, relapsing disease’ fail to mention these epidemiological studies. Why?
Could it have been because none of the surveys found that most addicts eventually relapse? What they suggested, inconveniently, was that between 60 and 80 per cent of individuals who met the criteria for lifetime addiction stopped using drugs in their late twenties or early thirties. In short, high remission rates would seem to be a stable feature of addiction.12 (#litres_trial_promo)
In 1970 there was a shockingly sudden burst of heroin addiction among GIs in Vietnam. As Alfred McCoy describes in his book The Politics of Heroin, until 1969 the ‘Golden Triangle’ of south-east Asia was harvesting nearly a thousand tons of raw opium annually – but there were no laboratories capable of turning it into high-grade heroin. That changed when Chinese master chemists from Hong Kong arrived in the region. Suddenly South Vietnam was full of fine-grained No. 4 heroin instead of the impure, chunky No. 3 grade.
‘Heroin addiction spread like the plague,’ writes McCoy. ‘Fourteen-year-old girls were selling heroin at roadside stands on the main highway from Saigon to the US army base at Long Binh; Saigon street peddlers stuffed plastic vials of 95 percent pure heroin into the pockets of GIs as they strolled through downtown Saigon; and “mama-sans”, or Vietnamese barracks’ maids, started carrying a few vials to work for sale to on-duty GIs.’13 (#litres_trial_promo)
By the summer of 1970, virtually every enlisted man in Vietnam was being offered high-quality heroin. Almost half of them took it at least once; between 15 and 20 per cent of GIs in the Mekong delta were snorting heroin or smoking cigarettes laced with it. Ironically, heroin use soared after the Army cracked down on the much more easily detectable habit of smoking pungent marijuana. But the key factor, argues McCoy, is that drug manufacturers could make $88 million a year from selling heroin to soldiers; no wonder that ‘base after base was overrun by these ant-armies of heroin pushers with their identical plastic vials’. Rumours spread that the North Vietnamese were behind this intense marketing campaign – what better way to immobilise the enemy? But the truth was that South Vietnamese government officials were protecting the pushers.
In any case, combat troops avoided heroin use in the field: being stoned, especially on a drug as soporific as heroin, was more likely to get them killed. But they made up for it when they returned to base. One soldier came back from a long patrol of 13 days; his first action was to tip a vial of heroin into a shot of vodka and knock it back.14 (#litres_trial_promo)
Panicky headlines about the ‘GI epidemic’ started appearing in American newspapers. The Nixon administration was terrified of a crime wave caused by the return of thousands of desperate junkies to American cities. But it never materialised. Instead, the addicted soldiers cleaned up their act – fast.
We know this because the US government, anticipating disaster, commissioned a medical study that recruited more than 400 returning soldiers who snorted, smoked or injected heroin and described themselves as addicted (making it possibly the largest ever study of heroin users). To researchers’ surprise, back in the United States only 12 per cent of these addicts carried on using heroin at a level that met the study’s criteria for addiction.15 (#litres_trial_promo)
This is really powerful evidence that changes in social environment can dramatically affect people’s drug-taking habits. As Professor Michael Gossop, a leading researcher at the National Addiction Centre, King’s College, London, explains: ‘The young men who served in Vietnam were removed from their normal social environment and from many of its usual social and moral constraints. For many of them it was a confusing, chaotic and often extremely frightening experience and the chances of physical escape were remote except through the hazardous possibilities of self-inflicted injury.’16 (#litres_trial_promo) Gossop uses the phrase ‘inward desertion’ to describe what heroin offered the soldiers: a cheap trip to another world.
The scared, disorientated soldiers in Vietnam were being offered a chemical fix to relieve their fear. The social and psychological pressure to do something they would never dream of doing in America – take heroin – was intense: one in five slid all the way into addiction. But, once home again, they weren’t scared any more. They weren’t mixing with other users. The drug was expensive, hard to find, low-grade and highly illegal. The pressure went into reverse. In other words, the same combination of social and psychological factors that turned these men into addicts explains why they were able to stop.
True, these were remarkable circumstances. So we might expect other addicts, whose initiation into drug use was less dramatic and more gradual, to recover at a slower rate. And that’s precisely what those four big epidemiological studies show: they paint a picture of users slowly changing their behaviour when their circumstances changed. They don’t support the progressive disease model. The Vietnam statistics, meanwhile, directly undermine it. The US government went to a lot of trouble to make sure that the soldiers it was testing were addicts. Are we supposed to believe that the 88 per cent who later kicked the habit were misdiagnosed? Or that being drafted to fight in heroin-saturated Vietnam ‘doesn’t count’ because it was such an unusual situation?
The Vietnam survey identifies a key factor in addiction: availability. To quote Michael Gossop: ‘Availability is such an obvious determinant of drug taking that it is often overlooked. In its simplest form the availability hypothesis states that the greater the availability of a drug in a society, the more people are likely to use it and the more they are likely to run into problems with it [my italics].’17 (#litres_trial_promo)
This hypothesis might seem like a statement of the obvious. Actually, as Gossop says, the question of availability is often treated as a secondary factor, less important than any predisposition to a so-called ‘disease’.
Gossop identifies different dimensions of availability. There’s physical availability, obviously, but also psychological availability (whether someone’s personality, background and beliefs increases their interest in using particular drugs), economic availability (whether the drugs are affordable) and social availability (whether the social context encourages use of the drugs). In the case of Vietnam, he points out, many soldiers found that all the boxes were ticked. Troops in Thailand, by contrast, could easily get hold of heroin – but their lives were not in danger, they were free to move among a friendly population and their peers were not using it. Less than one per cent of military personnel took the drug.18 (#litres_trial_promo)
Availability doesn’t offer a comprehensive explanation for addiction, but it reminds us that we cannot hope to understand why people engage in addictive activities – be it shooting up heroin in the jungle or gorging on muffins in Starbucks – unless we take account of what that activity means in its social setting.
No one who has watched The Wire, the magnificent television epic of life in drug-saturated districts of Baltimore, can seriously propose that it depicts a black population afflicted by chronic disease. The characters in the show who smoke heroin do so, basically, because they live in districts where everyone does. If I lived there, I’d be a smack addict. Since I’m an addict, perhaps that goes without saying. But I have a sneaking feeling that even my local vicar would be hooked on the stuff.
Gossop, who has advised the British government on drug policy, is unusual among addiction experts for the bluntness with which he dismisses the disease theory. He describes addiction as a ‘habit’. That may sound less scary than an irreversible disease, but it isn’t. In a society overflowing with abundance, the implications of a habit of addiction driven by availability are every bit as alarming as those of a disease that strikes only individuals with malfunctioning brains.
This isn’t to deny that some people are naturally more vulnerable to addiction than others. And we can’t ignore recent discoveries in neuroscience, which show how the brain’s natural reward systems are being hijacked by newly available substances and gadgets. In the next chapter, we’ll look at what the brain does and doesn’t tell us about addiction.
But I want to end this chapter by stressing, yet again, the inadequacies of the disease model. If the word ‘disease’ is at all useful in this context, it’s as a metaphor for addiction, not as a diagnosis. And I can think of another vivid metaphor that works just as well. Modern consumers are like soldiers drafted to Vietnam – disorientated, fearful and relentlessly tempted by fixes that promise to make reality more bearable. You don’t have to be ill to give in; just human.
3 (#u1b752989-d442-5211-8933-8d687b802192)
WHAT THE BRAIN TELLS US (AND WHAT IT DOESN’T) (#u1b752989-d442-5211-8933-8d687b802192)
Imagine the embarrassment. You are a retired civil servant with Parkinson’s disease. You are industrious and introverted, like many sufferers from the condition. (We don’t know for sure why it often strikes people with this type of personality, but the correlation was noted as long ago as the 19th century.1 (#litres_trial_promo)) You’re a regular at your local pub, where you’re known as a modest, affable chap who orders half-pints rather than pints. Occasionally you while away 20 minutes by pushing a few coins into the slot machine, accepting your losses with a philosophical shrug.
Then something odd happens. Without warning, you develop an obsession with playing the machine. You stand in front of it from opening time until last orders, much to the bemusement of the other regulars. You know that the pub’s fruit machine is programmed to return only 80 per cent of the money you put into it, but one day you hit multiple jackpots that earn you £50. The thrill of this experience – and the possibility of it happening again – reinforces your new preoccupation. You are no longer thinking rationally.
Eventually the teasing from other patrons turns to alarm as they see you pouring away your pension. The pub landlord has ‘a quiet word’ and asks you to stop playing. You’re mortified and stop going to the pub – but, instead of finding another place to drink, you slip into your local betting shop, where the jackpots are bigger. Then a newspaper article about online gambling catches your eye and before long you are shutting yourself away in your study, steadily building up credit card bills as you accrue greater and greater losses. Your wife still doesn’t have a clue.
But your problems don’t end there. Somewhere along the line, much to your own surprise, you discover a taste for internet pornography. Under normal circumstances, porn would have no appeal – you’re 70 years old, after all. But even before you stumbled across these sites you had noticed that your sexual appetite had mysteriously reawakened.
This story sounds implausible, but something very much like it happened to several Parkinson’s patients recently. They developed gambling urges out of nowhere, and in certain cases these were accompanied by a revived sex drive. There were other permutations: patients experienced a revved-up sex drive without the gambling urges, or started binge eating. Some began shopping obsessively, perhaps combining it with other risk-taking activities. The common thread was the startling change in the behaviour of people who, until recently, had devoted most of their leisure time to tending their begonias.
But the culprit wasn’t the disease. It was the medication designed to reverse its symptoms. The medicine wasn’t supposed to produce those results, but the fact that it did so provides us with vital information about the strange, self-defeating behaviours that we call addictions.
These Parkinson’s patients had been given drugs that mimicked the action of dopamine. This is a neurotransmitter, or chemical messenger, that affects our experience of pleasure and also has the ability to map out new reward pathways in the brain – in other words, to rewire it.
That’s a trendy way of describing complex changes in the brain. This is arguably the most impenetrable subject human beings have ever tried to understand. Scientists who have devoted their careers to it admit that they have only pieced together a tiny section of the jigsaw. That’s frustrating – but bear with me, because what they have discovered has fascinating implications. Dopamine is an ancient mechanism: it’s found in lizards and every other animal along the evolutionary tree. It has been called the ‘pleasure chemical’ because it is released whenever we eat good food, enjoy sex or take pleasure-enhancing drugs.
Recently, scientists have refined their understanding of dopamine. They now think that it has more to do with desire than pleasure – or, to use the refreshingly simple terms that now loom large in scientific discussions of addiction, with wanting rather than liking.
In a series of experiments on the brains of rats, the psychologist Kent Berridge of the University of Michigan came to the conclusion that ‘wanting’ (desire) and ‘liking’ (pleasure) are separate urges controlled by different brain circuits in humans as well as animals. That is an important discovery that we need to keep at the back of our minds whenever we think about how and why we are behaving addictively.
Dopamine is involved in both brain circuits, but its main function is to stimulate wanting; liking is more affected by the opioid system, which contains endorphins, the brain’s natural morphine-like compounds.2 (#litres_trial_promo) Of the two urges, wanting is more powerful. ‘The brain seems to be more stingy with mechanisms for pleasure than for desire,’ says Berridge.3 (#litres_trial_promo)
This helps us understand another apparently simple distinction made by scientists that we came across in Chapter 1 – between the Stop and Go impulses in the brain. The Go impulse tells us to reach out for an immediate reward; it’s ancient, it’s powerful and it’s shared with animals. As you might expect, it goes into overdrive at the prospect of food and sex. Dopamine and ‘wanting’ are central to this urge – but different levels of ‘liking’ also determine the strength of the Go message.4 (#litres_trial_promo)
The Stop impulse is highly developed only in humans. It helps us manage our Go impulse by spelling out the consequences of immediate reward. You could call it the voice of reason; it comes from the frontal lobes of the human brain. These are not fully developed in adolescents, who are therefore poor at managing the Stop impulse. This will not come as a surprise to the parents of teenage children.
Let’s return to the traumatic experience of those Parkinson’s patients. Their disease drains the brain of dopamine. Indeed, it may begin to do so decades before more obvious symptoms become apparent. That could explain why Parkinson’s seems to disproportionately affect people with introverted personalities: those self-effacing traits may not be signs of natural, life-long introversion but, rather, the first symptoms of the disease, appearing years before diagnosis.
The patients who developed sudden gambling or other impulsive habits had been given dopamine agonists, which, by boosting dopamine, usually slow down the progression of the disease. They are a common treatment and can be remarkably effective. An aunt of mine with Parkinson’s was given one of these drugs. The brightening of her personality and her fresh pleasure in everyday experiences, such as looking at her garden, seemed almost miraculous. For some patients, however, the same chemical that restored my aunt’s joie de vivre was psychological poison.
Alan Burrows, a pensioner from Queensland, was one of 100 Australians who sued the drug company Pfizer after taking its dopamine agonist medication Cabaser. He claims that it caused him to start binge gambling on ‘pokies’ (Australian slang for slot machines). Eventually, he had to sell his house to pay off his $300,000 gambling debts. ‘Once I started I had to keep going, by withdrawing money every hour, until I couldn’t get any more money,’ he said. ‘It was a compulsion to do it. You became really devious, disgusting.’5 (#litres_trial_promo)
It’s probably no consolation to Mr Burrows, but what happened to him and to the other Parkinson’s sufferers who developed compulsive habits helps us to draw the boundaries of addiction. Their ordeal suggests that dopamine is a common factor in habits that society has been slow to label ‘addictions’ because they don’t involve drugs.
After the stories of bad reactions to Parkinson’s drugs surfaced, Dr Valerie Voon of the US National Institutes of Health led a study of patients given dopamine agonists. She found that 13 per cent exhibited ‘a constellation of pathological behaviours, including gambling, shopping, binge eating and hypersexuality’.6 (#litres_trial_promo) They did so because they were being over-supplied with dopamine.
The inference we can draw from this is valuable. It seems that people who don’t have Parkinson’s disease but engage in the same pathological habits are also having problems with their dopamine levels. Gambling, obsessive shopping, binge eating, hypersexuality – note how those Parkinson’s patients found themselves caught up in the sort of activities where wanting overwhelms liking. Also, they were being driven by repetitive urges. This is typical of dopamine at work, laying down new patterns in the brain as it takes effect. As the psychiatrist Norman Doidge explains: ‘The same surge of dopamine that thrills us also consolidates the neuronal connections responsible for the behaviours that led us to accomplish our goal.’7 (#litres_trial_promo)
In other words, the more we experience dopamine-induced pleasure, the more we want to repeat the experience. But, thanks to levels of tolerance that have been raised by rewiring, the harder we have to work to repeat it to our satisfaction. That is why addicts always seem to be looking for a bigger and bigger hit.
All substance abusers experience surges of dopamine, often accompanied by craving – that is, very strong feelings of wanting. Alcohol, amphetamine, cocaine, heroin, marijuana and nicotine all increase the supply of dopamine to the nucleus accumbens, a pleasure centre buried deep in the brain that has been called the final destination of the reward pathway.8 (#litres_trial_promo)
This does not mean that addicts are people born with naturally high or low levels of dopamine, nor that they have inherited cravings that force them to keep stimulating the rush of dopamine into their nucleus accumbens. If any of these things could be proved, then the study of addiction science wouldn’t involve so much infuriating guesswork.
Different recreational drugs do different things to the brain. They produce different rewards – and different punishments. You don’t have to take them to know that; you just have to observe the behaviour of their users. It’s a bit like visiting the zoo.
Coke-heads and speed freaks gabble excitedly as they are swept along on a tide of dopamine. When that tide pulls out, they experience a particular sort of come-down. ‘Coke is the drug we save for the time after we get back from clubbing,’ says Olly, 27, a graphic designer. ‘It runs out pretty quickly. Presuming we don’t order more, by 4 a.m. everyone is getting jittery and anxious. You see people’s eyes flicking around the room wondering if anyone’s got any left. A group of four chatty and gobby friends suddenly becomes four individuals chewing the insides of their cheeks. The next morning we go for brunch to cure our hangovers but everyone’s coming down off the coke, snapping at each other. Some people feel blue for days.’
Heroin users don’t inflict logorrhea on their friends: their drug is forcing the brain to over-produce endorphins, those natural euphoria-inducing and painkilling neurotransmitters. Heroin suppresses neurotransmission in the central nervous system, which can produce an exquisitely calm feeling, particularly if your nerves were shot to pieces in the first place. This can take people to the gates of paradise, but also to hell: the come-down is long and usually profoundly depressing, because the nucleus accumbens is extremely sensitive to opioid withdrawal.9 (#litres_trial_promo)
Also, the brain’s self-regulatory process means that junkies quickly need to increase their doses to slow down neurotransmission; in severe cases, they inject themselves hourly in order to maintain a state of mental paralysis. William Burroughs, writing about his last year of addiction in North Africa, said he could look at the end of his shoe for eight hours. And if a friend had visited him and died on the spot, ‘I would have sat there looking at my shoe waiting to go through his pockets’.10 (#litres_trial_promo)
Ecstasy releases serotonin, a neurotransmitter associated with happiness; hence its users’ indiscriminate declarations of affection. ‘One of the reasons I don’t do pills is seeing how fucking annoying people are when they’re “loved up”,’ says Ollie. ‘MDMA [a purer form of Ecstasy] is even worse. You see groups of heterosexual men hugging and kissing each other. There’s this idiotic bear hugging that goes on for hours, and I’m afraid it makes me laugh when I see them at work on Monday, looking sheepish and sad.’ The sheepishness is self-explanatory; the sadness is pure dopamine deprivation.
Alcohol, meanwhile, has been called the most ruthless of all brain-hijackers. Looking back on my drinking, I now have some idea of what was happening to my body; I just wish I’d known at the time, if only to avoid some hangovers of apocalyptic proportions.
Alcohol molecules are quite unlike those of other addicting drugs. They have the ability to speed up the transmission of chemicals that excite us and also, later, those that relax us, sometimes to the point of stupor. We’re talking about a fiendishly complicated neurochemical dance that releases inhibitions and twists moods over the course of an evening. I reckon my own dopamine would peak around the third glass of red wine, which was the moment when – if I was on form – I was most fun to be around. By the third bottle the flow of mood-enhancing chemicals would have slowed down and the inhibitory neurotransmitter GABA would be in the ascendant. My voice would become slurred and my thoughts confused – but I’d be chasing the vanishing high by drinking even faster. And my friends, sensibly, would have made their excuses and left.
As for the hangovers – well, if ever I feel like going back on the sauce after 18 years I have only to cast my mind back to any of the thousand or so I inflicted on myself. Perhaps it was the ability of the alcohol molecule to insinuate itself into so many different functions of the brain that produced such all-encompassing misery. But, as we’ll see later, I eventually discovered an effective but fabulously stupid pharmaceutical remedy for those feelings.
All intoxicating experiences involve a cocktail of brain chemicals that are mixed quite differently depending on the nature of the behaviour. But dopamine is still the master drug that, in the words of the research psychiatrist Morten Kringelbach, ‘appears to encode desire’ and can make us chase after something long after we’ve ceased to derive much pleasure from it.11 (#litres_trial_promo) To quote Dirk Hansen, ‘dopamine is part of the reason why we remember how much we liked getting high yesterday’.12 (#litres_trial_promo)
As this suggests, it’s good at fastening on to cues. One sensible piece of advice that 12-step groups dole out to their members is to avoid ‘people, places and things’ that were part of their old habits. ‘If you hang around barbers’ shops, sooner or later you’re going to get a haircut,’ is an AA saying – meaning, of course, that sitting around drinking orange juice in the pub is risky for an alcoholic. The more addicted you become to something, the more sensitive you become to these cues – even after years of abstinence. Significantly, these cues are often the ‘things’ that have come to replace people in your life.
But the link between cues and desire isn’t confined to addicts. It’s part of everyday existence for people situated all along the addictive spectrum – that is, all human beings.
You don’t need to ingest any substance at all to experience a rush of dopamine: the cue is enough. The smell or even just the sight of food increases dopamine in the nucleus accumbens, the region of the brain involved in reward and motivation. It’s why our mouths water. As the psychology professors Harvey Milkman and Stanley Sunderwirth explain, this is the same type of neurochemical response that occurs when a cocaine addict sees a video of people snorting a fat line of white powder: ‘The dopamine messenger impels the organism to action, an impulse that sheer willpower cannot easily overcome.’13 (#litres_trial_promo)
I know what they mean. For some reason, watching characters drink red wine on television is more tempting for me than seeing them do it in real life; it makes me long to nip to the supermarket for a bottle of Rioja. (I don’t, I hasten to add.) Why this should be I don’t know, but in AA meetings I quite often heard speakers complain of the same thing. Some people even ‘had a slip’, to use 12-step terminology, thanks to things they had seen on screen. Cues can be made more powerful by being detached from everyday networks. This is why many slips happen when alcoholics are on holiday, away from the company of people who know they have a problem, where the booze is presented in an exotic setting that somehow detoxifies it. One businessman I know found himself – to his own astonishment – accepting a rum and coke from a stewardess on a plane flight. ‘We were so high up that it didn’t seem to count,’ he said. And thus ended the decade of abstinence of which he’d been so proud.
Milkman and Sunderwirth have produced a list of activities that boost dopamine in the nucleus accumbens. They are: crime, eating, gambling, risk-taking, sex … and hugging your loved ones. With the possible exception of hugging, there’s an addiction (or, more accurately, a huge range of addictions) lurking in all of them.
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Damian Thompson
Тип: электронная книга
Жанр: Социология
Язык: на английском языке
Издательство: HarperCollins
Дата публикации: 07.05.2024
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О книге: Addictions to iphones, painkillers, cupcakes, alcohol and sex are taking over our lives.Our most casual daily habits can quickly become obsessions that move beyond our control. Damian Thompson, who has himself struggled with a range of addictions, argues that human desire is in the process of being reshaped. Shunning the concept of addiction as disease, he shows how manufacturers are producing substances like ipads, muffins and computer games that we learn to like too much and supplement tradition addictions to alcohol, drugs and gambling. He argues that addictive behaviour is becoming a substitute for family and work bonds that are being swept away by globalisation and urbanisation.This battle to control addiction will soon overshadow familiar ideological debates about how to run the economy, and as whole societies set about “fixing” themselves, the architecture of human relations will come under strain as never before.The Fix offers a truly frightening glimpse of the future and is essential reading for fans of Naomi Klein’s ‘No Logo’, Oliver James’s ‘Affluenza’ and Francis Wheen’s ‘How Mumbo-jumbo Conquered the World’.