The association considered the matter for more than a decade while research accumulated on how gambling resembles drug addiction. Insatiable desire, preoccupation, and uncontrollable urges. The fast thrill and the need to keep upping the ante to feel the fireworks. An inability to stop, despite promises and resolve. Potenza did some of the first brain-imaging studies of gamblers and discovered that they looked similar to scans of drug addicts, with sluggish activity in the parts of the brain responsible for impulse control.
Now that the psychiatric establishment accepts the idea that addiction is possible without drugs, researchers are trying to determine what types of behaviors qualify as addictions. Are all pleasurable activities potentially addictive? Or are we medicalizing every habit, from the minute-to-minute glance at email to the late-afternoon candy break?
In the United States the Diagnostic and Statistical Manual now lists Internet gaming disorder as a condition worthy of more study, along with chronic, debilitating grief and caffeine-use disorder. Internet addiction didn’t make it.
But it makes psychiatrist Jon Grant’s list of addictions. So do compulsive shopping and sex, food addiction, and kleptomania. “Anything that’s overly rewarding, anything that induces euphoria or is calming, can be addictive,” says Grant, who runs the Addictive, Compulsive and Impulsive Disorders Clinic at the University of Chicago. Whether it will be addictive depends on a person’s vulnerability, which is affected by genetics, trauma, and depression, among other factors. “We don’t all get addicted,” he says.
Perhaps the most controversial of the “new” addictions are food and sex. Can a primal desire be addictive? The World Health Organization has recommended including compulsive sex as an impulse control disorder in its next edition of the International Classification of Diseases, due out by 2018. But the American Psychiatric Association rejected compulsive sex for its latest diagnostic manual, after serious debate about whether the problem is real. The association didn’t consider food addiction.
Nicole Avena, a neuroscientist at Mount Sinai St. Luke’s Hospital in New York, has shown that rats will keep gobbling sugar if you let them, and they develop tolerance, craving, and withdrawal, just as they do when they get hooked on cocaine. She says high-fat foods and highly processed foods such as refined flour may be as problematic as sugar. Avena and researchers at the University of Michigan recently surveyed 384 adults: Ninety-two percent reported a persistent desire to eat certain foods and repeated unsuccessful attempts to stop, two hallmarks of addiction. The respondents ranked pizza—typically made with a white-flour crust and topped with sugar-laden tomato sauce—as the most addictive food, with chips and chocolate tied for second place. Avena has no doubt food addiction is real. “That’s a major reason why people struggle with obesity.”
Science has been more successful in charting what goes awry in the addicted brain than in devising ways to fix it. A few medications can help people overcome certain addictions. For example, naltrexone was developed to treat opioid misuse, but it’s also prescribed to help cut down or stop drinking, binge eating, and gambling.
Buprenorphine activates opioid receptors in the brain but to a much lesser degree than heroin does. The medication suppresses the awful symptoms of craving and withdrawal so people can break addictive patterns. “It’s a miracle,” says Justin Nathanson, a filmmaker and gallery owner in Charleston, South Carolina. He used heroin for years and tried rehab twice but relapsed. Then a doctor prescribed buprenorphine. “In five minutes I felt completely normal,” he says. He hasn’t used heroin for 13 years.
Most medications used to treat addiction have been around for years. The latest advances in neuroscience have yet to produce a breakthrough cure. Researchers have tested dozens of compounds, but while many show promise in the lab, results in clinical trials have been mixed at best. Brain stimulation for addiction treatment, an outgrowth of recent neuroscience discoveries, is still experimental.
Although 12-step programs, cognitive therapy, and other psychotherapeutic approaches are transformative for many people, they don’t work for everyone, and relapse rates are high.
In the world of addiction treatment, there are two camps. One believes that a cure lies in fixing the faulty chemistry or wiring of the addicted brain through medication or techniques like TMS, with psychosocial support as an adjunct. The other sees medication as the adjunct, a way to reduce craving and the agony of withdrawal while allowing people to do the psychological work essential to addiction recovery. Both camps agree on one thing: Current treatment falls short. “Meanwhile my patients are suffering,” says Brewer, the mindfulness researcher in Massachusetts.
Brewer is a student of Buddhist psychology. He’s also a psychiatrist who specializes in addiction. He believes the best hope for treating addiction lies in melding modern science and ancient contemplative practice. He’s an evangelist for mindfulness, which uses meditation and other techniques to bring awareness to what we’re doing and feeling, especially to habits that drive self-defeating behavior.
In Buddhist philosophy, craving is viewed as the root of all suffering. The Buddha wasn’t talking about heroin or ice cream or some of the other compulsions that bring people to Brewer’s groups. But there’s growing evidence that mindfulness can counter the dopamine flood of contemporary life. Researchers at the University of Washington showed that a program based on mindfulness was more effective in preventing drug-addiction relapse than 12-step programs. In a head-to-head comparison, Brewer showed that mindfulness training was twice as effective as the gold-standard behavioral antismoking program.
Mindfulness trains people to pay attention to cravings without reacting to them. The idea is to ride out the wave of intense desire. Mindfulness also encourages people to notice why they feel pulled to indulge. Brewer and others have shown that meditation quiets the posterior cingulate cortex, the neural space involved in the kind of rumination that can lead to a loop of obsession.
Brewer speaks in the soothing tones you’d want in your therapist. His sentences toggle between scientific terms—hippocampus, insula—and Pali, a language of Buddhist texts. On a recent evening he stands in front of 23 stress eaters, who sit in a semicircle in beige molded plastic chairs, red round cushions nestling their stockinged feet.
Donnamarie Larievy, a marketing consultant and executive coach, joined the weekly mindfulness group to break her ice cream and chocolate habit. Four months in, she eats healthier food and enjoys an occasional scoop of double fudge but rarely yearns for it. “It has been a life changer,” she says. “Bottom line, my cravings have decreased.”
Nathan Abels has decided to stop drinking—several times. In July 2016 he ended up in the emergency room at the Medical University of South Carolina in Charleston, hallucinating after a three-day, gin-fueled bender. While undergoing treatment, he volunteered for a TMS study by neuroscientist Colleen A. Hanlon.
For Abels, 28, a craftsman and lighting design technician who understands how circuitry works, the insights of neuroscience provide a sense of relief. He doesn’t feel trapped by biology or stripped of responsibility for his drinking. Instead he feels less shame. “I forever thought of drinking as a weakness,” he says. “There’s so much power in understanding it’s a disease.”
He’s throwing everything that the medical center offers at his recovery—medication, psychotherapy, support groups, and electromagnetic zaps to the head. “The brain can rebuild itself,” he says. “That’s the most amazing thing.”