Chapter 1. Addiction to Alcohol and Other Drugs | Psychiatry Online (2025)

The Role of Biology

Drugs are chemicals that trick the brain’s natural control system. Through this control system, located at the base of the brain in the center of the head, people experience feelings of pleasure and pain. The brain is designed to manage fundamental behaviors such as aggression, feeding, and reproduction.

Communities have learned techniques for managing anger, fear, eating, and sex over thousands of years of cultural evolution, much as individuals learn during their lifetimes how to manage their own feelings. Human behavior is managed by relatively changeable and adaptive cultures even though the brain mechanisms that underlie behavior remain fixed and powerful. Individuals manage behaviors based on their values, experiences, and knowledge. When it comes to behaviors rooted in strong feelings, the family and the community are the principal locations of the hard-won, culturally based behavior management expertise.

When the brain’s reward or pleasure centers are stimulated, the brain sends out powerful signals to repeat the pleasure-producing behaviors. With respect to aggression, fear, feeding, and sexuality, the brain is selfish. It simply wants what it wants right now. The brain knows only “more” and “no more” or, in computer language, “on” and “off.” The brain directs the person to relieve distress and to promote pleasure. When it comes to many natural pleasures, the brain has built-in protections. It has powerful feedback systems to say “enough” when it comes to natural behaviors, including aggression, feeding, and sex.

These basic, primitive mechanisms, which are common to animals, do not consciously consider future consequences or values. These are genetically determined shut-off systems. Automatic brain mechanisms do not consider other people’s feelings or needs or know the importance of delayed gratification. That is why I call this basic pleasure/pain organ the selfish brain.

Addiction begins when the brain comes into contact with an addicting substance such as alcohol or other drugs. Without this interaction of the reinforcing chemical and the pleasure centers, there is no addiction. That is why prevention techniques that discourage exposure to addicting drugs, outside rigidly controlled traditional medical and religious contexts, are powerful and effective in preventing addiction to the extent that they can prevent the use of alcohol and other drugs.

People who have never been addicted find the behavior of addicts to be incomprehensible: “Why would anyone pay thousands of dollars every year for a powder to sniff up their noses?” “Why would anyone want to get drunk?” “I cannot imagine wanting to put a needle in my veins five or six times a day, every day of my life.” “It is such an awful feeling to have your brain poisoned by alcohol or drugs!”

Compare the drug addict’s behavior with the experience of sex. If you take out the pleasurable sensations, it is unbelievable that anyone (or any animal) would engage in such a seemingly bizarre and irrational behavior as sexual intercourse. The explanation for seemingly irrational behaviors (such as drug use and sexual behaviors) can be found in the feelings, including sensations and emotions. The feelings experienced by addicts are intense and compelling. In the end, these feelings, misleadingly called “pleasure” because that word is too mild, take over the whole self of addicts. For this reason, members of Alcoholics Anonymous (AA) call addiction “cunning, baffling, and powerful.”

Learning From Animals

Why do otherwise intelligent addicted people repeatedly do things that cause themselves and those they love such pain? The biologically rooted power of addiction can be seen in experiments with laboratory rats that had electrodes placed in the pleasure centers of their brains. When their pleasure centers were stimulated, these rats repeated behaviors controlled by the researchers to get more brain stimulation.

Rats find even mild electric shocks to their feet to be extremely unpleasant. Laboratory rats were placed in a cage that had an electric grid down the middle, which the rats had to cross to get various rewards. The electric shocks to their feet were not strong enough to cause them harm, but they were sufficiently unpleasant to the rats so that they would not cross the electrified grid to have sex or to get food or water. They would die of dehydration and starvation rather than cross that grid. But the rats walked across that electrified grid as if it were not there to get the pleasure centers of their brains stimulated directly.

In other experiments, research scientists gave monkeys cocaine only when the monkeys worked hard enough. The monkeys were also given sex, food, and water as alternative rewards after long periods of deprivation. The researchers measured how much work the monkeys would do to get each of these rewards, all of which produced stimulation of the brain’s pleasure centers. The monkeys worked harder for the cocaine than for any other stimulation, including for sex or food. In fact, when the monkeys were permitted to use as much cocaine as they wanted, they used the drug until they died of convulsions and heart failure.

These laboratory experiments with animals make clear that stimulation of the brain’s pleasure centers by drugs or by direct electrical stimulation is far more rewarding and controlling of behavior than natural stimulation of these same brain mechanisms, even by food or sex. This same picture is repeated thousands of times a day by addicted humans who put alcohol and other drug use first in their lives. This comparison is not meant to minimize the power of food and sex in controlling human or animal behavior. Clearly, the stimulations of food and sex are often as powerful and sometimes even overwhelming. However, as powerful as food and sex are as stimulators of behavior, they pale in comparison to the potency of addiction to alcohol and other drugs.

With few exceptions, such as a bird occasionally eating a fermented fruit, animals in natural states do not encounter or use alcohol or other drugs. Some students of addiction have discovered that animals in the wild occasionally do encounter plants that have drug effects and that the animals do become intoxicated when they eat these plants. Three conclusions can be reached about these observations of alcohol and drug use in natural populations of animals. First, these natural exposures to intoxicants are distinctly unusual experiences. Second, the experience of intoxication is dangerous for animals (as it is for humans), often leading to the animals becoming victims of predators that they would have avoided if sober. Third, no wild animals have daily access to intoxicating drugs as do human addicts.

A recent experiment shed light on why it is useful to plants to produce intoxicating chemicals. Scientists noticed that the coca bush in South America, containing small concentrations of cocaine, was seldom subject to insect predators, as were other nearby plants. Even young coca leaves rarely show evidence of insect damage. To understand how this worked, botanists sprayed cocaine-containing dust on tender tomato plants before releasing insects known to love tomato plants. After a few minutes of exposure to the plants dusted with cocaine, the insects acted bizarrely and stopped eating, dying within a day or two. The scientists found that the cocaine boosted the effects of the neurotransmitter octopamine in the insects’ nerves, hopelessly scrambling their messages. As we see in Chapter 5, cocaine works in human brains by affecting the neurotransmitters norepinephrine and dopamine. This experiment left little doubt as to why wild animals, including insects, generally do not eat coca leaves.

In contrast to animals, it is harder to understand addictive behavior in humans because there are so many complex factors shaping a person’s actions. Each act of an individual has many possible explanations. Some observers of human addiction have explained it as a form of slow-motion suicide; as an expression of anger toward spouses or parents; as an economic, racial, political, or ethnic protest; or as an expression of a deep psychological disorder.

The fundamental explanation for addiction is far more simple, as seen in laboratory experiments with addicting drugs. Human addicts use alcohol and other drugs for the same reasons that laboratory animals do, for the brain-reward effects of the substance use. In these animal experiments it is unmistakably clear that the experience of using addicting drugs is more powerful than other rewards and that this behavior does not depend on complex psychological, historical, or economic factors. Addiction to alcohol and other drugs is a universal biological process run amok.

Diversity of Risk of Addiction

Over thousands of years, human beings in all cultures have developed reasonably effective guidelines to deal with pleasure and pain and with associated behaviors. Cultures define when and how aggression, fear, feeding, sexuality, and many more complex but equally important feelings are expressed by human beings living in communities that share many values. Human communities permit and even encourage aggressive behavior in contests and sports, often imposing elaborate rules on the most intensely aggressive behaviors. Exposure to and mastery of fear is managed by common rituals. Culturally based rules are established in human societies for feeding and sexual activity. No human community could exist with unbridled expression of these powerful feelings by each individual community member. The survival of the community itself, as well as the survival of the individuals in the community, depends on the adherence to the community’s social contracts governing aggression, fear, feeding, and sex.

Within any community there is a high level of diversity, both cultural and biological. Some people are tall and some are short; some are thin and some are fat; some are quick-tempered and others are calm. Like physical characteristics, habitual behaviors also show great diversity in human (and animal) populations. Some people instinctively court danger and excitement, whereas others strenuously avoid both. Similarly, some people conform to community norms governing pleasure-driven behavior and some do not. Nature has seen to it that biological and cultural diversity is maintained because diverse populations are best able to adapt to changing environments and to exploit changing opportunities. Diversity is as important for adaptations of populations when it comes to values as it is in such physical characteristics as height and weight.

Cultural and characterological diversity means that within any community there are widely different personal values managing the experiences of aggression, fear, feeding, sexuality, and the use of addictive drugs. This diversity translates into diverse risk of addiction to alcohol and other drugs. Some personal values are relatively protective of individuals and the community, and others are less protective when it comes to addiction. Every day we see the consequences of this inescapable diversity of risk of addiction in families, communities, and nations. In a family with three or four children, it is common to see that one child has a drug or alcohol problem whereas the others do not. Similarly, some segments of communities have larger problems with addiction, and others have smaller problems. Age and gender have major effects on the rates of problem behaviors related to the brain, including addiction.

Values and Drug Use in Traditional Cultures

Humans living in relatively homogeneous traditional cultures in all parts of the world did not encounter drugs and had no way of personally controlling alcohol or other drug intoxication, with rare exceptions (see Chapter 2, in which we explore the history of addiction). For these reasons, the brain’s hardware in both animals and humans developed without protections from drug-caused risks. Only human beings have developed the capacity to use intoxicating drugs repeatedly, and only in recent times have people learned how to use purified, highly potent brain-stimulating drugs.

Drugs defy the brain’s built-in control mechanisms for dangerous behaviors like fear of predators and fear of heights that have developed over millions of years. Traditional values acted to limit exposure to alcohol and drugs as they were experienced in premodern cultures. Traditional values of human societies prohibited the use of intoxicating drugs outside medical and religious ceremonies. Drug use, in all stable premodern cultures, was controlled not by the individual drug user but by the medical or religious leaders of the community.

Early human communities were relatively small, isolated, and culturally homogeneous. The diversity of these communities was limited as the community shared values about the management of aggression, fear, sex, and feeding. Traditional cultures permitted relatively few different roles and little personal choice of behavior. The shared values within these cultures served to inhibit the use of alcohol and other drugs to the extent that there was any exposure to these substances.

Values and Drug Use in Modern Cultures

Since about 1970, a new challenge regarding addiction has emerged as large segments of human populations, especially youth in North America, have been exposed to dozens of addicting drugs, in settings that permit or even encourage drug use. Modern values emphasizing the importance of personal control of one’s life and simultaneous increases in the social tolerance for alternative lifestyles have provided a fertile ground for the contemporary drug abuse epidemic. These values have been prominent in North America, especially for youth, in the last three decades.

Modern countries with great cultural diversity have large numbers of people living in complex and interdependent communities. Not only are these modern communities much more diverse with respect to values that determine the risk of addiction, but individuals in them function with far more anonymity and independence than was true in premodern cultures.

Modern communities have many advantages over earlier village-based cultures, permitting, for example, a wider range of lifestyles and greater personal control by each person over his or her own life. However, one result of the new, more diverse, larger, and more anonymous communities is an increased risk of addiction. A major challenge for the future in all parts of the world is to fit effective prevention and treatment for addiction into this modern value system. The challenge is great, as the conflict of values found throughout this book demonstrates.

People are not equally vulnerable to addiction to alcohol and other drugs. Genetic and environmental factors, in particular, heighten vulnerability. People whose parents and other family members are addicts and people who live in environments relatively accepting of alcohol and other drug use are at increased risk of addiction. People who are oriented to immediate reward rather than to delayed gratification, people who are self-centered rather than concerned with the needs of others, people who lack religious values, and people who are impulsive and extroverted are all more at risk of addiction. Relative risk of addiction is affected by many other factors as well, including availability of intoxicating substances, gender, age, drug substance, and route of administration of the drug. For example, addictions to alcohol and other drugs are more common among males and among people ages 15 to 30.

Genetic predisposition to alcoholism and drug addiction is real, important, and increasingly the subject of scientific study. Animal experiments show that some strains of dogs, rats, and other mammals are more likely to drink alcohol than are other strains of the same species. Such heightened vulnerability in animal strains is passed to offspring without regard to life experiences. Careful studies of humans show that the risk of becoming alcoholic is about 15% for the daughters of alcoholics and about 30% for the sons of alcoholics.

Both nonhuman animal studies and human studies show that genetics is not the only factor influencing addiction. The majority of the children of alcoholics or drug addicts do not themselves become alcoholics or drug addicts. Many addicted people do not have parents or siblings who were addicted to alcohol or other drugs. To the extent that addiction is inherited, what is passed on from one generation to the next is the vulnerability to addiction, not the addiction itself. The development of addiction to alcohol and other drugs requires many other forces, including those that are environmental and experiential.

The substance being used affects the risk of addiction. Cocaine and heroin are far more likely to produce addiction than is alcohol, given the same level of use, genetic vulnerability, and social tolerance. Routes of administration are also important in establishing relative risk of addiction. Cocaine is more addictive when smoked or injected than when it is sniffed up the nose. While these factors, and many others, govern relative risk of addiction, all people are vulnerable to addiction. Diversity of risk does not mean that some people are vulnerable to addiction and others are not, but it does mean that some people are relatively more vulnerable than others.

To the extent that people, especially young people, are exposed to nonmedical drug use in relatively permissive environments, the drug problem worsens. Exposure to drugs in settings that are controlled by medical or religious traditions is less risky in terms of addiction. For example, the use of Ritalin (methylphenidate hydrochloride), a stimulant used to treat hyperactivity in children, generally does not lead to addiction. Neither does drinking communion wine in church.

On the other hand, even medical or religious exposure to potentially intoxicating substances does pose some risk of addiction for people who are biologically predisposed to addiction, especially for people who also have access to these substances for self-administration. Self-controlled exposure to alcohol and other drugs, especially by teenagers who are in peer groups without the presence of responsible adults, poses an especially high risk of addiction.

The human experience of getting high is more than the biology of the brain interacting with the drug. The setting in which the drug is taken influences the drug-taking experience. Similarly, the set of a drug user (a term used for the expectation that the drug user has when the drug use takes place) affects the drug experience as well.

The most high-risk picture for the development of addiction is not difficult to define. When a person with a high genetic vulnerability (e.g., parents or siblings who are addicted to alcohol and other drugs) and impulsive character traits is exposed to a highly addictive drug taken by a high-risk route of administration (smoking or injecting) in a setting that promotes drug intoxication with an expectation of getting good feelings (the setting and the set), the gun of addiction is loaded, it is aimed at the center of the brain, and the trigger is pulled. Sometimes addiction does not require all these high-risk factors to be present, but surprisingly often, especially in the most malignant cases of addiction, they are all lined up in just this way.

Blaming the Victim

As a physician, I am committed to the disease concept of addiction. How can a sick person be held responsible for the behavior that defines the disease? Is not this blaming the victim? We do not hold people with diabetes responsible for their disease, so how can a compassionate person hold alcoholics or other drug addicts responsible for their behaviors?

Although addicted people, like other sick people, are not responsible for their diseases, they are fully responsible for their behaviors during every stage of the disease. The addicted person’s disease is a heightened vulnerability to drug-induced rewarding experiences, which has both biological and environmental elements. Addicts’ behaviors, including their use of alcohol and other drugs, is entirely their responsibility, as is their use, or nonuse, of various recovery options, including the totally free and widely available 12-step programs, such as Alcoholics Anonymous and Narcotics Anonymous.

People with diabetes are not responsible for their disease, but they are responsible for their behaviors, including how they manage their illness. Adherence to proper diet and wise use of medicines are the personal responsibility of each diabetic person. The consequences of failure to care for the disease of diabetes mellitus are often added suffering and early death. The same is true for addiction. Denial and wishful thinking are deadly threats to people with all kinds of diseases. Addicted people, like people with diabetes, are responsible for the management of their diseases. As with addiction, genetics and behavior before the onset of the disease sometimes play important parts in the experience of the disease of diabetes.

Even in the absence of any therapeutic options, addicted people are responsible for all of their behaviors, including all of their use of alcohol and drugs. Addicted people are not likely to get well unless they are held responsible for their behaviors. Prevention efforts are inhibited by excusing alcoholics and drug addicts, because excusing removes socially imposed consequences for using alcohol and other drugs. Tough antidrug sanctions are a principal reason people choose not to use alcohol and other drugs or to stop using these substances. These sanctions are vital to successful prevention and treatment of addiction.

Think about how a family or a society could function if it excused alcoholics for their behaviors when drunk, behaviors that include inflicting injury on others and even committing murder, rape, and robbery. Is a drunk driver personally and legally responsible for killing an innocent pedestrian? In making the determination of personal responsibility for the drunk driving accident, does it matter whether the driver was an active alcoholic or merely a social drinker who had one too many drinks before taking the wheel? Think what a society would be like if it excused heroin addicts of their responsibility for robbing to get money to pay for their drugs, or cocaine addicts of their responsibility for selling drugs to others. It does not take deep thought to realize that excuses for addicts’ behaviors make society unlivable and do immeasurable harm to addicts themselves.

This excusing is yet another well-meaning but misguided form of enabling. It is a principal environmental cause of addiction. Enabling is the ultimate form of both irresponsibility and uncaring. When it comes to addiction, enabling is love turned cruel, not by its intentions but by its inescapable consequences. Holding addicts responsible for all of their behaviors, for their personal choices, is not blaming or controlling, it is simply being realistic. Recognition of the disease concept of addiction does not label addicts as “victims” who are not responsible for their actions; it offers both addicts and nonaddicted people a practical, understandable way to approach the otherwise bizarre and confusing behaviors of addicts and those around them.

Many well-meaning people today seek to soften the edges in dealing with addicted people by avoiding words such as alcoholic, addict, and character defects. They find such blunt, old words prejudicial and offensive. It is no accident that the 12-step programs and the best addiction treatment programs use these tough, clear words. By not using them, denial of the deadly disease of addiction is promoted. By using these words without apology or ambiguity, denial is stripped away and the real work of getting well from addiction can go forward. I use strong words in this book because I have learned to use them from my work with recovering people. Recovering people use these words to describe themselves and their behaviors when they were actively addicted to alcohol and other drugs. The addicted people in recovery with whom I have worked have characterized their lives when they were using alcohol and other drugs as filled with deceit and dishonesty when it came to the chemicals they loved to use. None has objected to my characterization of addiction, which focuses on two central features: 1) the loss of control over the use of alcohol and other drugs and 2) dishonesty.

Putting Limits on Personal Choice of Dangerous Behaviors

John Stuart Mill, the 19th-century English philosopher who helped to extend many of the modern values of individualism and the pursuit of pleasure that were embodied in the U.S. Constitution and the Bill of Rights, said that one person’s right to swing his arm ends when it hits another person’s nose. Drug users’ arms frequently hit other people’s noses. Most frequently, they hit the noses of people in their families and with whom they attend school or work.

A society does not have to wait until a nose is broken to define the limits of arm swinging. The highway is a dangerous common space in society, so, for all drivers, many limits on personal choice of specific behaviors are defined and legally enforced. Examples include wearing seat belts, obeying speed limits, and not driving after drinking. Being required to go through a metal detector before boarding an airplane or entering some public buildings is an example of a universal search that is growing more common in modern life in all parts of the world. The loss of privacy and personal choice of behaviors in each instance is balanced against urgent public benefits. This same balancing of privacy and social responsibilities underlies the limits society increasingly imposes on the use of alcohol and other drugs.

Although many people can drive without seat belts for their lifetimes without any harm to themselves or anyone else, most Americans are now required by law to wear seat belts whether they want to or not. A few complain about the infringement of their rights because of this legal requirement for all people who drive or who are passengers in automobiles. How can this government-ordered infringement on personal choice of some behaviors be justified when we do not hurt anyone but ourselves by our decision not to wear seat belts?

One answer is that the costs of my injury, if I do not wear a seat belt, are borne by you, and by everyone else, through lost productivity and increased health care costs. In this example, my choice of behavior—not wearing a seat belt—has harmful effects that extend beyond my own welfare to the welfare of others. Another more fundamental answer is that people in communities care about each others’ welfare.

Therefore, in many situations, society reasonably defines the limits to which I swing my arm, whether I like it or not. I must wear a seat belt when driving or risk criminal punishments. Society arrived at this decision collectively and democratically. The seat belt laws are new. Thirty years ago, cars were not equipped with seat belts. Today it is not legal to drive a car without wearing a seat belt. This example makes clear that legal boundaries to arm swinging change over time. It also demonstrates an increasing use of laws to promote health-related behaviors and the lack of any political or constitutional barrier to these laws in many situations for all citizens. As more is known about the probable outcome of various behaviors, and as social attitudes toward particular behaviors change, the limits of arm swinging change.

Arm swinging is not only limited by laws. There are many other formal and informal social mechanisms to limit it. Laws and social customs reinforce each other. As the social tolerance for cigarette smoking diminishes, the laws against smoking get tougher. As the laws get tougher, the informal social customs about tobacco smoking become more intolerant. The limits on cigarette smoking today are being redefined rapidly and profoundly in North America, not only by new laws about where smoking is not permitted, but by informal and widely shared social customs. A few years ago a smoker could ask, to be polite, “Do you mind if I smoke?” The answer was invariably, “No, not at all.” Today that is so seldom the answer to this question in the United States that few smokers even ask it. They either do not smoke around nonsmokers, or they receive hostile social responses.

Like the laws regarding speed limits or seat belts, the laws governing drug use are set politically, with the majority defining the limits of tolerable arm swinging when it comes to drug use. In the United States, the actions of the majority are limited by the Constitution. Not only are the swinging arms of drug abusers limited by laws, but the highest law of the land also limits the ability of the majority to restrict arm swinging generally, including the arm swinging of drug abusers.

The balance of these conflicting values—the growing North American intolerance of nonmedical drug use versus the limits on the majority’s power to legislate controls on personal behaviors—is now being hammered out. Those who want to swing their arms farther by legalizing the currently illegal drugs, such as marijuana and cocaine, must make their cases in the political processes, to their fellow citizens, and ultimately to the legislative and executive branches of government at the local, state, and national levels.

Those who want further restrictions on arm swinging, greater restrictions on the use of alcohol and other drugs, must enter this same political marketplace. Both are subject to review by courts. This conflict of values is seen most clearly in the workplace and other drug testing cases now coming to court. Over time, these cases will define what employers, schools, and others can do legally to prevent drug use. The same legal struggle can be seen in the question of roadblocks to identify drunk drivers. Can police stop drivers randomly to check for alcohol intoxication, or must they wait to see particular drivers weave or otherwise drive dangerously before pulling them over and giving them a sobriety check?

Drug Tests: Denial Busters

Drug tests use modern biotechnology to identify the recent use of alcohol and other drugs. Without drug tests, dishonesty hides addictive substance use and retards the forces in families and communities that would otherwise act to end illicit drug use. The modern drug test involves a comprehensive system designed to be safe and reliable. The first step is a screening test. If the screening test is negative, meaning that no controlled substance use is identified by the laboratory, that ends the testing on that sample. If the screening test is positive for the use of alcohol and/or other drugs, the second step is a confirming test on the same sample.

In the workplace, where concern is high over prescribed medicine use possibly being confused with nonmedical drug use, a third step is added. This safety check is the Medical Review Officer (MRO), a physician who is an expert in drug abuse. The MRO reviews the laboratory results and, if necessary, verifies the appropriate use of medicine before the test results are reported to the employer. Laboratory tests that are positive as a result of the appropriate use of prescribed medicines are reported to the employer as negative drug tests. The employer is not informed of the medicine use in such cases because the drug test result is returned to the employer as showing no drug use. The standard in the workplace today is to retain positive drug test samples for retest for at least a year if the employee disputes a positive drug test result.

This comprehensive drug test system does not produce false positives. This means that people can be drug tested with confidence that they will not be falsely accused of having taken a drug nonmedically. It also means that medical treatments will not be the basis for a positive drug test.

Urine drug tests generally are positive for 1 to 3 days after the most recent use of a drug. Hair tests for abused drugs identify drug use within 90 days before testing. Hair tests use the same reliable system as urine tests to detect drug use. Because of its longer window of detection, hair testing offers major advantages over urine tests, especially in preemployment testing and other scheduled drug tests. Hair testing is more resistant to cheating than is urine testing, and hair testing permits both collection of a second sample in disputed results and quantification of drug use intensity, permitting the distinction between a person who uses a drug only occasionally from one who uses it intensively.

Drugs are dream busters. Drugs rob individuals, families, and communities of their hopes, making life unmanageable for everyone. Drug tests are denial busters, exposing the nonmedical drug user to the healing forces of family and community life and giving good, immediate reasons to say “no” to illicit drug use. Because marijuana and cocaine are the most commonly used illicit drugs, they are also the drugs most often found on positive results of workplace drug tests. One of my patients called workplace drug tests “cocaine Antabuse” because drug tests give cocaine users a good reason not to use the drug, just as Antabuse, the medicine that makes people feel sick if they drink, gives alcoholics a good reason not to use alcohol.

The Social Contract for Drug Use

The “social contract for drug use,” which forms the foundation of my thinking about drug policies, can be simply stated: Self-controlled use, as well as sale, of addictive drugs is prohibited. Examples of prohibited drugs are marijuana, cocaine, and heroin. However, when one of these drugs, or drugs similar to them, is judged by formal scientific standards to be useful in the treatment of an illness or disease other than addiction, then its use as part of medical treatment, controlled by an informed prescribing physician, is legal. Medical use of a potentially addicting medicine is not self-controlled. The use of medicines is not characterized by deceit and dishonesty.

Many dangerous and potentially abused drugs have legitimate medical uses. Morphine is a good example. Use of potentially addicting drugs within controlled medical practice is encouraged for medical purposes, as long as the illness being treated is not addiction itself and as long as the supply of the potentially addicting medicine is restricted to the patient and does not find its way into other hands. This social contract for drug use is relatively simple and easily understood. It is a solid foundation for successful personal, family, and community drug policy.

In North America, the nonmedical use of alcohol and tobacco is legally accepted for adults. In fact, until recently most people did not consider these substances to be drugs. Even today international treaties do not consider them to be drugs. On the other hand, the use of these two substances by youth is legally prohibited, unlike all other consumer products, underlining just how different alcohol and tobacco are from chocolate and blue jeans. Many formal and informal rules of conduct restrict the use of alcohol and tobacco by adults, making clear that these are not routine commercial products.

Good Fun and Bad Fun

Pleasure or fun is inherently good. Some ways to have fun produce long-term good, and some ways do not. It is easy to think of addiction as a disease of pleasure and to conclude that pleasure itself is the problem. Active addicts, not wanting to stop use of alcohol and other drugs, often assume that my message is, “Just live an unhappy life and you can prevent addiction.” This simplesounding view is just plain wrong. Being against fun is a losing strategy for either the prevention or the treatment of addiction.

The goal of a good life is not to avoid pleasure; it is to maximize pleasure for yourself and others over time by fitting your fun into a full, productive life that reflects your highest values. Drugs and alcohol produce pleasure when taken, but the inevitable outcome of the pursuit of chemical pleasure is pain and suffering for the addict and for the people around the addict. Take a look at any addict and you will see a miserable person. Talk with the family of an addict and you will learn about the depths to which pain can penetrate the soul of an entire family.

There are two criteria for pleasure-producing behaviors to be good behaviors. First, fun must be able to persist over the long term. The excessive use of alcohol, as well as any use of an illicit drug, simply does not meet this requirement for healthy long-term pleasure. The selfish brain automatically seeks short-term reward. Culture and humane values insist that, socially and morally, acceptable pleasure be subjected to the long-term test. Where does today’s pleasure lead? What is the likely outcome of a person’s particular choices about addicting substances, not just for the person who uses the alcohol and/or other drugs but for the entire society? Active addicts do not think this way. They are dominated by the immediate reward of alcohol and other drug use, and they are blinded by denial to the negative long-term consequences of their substance use. Pleasure now, pain later—the pattern seen in addiction—is not a good deal for anyone.

The second, equally important requirement for healthy pleasure is that fun is good only if it can be openly and honestly shared with others who care about the person having the fun. One inescapable element of addiction is dishonesty. A person cannot be an addict without being a liar—to oneself, to those who care, and to the community at large. Behaviors that do not fit with the honesty principle simply are not good ways to have fun. The hardware of the selfish brain does not contain an honesty test. That test comes from cultural values. When it comes to pleasure-producing behaviors, including the possible use of alcohol and other drugs, consider the following question: “Can I tell those who care about me the truth, the whole truth, and nothing but the truth about what I do to have fun, whether it is basketball, sex, or my alcohol and/or drug use?”

Remember as you are reading this book that pleasure is generally good, not bad. These same two questions can be usefully asked about all feeling-driven behaviors, including feeding, sex, and aggression, as well as about the use of addictive chemicals: 1) Will the behavior produce pleasure over the long term?; and 2) Can the behavior be honestly and openly shared with those who care about you? In summary, there are two simple universal tests that can be applied to any pleasurable activity to separate good pleasure from bad pleasure: the long-term test and the honesty test.

Fun must have the capacity for persistence over time, and it must be socially acceptable. With those conditions, which are easily understood and not too hard for most people to follow, addiction generally can be avoided, and, if it occurs, it usually can be cured. Trying to skimp on those two requirements for fun enables addiction to grow.

Attendance at 12-Step Meetings

Before concluding this introduction to the story of addiction, I have a suggestion for every reader. As you will see in later sections of this book, I strongly support the 12-step programs based on, and including, Alcoholics Anonymous. These programs, the subject of Chapter 11, are called 12-step programs because they all use the same 12 steps to recovery that form the foundation of the program of Alcoholics Anonymous. At the meetings of any 12-step program, you can see for yourself the disease of addiction and the process of recovery. These meetings are easily accessible to virtually everyone in North America today. If you have a friend who goes to 12-step meetings, ask if you can go along for a few meetings. If you do not know anyone who goes to meetings, look in your directory for the telephone number for one of these three programs: Alcoholics Anonymous, Narcotics Anonymous, or Al-Anon. The first program deals with personal alcohol use, the second deals with personal use of other drugs, and the third deals with the experience of living in a family dominated by alcohol.

Ask for the time and location of an “open meeting” that is convenient for you. An open meeting is one that is open to people who either think they may have a problem with addiction or simply want to learn more about the subject. Plan to arrive at the meeting about 15 minutes early. Introduce yourself by your first name and say that you are new to the program and that you have come to learn. Ask if you can sit next to someone who can help you understand what is happening. At the meeting, soak up what is going on. If you are called on, although you are not likely to be, simply give your first name and say that you are not comfortable speaking or that you are there to learn. If, however, you want to enter right into the meeting, just say whatever you want.

Meetings usually last 1 hour. They are free, although a small donation may be accepted to help pay for space and coffee. One dollar is a common contribution at meetings, but a donation is not required. When the 12-step meeting is over, stick around and talk with the members of the fellowship. Ask them whatever you would like to ask about the nature of addiction and about what it takes to get well. The people at these meetings are the experts on addiction. They are writing the really big book on addiction, every day of their lives. If my book does nothing more than to let you know that these 12-step meetings are the place to find in-depth, real-life expertise about addiction, and if the book helps you find your way to meetings, I will be fully satisfied in my efforts.

Case Histories

These are the first of many case histories in this book. They give an idea of the range of experiences of people who are addicted.

Lonnie

Lonnie’s parents first came to me for help when he was a senior in high school. Rebellious and willful, Lonnie was a more-or-less everyday pot smoker who did not do his homework and who had moved his girlfriend into his bedroom at home for his convenience. Neither his parents nor his successful, traditional older brother had ever had an alcohol or drug problem. Lonnie’s parents were perplexed about what they could do about his outrageous behavior. When I suggested that they consider insisting that he stop using pot, with a regular urine test to enforce the standard, that they ask his girlfriend to leave, and that they require a modest level of school work if he was to use the family car, they were not surprised but neither were they interested in those ideas, which they considered conventional. His mother said, “We want to let him run his own life because that’s the way we have raised our children. It’s way too late for us to be prudish parents or narcotics cops.”

I spoke with Lonnie, who told me that he liked smoking pot and having his girlfriend in his bedroom. He saw no reason to stop either practice. He had held a job as a salesman at a local waterbed store for over 2 years. His smooth-talking salesmanship and steady work performance got him a promotion to manager of the store. He told me he had big ideas for his future, including making a lot of money. He was never arrested or expelled from school.

When I had not seen any of Lonnie’s family for several years, I called to find out what had become of him. His mother told me he had almost stopped using pot: “He still uses it every now and then to show that he has not knuckled under to the establishment.” He had become a good, but uneven student in college, focusing on business. He had developed his own business selling rugs to incoming students for their dorm rooms, which proved quite lucrative. He was proud that he contributed significantly to his own college costs. Lonnie was looking forward to starting a business of his own when he graduated.

Lisa

Lisa’s mother came to me when Lisa was a freshman in high school and had been expelled for the use of alcohol and marijuana. Lisa’s mother, who became a single parent after her husband, an active alcoholic, had left her several years before, was worried about her daughter. I met with Lisa several times, but she had no interest in working with me because she wanted to do things her way, including continuing to use alcohol and drugs. Lisa was intelligent and attractive. When she liked her teachers and her courses, she got good grades. She wanted to be with her friends, not with her mother, with me, or with any other adult. She rejected my suggestion that she go to Narcotics Anonymous meetings. She correctly saw that I was not friendly to her continued use of alcohol and drugs so, as she asked, “Why would I want to work with you?”

I lost track of this family until I got a call from Lisa’s mother nearly 10 years later. She called to say that Lisa had been killed in a car accident the week before. She added that Lisa had dropped out of high school and had been in many addiction treatment programs in our area over the last few years, but each time she left she relapsed to drug use. Lisa had attended many Narcotics Anonymous meetings and would stop drug use for a while when she went to meetings. However, she repeatedly stopped going to 12-step meetings and quickly relapsed to drug use, progressing over the years from marijuana to cocaine and ultimately to intravenous heroin use. Over the telephone, her mother and I shared some sad moments and feelings of regret at our inability to help Lisa help herself.

These stories make several important points. Lonnie used a lot of drugs as a teenager and showed many other characteristics of a drug addict, but he did not have any relatives who were addicted, his family environment was unusually permissive to his drug use, and he had shown from an early age both a strong desire to succeed in life and the ability to stick over time with projects he cared about. He held one job for several years, and he had a good relationship with his parents. Lonnie was a pseudoaddict as described in Chapter 7.

By contrast, Lisa had a strong genetic history of addiction, and she lacked the positive outcome predictors that Lonnie had. Her experience, including using several addiction treatment programs without long-term success, is unfortunately common. Also common was the tragic ending of her disease with her death at a young age.

This concludes our overview of addiction. I hope it has whetted your appetite for what follows. In the next two chapters we explore the history of drug abuse and the current global drug scene.