March 7, 2007 — -- More than 23 million Americans struggle with some kind of addiction, but less than 10 percent get treatment for it. The Addiction Project, which includes a documentary on HBO and a book, presents addiction as a chronic but treatable brain disease. The book "Addiction: Why Can't They Just Stop?" guides readers through the ins and outs of addiction treatment. The following is an excerpt.
Want more information on addiction and the HBO series? Visit www.addictionaction.org.
It was like a hard-hitting reality -- "I am an alcoholic." I am one of those people I see on TV. I am one of those people I used to criticize, thinking, How can they be so weak?
--JULIE, RECOVERING ALCOHOLIC
It was December, a peaceful evening, the sidewalks covered in fallen leaves. Along with a few colleagues, Timothy* ducked out of his office. The 42-year-old engineer wore a new blazer and gray wool slacks underneath a gray overcoat, which he pulled tighter when he felt the cold night.
Timothy, tall with hazel eyes and dark hair parted on the side, ran a small, elite R&D division at a software company. He was a popular boss. He loved his job, though not the required seasonal office parties like the one he was walking to that evening.
En route, Timothy held back from his colleagues for a moment. Retrieving his cell phone from underneath his coat, he dialed home. Lara*, his wife, answered on the first ring. Their 14-month-old was singing in the background and banging on a toy drum.
After asking about the kids and Lara's day, Timothy promised, "I'll be home in a couple of hours. I'll escape as quickly as humanly possible." When Lara told him to have fun, he half groaned. "You know what these things are like," he said. "I'll pay my respects and be home soon. I love you."
"I love you."
The restaurant was decorated for the holidays with twinkling white lights, a flocked Christmas tree, and red-leafed poinsettias on white-clothed tables. A jazz combo, set up in a corner of the room under mistletoe, played a vaguely recognizable version of "O Holy Night."
Timothy's colleagues dispersed, making their way toward other early arrivals, and meanwhile a waiter approached him and asked what he would like to drink. Without giving it a second thought, he asked for a sparkling water. In recovery for three years, he had made sparkling water a habit. At AA meetings, he joked that it had become his drug of choice -- having replaced the drugs that previously had vied for that title: cocaine, methamphetamine, and prescription pills such as Valium and Vicodin. It was those drugs, when mixed and combined with a new Toyota Prius, that landed him in a hospital emergency room. The car was totaled but he was fine. Miraculously. The greatest miracle, however, was that he had driven his car into a tree and not an oncoming car. Afterward, he dwelled on this detail. A head-on collision probably would have been fatal, but that wasn't the worst scenario. Much worse, Timothy knew, would have been to have survived the accident but harmed someone. Or killed someone. He could not have lived with that. It was a sobering realization. Figuratively and literally.
Timothy claimed that even if not for the DUI and threatened criminal charges, he would have checked into rehab. It was his second time. In the initial rehab three years earlier, he learned that there's a myth that addicts and alcoholics have to hit bottom -- whatever that is -- before they become sober, but the reality is that everyone is different -- there is no predicting what will impel someone to seek treatment. That first time, he had been in wretched shape. His wife had threatened to leave him if he didn't get help. But the accident was the clarion call of the variety that many addicts speak about in twelve-step meetings. "I got it," he would say when he told his story. "Only by the grace of God was I still here. That was that. I checked myself into treatment." For the second time. He promised his wife -- he vowed -- there would not be a third time.
Since then, he and Lara had another child, a beautiful daughter with large brown eyes and a serene smile. His career, which had floundered while he used, was back on track. He was committed to recovery, a regular attendee at Alcoholics Anonymous meetings. He had a full life, a happy life.
At the Christmas party, soon after his call home and after he ordered the sparkling water, something caught Timothy's eye. Later, he describes it. "It sat there on an isolated table," he says. "The rest of the room -- the people, the sounds, the light -- it all faded away. I sort of laughed it off. Like God was testing me. You can't fool me, I thought." A glass of Scotch, abandoned, set by a poinsettia on a white table, illuminated as if by a spotlight. He walked over, picked it up, and sniffed it. "A billon thoughts went through my mind," he explains afterward. "A billion thoughts and no thoughts." He spoke wistfully. "The glistening amber liquid. The intoxicating smell. Wood smoke. Euphoria."
Maybe, in that moment, he could have made a different decision -- or maybe that moment was too late. "My mind simultaneously raced and froze," he says. "I thought, After three years a sip won't hurt. I am so bored. What a waste of good liquor. I deserve it. I hate parties. It's a night of celebration. Christmastime. I am impervious. I am one of the lucky ones. My gorgeous children. My family. Three years sober and a sip. A sip. Half thoughts like those and no thought at all."
He says it was almost like watching someone else -- someone in a movie. Like he left his body. He felt a sense of horror, he says. Horror and also, incongruously, reckless delight. He sipped the Scotch. He breathed it. The taste was "heaven." He sipped again. "Glorious." He drained the glass. The reaction inside his head was instantaneous and intense. "I was filled with electric warmth," he recalls. "A smoldering fire was rekindled. I felt enlivened. The taste was... and I felt so..." He could not find the exact words. "I was horrified and felt perfect, both, but perfect won."
He said the required goodbyes and left the party. Again wrapped in his overcoat, walking to his car, he thought, See? They say that I can't have one drink. I can and I did. A glass of Scotch. One glass. I am in recovery. Three years. My judgment isn't impaired. It's sharper than ever.
Driving, he thought, One drink. I missed the taste. The faint buzz. No problem. I've licked my addiction. Maybe "they" -- "they" in the rehab programs, "they" in AA meetings -- can't have just one, but I am not like them. I never have been. I talked the talk and walked the walk. I played along. But I'm not like them. He laughed. Aloud.
He drove home, had every intention of driving home. His car came to the same intersection he drove through every morning and every evening before and after work. The car turned. By itself. Left instead of right. He smiled. Nervous now. The car had a mind of its own. Right would have led home. Left led to...
For a little holiday cheer, he told himself. I deserve it after three years. Everything is in my life is great. Celebration. I am not like them. One line.
Some addicts think it's okay to drink or smoke -- "Just a little pot," "One beer" -- as long as they don't use whatever was their drug of choice. However, according to Richard Rawson, PhD, associate director of UCLA's Integrated Substance Abuse Programs, an addict is far more likely to relapse on hard drugs if they drink or smoke marijuana.
Driving this familiar route, Timothy felt what he later describes as "a secret thrill. It filled my body." Driving itself, the car wound down a quiet suburban street -- he chuckled as he always did when he turned on the road because it was called High Street -- and pulled over in front of a cheery house. Peter. His friend. His buddy. The house dressed brightly for the holidays with a wreath on the front door.
Inside, after a bear hug from Peter, he noticed a clock. It was 7:30. Early. Plenty of time. At nine o'clock, he ignored his chiming cell phone. It rang again at 9:12. Then again. At 9:30, after the incessant ringing, he shuddered and turned off the phone. At dawn, he thought, I am making up for lost time. I'm flying. How I have missed this in my life. Who have I been kidding? Later he explains that there was something else inside him, a barely remembered sense somewhere in some part of his consciousness: Lara. The children. Home. Christmas. His job. Friends -- a life. Someone else's life. That life was an abstraction so distant as to be unreal. What was completely and utterly real was the moment: life coursed through his veins. "I felt powerful and alert. Whole."
Earlier there had been a first line -- the first line in three years -- followed by another. At eleven or so, he asked Peter if he had rigs (syringes). Peter smiled. "What took you so long?" he asked, embracing his friend. "I've missed you, bro." Timothy shot up, thinking, And I have missed this! How could I have lived without it? I am in control. I'm fine. A celebration. One night after three years. I'll go home soon and sleep it off. He says later, "High again, I felt immune, invulnerable, at peace."
He was awake. At four in the morning. Shooting. It was as if no time had passed between him and Peter, his dearest, truest friend. They drank Scotch and smoked weed. They talked. How he had missed talk like this -- genuine and open and alive. "I'm glad I'm over this shit," Timothy said at one point. "Now I can take it or leave it."
The following day, he thought for a fleeting moment that maybe he should call Lara, but he pushed the thought aside. He shot up more and another day and another night were gone.
Lara's husband had not returned home for seventy-two hours. Three days. Lara did what wives and parents and children and lovers and friends of addicts do. She imagined every scenario, no matter how implausible. Timothy had been murdered. He had been kidnapped. She imagined a terrorist attack and accidents. Horrible accidents that involved dozens of cars. Ludicrously, sleepless in the middle of the night, she imagined a 747 hitting the freeway. She concocted preposterous scenarios, while all the while knowing that the truth was simpler. He had relapsed. It was the obvious but most discouraging explanation. She had already done what people who love addicts do. She had called his friends and colleagues and then, bracing herself, called the hospital emergency rooms and the police. Nothing.
Not knowing but knowing. She felt what family members feel: the horror, the dread, the terror. After the imagined 747 crash, she replayed much more likely fantasies -- horrific fantasies. He has overdosed. He has gone out to kill himself. High, he crashed. Again. He is dead. She thought, What did I do wrong? Besides the self-blame, she also felt guilt for something else that flooded her -- another thing that most people who love addicts feel and simultaneously feel guilty for feeling: she was enraged. By habit and for the children, her rage was contained. But tormented, she thought, How could he do this to us? The bastard. Again. She felt rage toward him and blamed herself. Both. How could I have trusted him? I am a terrible mother. How can I put my children through this? The bastard. Poor Timothy. Poor Timothy? Poor us. The bastard. Where is he?
Dawn on Monday the sky was smoky gray. Normally, Timothy would be on his way to work, stopping for coffee and a newspaper. That morning, however, he shakily drove across town and parked in front of another building that was familiar to him. A pallid, jittery ghost with sunken eyes, he walked up a flight of stairs and pushed through the glass door of the same rehab facility he had graduated from three years ago. By coincidence, the first person he saw was a counselor with whom he had been close. She glanced up and noticed him. She looked again, closer, and knew. She shook her head and without a word came up and hugged him. He wept.
Through tears, he whispered the obvious: "I relapsed."
"But you're here now," she said.
Addicts or their family members must contend with what may be one of the most difficult concepts of all to comprehend: at various points on the road to recovery, addicts may relapse. In some cases, it may be a failure of their treatment. "Some addicts fail to respond," says Nora Volkow, MD, director of the National Institute on Drug Abuse (NIDA). "There are many reasons. It wasn't a good program. The treatment was good, but it did not fit the person." In most cases, however, a relapse does not mean the efforts in recovery thus far haven't been effective.
"Some heavy users will go through treatment once," says UCLA's Rawson. "They will stay sober after that. But for many, it will take multiple tries." Michael Dennis, PhD, a senior research psychologist in the Lighthouse Institute of Chestnut Health Systems in Bloomington, Illinois, says that 70 percent of the patients relapse after their first time in treatment. "It's not like fixing a broken bone," he says.
Gantt Galloway, PharmD, a scientist in the Addiction Pharmacology Research Laboratory at the California Pacific Medical Center Research Institute in San Francisco, explains, "If we look at recovery as a lifelong process that may include one or many relapses, a far more realistic view of success emerges. We need to think of a treatment trajectory: it may take five, seven, nine times before they get it. Chronic depression has similar success rates. Seizure patients? The noncompliance rate is just as high. High blood pressure? All they have to do is take their medicine. It's not as difficult as staying sober, but the rate of noncompliance is just as high."
"Relapse is not a failure of treatment," says Anna Rose Childress, PhD, research associate professor at the University of Pennsylvania School of Medicine. "Relapse is part of the disorder." Kathleen Brady, MD, PhD, director of the Clinical Neuroscience Division at the Medical University of South Carolina and president of the American Academy of Addiction Psychiatry, explains, "[Addicts] have changed their brain in ways that make them vulnerable to relapse."
While relapse is common following treatment, the good news is that, in the long term, slightly more than half of the drug addicts who receive treatment ultimately achieve a state of stable remission. For alcoholics, the recovery rate is encouraging, according to Mark Willenbring, MD, of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Though a third may relapse, they still are much improved. Over the course of many years, about two-thirds of them eventually recover. For young people, the numbers are even more optimistic. Twenty years after the onset of alcohol dependence, only 7 percent were still dependent, with 20 percent improved. The rest were in full recovery. "Compare that to diabetes, asthma, arthritis, heart disease, or hypertension!" says Willenbring. "When was the last time you knew someone with diabetes who no longer required treatment and was fully recovered?"
Though these statistics are encouraging, no one -- not the addict, not their family -- wants to hear that addicts in recovery often relapse. After Timothy's relapse, when Lara came to visit him at his rehab program, she angrily asked, "Why, Timothy? Why? What was it?" He shook his head and said, "I don't know. It was like I didn't have a choice."
"You had a choice," she responded with a flash of anger. She was crying again. She had cried throughout the morning session. She cried throughout the afternoon session.
Timothy said, "I may not have felt as if it was a choice, but, yes, on some level I must have chosen it. No one forced me."
Addiction is a complex disease. It has profound effects on the health and well-being of the individual addict, as well as those around them, and society at large. Like other chronic illnesses, addiction -- with the proper treatment -- can be managed, so that an addict can live a life without drugs. The road to recovery, however, is often fraught with devastating consequences, some of which are short-lived and others, lifelong. Health, reputation, livelihood, and interpersonal relationships are just a few areas that can be severely affected by drug and alcohol abuse -- and that, in many cases, can be repaired in recovery.
Today's epidemic of addiction to drugs or alcohol is a subject that is talked about candidly only with extreme difficulty. Why? The stigma and shame associated with drug and alcohol dependence have helped to build an invisible wall that can isolate addicts and their loved ones in times of deep crisis. Common misconceptions as to both the causes of addiction and the ways in which it can be successfully (or not) treated add to the fog of mystery and confusion. As Timothy and Lara and so many others have learned, the cost for society's prejudices and misunderstandings is simply too high. Not just because of individual lives ruined or lost (as if they weren't cause enough for concern), but because the disease of addiction is everywhere; it is spreading -- and it never affects just one person.
Among addiction treatment professionals, conventional wisdom holds that an addict has a direct negative impact on anywhere between four and fifteen people. Count up the people you know, the ones you regularly talk to or see. Husbands and wives. Parents and children. Your spouse's siblings and your own. Your boss, your colleagues. Your children's friends, classmates, teammates. The church, the book club, the Scout troop. It's easier than you think for each of us to tote up fifty, perhaps even one hundred people who are regularly in our lives. Multiply that number by 22.2 million addicts and you have a rough idea of the devastating impact of addiction on this country.
For all of us, it is important to see that addiction doesn't exist "over there," on the other side of the figurative tracks. Addiction has many faces: black and white and all the colors in between. It is rural and urban, rich and poor. The disease does not confine itself to socioeconomic groups or specific neighborhoods, whether the South Bronx or Beverly Hills. It fills emergency rooms, clogs our court system, and overcrowds our jails. It ends marriages, shatters families, kills our children, and drains our tax dollars. Of its many faces, one thing is almost guaranteed: it is a face you know.
In Cranberry Township, a community outside Pittsburgh -- the type of sedate, leafy suburb that is likely to be voted "best place to live" by its residents -- a program called Bridges to Hope regularly draws together a group of women who share stories of children suffering from continued drug relapses, brushes with the law, and dead-end life situations. In the meeting at her home, Joan Ward tells the group, "The message I want people to receive is, we are in the middle of suburbia and we could go down any cul-de-sac in this whole area and we would find addiction, we would find everything that goes with it," she says. "First we have to be courageous enough to say, 'It's in my living room,' and that's hard to do."
The USA Today/HBO Family Drug Addiction Poll conducted by Gallup in 2006 of 902 adults with an immediate family member who suffers from addiction begins to show the impact of this problem. About half the respondents with an addicted spouse said the experience has taken a major negative toll on their emotional health. Almost half said they suffer from shame over having an addicted family member. Although women were more likely than men to say that their family member's addiction had "hurt their mental and physical health, as well as their marriage," the words that everyone used were powerfully negative: "devastating," "abusive," "horrible."
Each addict leaves a unique footprint on their family and community. Depending on who the addicts are, what they're using, how they get it, and the behavior the addiction encourages -- erratic mood swings, manic spending, inexplicable fears, sullen apathy, spousal abuse, petty theft, the list goes on -- the impact of the addiction can range from quietly devastating to openly dangerous. Whether it's the child addict whose habit upends her family's ability to get through the day or the hooked adult who commits crimes to support his fix, every addict spreads tentacles of consequences through their home and neighborhood. Yet the problem remains cloaked in shame, denial, and stigma, discussed in hushed tones, as if the people who suffer from the disease are somehow responsible for it. After all, addicts invited this particular problem on themselves, didn't they?
Well, yes. And no. Addiction was first defined as a disease by the American Medical Association in 1956, and it has taken a full half-century of research and treatment for even medical and psychological professionals to shed old beliefs. So perhaps it should come as no surprise that society at large has difficulty seeing an old disease in a new way.
Addicts are weak, the myth goes. Weak of mind, weak of character. Or they're willfully self-destructive. Or they're unbearably selfish. They must be. Otherwise they'd stop hurting themselves and hurting others as well, right? "That's the real mistake that people make," says senior research psychologist Dennis. "They think it's about a morality play, a moral shortcoming. That somehow you've failed as a person."
According to a recent survey by the National Council on Alcoholism and Drug Dependence, half the public believes that addiction is a personal weakness. In the 2006 USA Today/HBO Family Drug Addiction Poll, while 76 percent of those polled identified addiction as a "disease," they identified "lack of willpower" as the main problem facing addicts.
In fact, the new understanding of drug and alcohol addiction that top scientists like Volkow and Willenbring agree on suggests the opposite. A more accurate way to put it would be that any so-called lack of willpower in an addict has been caused by changes in the brain. Dependence on drugs or alcohol caused these very changes. The inability to make clear decisions is a by-product of the same disease from which the addict is trying to escape. What could be more insidious? More clearly than ever, today's addiction specialists understand this conundrum: repeated use of drugs and alcohol alters the way the brain works. These alterations can now be observed and described in precise detail. The sea change in our understanding of addiction has begun to yield new treatments, including new types of medications that help restore the brain's normal functions. The first step, therefore, is to call addiction what it is, instead of the well-worn metaphors that polite, embarrassed, or justifiably frightened people have used for generations. It is not a "problem." It is not "a phase she's going through." It is not "shaking out the jams before he settles down." It is a chronic, relapsing brain disease.
It is hard to dismiss the mythical role that pop culture depictions of "altered states" have played in each generation's responses to drug and alcohol use. Just look at D.W. Griffith's A Drunkard's Reformation in 1909, or 1915's Charlie's Drunken Daze, when Charlie Chaplin's wild night on the town ends in a hotel room mix-up with a pretty girl. In 1936, Reefer Madness was supposed to serve as a warning about marijuana, but instead has come to be viewed as an inadvertently camp comedy; in 1981, Dudley Moore was a hilarious yet ultimately pathetic drunk in Arthur. In 1988, Clean and Sober depicted a cocaine addict hiding out from the law in a rehab center, where he's confronted by the one person anyone would devoutly wish to have not just as an addiction sponsor but a life coach: Morgan Freeman. And 2004's Sideways begins as a sophisticated buddy movie about a California wine country tour, but devolves into a story of an alcoholic whose life is in shambles.
In spite of the chaos portrayed in films and plays about addiction, there is still at the root of them something melancholy, almost romantic -- an often confusing message containing both attraction and revulsion. Even the most tragic addict is somehow viewed as heroic or noble in his suffering (see Nicolas Cage in Leaving Las Vegas). The "tragic artist as addict" motif runs through music and literature as well; writers such as Hemingway, Fitzgerald, and Faulkner all worried that sobriety would kill their creativity, and that alcohol was somehow necessary to the Muse. Do we see Kurt Cobain, Brian Jones, or Jim Morrison as tortured artists whose creativity required drugs, or do we see them clearly as addicts with compromised lives who somehow managed to make some music -- but possibly not as much as they might have? When kids hear hip-hop lyrics that tout a life of champagne and blunts, are they attracted to what they're hearing or are they able to understand the context, and reject it?
There are hopeful signs that attitudes are changing in the music industry (at least toward the plight of the musicians themselves) with the inception of support groups such as MusiCares, the Musicians' Assistance Program, and Road Recovery. Musicians such as James Taylor and Bonnie Raitt have often spoken out about their own battles with addiction. Some veteran rap musicians have also spoken of their desire to see hip-hop lyrics move away from the one-note deification of "thug life" behavior. Nevertheless, our culture's continuing fascination with celebrities often dilutes the grim seriousness of their struggle.
In October of 2006, Susan Murray, an assistant professor of culture and communications at New York University's Steinhardt School of Education, reported that alcohol use in reality TV programs was "a pretty common ploy to make the plot line move along and make it interesting." Murray, the coeditor of a compilation of scholarly essays titled Reality TV: Remaking Television Culture, said the excessive drinking, arranged and sanctioned by the programs' producers, was a clear attempt to manipulate the situations and the people who were in them. An 18-year-old might have no trouble realizing these are real people with some real problems -- but would a 14-year-old?
Perhaps even more damaging than pop culture's gauzy view of drug and alcohol use is its skewed version of treatment and rehabilitation for the same substances. A casual flip through People magazine suggests that 2006 was a year for the famous and the infamous to hit rock bottom and then rise from the ashes. A drunk Mel Gibson gets pulled over by the cops, spews an anti-Semitic tirade, and then makes public apologies and proclaims his addiction and his intention to get help.
The story line seems ubiquitous: some famous movie star or politician has a potentially career-ending lapse in behavior and the explanation, that drugs or alcohol are to blame, is immediately followed by seclusion in rehab, a cycle implying that recovery and resurrection are sure to follow.
Numerous myths stand between addicts and effective help. And unfortunately, 2006 proved to be a good year for perpetuating them, as the drama of who was or wasn't fighting an addiction played out repeatedly on the public stage.
When Congressman Bob Ney of Ohio pleaded guilty last year to making false statements and conspiring to commit fraud, admitting that he accepted thousands of dollars in free travel, meals, and sporting events from disgraced lobbyist Jack Abramoff, he said, "I have come to realize that dependency on alcohol has been a problem for me."
What could Congressman Mark Foley of Florida possibly say to excuse his behavior, after news broke that he had been sending sexually explicit text messages to teenage male pages on Capitol Hill? He had fought for laws against sexual predators as head of a House caucus on missing and exploited children, but now appeared to be one. His lawyer publicly announced that Foley had checked into a treatment center. "The combination of alcohol and mental illness can result in inappropriate conduct," the lawyer said, citing experts.
Rush Limbaugh, the radio shock jock, admitted to being hooked on OxyContin and hydrocodone after being investigated by Florida authorities for illegally buying narcotic painkillers. He told his radio audience that he was checking into a treatment center for a month to "once and for all break the hold this highly addictive medication has on me."
That one could hit rock bottom, look in the mirror, decide to overhaul one's life, check into a thirty-day rehab program, and emerge healed is certainly a seductive notion. But it's based on pernicious myths about addiction and does little to help those struggling with the lifetime grip of addiction and the hard work of quitting.
Brady, president of the American Academy of Addiction Psychiatry, says, "The whole idea that an individual needs to reach rock bottom before they can get any help" is "absolutely wrong." In fact, recovery is easier when there is more to live for -- before someone has lost a spouse or a job, or has a criminal record.
Real-life addiction rarely has a tidy or triumphant story line, as the USA Today/HBO poll makes clear. It elicited tragic and all-too-real stories of families torn apart, people dead of liver disease or drunk-driving accidents, and the unfathomable grief of parents who had lost children (and children who had lost parents). After the poll ran, numerous readers responded with accounts of their own twelve-step successes and failures, multiple treatments at rehab centers, and family homes sold at auction because of the high cost of repeated attempts at treatment and recovery.
Senior research psychologist Dennis, a leading expert in the treatment of adolescent addicts, has heard hundreds of similar stories through the years. "It's not as simple as just saying no, or just stopping," he argues. "Once someone's arrived at the chronic condition of alcohol or drug dependence, it's not that easy for them to quit."
Before talking in more detail about the ins and outs of treatment and recovery -- what works, what doesn't, and why -- it is important to remember that each addict deserves a treatment tailored to their personal circumstances and addiction, specifically the substance(s) in question and any co-occurring mood or anxiety disorders. The origins of addiction are as varied as the addicts themselves. Each case needs to be understood as a human faced with a particular set of variables -- parents, economic status, psychological environment -- all of which are relevant but no single one of which can rightly be called decisive. Some addicts come from families where alcoholism or drug addiction appear unfairly predestined; others seem to have every advantage in the world, genetic and otherwise, and still addiction lays them low. Attempts to pass judgment seem misguided after one considers the extreme range of circumstances that have resulted in addiction for different types of people.
For Jimmy, a successful criminal defense lawyer in Massachusetts, addiction was always someone else's problem. Addicts and drug dealers were Jimmy's clients, whom he represented with so much skill. They were the people who came into the courtroom drunk, day after day. But in 1999, after a car accident literally turned his world upside down, he began a journey into addiction that would change his perspective -- and his life -- forever.
After a head-on collison, Jimmy landed on the roof of his car with his briefcase whizzing past his face and awoke, minus his spleen, to a long, painful recovery. Three years later, his wife, whom he had relied on entirely, died of a brain aneurysm. Those agonizing events led him to take refuge in the painkiller OxyContin, which his doctor had prescribed after the accident. Before long, he was into almost anything he could scrounge up, from cocaine to heroin to crystal meth.
The only way to quit, he concluded, would be if he was "plucked off the face of the earth and thrown into a jail cell" -- which finally happened. Before, he had seen the scourge of addiction through his perspective as a lawyer. This time, the addict -- the person standing before the judge, lying to his family -- was him.
For some, addiction can turn up in the middle of their lives seemingly without any warning or for any valid reason at all. "Even though I lived through it, I still don't understand it," says Emma*, "and I don't know if I ever will." The mother of four and former wife of a successful businessman speaks in the quiet tones of someone who's squared off against catastrophe and is still standing.
"People will ask, 'What did you do this weekend?' I'm always saying, 'My son and I did this and my son and I did that.' They'll ask, 'Doesn't he ever spend time with his dad?" And I say, 'Well, he can't. His dad's in prison.' It always gets a gasp. Long story -- basically drugs, alcohol, and white-collar crime."
Emma and her family lived in a nice, middle-class neighborhood, in a big house, with a nice life -- church every Sunday, the kids in Catholic school, everyone doing well and every reason to believe it would only get better. "The kids were our lives," she says. "And my husband was so dedicated to them, and so was I -- people kind of thought of us as the Leave It to Beaver family."
Then Emma's husband began to struggle with depression. Wisely, he sought therapy. The counselor sent him to a physician, who gave him prescriptions for dextroamphetamine (Dexedrine) and amphetamine-dextroamphetamine (Adderall). "I didn't find out until later," Emma says, "but the doctor had actually prescribed four times the recommended amount of Adderall per day. And four times the amount of Dexedrine. And four times the amount of whatever he was supposed to take at night to sleep."
Very quickly, the husband and dad they all knew vanished. "He just got strange all of a sudden. He'd disappear into the attic for hours, maybe seven hours, and come out and tell us how well he had insulated it," says Emma. "I took all my kids down to my daughter's cheerleading competition, and when we came home, we were excited because we'd taken first in the state. And he said, 'That's great. You know what I did this weekend? I took apart the washer and dryer and fixed them.' I said, 'I didn't know they were broken.' He said, 'Well, I just wanted to make sure.'"
When Emma's father-in-law died, her husband decided he needed to quit his prescription drugs cold turkey -- a decision that could have killed him, the medical experts later told her. Instead, it drove him crazy. "He threw furniture in the pool," she says, "and then he started drinking. Just replaced one for the other. He'd look me straight in the eye and say, 'I'm not drinking.' I'd known this man since I was 13, I knew what kind of person he was, I knew how he'd raised my kids. And all of a sudden, there was this man I didn't know. And I didn't know that the mortgage wasn't being paid. I didn't know that the bills weren't being paid -- he'd intercept the mail and all the phone calls."
If her husband had received better treatment for his depression in the first place, would the rest have ever occurred? Impossible to judge. The fact that he became a drug addict only verifies that a predisposition was there: the wrong drugs for the wrong brain at the wrong moment.
The worsening financial crisis led to court proceedings, which Emma's husband missed; in fact, he simply disappeared. A warrant was issued for his arrest. The next she heard, he was being held in prison on federal charges stemming from a bad financial mess at his workplace. When she returned home from his hearing, there was a notice on her door that the bank had foreclosed on their home. The cars were repossessed and the bank accounts were all overdrawn. It was a scenario she'd expect on The Jerry Springer Show, not in her own life. It was the result, she says, of a "scary disease" called addiction. "There are days when I'm so mad that I can't even think straight. There are days when I cry for the dream I had for our family. I cry for that dream because that dream is gone."
White middle-aged Americans like Jimmy and Emma's husband are the nation's fastest growing population of drug abusers, according to a 2007 article from the New York Times. Author Mike Males, PhD, a senior researcher at the Center on Juvenile and Criminal Justice also noted that deaths from illegal-drug overdoses among people in their forties and fifties have risen by 800 percent since 1980, and 300 percent in the past decade.
In total, the Substance Abuse and Mental Health Services Administration found that between 2002 and 2005, the rate of illegal drug use among adults ages 50 to 59 rose from 2.7 percent to 4.4 percent. According to recent data, abuse and dependence have increased for senior citizens as well, in what one expert calls a "silent epidemic" because it is so rarely diagnosed or treated correctly. (Substance abuse is most common between the ages of 18 and 25.) In total, the 2005 National Survey on Drug Use and Health estimated that 22.2 million Americans, age 12 and older, suffer from dependence on, or abuse of, drugs and alcohol. Of these, approximately 3.3 million people were dependent on or abused both alcohol and illegal drugs; 3.6 million were dependent on or abused illegal drugs (excluding alcohol) only; 15.4 million were dependent on or abuse alcohol alone.
One nationwide survey in 2001 reported that six million children in America live with at least one parent who abuses alcohol or drugs, and substance abuse by parents is a major contributing factor in the number of children currently in foster care -- half a million to date. It is estimated that approximately one-third of the 500,000 people currently homeless in America have addiction disorders.
Drug overdose deaths have increased 540 percent since 1980. One-quarter of all emergency room admissions are alcohol related (although many ER doctors will tell you that the actual figure is likely much higher). Traditionally, doctors have not been trained to diagnose addiction, so its presence as a factor in injuries or diseases is often overlooked. One-third of all suicides, and more than half of all homicides and domestic violence incidents, are alcohol related as well. Excessive alcohol use -- the third most common cause of preventable death, behind smoking and obesity -- kills 75,000 Americans a year.
According to Samuel Bacharach, PhD, director of the Smithers Institute for Alcohol-Related Workplace Studies at Cornell University, the most recent federal data from 2002 estimate that alcohol and drug use cost U.S. employers over $128.6 billion in lost productivity and an additional $15.8 billion in substance-use related employee healthcare costs. Addiction alone accounts for 500 million lost workdays each year, not to mention job-site accidents and increased insurance premiums. "Addiction and alcohol problems are probably the most underdetected, undertreated health problems in the American workplace," says Eric Goplerud, PhD, director of Ensuring Solutions to Alcohol Problems, which reviews state insurance policies for the Department of Health Policy at George Washington University in Washington, DC. "It affects eight workers out of a hundred, and yet most of them never get the treatment that they need or could benefit from."
But with all of this sameness, and the drumbeat of intractability surrounding this problem, there is something new: the medical and scientific paradigm shift whose significance has just begun to be fully exploited.
The Massachusetts lawyer, Jimmy, was addicted long before he realized it. In his mind, he took drugs in order to function, in order to wake up every day and go to work, not to get high. But he now realizes that he was kidding himself about the seriousness of his addiction and says that he probably should have been institutionalized after his wife's death. "I had no right being out of this house," he says, when he considers that he drove while high. "Thank God I didn't kill anybody."
Jimmy agrees that naming the problem is an important first step toward recovery. For him, it began when he was arrested while buying drugs. "From that moment I was plucked off the street ... I knew, Okay, this is how it is that there's an end. From that second, it's like everything changed."
It is not that recovery was easy for him. It was agony, both physical and mental. But his arrest collapsed the myths he'd constructed: that using drugs was helping him to function as a professional and earn a living to support his kids. In treatment, he had to confront a far more painful reality: that he had not stopped despite the needs of his children. "I said to my therapist, 'I'm ashamed because I looked into the eyes of my children -- and that wasn't enough to make me stop.' When I said that to her, she threw a book at me and said, 'It's physical. It's a physical addiction.' And I've come to forgive myself."
If you're an addict or you love one, quitting often seems like an impossible dream, something you talk about and never do. "I became a great liar," says Jimmy. "I looked people dead straight in the eye and told them I wasn't on drugs time and time again." All the while, he was completely hooked. "I'd have to do drugs to go to sleep," he recalls. If I woke up in the middle of the night, I'd have to do them to get back to sleep. I'd wake up in the morning and have to do them to get up."
For seven years, Jimmy could not function without drugs. And in the process, he lost everything: his house, cars, law license, and his public standing. But today, Jimmy has finally quit.
"People take the drug despite tremendous social and personal cost," says NIDA's Volkow. "Even though they know they are going to end up in jail. Even though they know their spouse is going to abandon them. Even though they know their children are going to be taken away. It's not that these people don't care about these things -- they care very much -- it's that something very fundamental has changed in their brain."
That something is the question Volkow has been exploring for the past two decades. Breakthroughs in imaging technology have allowed her and other researchers to literally peer inside the human brain and observe what it looks like while addicted to any number of different substances, and what it looks like in recovery. What Volkow and others have discovered (or perhaps more accurately, reaffirmed and given new meaning to) bears repeating: addiction is a progressive, chronic, relapsing disorder of the brain. Addiction can be successfully treated. It is not a moral failing but something much closer in its nature to diseases like asthma or diabetes.
"The science of understanding addiction has just been exploding in recent years through the use of any number of different technologies, including genetics, animal studies, studies in humans, and brain imaging," says NIAAA's Willenbring. "We are really starting to piece together some of the brain mechanisms involved in the development of and resolution of drug dependence and alcohol dependence." Such advances mean a new ability to objectively measure the success of different treatments and to develop new treatments that can be clinically proven to work. This watershed moment promises to help sweep away decades of moralistic cant and punitive condemnation surrounding the fate of addicts in this country. No longer should addicts be expected to just tough it out when the true, slippery nature of their disease can be so much more finely calibrated.
This new understanding has already helped addicts like Jimmy. Addicts seemingly lost forever to their families or themselves have come back from oblivion. What scientists like Volkow and Willenbring have helped the public to understand is that brains harmed by addiction can be repaired. It may take more than one try; it most certainly won't be an easy road, but it can be done. Perhaps the most startling recognition is that new medications -- pills that have been clinically tested and are available by prescription from a doctor -- can help restore the brain's normal functioning and control or eliminate the craving for certain drugs and alcohol.
Tom is among the addicts who have been spared years of suffering, if not death, thanks to one of these new medications. By his own description, Tom was always a "functional drunk." He was never in trouble with the law, rarely missed work selling building materials, and got along with his neighbors. But he drank hard every day. Once he retired he found himself drinking "twenty-four hours a day, seven days a week." In about eight years of retirement, he only played two rounds of golf. His life was "in the toilet."
And then he learned that a good friend had cancer and was yearning to stay alive. "Here I am, with the gift of life, and I'm pissing it away at the bottom of a whiskey bottle," Tom realized.
He enrolled in a treatment program that was testing a promising new medication called topiramate, typically used to reduce seizures by quieting abnormal brain activity. From the day he enrolled in the program, he never drank again. He attributes this both to the medicine and to his will to stop. "There's no light-switch therapy," he says. "You've got to mentally want to, and then medication can help you."
He continues, "In days gone by, I know what I'd do. I'd be sitting here drinking in the middle of the day." Now, instead of spending the entire day drinking, he chooses what to do with his days.
His only regret? "It's too bad I didn't come to this realization a long time ago. I can't change that. But I can determine what's going to happen tomorrow. And I'm not going to drink."