Understanding

Addiction
What We Know. What We’re Learning.
CONFRONTING SUPPORTING TREATMENT
AN EPIDEMIC LOVED ONES AND HOPE
 THOSE
STRUGGLING
WITH ADDICTION
CAN FIND COMFORT
IN SHARING THEIR
STORIES WITH OTHERS
FACING SIMILAR
CHALLENGES.

2 H E A LT H
Contents
4 The Agony of Addiction

CHAPTER 1

The Addiction
8 The Science of Addiction
16 Written in the Genes?
22 Compulsion Without the Chemicals
30 Attack of the Phones
34 Hunger Pains
38 Can You Really Be Addicted to Sex?
40 Opioids: A National Crisis
46 Rethinking Drinking
50 The Hardest Drug to Quit

CHAPTER 2

The Response
58 Beyond the 12 Steps
64 Treatments at the Fringes
68 A Father’s Fight for His Son

CHAPTER 3

The Stories
74 The Addictive Creative
80 “My Son Is Always With Me”
84 Battling the Odds
90 Fictional Addicts, Real Pain
96 How to Get Help

Parts of this special edition were previously

published by HelloGiggles and People.

This book is for general information purposes only, and

nothing contained it is intended to be a substitute for
the individualized advice of a physician or other health
professional. The reader should consult the appropriate
health professional in matters relating to physical and
mental health and particularly with respect to any
symptoms that may require diagnosis or treatment.

H E A LT H 3
 THE AGONY OF
ADDICTION
An increased urgency in studying the causes of
habitual substance abuse and other compulsive behaviors
is slowly bringing hope to millions who struggle.
BY RICHARD JEROME

“I HAVE ABSOLUTELY no pleasure in the stimulants
in which I sometimes so madly indulge,” explained
Edgar Allan Poe in an 1848 letter. “It has not been in
the pursuit of pleasure that I have periled life and
reputation and reason. It has been the desperate
attempt to escape from torturing memories, from a
sense of insupportable loneliness and a dread of some
strange impending doom.” A prescient thought, for
the next year, Poe died at 40; he’d packed quite a bit
into his brief stay—inventing detective fiction, pio-
neering the short story, and, of course, creating the
macabre masterpieces for which he is so celebrated.
Poe was also a notorious alcoholic; though, to a degree,
that reputation may have been posthumously embel-
lished. For instance, recent scholars dispute the long-
held assumption that he drank himself to death. Even
so, Poe was a haunted soul who regularly drowned
his demons in brandy and regretted the toll it took on
his life. It’s part of his legend; indeed, our culture has
romanticized the substance-addicted artist—boozing
and drugging lent a louche mystique to the likes of
Ernest Hemingway, Jackson Pollock, and Kurt
Cobain, among innumerable writers, painters, musi-
cians, and other talents.
In the real world, of course, there’s nothing remotely
romantic about a serious addiction—whether you’re
a rock star or an unemployed welder from Wichita.
Whatever the momentary highs, the lows are grim
and destructive when you’re actually living them—or,
at worst, dying from them, which Americans are doing
at an alarming rate. According to the Centers for
Disease Control and Prevention, excessive alcohol use
is responsible for nearly 100,000 deaths in the U.S.
each year, making it a leading cause of preventable
mortality. More than half of these deaths result from
long-term alcohol abuse over the span of years, which
can lead to various kinds of cancer, liver disease, and
heart disease. (Other, more immediate alcohol-
induced deaths include poisoning, suicide, and motor
vehicle accidents.) Meanwhile, more than 93,000
Americans died from a drug-involved overdose in
2020—the highest number ever recorded for a
12-month period—including prescription opioids as
well as illicit substances, such as heroin, cocaine, and
methamphetamine. It’s been well publicized that
Americans are in the throes of an opioid crisis.
Between 2010 and 2019, overdose deaths from those
drugs more than doubled, to nearly 50,000.
Researchers have noted rising mortality rates from
opioid addiction, drug overdoses, and alcohol-related
liver disease among white Americans without college
degrees, loosely characterizing these as “deaths of
despair,” after the title of a 2020 book by married
economists Anne Case and Angus Deaton.
Do all the people who have died from these kinds
of alcohol and drug abuse qualify as addicts? Not
likely, no matter how we define the term. And to be
sure, there is far from universal agreement among
experts about the meaning of addiction, which has
come to be applied not only to intoxicants but also to
a range of habitual behaviors, including gambling,
shopping, sex, gaming, and internet use. These and
other activities can trigger heightened levels of the
neurotransmitter dopamine, which lights up our

4 H E A LT H
The reward pathways of the brain. A stimulus (like drugs) triggers the release of dopamine, which causes feelings of pleasure.
brain’s reward system—and keeps us going back for
more. Most people, at some point, experience the pull
of a recurring urge, an itch we just have to scratch.
Maybe it beckons from our cell phones—which are
always at the ready, like a gunslinger’s Colt .45. There
is the irresistible allure of an unread email, that 29th
“like” for our latest Instagram food pic, a news alert
from our ideological silo. Sure, we might put the phone
down for a while, maybe even talk to someone, or
watch a movie, or eat—but then that little gremlin in
our craw pokes us and we’ll steal a peek.
Still, nursing a habit, however compulsively, doesn’t
necessarily make us addicts. The psychologist
Stanton Peele, PhD, who has researched the field for
more than 40 years, measures addiction according
to the consequences of the particular behavior. In his
view, someone who, for example, gambles regularly,
or can’t get enough internet porn, becomes an addict
when the habit spirals out of control and causes them
to, say, sell their house, lose their job, or wreck their
marriage. Peele is known as something of an icono-
clast because he has long strenuously opposed the
widely held theory that addiction is a disease, a notion
that has helped fuel a massive, medicalized recovery
and rehab industry. The disease model, he argues,
promotes the image of the addict as passive victim,
and often ignores underlying conditions that drive
people to their dopamine-stoking reward of choice—
be it poverty, loss of social connection, family dys-
function, work stress, or Poe’s “sense of insupportable
loneliness and a dread of some strange impending
doom.” Widely respected in many quarters, Peele,
who considers himself a liberal, nevertheless draws
attacks from the left as well as the right, evidence that
addiction is a phenomenon that remains complicated,
elusive—and distressingly enduring. ●
H E A LT H 5
 CHAP TER

The
Addiction
The causes of addiction, much like
the individuals it affects, are unique.
But our brains, our genes, and the
greater world around us may hold
answers to issues from behavioral
fixations to chemical compulsions.

● The Science of Addiction

● Written in the Genes?
● Compulsion Without the Chemicals
● Attack of the Phones
● Hunger Pains
● Can You Really Be Addicted to Sex?
● Opioids: A National Crisis
● Rethinking Drinking
● The Hardest Drug to Quit

6 H E A LT H
 THE SCIENCE
OF ADDICTION
The roots of substance use disorders are
complex and varied, and treating
these conditions is often complicated by
stigmas and outdated attitudes.
BY MAIA SZALAVITZ

AFTER NORA VOLKOW, MD, underwent surgery a few years back,

she required opioid medication to treat her pain. As the director of
the National Institute on Drug Abuse (NIDA)—the federal agency
that funds most of the world’s addiction research—she was curious
about what it would be like.
“It was extraordinary,” she says of the euphoria she felt. “But it
freaked me out.” She adds, “I did need it, but the moment I left the
hospital, I stopped.”
Dr. Volkow says the high gave her some insight into what people
who do become addicted may feel in terms of the attractiveness of the
drug. However, her ability to quit also reflects the most common
outcome. Because she has few risk factors—and many protective
ones—she did not become one of the roughly 1 percent of adult patients
who develop addiction after surgery.
In fact, the cause of addiction is far more complicated than simply
being exposed to a drug. Factors such as age, genetics, stress, childhood
trauma, gender, and the availability of both drugs and alternative
sources of meaning and comfort all play critical roles. When it comes
to recreational use of drugs such as cocaine, methamphetamine, and
heroin, around 10 percent to 20 percent of people get hooked.

8 H E A LT H
H E A LT H 9
 THE ADDICTION
This is obviously not to minimize the significant
risk of using such drugs. But understanding what
really causes addiction is the key both to finding effec-
tive treatment for it and figuring out the best ways for
family members to help. Focusing only on the drugs
can lead to ineffective approaches that don’t address
why a particular person takes a specific substance
repeatedly, at great cost.
These days, NIDA defines addiction as a chronic,
relapsing brain disorder that results in compulsive
drug use that continues despite negative consequences.
The preferred term for it in medicine is substance use
disorder not substance dependence or substance abuse—
both of which were removed from psychiatry’s diag-
nostic manual for being inaccurate or stigmatizing.
Note what’s not included in this definition: physical
dependence. Addiction isn’t simply needing a sub-
stance to function and avoid with-
drawal. For example, long-term
use of opioid medications can
cause dependence, which means
Addiction
that if the drugs are stopped sud-
as a chronic,
denly, unpleasant withdrawal
relapsing
symptoms will occur. But the same
disorder
thing can occur with some antide-
results in compulsive
pressants and blood pressure med-
drug
ications—even though they don’t
continues
cause a high or craving for more.
negative
Misunderstanding of the differ-
consequences.
ences between needing a drug to
function without withdrawal (phys-
ical dependence) and compulsive behavior that causes
harm (addiction) is why experts stopped using the term
dependence to mean addiction.
Addiction isn’t just pursuing an intense passion,
either. If you are an obsessive K-pop fan or a devoted
runner and you aren’t repeatedly neglecting work or
family obligations to participate in your preferred
activity, it’s not an addiction, even though you might
joke about how much you do it.
According to Dr. Volkow, the most important risk
factor for addiction is family history. For example,
even if children of people with severe alcohol use
disorder (AUD) are adopted at birth by typical parents
without addictions, they are still at a much greater
risk of developing AUD than those who don’t have
that genetic background.
Environmental factors matter as well. Dr.
Volkow says that “having been raised in an adverse
environment that includes neglect, sexual abuse,
10 H E A LT H
physical abuse, and other trauma” also significantly
raises risk—as does having psychiatric disorders,
especially attention deficit hyperactivity disorder,
depression, schizophrenia, and bipolar disorder.
Antisocial personality disorder and borderline per-
sonality are also risk factors.
To complicate matters, often childhood trauma
can be the difference between someone with just a
genetic predisposition to a psychiatric, personality,
or addictive disorder and one who actually develops
a condition. The context matters tremendously,
starting early in life.
For both genetic and trauma-related reasons, people
who are at risk for addiction often feel “different” from
others during childhood and tend to have difficulty
regulating their sensory or emotional reactions. Their
temperaments and reactivity can make them the tar-
gets of bullies and leave them
socially isolated from their peers.
This can lead to seeking drugs as a
is defined way to self-medicate or fit in and
make friends. Youth itself also puts
brain them at risk: 90 percent of all
that addictions begin in adolescence or
early adulthood because the devel-
use that oping brain is more vulnerable.
despite Adds Dr. Volkow: “Another factor
that we cannot minimize is easy
accessibility and acceptance of the
use of the drug by the culture.”
However, once people—even
those at high risk—are exposed to a substance, repeated
experience is required before addiction can develop.
Both psychologically and within the brain, the process
is similar to falling in love. While there can be what
might be called “love at first sight” with either a person
or a drug, ongoing contact is necessary to create the
associations and shift in priorities that drive craving
and change behavior. “You have to have repeated expo-
sure,” says Dr. Volkow. “When you experience these
extraordinary sensations, it creates a very deep mem-
ory almost immediately, and that, in turn, will generate
desire the next time you are in those circumstances.”
The brain systems involved in both addiction and love
use neurotransmitters like dopamine (which is linked
with feelings of desire) and the brain’s natural opioids
(which are involved in feeling connected and satisfied)
to influence behavior.
Although both love and addiction can move people
to do things that they wouldn’t otherwise consider,
National Institute on Drug Abuse director Nora Volkow has pioneered the use of brain imaging to better understand drug addiction.
these behaviors are not automatic and are affected
by circumstances. For example, many people will lie
to hide addictions or affairs, but few also start lying
about other things as well unless they have always
been prone to prevarication.
Seeing addiction as simply having a “hijacked
brain” fails to account for this complexity, says Ayana
Jordan, MD, assistant professor of psychiatry at the
Yale School of Medicine. “This is a grossly over­
simplified take, which minimizes how environment,
trauma, and stresses such as racism, sexism, and
poverty affect addiction and one’s ability to recover.”
That said, brain changes during addiction do push
people to prioritize drug use above almost everything
else: As with being in love, the feeling they have is that
they can’t survive emotionally without the substance
or person. These alterations occur in specific brain
circuits, particularly those that connect a region
known as the nucleus accumbens and the prefrontal
cortex. “Many addictive processes disrupt or affect
these projections and can lead to cravings, inability
to make wise decisions, return to substances, and
dysregulation of delayed gratification,” Dr. Jordan
says. “However, given a particular environment,
access to resources—both physical and emotional—
can also manipulate these connections, which makes
the story much more complex.”
This means that while the ability to make better
choices is impaired during addiction, it is not elimi­
nated. Understanding this is crucial because people
do learn even while actively addicted and can start to
improve their health long before they quit.
Gender can also affect addiction. Although men
and women appear to be equally susceptible to sub­
stance disorders, two­thirds of all people treated for
addiction are men. “The stigma for a woman is greater
than for a man,” says Dr. Volkow. “There are policies
that make it actually almost impossible for women
with children to want to seek help, because [the
authorities] will take custody of their children.” And
since women are more prone to depression, she says,
this also increases their risk.
According to Dr. Jordan, there are also differences
in the types of substances used and the age at which
the problem begins: Women are more likely to misuse
prescription anti­anxiety medications like Xanax or
Valium, and their addictions tend to start later in life
but progress more quickly than in men. Moreover,
most addiction treatments were devised with men in
mind, meaning that women who do seek help often
aren’t receiving appropriate care.
THE GOOD NEWS is that there are effective treat­
ments for addiction for both men and women.
Research shows that if they can avoid overdose,
most people do recover. The bad news, however, is
H E A LT H 11
 that good treatment is hard to find.
A big part of the problem is widespread misconcep-
tions about what addiction treatment should look like.
For example, many people think that tough love is the
only answer—and that treatment needs to be harsh
and confrontational to be effective. “I would like to
believe that this is no longer the case,” says Dr. Volkow.
“But it was definitely a way of looking at addiction:
Make them suffer so that they can get out of it. And
there are some programs that are brutal in terms of
the amount of suffering that they put patients
through.” She stresses, however, that “there’s no evi-
dence whatsoever—scientific or clinical of any kind—
that this is beneficial.”
In fact, research now shows that the opposite
approach works best. Formerly derided as “enabling,”
or worsening addiction, programs like needle
exchanges—where people can get clean needles and
naloxone, the antidote to opioid overdose, actually tend
to spur recovery. Indeed, those who participate in nee-
dle exchanges are five times more likely to get treat-
ment than those who do not, according to the Centers
for Disease Control and Prevention.
Dr. Jordan says that in order to be most effective,
care must also be accessible, affordable, evidence-
based, and sensitive to cultural issues. For example,
Needle exchange programs do not lead to increased illegal drug use and often also help connect users to other health services.
12 H E A LT H
Black people often have their addictions “treated” by
punishment in the criminal prosecution system. This
results in criminal records, which affect one’s ability
to find work and housing—both of which are essential
to sustained recovery. Culturally informed treatment
recognizes this and helps people find their way
around these obstacles, including the emotional
impact of systemic racism.
It’s also critical for treatment to be able to address
mental illness and trauma exposure, both of which
can cause symptoms that interfere with recovery if
they are not treated. Unfortunately, while many pro-
grams claim to be “trauma informed” and able to treat
patients with “dual diagnoses” (e.g., both addiction
and another psychiatric disorder), these are just buzz-
words. To find care that truly does treat the whole
person, ask specifically about what is on offer for par-
ticular conditions—if the answer sounds generic or
one-size-fits-all, it is less likely to help.
Importantly, for people with opioid use disorder,
medication is an essential part of good treatment.
Two medications are proven to cut the death rate
from opioid addiction (which is among the highest
in all psychiatric conditions) by 50 percent or more:
methadone and buprenorphine (commonly sold
combined with naloxone under the brand name

Substance
and behavioral
addictions
ALCOHOL
About 14.5 million people,
or 5.6 percent of the
population, are addicted to
or abuse alcohol, and
13,000 more try it for the
first time every day.
Alcoholics Anonymous has
more than 2 million
members—impressive, but
only a small fraction of
those who need help.
DRUGS
An estimated 8.1 million
people are addicted to at
least one drug. On average,
27,000 try drugs for the
first time each day.
Marijuana, prescription pain
relievers, and prescription
tranquilizers are the leading
drugs of abuse. In 2018,
3.7 million people received
treatment for the use of
drugs and/or alcohol.
TOBACCO
There are about 59 million
users of tobacco products in
the U.S. About 15.3 percent
of men and 12.7 percent of
women are cigarette
smokers, with cigarette use
lowest in Western states
and highest in the Midwest;
although youth are smoking
fewer cigarettes, 21 percent
of high school students are
now vaping.
CAFFEINE
It’s the most widely used
mood-altering drug in the
THE ADDICTION
What Hooks Us
Addictions in America change over time.
Here’s a look at what we’re battling now.
BY GILLIAN ALDRICH
world and is ingested by
about 80 percent to
90 percent of Americans,
primarily through soda and
coffee. A daily brewed cup
of joe, with 100 mg of
caffeine, can lead to mild
physical dependence.
Withdrawal symptoms are
experienced by about half
of those trying to quit.
FOOD
Although food addiction is
not a classifiable disorder,
as many as 20 percent of
the population may fit the
criteria. Food addiction also
has some overlap with
binge-eating disorder
(which is classified), in that
it affects women much
more than it does men and
is linked to depression.
GAMBLING
Approximately 2.5 million
people, or 1 percent of the
U.S. population, have a
gambling disorder,
wagering heedless of the
consequences. In treatment surge in the wallet-draining INTERNET
populations, about half of addictive activity. With 90 percent of children
those with a gambling and teens and 65 percent
disorder have suicidal SEX of adults playing online
ideation, and 17 percent Some 3 percent to 6 percent, and video games regularly,
have attempted suicide. or 7.4 to 14.7 million, of the Diagnostic and
American adults struggle Statistical Manual of Mental
SHOPPING with what has recently been Disorders (DSM-5) includes
Research indicates that classified as compulsive online gaming disorder—
about 6 percent of the U.S. sexual behavior disorder. not as a diagnosis but as
population are compulsive Online porn addiction has a condition warranting
buyers, and women are escalated in recent years; further research. Research
only slightly more likely excessive masturbation and indicates that some heavy
to be affected as men. other obsessive thoughts users develop dysfunctional
The accessibility of online and behaviors often have symptoms that cause
shopping is thought to a strong correlation social, work, and emotional
have fueled a worldwide with childhood trauma. impairment.
H E A LT H 13
 THE ADDICTION

What Happens in the Brain

The path to reward is a delicate balance of dopamine release.
Break the balance, and you have addiction.

We feel good when neurons

in the reward pathway
release a neurotransmitter
called dopamine into the
nucleus accumbens and
other brain areas.

Neurons in the reward

pathway communicate by
sending electrical signals
down their axons. The
signal is passed to the next
neuron across a small gap
called the synapse.

Dopamine is released into

the synapse, crosses to the
next neuron, and binds to
receptors, providing a jolt of
pleasure. Excess dopamine
is taken back up by the
sending cell. Other nerve
cells release GABA, an
inhibitory neurotransmitter
that works to prevent the
receptor nerve from being
overstimulated.

Addictive substances
increase the amount of
dopamine in the synapse,
heightening the feeling of
pleasure. Addiction occurs
when repeated drug use
disrupts the normal
balance of brain circuits
that control rewards,
memory, and cognition,
ultimately leading to
compulsive drug-taking.

SOURCE: NATIONAL INSTITUTES OF HEALTH (NIH)

14 H E A LT H
Suboxone). However, these medications only con- punished for not knowing how to change. Further, in
tinue to protect against overdose if they are taken order to sustain recovery, most people will also need
indefinitely, sometimes for life. Sadly, such long- to find new sources of meaning and connection with
term use of these medications is highly stigmatized. others. Addiction is often an attempt to cope with
Because of confusion about the difference between stress, isolation, and despair.
addiction and dependence, many people see long- Some reconnect by attending 12-step groups like
term medication use as “not really being in recovery” Alcoholics Anonymous or Narcotics Anonymous;
or “substituting one addiction for another.” others find support in other mutual aid groups like
In fact, research shows that people who have been SMART Recovery (Self-Management and Recovery
stabilized on an appropriate dosage of these drugs are Training). Many, however, find joy and purpose
not “high” or “impaired,” and the consequences of their elsewhere—in everything from love and family to
medication use are not negative. While they physically exercise to religion, hobbies, and work. Again, what
need these drugs to function—just as with many other helps is highly individualized and usually involves
medications—their lives are no longer dominated by many different components. On its own, each of these
compulsive drug seeking. Essentially, they no longer factors probably won’t be enough to sustain recovery,
have addiction, but they still have physical dependence, but together people can create a web that supports a
which is not a problem when a drug’s benefits out- much healthier and happier life without addiction.
weighs its risks. Any treatment for As with other psychiatric ill-
opioid addiction that does not nesses, researchers are continu-
offer access to these lifesaving ing to seek better treatments.
Any treatment for
medications—or worse, stigma- Some scientists are excited about
opioid addiction that
tizes them—should be avoided. the potential of psychedelic drugs
does not offer access
Another common misconcep- like psilocybin (magic mush-
to medications—or
tion about addiction treatment is rooms) to interrupt addictions.
worse, stigmatizes
that residential care is the most Preliminary research has shown,
them—should
effective. For people who are for example, that psilocybin can
be avoided.
unhoused or whose home may be help people quit smoking.
compromised (by, for example, Other researchers are even
the presence of others with sub- looking for outright cures. But
stance use disorder or drug dealers), a new living here, too, addiction is complicated: Just as there has
situation will typically be required. However, long been disagreement on defining the illness,
because many residential programs actually ban or there is also controversy over determining what
stigmatize medication for opioid use disorder and would count as being cured. Some experts would
because many do not provide adequate and individ- only count a medication or therapy as a cure if it
ualized psychiatric care, it may be better to seek produced lifelong abstinence from the substance,
safer housing and addiction care separately. without any further need for help. Others would see
Signs of harmful or ineffective treatment, accord- a true “cure” as a drug or therapy that would allow
ing to Dr. Jordan, include punitive policies like expel- someone to return to use in moderation, without
ling patients who return to drug use. Since relapse is ever developing compulsive behavior. The lack of
actually a symptom of addiction, kicking people out consensus around these issues makes the whole
of treatment for having symptoms of their disorder question difficult to study.
makes little sense. Instead, effective programs teach “I don’t really think about a cure,” says Dr. Jordan.
people to use lapses as learning experiences by deter- Instead, her goal is for “people to be able to live their
mining what led up to them and working on finding lives optimally, without impairment in functioning,
alternative ways of coping. as witnessed by their ability to keep themselves safe,
Figuring out these “triggers” and discovering ways meet goals, and thrive according to the desires they
to manage them is an essential part of recovery. Just have set for themselves.”
as no one can learn to dance or speak a new language And that objective is already reachable for most
without building new skills and making errors along today—but only if we provide compassion, support,
the way, few recover from addiction simply by being and treatment based on evidence, not myth. ●

H E A LT H 15
 WRITTEN IN
THE GENES?
Addiction has a lot of causes.
One of the most basic might be found
in our DNA.
BY MARKHAM HEID

FOR CENTURIES, the nature-versus-nurture debate cast a long

shadow over the study of human behavior, including the phenome-
non of addiction. Are addicted people the products of their biology,
or are their compulsions shaped by their experiences and environ-
ment? Why do some people mess with highly addictive substances
at all, while others avoid them entirely? Great minds were split over
these questions.
Today, the debate is largely settled—though there is no clear victor.
Experts now recognize that every human being is the product of both
DNA and environment, which interact in endlessly complex ways to
produce any number of outcomes. But that’s not to say the ratio of
genetics to environment is the same from person to person. Just as
one person’s genetic risk for heart disease or diabetes differs from
another’s, not everyone’s risk for addiction is the same. Researchers
have identified specific genetic variables that, in some cases, can
substantially raise or lower the likelihood that someone will “exper-
iment” with addictive substances or go on to develop an addiction.
And even for people who don’t carry these specific high-risk genes,
DNA still plays a significant role in shaping their propensity for
developing an addiction disorder.

16 H E A LT H
 DNA PLAYS
A MAJOR ROLE
IN DETERMINING
HOW SUSCEPTIBLE
SOMEONE MAY BE
TO ADDICTION.
 THE ADDICTION
How significant? In 1999, a large study on male
identical and fraternal twins appeared in the American
Journal of Psychiatry. While identical twins share the
same DNA, fraternal twins each have their own
genetic blueprint and are no more alike in that respect
than any other two siblings. The study found that
alcohol use disorders tended to show up much more
commonly in both members of identical-twin pairs
than in fraternal-twin pairs. Based on this finding and
their subsequent analysis, the study authors deter-
mined that between 48 percent and 58 percent of a
man’s risk for an alcohol use disorder is dependent on
genetic variables, while the remainder of his risk
comes down to environmental factors. When it comes
to illicit drugs, genes are likely even more significant.
The results are all but certainly applicable to women,
too, though perhaps not in the same percentages.
Figures like those apply to the “average” person.
For a given individual, “we know
that both genetic and environ-
mental factors make important
contributions to addiction,” says
There
Arpana Agrawal, PhD, an addic-
thousands
tion researcher and a professor
variants
of psychiatry at Washington
contribute
University School of Medicine
susceptibility
in St.  Louis. Teasing apart the
addiction.
ways DNA affects a person’s risk
for addiction has proved to be
immensely challenging. For one thing, it’s very
unusual for a single gene variant—which is basically
a snippet of genetic material—to play a decisive role
in determining the risk for any disease. “We antici-
pate there are thousands of variants that contribute
to genetic susceptibility for addiction,” Agrawal says.
Genes and gene variants work in concert, not in
isolation, and each may have an effect on the opera-
tion of all the others. Think of them as billiard balls
caroming off one another to produce a particular
pattern, except in a far more orderly way. For this
reason, identifying a single addiction-related gene
usually isn’t enough to estimate its role in a person’s
risk for a substance disorder.
But there are exceptions.
“Pathways” to Addiction
The human genome, which is a person’s complete
genetic blueprint, contains up to 25,000 genes. And
from one person to the next, more than 99 percent
of the genetic sequences that comprise these genes
18 H E A LT H
are identical. It’s the variation in the less than 1 per-
cent that determines a person’s unique traits—from
height to eye color to the way the brain processes
information.
Much of the research into the ways these genetic
variations may fuel or dampen addiction has focused
on alcohol use disorders. “This is because alcohol
dependence is the most prevalent [form of substance
abuse] and the biggest killer,” says Danielle Dick,
PhD, an addiction researcher and a professor in the
departments of psychology and human and molec-
ular genetics at Virginia Commonwealth University.
She says researchers have identified a handful of
genes that have big effects.
Some of these genes affect enzymes referred to
as alcohol dehydrogenase (ADH) and aldehyde
dehydrogenase (ALDH). Both of these enzymes play
a role in the way the human body metabolizes etha-
nol, which is pure alcohol. “When
our body breaks down alcohol, it
first converts it to acetaldehyde,
are likely which is a nasty by-product,”
of genetic Dick explains. According to the
that National Institute on Alcohol
to genetic Abuse and Alcoholism, acetalde-
for hyde is a “highly toxic substance”
that can cause short-term symp-
toms like skin flushing and nau-
sea and that in the long term can
promote liver damage and cancer.
“Usually, acetaldehyde is quickly broken down
into acetate,” which is then eliminated from the
body, Dick says. But for people who carry certain
gene variants—also known as “polymorphisms”—
related to ADH or ALDH, the body’s normal alcohol-
breakdown processes are altered. For example,
some people who carry an ALDH gene polymor-
phism have low levels of the enzymes that turn
acetaldehyde into acetate. This causes acetaldehyde
to build up quickly and induce those short-term
symptoms. (Dick says this particular polymorphism
is mostly limited to people of East Asian descent.)
In others, the presence of one of these polymor-
phisms causes a rapid increase in the breakdown of
alcohol to acetaldehyde, which can also make a
person feel unwell. “If you feel sick when you drink,
you tend not to develop a problem,” she says. And
so individuals who carry one of these genetic vari-
ants are at lower risk than the average person for an
alcohol use disorder.
Young brains are wired for risky behavior, which can be a factor in developing addiction.
But even here, Dick stresses, “it’s unusual that a
single gene can play a big role in a person’s risk, and,
as it turns out, the way a person’s body responds to a
drug is really just a tiny part of the influence genes
have on addiction.” She says most of the strong links
between addiction and a person’s DNA have to do
with two “genetically influenced pathways” that
broadly affect how the human brain processes risk,
reward, and emotion.
The first of these is usually referred to as the “exter-
nalizing” pathway, and it’s used to describe individ-
uals who engage in behaviors that are impulsive or
risky. “These are people who were born with brains
wired for sensation-seeking and reward-seeking, and
they don’t stop to think about their actions or the
consequences of their actions as much as others,” she
explains. They are more likely to end up in risky envi-
ronments, Dick says, and they’re also more likely to
try addictive substances and to develop problems.
The second pathway is known as the “internaliz-
ing” pathway. “This one has to do with the way our
brains are wired to cope with fear and negative emo-
tion,” she says. Research from the University of North
Carolina has found that people who are genetically
predisposed toward internalizing are at greater risk
for depression and anxiety. And studies have found
that specific genetic variants that are associated with
internalizing are predictive of greater risk for
substance use disorders. “Individuals who are more
genetically predisposed this way often use sub-
stances to cope or to manage emotions,” Dick says.
To some extent, these pathways exist in everyone.
But our individual DNA helps determine where we
fall along each, which in turn helps to determine our
liability for addiction. Scoring high on both scales
would likely place you at particularly acute risk, but
Dick hastens to add that neither one of them is
innately bad. “We know entrepreneurs and CEOs
tend to be more risk-taking and sensation-seeking,”
she says. “And so there are ways to channel these
sorts of impulses toward constructive activities.”
Also, individual life experience and environment
can mediate both pathways. “Even if you have all the
high-risk genetic variables, that doesn’t mean you will
develop a disorder,” Dick says. For example, some
cultures and religious communities don’t engage in
H E A LT H 19
 Researchers hope to eventually identify genetic variances that are associated with substance use disorder.
alcohol consumption or drug use, so many of their
members are never exposed to these addictive sub-
stances. “Also, people who come from a family where
the parent has an addiction may choose not to drink
or use, and so they never develop a problem,” Dick says.
A Complicated Picture
A third variable—something that overlaps with envi-
ronment and genetics—also plays a part in a person’s
risk for addiction: timing.
“I mention young people a lot because, if we’re
talking about risk for substance abuse, we know most
people start using during adolescence and emerging
adulthood,” Dick says. This has to do somewhat with
genetics but more so with the way a young person’s
mind matures.
“During adolescence, the parts of the brain that
process reward are highly developed, which means
adolescents like to engage in reward-seeking,” she
says. At the same time, the parts of the brain that are
not as fully developed—such as the prefrontal cortex—
are the ones that help a person think through the
20 H E A LT H
long-term consequences of choices. Thus, to every
parent’s chagrin, “adolescents have brains that are
hardwired to get them into trouble,” Dick says. This
means that the environments a young person ends
up in—the friends who are there, the substances that
are available there—really matter.
Research in the journal JAMA Psychiatry has
determined that, when it comes to a young person’s
risk for developing an alcohol use disorder, environ-
mental influences play a larger role than genetics. But
this balance flips during adulthood. Once people
reach their mid-20s, approximately, genetic factors
seem to take the wheel and drive the larger share of
the risk for addiction.
Even if a person manages to escape youth without
developing an addiction, early and repeated exposure
to addictive substances may influence the risk for a
disorder later in life. “Some studies show differences
in brain structures related to reward response and
decision-making in individuals persistently exposed
to substances at an early age,” Agrawal explains. She
says brain scans of people with addiction disorders

have also revealed that, compared with nonaddicts,
their reward circuitry “just lights up” when presented
with imagery associated with their problem sub-
stance or behavior. Much of this research is mixed,
and it’s not clear whether these patterns of brain
activity are the cause or the result of a person’s addic-
tive behavior. But it’s possible that heavy exposure to
a substance at a young age may prime the brain for an
addiction later in life, Agrawal says.
Further complicating all of this is something
known as “epigenetics,” which blurs the line between
genes and environment. Just because you have genes
that code for a trait, that doesn’t mean that trait will
ever be expressed. The epigenome regulates whether
the relevant genes get switched on or not—and expe-
riences can play a role.
“Epigenetics describes how the genome can adapt
to cope with environmental factors,” says Jian Feng,
PhD, a molecular biologist at
Florida State University. By
“adapt,” Feng means the way genes
are transcribed or expressed after
Environmental
a person has been exposed to
influences
something like alcohol or opioids.
larger
A 2018 study led by researchers
genetics
at the Icahn School of Medicine
person’s
at Mount Sinai in New York City
alcohol use
found that exposing mice to
cocaine changed the expression of
genes associated with their brains’ reward centers.
And research on humans has turned up some of these
same associations. “When we compare the DNA of
opioid users to the DNA of healthy individuals, we
see an increase in DNA methylation,” says David
Nielsen, PhD, an epigenetics researcher and an asso-
ciate professor at Baylor College of Medicine.
Methylation describes changes to DNA molecules
that affect their expression.
There’s also research on animals that suggests that
these epigenetic changes may even be passed down to
an individual’s offspring. “If you give opioids to female
rats,” Nielsen says, “you can see changes two genera-
tions down.” And so it’s possible, though far from
proven, that a parent’s history with drugs or alcohol
could affect the offspring’s risk for an addiction.
The Future of Addiction
Prevention and Treatment
Despite the challenges experts face when determin-
ing how all these variables interact to raise or lower
THE ADDICTION
a person’s addiction risks, they say the latest genetic-
testing technologies should soon help clarify things.
“By taking huge groups of people—a million or more—
and scanning their entire genome, we can look for
genetic variance between people who have a problem
and those who don’t,” Dick says. Identifying these
patterns should one day allow doctors to estimate a
person’s risk for an addiction disorder before the first
taste of a substance.
The question then becomes: What to do with this
information? It’s possible that, for some, pharmaco-
logical interventions may help lower addiction or
relapse risks without unwanted side effects. There
are already drugs available to treat alcohol use disor-
ders, and one of them (Antabuse) works by mimicking
the action of those gene variants that cause some
people to feel sick after imbibing. It has helped many
people quit drinking. “For those who have had their
brain rewired to be dependent on
this extremely powerful reward, I
think we have the potential to
develop drugs to help these indi-
play a viduals get back to a more regu-
role than lated place,” Dick says. For others,
in a young risk-based education is the future
risk for an of addiction prevention. “If an
disorder. individual understands their spe-
cific liability, they can use this
information to reach their poten-
tial and avoid pitfalls,” she says.
In many ways, advances in genetic testing aren’t
needed to inform these sorts of interventions.
“Parents say to me, ‘Gosh, I wish I could know if
my kid is at risk,’ ” Dick says. “And I say to them, ‘You
can!’ ” Even as a toddler, her son was an impulsive
sensation-seeker. “He was the kid hanging from the
tops of tall trees,” she says. Based on the research
linking these behavioral traits with an increased risk
for substance-use problems, she knew her son needed
a little more parental oversight and counseling on the
risks of experimenting with drugs or alcohol. “You
can teach kids skills and intervene in ways that can
reduce their risk for problems,” she says.
The future of addiction research will surely pro-
duce new insights that will shape more-effective
treatments and prevention strategies. But today, what
experts have learned about the genetics of addiction
can help people avoid trouble and find relief. “Genetics
is not destiny,” Agrawal says. No one is born with DNA
that preordains a life of addiction. ●
H E A LT H 21
 COMPULSION WITHOUT
THE CHEMICALS
Getting hooked on gambling, sex, shopping, and other
behavioral vices is every bit as overwhelming as getting hooked on
alcohol and drugs. The latest brain research explains why.
BY BARBARA O’DAIR

IN THE EARLY 1980S, marriage and family therapist
Chris Anderson took a break from his practice to try
his hand at stock trading, joining a brokerage firm
in his hometown of Austin, Texas. Within a couple
of days, he doubled his money. Even though the sum
was relatively small, he did the math and decided he
liked what it told him.
“I went from not really knowing what I was doing,
to my mind filling with numbers so big that I couldn’t
even count them,” he recalls. “I had been known as
a tightwad in my family, ironically, but here I thought
I’d discovered something amazing.”
Hooked on the rush of getting rich quick, Anderson
studied the markets, developed strategies, and began
generating money for himself and his clients. Then
he started losing—which did not discourage him
as it might have some people who got ahead of them-
selves in an unfamiliar field such as investing.
Instead, he says, it only motivated him to take even
greater financial risks. He became obsessed with
making back the money he’d lost, and then some.
At the time, Anderson was married with two
young children. “It took me only a couple of years to
end up in bankruptcy court,” he says. His house was
foreclosed on, his wife divorced him, he did not see
his children for 10 years, and he ended up suicidal,
receiving treatment in Austin State Hospital.
Ultimately, Anderson found his way to a Gamblers
Anonymous meeting, where someone steered him
toward a conference in Dallas that weekend. While
there, he met the late Robert Custer, a renowned
psychiatrist who specialized in gambling disorder.
Custer looked Anderson in the eyes and said, “You’re
really hurting, aren’t you?”
“At that moment,” Anderson says, “I moved from
a place of despair to hope.”
Since the day he began his treatment with Custer,
Anderson says, he has been trying to understand
his relationship with gambling—which is what
speculative investment is for many people—and the

22 H E A LT H
 ABOUT
2.5 MILLION
U.S. ADULTS
MEET THE CRITERIA
FOR GAMBLING
DISORDER EACH YEAR,
ACCORDING TO THE
NATIONAL COUNCIL
FOR PROBLEM
GAMBLING.
 THE ADDICTION
disorder that cost him everything but his life. Now
in his late 60s and a compulsive-gambling counselor
himself, he has worked with hundreds of people with
gambling disorders to treat their addiction and
unravel its mysteries so they can heal. These days,
he says, he has two types of people in his life: “those
who want to talk to me because they know that I get
it, and those who want to avoid me like the plague
because they know that I get it.”
When it comes to an addictive behavior like
gambling—or shopping or eating or having sex or
exercising or playing video games—it’s always been
unclear whether anyone truly gets it. Indeed, it’s long
been debated whether the behavior is an addiction at
all. Drug or alcohol addictions, after all, require a
chemical, an external agent that enters the body and
messes with the workings of the brain itself. In some
cases, the chemical is so powerful, addiction seems
almost instantaneous—as it is with heroin or crystal
meth. In other cases, it takes a little while—nicotine,
marijuana. Either way, the brain often gets hooked.
But behavioral addictions are just that—behavioral.
No one smokes video games. No one shoots up shop-
ping. Yet the result is the same: the cravings, the com-
pulsions, the need for more and more in pursuit of a
high that offers less and less. The first question is:
How exactly does such repetitive behavior cause the
brain to tip into an addictive cycle? The second, more
pressing one is: How can an understanding of the
mechanisms lead us to a cure?
What’s in a Name?
In 1994, gambling disorder was classified as “patho-
logical gambling” and was grouped with other
“impulse control” disorders such as kleptomania and
pyromania in the benchmark psychiatric text
Diagnostic and Statistical Manual of Mental Disorders
(DSM). The authoritative reference for mental health
professionals is conservative in its approach to clas-
sification, making changes only slowly as scientific
evidence mounts to challenge old ideas. It took 21
years—from 1952 to 1973—for the DSM to remove
homosexuality from its list of mental disorders. So
it was a really big deal in 2013 when the fifth and most
recent edition, DSM-5, changed the diagnosis to
compulsive gambling and classified it as a “substance-
related and addictive disorder” alongside opioids,
alcohol, and other addictive substances.
Hypersexual disorder and gaming disorder were
also considered for inclusion, and although neither
24 H E A LT H
was classified, gaming disorder was included in the
manual’s Section III, which lists diagnostic categories
that require further research and may someday be
considered for classification. Then, in 2018, the World
Health Organization released a revised International
Classification of Diseases (the ICD-11), which included
gaming disorder and compulsive sexual behavior
disorder (CSBD), both classified as impulse-control
disorders (not addictive disorders akin to substance
abuse and, now, gambling). But that doesn’t mean
they’re not the same problem. “Some things generate
addiction at a higher rate—for example, nicotine or
opioids; fentanyl will kill you rapidly,” says psychia-
trist and research scientist Nora Volkow, MD, director
of the National Institute on Drug Abuse (NIDA),
which is part of the U.S. National Institutes of Health.
By comparison, “[compulsive] shopping won’t kill you,
but it will disrupt your life,” she says. “Likewise, video
gamers have been known to stop sleeping and eating
while in the grip of a game.”
Over the course of her long career, Dr. Volkow has
conducted research showing how heroin and other
opioids target the brain’s rewards system by flooding
the circuits with dopamine, a neurotransmitter that
regulates emotion, motivation, and pleasure, among
other things. When the system is activated at a normal
level, it rewards natural behaviors. When drugs over-
stimulate the system, however, they can produce
euphoric effects, strongly reinforcing the drug use.
Scientists have begun to understand that dopamine
not only contributes to the experience of pleasure
“but also plays a role in learning and memory—two
key elements in the transition from liking something
to becoming addicted to it,” according to a Harvard
Health Letter published in July 2011. This system
effectively teaches the drug user to repeat the behav-
ior, and it’s only a short step to the same circuits
teaching us to repeat nonchemically mediated behav-
iors just as compulsively.
“This system has an important role in sustaining
life because it links activities needed for human
survival (such as eating and sex) with pleasure and
reward,” the Health Letter goes on to explain.
“Addictive substances and behaviors stimulate the
same circuit—and then overload it.”
The Story of a Sex Addict
Erica Garza, who grew up in a Mexican American
family in Montebello, California, lived that pain. In
the early 1990s, when she was a tween, she began
thinking about sex—a lot. That’s hardly unusual for
people at that age, but the way she thought about it
was. She remembers keeping lists of boys she “wanted
to touch” and making crude sexual drawings. “At age
10,” Garza says, “it seemed I lusted after everyone—my
male and female teachers, the boys and girls in class.”
Once Garza became sexually active, “sex made me
feel temporarily satiated,” she says. “But it was almost
always tied up in shame about the kind of sex I’d had,
the kind of person he was, or the kind of fantasies I’d
feasted on throughout. There was always something
to feel bad about. I felt empty and anxious, waiting
for the next round with someone new.”
It got to the point that Garza became dependent
on shame in order to feel pleasure, she says. Her 20s
were marked by escalating, risky, unhealthy behav-
ior: “being secretive, cheating, looking for men who
would degrade me, having unprotected sex.”
A low point came one night in Paris when she was
recovering from the end of a significant relationship.
“I drank too much and went home with a young
waiter,” she recalls. “I only remember fragments of
the rough sex we had. After leaving his apartment in
bloodied, ripped clothing, I wandered the streets until
I found a taxi. I often think about how much worse
that night could have gone—alone, drunk, and half-
dressed.” It’s the first thing she thinks about when
she reflects on those days.
Eventually, Garza says, she began listening to a
voice in her head that kept “telling me to stop hurting
myself and others.” Thanks to a variety of interven-
tions, including a short-term 12-step program and a
therapeutic retreat, Garza began to shake herself
free, and she now considers that dark time to be safely
in her past. She’s married, with a child, and living in
Los Angeles, and she calls herself recovered. She
published a memoir, Getting Off, in 2018.
Dr. Volkow has seen dramas like Garza’s play
out countless times, with the cycle of addiction
and, sometimes, recovery more or less the same
whether chemicals or behaviors are involved.
“All addicted persons give great value to the thing
they’re addicted to, so that it’s constantly desired,”
she says. “Once a person addicted to food eats, they
have a need for more and more. Anything that has a
potential of activating the dopamine system has
H E A LT H 25
 THE ADDICTION
what we call an ‘addictive dimension.’ ”
There’s a lot more than mere semantics at play in
labels like that. DSM classifications can have serious
real-world ramifications. “How a disorder is classified
has a significant implication as to who might receive
care,” says Marc Potenza, MD, PhD, a professor of
psychiatry, child study, and neuroscience at the Yale
School of Medicine and director of the Center of
Excellence in Gambling Research at Yale. “If [a dis-
order] is seen in the realm of addiction, then people
providing care in treatment settings should be receiv-
ing training in that area.” Conversely, if that disorder
is not classified as an addiction, it’s much less likely
that the providers will have the necessary experience
to help the addicted person.
In addition, diagnostic criteria are used by clini-
cians when they write up their treatments for health
insurers, which naturally has an impact on reim-
bursement. Then, too, there is the social component.
If, say, food addiction or compulsive shopping were
to become officially designated as a disorder, it’s
probably safe to say that those behaviors could
26 H E A LT H
become less marginalized and less likely to be dis-
missed as simply self-indulgent.
Dr. Potenza was part of the working group that
recommended the reclassification of gambling dis-
order in the DSM-5, its arguments backed by studies
revealing commonalities between gambling disorder
behavior and substance use disorders. But not every-
one agrees with the new addiction model.
Mary Jeanne Kreek, MD, who died in March 2021,
was perhaps best known in the field of neuropsycho-
pharmacology and addictive disease for being part
of a team of three scientists who developed metha-
done maintenance therapy for heroin addiction. As
head of the Laboratory on the Biology of Addictive
Diseases at Rockefeller University in New York City,
Dr. Kreek brought a robust skepticism to what some
experts see as a troublesome trend.
“I’ll never call binge eating or sexual behaviors an
addiction,” she said in 2019. “Those are compulsive
behaviors.” She added, bluntly, that “behavior is
behavior,” distinct from “neurobiological changes in
the brain from the drugs that my lab and others have
been able to define in terms of addictive disease.”
Researchers do have legitimate concerns about
weakening the validity of diagnoses by being overly
inclusive. Assign everyone the same label, and
you prescribe everyone the same—or a very similar—
treatment. Clearly the person who continually relapses
on crystal meth requires a different recovery treat-
ment than the gamer who never leaves the computer.
Scientists have been studying behavioral disorders
vis-à-vis substance addiction for several decades and
“we’re still at an early stage of understanding the
specific similarities and differences,” concedes Dr.
Potenza. “You can always benefit from more research.”
Who Gets Hooked
Just as some people can drink in moderation while
others dare not go anywhere near alcohol because
one drink inevitably means a great many drinks, so
too can some people eat or shop or
have sex or gamble and feel satis-
fied relatively quickly. So what is it
that makes such basic parts of liv-
“All addicted
ing so fraught for so many?
persons
It would help if we knew just
value
how many “so many” is, but with-
they’re
out DSM classifications, an exact
Once a person
count of addictive behaviors is
addicted
impossible. An estimated 6 per-
eats,
cent of the U.S. population ages 12
a need
and over meet the criteria for a
and more.”
substance use disorder. That’s
roughly 20 million people who
battle addictions to alcohol or an illicit substance.
(This figure doesn’t include nicotine.) Even without
comparable numbers for addictive behaviors, if you
add all of the individuals in 12-step programs, resi-
dential facilities, and therapy offices for nonsub-
stance addictive behaviors, plus the undiagnosed
and the treatment- averse, the population of
people battling addiction would likely swell to many
more millions.
With the rise of interactive gambling and the
legalization of sports wagering (more than 30 states
and Washington, D.C., have legalized sports betting
or are in the process of legalizing it), there are
new and readily accessible routes to gambling
addiction all the time. Lia Nower, PhD, director of the
Center for Gambling Studies at Rutgers University’s
School of Social Work in New Brunswick, New
Jersey, first became interested in gambling when
she was a criminal attorney in Missouri.
“In the criminal court system, there were people
who never even had a parking ticket facing years in
prison because of gambling-related crimes,” she says.
“There were no programs for them because no one
thought gambling was a real addiction. And there are
still no diversion programs.”
Both substance and behavioral addictions are
multifactorial in origin, and one of those factors is
surely genetic. Researchers estimate that genetics
play anywhere from a 40 percent to 60 percent role in
a person’s vulnerability to addiction, even though no
single gene has ever been found—or ever will be
found—to pinpoint the cause of addiction. That’s just
not how genetics works.
“In genome-wide studies of gambling disorder,” says
Dr. Potenza, “no specific gene or a region of the genome
has reached genome-wide significance.” Instead,
addiction likely begins with a
whole suite of factors involving
both the genome and the lesser-
known epigenome—the sort of key-
give great board that sits atop the genes and
to the thing decides which will be played and
addicted to. which will remain silent. You might
carry a gene that predisposes you
to food to heart disease or depression, but
they have if certain chemical, environmental,
for more or experiential factors don’t acti-
vate the epigenome, the underlying
gene might do you no harm.
In the case of addiction, once
those genetic chords start to play, they may influence
all manner of behaviors. Similarities exist between
substance and behavioral addictions just as similar-
ities exist between specific substance use disorders.
That’s why addicts may be cross-addicted, as the
12-step programs aptly put it, with alcohol, for exam-
ple, helping to fuel binges of gambling or sex. It’s why
Alcoholics Anonymous meetings are so often choked
by cigarette smoke. Las Vegas, where free booze in
casinos and a legal gambling and sex trade coexist
24 hours a day, relies on this behavioral mash-up.
Simple temperament may be part of things too.
People who like risk may jump out of airplanes or ride
roller coasters—and may similarly like the high-
stakes thrill of getting rich or going broke on a single
hand of poker. Risk-averse people find none of this
appealing; that might mean a life of fewer thrills, but
it also may mean fewer disasters.
H E A LT H 27
 THE ADDICTION
Before his descent into addictive investing, Chris
Anderson exhibited impaired impulse control, prob-
lems in social interactions, a tendency to court danger,
and a need for greater and greater risk stimulation—
a constant upping of the ante—to achieve the same
level of thrill. Those four traits alone check all of the
DSM boxes for a substance addiction. The manual
lists nine characteristics for compulsive gambling—
including repeated, failed attempts to cut back on
gambling; frequent thoughts about gambling; often
gambling when feeling distressed; and lying to con-
ceal gambling activity. Anderson checked all nine.
“Domains like reward processing may show com-
monalities across addictions, as might impaired con-
trol or poor emotional regulation,” says Dr. Potenza.
“It’s important, if we are going to advance prevention
and treatment efforts, that we understand both sim-
ilarities and differences.”
Treating the Disease
Generally, behavioral addictions pose a significant
challenge for treatment and recovery. That’s partly
because the behaviors that cause problems are, most
of the time, not ones that lend themselves to absti-
nence. Plenty of people go their entire lives without
drinking or smoking or doing drugs, and those who
start can often stop. That’s true too of behavioral
addictions such as gambling and video gaming. But
there’s no such thing as swearing off eating or shop-
ping or sex. They’re fundamental parts of human life.
That fact requires people with compulsive, addictive
behaviors to live in a state of gray—a little but not too
much of the dangerous behavior—and addicts are
very, very bad at gray.
One person struggling with compulsive sexual
behavior disorder, for whom exhibitionism became
part of the compulsive cycle, began driving around in
his car looking for women to whom he could expose
himself. At first he did it occasionally, then all the
time. His need began to escalate, he says, in the same
way that “an alcoholic might move from six beers to
a dozen, and then to a dozen with a Jack Daniels on
the side.” For him, the spiral ended only when he
exposed himself to a woman who turned out to be an
off-duty police officer. She copied down the license
plate number of his car, and he spent eight months
behind bars. After his release, he entered a recovery
program that has been, so far, successful.
In some cases, the 12-step model or other forms of
group therapy can be a part of that process, putting
28 H E A LT H
people with behavioral addictions in the company of
other people fighting the same fight—and calling on
them to be accountable for their choices when they
come back the next day or week.
Some antidepressants or other psychotropic
medications may work too, at least by taking the edge
off the anxiety or emptiness that comes from not
indulging in the desired behavior. And while targeted
medications are a key component of substance-use
treatment, there is no FDA-approved pharmacolog-
ical approach to gambling or other behavioral disor-
ders. There is limited data on treatments with all
classes of medication, including opioid analgesics.
Experts like Dr. Volkow agree, however, that this area
is wide open for much further study.
“There’s a lot of interest in medications,” she says.
“We see big patterns between food, sex, and drugs,
and we need meds to block that.”
People with addictive behaviors may also benefit
from cognitive-behavioral reframing: challenging
the internal narrative that a third doughnut, a fourth
shirt in the same color, a fifth sexual partner will
bring lasting peace and relief. That kind of approach
can work for problem gambling, too.
Nower has learned that successful treatment for
gambling addiction involves unraveling the magical
thinking that’s fueled by illogical thoughts about
randomness. “If you roll a six-sided die and three
comes up three times and one doesn’t ever come up,
and you ask educated people, ‘What do you think the
next number is going to be?’ some will say ‘three’
because it’s hot and some will say ‘one’ because it’s
due,” Nower explains. That, however, is not how prob-
abilities work, and challenged on the point, most
people realize that fact.
“The reality is they all know every roll is indepen-
dent of that which comes before. But we’re taught to
look for patterns in our lives, and so we look for pat-
terns in gambling. Those are things you have to
address in treatment,” Nower says.
Like people with so many other psychological dis-
orders, those with addictive behaviors who are work-
ing to get well also have to overcome shame and social
scorn—the notion that they brought their problems
on themselves and are to be blamed for not getting
them under control. In some ways, that’s the result
of science chiding itself. “Addicted persons get stig-
matized because we can’t help them,” Dr. Volkow says.
“We’re advancing, but there are a lot of unknowns
about the brain.”
 Across all addictions, people trying to break out of
impulse and dependency can benefit from confronting
a simple truth: Whatever their compulsion is, it long
ago stopped being fun. The buzz of a drug, the ease of
a drink, the thrill of roulette are no longer to be had—
replaced by an urgency and a desperation, a need sim-
ply to get back to a baseline at which the pain of being
addicted goes away. It’s a rueful refrain among alco-
holics that no one ever wants a second drink, much less
a third or a fifth or a tenth. They all want that first drink
all over again—the moment when the familiar expec-
tation of peace settles in. They spend their drinking
lives chasing that feeling, just like Anderson chased
his initial investment losses, just like someone who
hops from bed to bed chases the thrill of when sex was
new. “An addicted person’s compulsion is like driving
a car without brakes,” Dr. Volkow has written.
No two addictions are identical, nor are any two
treatments. Still, nearly all people in recovery share
some of the same treatment protocols, including:
■ Detox support to achieve initial stability.
■ Diagnosis and evaluation to address
co-occurring disorders.
■ A treatment plan with a trained specialist,
appropriate therapies, and goals for recovery.
■ Ongoing peer support and accountability,
such as a 12-step program with people in
similar situations.
■ Family support, including support
groups for family members; education; and
family therapy.
None of those approaches are easy, and none are
certain to work. All take a lifetime commitment to
remaining in control of urges that are straining
to break free. All the same, asked what she would
tell people struggling with addiction right now,
Dr. Volkow remains optimistic: “That you can
recover. Don’t give up. Treatment works.” Then she
adds ruefully, “But it doesn’t cure it.” ●
H E A LT H 29
30 H E A LT H
 ATTACK OF
THE PHONES
Spending too much time on your devices?
Here’s how to realistically
break your social media habit.
BY KATHERINE PLUMHOFF

EVER SINCE the introduction of social media apps, people have

slowly developed a deeper relationship with their cell phones. What
used to be a device that only stored phone numbers and digital games
like Snake can now hold gigabytes of information and connect us
with billions of people across the world.
According to a 2018 Deloitte study, the average person checks
their cell phone 52 times a day and prefers to use their device to
access social media. While one might view this as a negative thing,
our phones can be vital tools for work and life as certain apps
and platforms help us connect and share with other people and
loved ones.
But excessively checking social media has been proven to create
anxiety, self-esteem issues, and stress. Thankfully, we’re realizing
how these devices are affecting us: According to the study, 60 percent
of 18- to 34-year-olds think they use their phones too much, and
63 percent of all consumers are trying to limit their usage.
If you think your relationship with your social media accounts
needs to be evaluated, then you’ve come to the right place. We talked
with therapists about signs of overuse and how to cut down on time
spent on social media.

H E A LT H 31
 THE ADDICTION
The good, the bad, and the ugly
of social media use
“Social media is a double-edged sword,” says Rachelle
Strauss, health and wellness coach and cofounder of
the U.K.-based Health and Wellness Grid. “Some of
my clients have found support groups online where
they feel a sense of belonging. I’ve also had clients who
have found me through social media and [have] helped
with their health goals. And others have made close
friendships through Facebook groups,” she explains.
But it’s not all camaraderie. Strauss highlights the
risk areas with social media use, including addiction
to devices, lower self-esteem from comparing oneself
to others, trolling, and abuse.
If you experience amplified feelings of loneliness
or insecurity while scrolling on your Instagram,
Twitter, or TikTok feeds, or feel anxiety immediately
after exiting out of your apps, then it might be worth
trying to reduce your social media use. Even if you
don’t see negative side effects, you may be using social
media as a time filler.
“What I often see in my clients is that social media
serves to fill the void of not knowing what to do next.
Instead of reflecting on what they are feeling and what
would be a good thing to do next, they automatically
reach for the phone,” says Ana Sokolovic, MS, psy-
chologist and life coach at ParentingPod.com.
How to realistically take a social
media break
1. UNDERSTAND THE SCOPE OF THE PROBLEM
Do you spend two hours a day on social media?
Four hours? Six hours? Knowing your baseline use
will allow you to make a plan for your specific situa-
tion, says Strauss. If your phone has a screen usage
function, start there—otherwise, you can use a time-
tracking app on your phone or computer to get a sense
of how you’re spending your time.
2. SET GOALS AND CREATE A PLAN
“Social media can be genuinely addictive,” says
Strauss. “And just like with any addiction…some peo-
ple do better with a cold-turkey approach, [while]
others need gentle reductions and rewards.” Does a
weeklong detox feel right? Will cutting your social
media phone time in half give you the time back you’re
looking for? Define what result you’d like to see—
mornings spent reading the paper instead of scrolling
through Twitter; an extra hour each day to go to the
gym—and how you’d like to get there.
32 H E A LT H
Sokolovic suggests asking yourself what experi-
ences you would like to have instead of spending so
much time on social media and using that answer to
drive your plan.
3. REDUCE ACCESS OR EXPOSURE
All plans will need to have some element of reducing
use or access to social media—but what that will look
like will depend on you, your habits, and your goals.
Try these therapist-sourced ideas, listed from least
to most extreme:
Curate your feed. Consider the kind of content
that makes you feel happy and the kind that doesn’t,
says Jor-El Caraballo, LMHC, therapist and cofounder
of Viva Wellness. “Sure, you might like X apparel brand,
but do you feel isolated because none of their images
feature people who look like you? Then maybe it’s time
to unfollow them so that you’re not absorbing the
negative messaging that you don’t fit with their brand,”
he says. If your friends’ posts bother you or make you
feel anxious but unfollowing them could cause drama,
then make liberal use of the “mute” function.
Schedule your social media time. Use apps that
block your access to social media once you’ve spent
a certain amount of time on them. Or set alarms in
the morning and evening to signal when you can look
at your feeds for the first and last time each day.
Rachel Gersten, LMHC, therapist and the other
cofounder of Viva Wellness, suggests shutting down
your apps an hour before bed for both your mental
health and sleep hygiene.
Take applications off of your phone—or at least
turn off the notifications. While you want to keep
your Facebook account active to stay in the loop on
event notifications and your cousin’s baby photos,
do you need to have access to these things on your
phone? Sokolovic cites a client of hers who unin-
stalled the majority of his phone’s social media apps.
“Removing the [social media apps] was an easy way
[for him] not to access them. Instead, he started to
spend his time listening to audiobooks, watching
TED Talks, or taking walks during his breaks at
work,” she says. If you need to keep the apps closed,
turn off their proactive notifications so that you only
see what’s new when you decide to open them on
your phone.
4. BE INTENTIONAL AND POSITIVE
After reducing your access to social media or doing a
time-boxed detox, be thoughtful about how you
Try spending time outdoors, calling a friend, or exercising rather than just mindlessly scrolling.
reintroduce it into your life. Annalise Harness, MA,
LPC, a therapist, advises her clients to set an intention
before getting back on social media. “If you know why
and for how long you plan to be on your phone, it’ll help
to keep [yourself] accountable,” she says. Are you
looking for news updates? Wanting to share a funny
tweet? Either way, give yourself five minutes to do
that thing and get off the app. If you realize you’re just
going on to kill some time, contemplate whether
there’s something else you can do instead, like calling
a friend, listening to a podcast, or going for a walk.
But if you’re using social media to build commu-
nity, Caraballo suggests that you focus on truly
engaging in that process instead of simply auto-
scrolling and auto-liking content as it streams by.
“I would issue a challenge to people: Instead of just
liking a picture, also add in a comment and tell the
person why you like it. This can be a great way to work
on building a community online and spreading pos-
itivity with very little investment,” he says. ●
H E A LT H 33
 HUNGER PAINS
Is food addiction real?
Eating disorder experts can’t agree
on an answer.
BY KASANDRA BRABAW

WHEN LAY’S potato chips challenged Americans with its slogan

“Betcha can’t eat just one” in the 1960s, the company was making
a pretty safe bet. Potato chips, like pizza, ice cream, and fries,
top the list of the most “addictive” foods. We know that certain features
of these foods, like being high in sugar and low in fiber—
the kinds of foods that are designed to burn fast and taste really good—
trigger the brain’s pleasure center and make it difficult to stop eating.
But when we say these foods are “addictive,” do we really mean
it? Can you literally be addicted to food?
It’s a controversial question among researchers. “Food addiction
is not universally recognized by medical professionals, but there are
individual practitioners who believe, based on their view of current
research, that it is a concept that has utility,” says Chevese Turner,
chief policy and strategy officer for the National Eating Disorder
Association (NEDA).
Unlike alcoholism or addiction to narcotics, food addiction isn’t
covered in the Diagnostic and Statistical Manual of Mental Disorders
(DSM ). However, you can find programs akin to Alcoholics
Anonymous that treat food addiction. Despite the addiction not
being unanimously accepted in the medical community, some people

34 H E A LT H
H E A LT H 35
 THE ADDICTION
out there are trying to “fix” it.
Unlike seeking help for substance use disorders,
though, trying to get treatment for food addiction
could be dangerous. Eating disorder experts worry
that a treatment plan that asks supposed food addicts
to abstain from certain foods could encourage
disordered eating. And, to be honest, the “symptoms”
of food addiction, according to Food Addicts Anony­
mous, are a little questionable. Their website asks:
“Have you tried different diets or weight loss pro­
grams, but none has worked permanently? Do you
eat in private so no one will see you? Do you avoid
social interactions because you feel you do not look
good enough or do not have the proper fitting clothes?”
Many people could answer yes to these questions.
We live in a culture that shames and bullies people of
a certain size. Does that mean that every plus­size
person is actually a food addict? Of course not. “People
who have drafted themselves into the anti­fat­person
army feel comfortable and justified in judging fat
people’s food choices,” activist Ragen Chastain wrote
in her blog, Dances With Fat. “Whether they are
shaming us for eating something that they don’t think
we should be eating, or congratulating us for eating
something of which they approve, fat people can find
ourselves dealing with all kinds of inappropriate
interactions involving food.”
Other symptoms listed by Food Addicts Anony­
mous sound more legitimate: “Have you found your­
self vomiting, using laxatives, diuretics, or exercising
a lot to avoid a weight gain after you have eaten a
lot?” This kind of symptom certainly points to dis­
ordered eating, if not food addiction.
36 H E A LT H
Perhaps the closest recognized condition to food
addiction is binge eating disorder (BED). But BED
and food addiction are not the same thing. “Food
addiction is defined as causing a preoccupation with
foods that provide intense pleasure and dopamine
increases like drugs, alcohol, shopping, gambling,”
Turner says. “While people with BED may binge on
highly palatable foods, bingeing is only one part of
the behaviors associated with the disorder and,
therefore, treatment is complex.”
Often, people who binge also engage in restrictive
behaviors like overexercising and fasting, Turner
says. People who have BED also tend to have depres­
sion, anxiety, PTSD, or other mood disorders. While
treatment for food addiction typically calls for avoid­
ing white flour, sugar, and other so­called “addictive”
foods, treatment for BED is more involved. BED treat­
ment tries to address underlying issues, including
traumatic experiences and mental health, as well as
decrease the urge to binge and restrict food. “Body
image and acceptance are a big part of BED recovery
as well,” Turner says.
In treatment for food addiction, restriction typi­
cally goes unaddressed. While eating disorder
experts agree that some foods are engineered to be
as tasty and addictive as possible (like those potato
chips), many worry that the concept of food addic­
tion could be more harmful than helpful. ●
If you are struggling with an eating disorder and in
need of support, call the National Eating Disorders
Association Helpline at 1-800-931-2237. For a 24-hour
crisis line, text “NEDA” to 741741.
 Our Caffeinated Lives
Your morning coffee brings plenty of benefits,
but when you skip that jolt, it sure can be a buzzkill.
BY KRISTIN CANNING

If a hot mug of joe or an icy

Starbucks grande is your
preferred way to start the
day, you’ve probably noticed
that you feel, well, off when
don’t get your coffee fix.
On those especially hectic
mornings, you might even
sort of hate the world. But
that reaction isn’t in your
head, says Michael J. Kuhar,
PhD, professor of neuro­
pharmacology at Emory
University.
Caffeine can make you
feel energized, alert, and
less depressed, Kuhar
explains. It can even
improve your motor skills
and learning ability. (And
there’s significant evidence
that coffee has many health
benefits, including lowering
the chance of some
diseases.) When you skip
your usual stimulant high,
you might feel down,
drowsy, sluggish, and
irritable. You may also
experience headaches and
a drop in blood pressure. In
a Johns Hopkins University
review of studies,
researchers found that
some people deprived of
caffeine even experienced
flu­like symptoms, such as And since it takes about says. “And the feelings you to say when the withdrawal
nausea, vomiting, and 24 hours for caffeine to get from caffeine reinforce effects will go away, says
muscle pain and stiffness. completely leave your that association. It’s Kuhar, because it’s different
“You’re basically going system, it makes sense that embedded in our lives as for everyone. And simply
through withdrawal,” says you wake up craving it. this friendly and socially seeing a Dunkin’ cup—or
Kuhar. While you can’t “Lots of people have acceptable ritual.” smelling a freshly brewed
become addicted to their coffee in the morning But there are reasons pot—can trigger cravings. If
caffeine in the same sense when they read the you might want to wean you’re trying to cut back, it’s
that people become newspaper, or when they yourself off coffee—if you’re best to do so gradually, he
addicted to drugs or meet up with friends, and having trouble sleeping, for says, until you’re drinking a
alcohol, your body can it’s viewed as this very example, or dealing with more reasonable amount,
become dependent on it. enjoyable moment,” Kuhar digestive issues. It’s difficult or none at all.

H E A LT H 37
 THE ADDICTION

CAN YOU REALLY

BE ADDICTED TO SEX?
Experts disagree on whether sexual behavior
warrants a formal diagnosis.
BY SARAH KLEIN

38 H E A LT H
WHEN THE #METOO
movement began in
2017 with numerous women
coming forward with
allegations of sexual
harassment and assault
perpetrated by Harvey
Weinstein, the disgraced
(and since convicted) movie
mogul reportedly entered a
treatment facility for sex
addiction. Although he wasn’t
the first high-profile person
to have sought treatment for
sex addiction, the diagnosis
tends to elicit eye-rolling and
sarcastic reactions. So is this
just a convenient cover-up for
inappropriate, harmful
behavior—or can you really
be addicted to sex?
To some, saying you have
a sex addiction is a bit like
saying you’re addicted to
the gym or eating cookies;
it’s an innocent exaggeration.
Many experts aren’t
convinced sex addiction is a
legit diagnosis either—sexual
addiction is not formally
recognized in the bible of
psychiatry, the Diagnostic and
Statistical Manual of Mental
Disorders (DSM).
True, sex may lead to
serious relationship-wrecking
and life-altering (not in a
good way) behavior. But it’s
not supported by the same
hard evidence that backs up
drug or alcohol addiction,
says Charles O’Brien, MD,
emeritus professor of
psychiatry at the Center for
Studies of Addiction at the
University of Pennsylvania.
“Drugs activate [an addict’s]
brain’s reward system
directly, like getting food or
water,” says Dr. O’Brien. “It
could be that there are some
similarities in those people
who are called ‘sex addicts,’
but it hasn’t been studied or
demonstrated.”
Still, sex addiction therapy
and rehab programs are
booming, and some patients
swear by their treatment.
Despite the debate over the
diagnosis, sex addiction
counselors say there are
distinct differences between
the sexually addicted and
people who just love sex.
“Individuals who act out
sexually are usually doing so
because they do not want
to feel their feelings,” says
Maureen Canning, a licensed
marriage and family therapist
and the author of Lust, Anger,
Love: Understanding Sexual
Addiction and the Road to
Healthy Intimacy. “They’re
using this as a way to get high.
They use their sexuality as a
means of escape.”
Research suggests
that about 75 percent to
80 percent of sex addicts are
men. About 25 percent of
The percent-
those men have experienced
overt sexual traumas like
sexual abuse or incest
during their childhood, says
Robert Weiss, LCSW, PhD,
symptoms of
a certified sex addiction
therapist in Los Angeles.
About 75 percent of female
sex addicts have had a
disorder. Men
similar experience, he adds.
(10.3%) were
The addiction is less about
slightly more
sex and more about the
obsessive behavior pattern
women (7%)
that accompanies it, says
Weiss. Sex addiction is similar
to gambling, overexercising,
and impulsive spending,
AMERICAN MEDICAL
which are known as behavior
addictions—in which a person
is addicted to a set of rituals
rather than to a mood-
altering substance.
“Neurologically, acting out
or thinking about acting out
[sexually] releases dopamine,
serotonin, and adrenaline,
creating a chemical cocktail
in the brain that is extremely
pleasurable,” says Canning.
“It creates a euphoria.” This
euphoria keeps a person
coming back for more. “Most
[addicts] have difficulty
tolerating day-to-day
stressors and use fantasy
and intense arousal to
distract themselves,”
says Weiss.
Addicts often say they’ve
experienced potentially
life-altering, and even life-
threatening, consequences
of their behavior, according
to SexHelp.com, created by
psychologist Patrick Carnes,
PhD. Almost 70 percent
of so-called sex addicts
have exposed themselves
to AIDS and other sexually
transmitted diseases,
and 40 percent have had
unwanted pregnancies.
More than 70 percent have
reported thoughts of suicide,
and 17 percent have actually
attempted to end their lives.
Often the consequences
worsen over time as the
8.6% behaviors continue.
A spouse or partner of
a sex addict is likely to notice
age of
emotional distancing, as
American
well as a decrease in sexual
adults who
intimacy. And people may
reported
find their behavior has
caused them to lose close
compulsive
friends, compromise their
sexual
values, lie to those closest to
behavior
them, or put themselves in
serious danger, says
Canning. “We [have] them
look at where their life is
likely than
today when they start
[treatment] to help them see
to be
how much their behavior
affected.
SOURCE:
is encroaching on what they
JOURNAL OF THE thought was important in
ASSOCIATION their lives,” she says. “Often
they will start to see that
it’s more of a problem than
they thought.”
Although sex addiction
is not currently a psychiatric
diagnosis like other
addictions, Canning says
therapists treat it like one
by comparing behaviors
to the list of criteria used
to diagnose chemical
dependency. Most treatments
follow a typical 12-step
model, just like Alcoholics
Anonymous. Addicts can
attend meetings through Sex
Addicts Anonymous, spend
time at a rehab facility, or
meet with licensed therapists
in private practices. ●
H E A LT H 39
 OPIOIDS:
A NATIONAL CRISIS
How corporate greed created
an epidemic that has torn through America.
BY DANIEL S. LEVY
OVER THE PRESIDENTS’ DAY weekend in February
2001, Eddie Bisch got together with some of his friends
in Philadelphia’s Fishtown district. Eddie was finish-
ing his senior year in high school, and excited about
heading to culinary school in the fall. Early on Sunday,
the 18-year-old popped a Xanax, and later drank some
beer at a party. He then split a 40-mg OxyContin tablet
with his best friend. Eddie made it home and, as his
father, Ed, recalls, “he went to bed and never woke up.”
When word spread of Eddie’s death, his friends gath-
ered at the Bisch home. Ed Bisch went outside to talk
to them and pleaded, “Tell me. Tell me what he did.”
When they told him what his son had taken, he replied,
“What the hell’s an OxyContin?” They explained that
it was similar to a strong dose of Percocet pain medi-
cation. Bisch didn’t believe them, and said, “No. No.
My son’s dead in his bed.”
Bisch, now 58, went back inside, and with his sister
started to search for information on OxyContin. “We
pulled up these stories and started seeing all these
40 H E A LT H
stories about this new drug called OxyContin that was
killing kids.” Bisch alerted Eddie’s school and began
a crusade to raise awareness about this powerful
opioid: “I’ve been trying to warn people ever since.”
EDDIE BISCH was one of nearly 10,000 Americans
to die from an opioid overdose in 2001. Back then the
opioid crisis was only a few years old, but it has since
grown and devastated families and communities,
killing nearly half a million people over the past quar-
ter of a century. Opioids are now the leading cause of
death for those under 50. So much of this suffering,
though, was caused not by foreign drug cartels, but
by Fortune 500 pharmaceutical companies like
Purdue Pharma (which produces OxyContin), drug
distributors, doctors, and pharmacists who raked in
billions of dollars while spreading death.
The use of opioids is nothing new. Cultivation of
the opium poppy plant—from which opioids are
derived—goes back to ancient Mesopotamia in the
 THE ADDICTION
Near East in 3400 BCE. The milky substance
extracted from its bulbous seed capsule can relieve
pain. Its most active substance is morphine—named
for Morpheus, the Greek god of sleep and dreams—
and it triggers the brain’s feel-good neurotransmit-
ters, muffling the sense of pain while increasing
feelings of pleasure. During the American Revolution
it was used to treat the wounded, and in the 19th
century it became widely available in a popular med-
ication called laudanum, sold to treat everything from
depression to menstrual cramps. The British even
fought two wars with China to ensure that they could
continue to ship opium to China.
When the effect of the drug wears off, some users
crave the resumption of the relief, making the drug
highly addictive. Instead of the sweet dreams
bestowed by Morpheus, its effects bring to mind
Epiales, the Greek spirit of nightmares. While
Congress in 1914 limited the distribution of opiates
to doctors, the flow of illegal substances continued.
Synthetic forms of opioids were introduced in the
1960s. The Sackler family, the founders of the phar-
maceutical company Purdue Pharma, had entered
the pharmaceutical business in 1952, and in 1980 their
Napp Laboratories released MS Contin in Britain.
The drug had a coating that allowed for a slow release
into the patient’s bloodstream, allowing cancer
patients to use it at home. Purdue Pharma brought
the drug to the United States in 1984.
WITHIN A DECADE, Purdue’s patent was expiring.
Fearing that generic versions would grab parts of their
profitable market share, Purdue created OxyContin,
which is twice as strong as morphine. In the paperwork
submitted to the Food and Drug Administration in
1994, they claimed that OxyContin was not very addic-
tive and not prone to abuse. The FDA approved the
drug, and Richard Sackler, who would soon after take
over as the firm’s president, boasted: “The launch of
OxyContin tablets will be followed by a blizzard of
prescriptions that will bury the competition. The pre-
scription blizzard will be so deep, dense, and white.”
As they marketed OxyContin, Purdue promoted
it not only for temporary relief following surgery or
for those near the end of life, but also as a treatment
for common pain, with the FDA allowing them to
state: “Delayed absorption, as provided by OxyContin
tablets, is believed to reduce the abuse liability of
a drug.” Yet as users grew accustomed to it in their
systems, they yearned for higher doses to receive the
42 H E A LT H
same level of relief. To meet the growing demand, the
company marketed not only its 10-mg pills, but 20-,
40-, 80-, and 160-mg versions, too.
Reports of problems began in the late 1990s, and
some Purdue employees raised concerns. Sales rep
Mark Ross warned his superiors about the rise in addic-
tion in places like his home state of West Virginia, yet
his protestations were ignored. “I was sort of like a
canary in the coal mine,” he said in Alex Gibney’s 2021
documentary on the epidemic, The Crime of the Century,
“but nobody was running. Nobody was leaving.”
Purdue insisted that there was a difference between
legitimate patients and those who were recklessly
using the drug. Still, OxyContin was being abused by
both those who had prescriptions and those who
acquired pills illegally. Some people would “doctor
shop,” searching for a physician who would prescribe
them the medication. The time-release coating could
be easily scraped off to make the drug act faster, earn-
ing the pills the nickname Peelers, with 30-mg purple
versions dubbed Purple Peelers. Some users chewed
or else crushed and snorted the powder or dissolved
it in water for injection. The problem proved espe-
cially rampant in economically distressed regions of
America such as Appalachia, where some of the pills
earned the nickname “hillbilly heroin.”
Although Purdue helped ignite the opioid crisis,
many other firms similarly profited. Back in the
1990s, Johnson & Johnson discovered a way to genet-
ically modify opium poppies to produce a superplant
packed with high levels of thebaine, a key ingredient
needed to make the drugs. Numerous pharmaceuti-
cal companies like SpecGx, Actavis Pharma, and
Par Pharmaceutical marketed their own version of
pain pills.
Protests against producers and distributors spread.
Ed Bisch and others founded Relatives Against Purdue
Pharma and picketed at places like the corporation’s
Stamford, Connecticut, headquarters. To redirect
responsibility, Richard Sackler in 2001 advised sales
reps and others to simply blame the problem on those
who had become addicted. “They are the culprits and
the problem,” he wrote in an email.
By the early 2000s, federal prosecutors had started
to investigate his firm, and the company hired former
New York City mayor Rudy Giuliani to help their
defense. A case went to trial in a federal court in
Virginia in 2007, and prosecutors sought the indict-
ment of some of the firm’s executives on felony charges.
The judge allowed those harmed by the drug to briefly
speak in the courtroom. Lee Nuss held up a jar con-
taining her 18-year-old son Randall’s ashes, saying,
“Here he is, for you all to see.” Bisch told the court, “The
lies and deceit started at the top and have cost or ruined
countless lives.” The defense, though, managed to have
the charges reduced. Purdue ended up just paying a
$634.5 million fine, while three of its top executives
earned misdemeanor charges and paid $34.5 million
combined. The firm promised not to violate the law,
and sales of OxyContin were allowed to continue. As
Bisch notes, “As the sales went up, the deaths went up.”
By then, the country was awash with opioids. People
could order pills online, and pain clinics with little
oversight were popping up. These “pill mills” essen-
tially existed as cash-only fronts for corrupt doctors.
Buyers either used them or trafficked them to other
states. A pill mill in Bensalem, Pennsylvania, that
Ed Bisch believes supplied the capsule that killed his
son was run by Richard Paolino. “People from the
neighborhood were going up there in carloads, getting
prescriptions from Paolino, getting them filled,”
says Bisch. (In 2002, Paolino was sentenced to 30 to
Advocacy groups protested at Purdue Pharma’s Connecticut headquarters in 2019.
120 years for his activities.) Florida became a major
market for opioids, and Interstate 75, which runs from
the state’s southern tip to the top of Michigan, earned
the nickname “The Oxy Highway.”
It wasn’t just residents of depressed communities
who were hooked and dying. The rich and famous have
been affected, with opioids over the years taking the
lives of the actor Heath Ledger and the musician
Prince, among others. Nor is the damage isolated to
adults. In the United States, a child is born every
15 minutes with a dependency on the drug. Many will
most likely face lifelong developmental and learning
disabilities. And the Centers for Disease Control and
Prevention (CDC) reported that some 5.5 million chil-
dren under age 11 live in a home where a parent has an
abuse problem. A third of them will enter foster care.
Throughout, much of the medications made their
way through three distribution companies (McKesson,
Cardinal Health, and AmerisourceBergen) before
heading to pharmacies such as Walgreens, CVS, and
Walmart. Firms are obligated to check if a sale is sus-
picious, and a Cardinal Health distribution center was
H E A LT H 43
 THE ADDICTION
discovered to have improperly sent millions of pills
to pharmacies. The Drug Enforcement Agency issued
an immediate suspension order for the purchases,
and shut down that center, but Cardinal Health
simply paid a $34 million fine. Corporations then
pushed for a softening of regulations. While the
2014 Ensuring Patient Access and Effective Drug
Enforcement Act has a tough-sounding name, it effec-
tively undercut the ability of the agency to stop the
flood of narcotics by setting a higher bar for what is
considered an immediate threat.
With the DEA’s enforcement powers hampered,
abuse only grew. Overdoses skyrocketed, and a huge
community of people looking for a fix found themselves
progressing to more powerful drugs like heroin and
the synthetic opioid fentanyl, which allowed both drug
cartels and drug companies to prosper. The COVID-19
pandemic and the isolation and
stress that many experienced only
contributed to an increase in
dependency, with the number of
Opioids grab
opioid-related deaths rising from
a person’s
50,963 in 2019 to 69,710 in 2020,
making it very
according to the CDC’s National
to stop
Center for Health Statistics.
and stay sober—
withdrawal
OPIOID ADDICTION is a chronic
symptoms
medical problem. The drug grabs
to relapse.
hold of a person’s will, making it
very hard for a user to stop and to
stay sober. Withdrawal symptoms can lead to relapse.
Thankfully, there are treatments for overdoses,
including Naloxone, which rapidly blocks and reverses
the drug’s effects and restores normal breathing.
Pharmacies carry it, and some states do not require a
prescription. Other treatments include medications
like methadone and buprenorphine, as well as coun-
seling. Intervention is also needed for those living with
someone suffering from the addiction.
Public awareness has grown, with increased media
coverage, including the aforementioned The Crime of
the Century documentary, which aired on HBO. In
2019 Sesame Street introduced Karli, a green furry
friend of Elmo, whose mother is battling addiction.
Her presence on the children’s TV show has given
youngsters a chance to understand what is happening
to their families.
Federal, state, and local criminal investigations
continue against pharmaceutical companies. Towns
and communities started suing firms and distributors,
44 H E A LT H
and fines and settlements were struck. One federal
judge has consolidated more than 3,000 cases. In 2019
distribution companies AmerisourceBergen, Cardinal
Health, McKesson, and Teva Pharmaceuticals settled
with Ohio’s Cuyahoga and Summit counties, paying
$260  million to avoid a trial. In February 2021,
Mallinckrodt, the largest producer of generic opioids,
agreed to a settlement in principal of $1.6 billion to
resolve thousands of claims. Five months later,
Johnson & Johnson, Cardinal Health, McKesson, and
AmerisourceBergen reached a $26 billion agreement
to both settle thousands of lawsuits and pay for addic-
tion and prevention services.
Purdue, which started the crisis, has earned $35 bil-
lion from OxyContin since the mid 1990s. It has made
the Sacklers enormously wealthy, and family members
have long prided themselves on being major philan-
thropists, making contributions
to cultural institutions like the
Metropolitan Museum of Art and
hold of the Louvre, as well as financing
will, buildings at Harvard and Oxford.
hard But the backlash from the legal bat-
using tles has led to the chiseling of the
Sackler name from many of those
hallowed halls. In 2019, Purdue
can lead filed for Chapter 11 bankruptcy. By
seeking restructuring, they were
able to shield the multinational
organization from lawsuits. The
following year, the firm reached an $8 billion settle-
ment with the Justice Department and the Sacklers
agreed to pay $225 million. Then, in July 2021, the
company said it would release some 33 million docu-
ments, including letters, depositions, work emails, and
communications with lawyers from the past 20 years,
in return for states agreeing not to oppose the firm’s
bankruptcy move. The Sacklers also promised to pay
$4.2 billion to resolve various civil claims.
Like others affected by the crisis, Ed Bisch has filed
wrongful death claims in his and Eddie’s name so as
to have a voice in the bankruptcy proceedings and
what happens to the firm, the Sacklers, and those
responsible for the death of Eddie and so many others.
Bisch sees the bankruptcy as just one more way for
Purdue and the Sacklers to skirt responsibility for
their contribution to a crisis that has taken the lives
of half a million people. “All the harm and damage
they’ve caused over the years, it is just another slap
in the face,” he says. “They should be sitting in jail.” ●
THE LONG HISTORY OF ADDICTION
4000 3400 1492
BC BC

Evidence Earliest known Indigenous people

of first cultivation of in the Bahamas
winemaking opium in ancient offer Christopher
facility in Mesopotamia Columbus dried
Armenia tobacco leaves

1830 1600

1919 Industrialization Marijuana cultivation

needs an efficient begins in the U.S. with
workforce; the Jamestown settlers, who
The Volstead Act
U.K.’s temperance use its strong fibers to
is passed to cease
movement is born make ropes and clothing
the production
and sale of alcohol
(voided in ’33)

1925 1935 1971

Lucky Strike cigarette A stockbroker President

brand launches diet and a surgeon Richard Nixon
campaign advising begin Alcoholics declares a
to “reach for a Lucky Anonymous “war on drugs”
instead of a sweet”

1985 1982

Crack cocaine 10.5 million

makes Americans
headlines in report using
NYC and L.A. cocaine

1994 2017 2018 2021

Tobacco U.S. declares U.S. Surgeon Several pharmaceutical

industry “public health General companies agree to
denies that emergency” as declares multibillion-dollar settlements
nicotine opioid overdoses vaping an for their role in creating
is addictive average 130 per day epidemic the opioid epidemic

H E A LT H 45
 RETHINKING
DRINKING
Why are women drinking more
than ever before, and what does it mean
for their health and wellness?
BY GINNY GRAVES

SIX YEARS AGO, when she was 40, Amelia Murphy* and her husband
moved from Pittsburgh, where she had lots of close friends, to
Arlington, Virginia, a suburb filled with strangers. Murphy’s job as a
content manager for a large corporation was demanding, and to
unwind, she’d grab drinks with colleagues a few nights a week. She
usually came home to an empty house, so to keep her buzz going, she’d
have some vodka or bourbon, and once her husband arrived an hour
later, she’d have a glass of wine with him.
Eventually, she made friends, and when they got together on the
weekends, she’d often end up having four or five drinks. “All our social
activities revolved around alcohol,” says Murphy, who has since cut
way back on her drinking by using a spreadsheet to track how much
she consumes. “A part of me felt it was excessive, but alcohol is a quick,
easy way to shift gears—and when everyone’s doing the same thing,
it doesn’t seem like a problem. It’s just the norm.”
That’s never been truer than now. The stats confirm what most of
us who enjoy mimosas with brunch already know: More women are
drinking—and women are drinking more. A 2017 study sponsored by
the National Institute on Alcohol Abuse and Alcoholism laid out our
pro-booze culture in stark terms: From 2001 to 2013, the prevalence

46 H E A LT H *Names have been changed to protect the privacy of individuals.

H E A LT H 47
 THE ADDICTION

of alcohol use among women in the U.S. rose nearly tendency to escalate—one glass turns into two and
16 percent. And during the same time frame, the per- then three,” says psychologist Joseph Nowinski,
centage of women who have four or more drinks on a PhD, author of Almost Alcoholic. “That doesn’t mean
given day on a weekly basis shot up 58 percent. you’re an addict, but you should be aware that you’ve
Between career and financial pressure, the needs moved from low-risk drinking to a level that’s more
of kids and senior parents, and adjusting to empty dangerous.”
nests and aging bodies, life can feel like a high-wire People have long used alcohol to self-medicate.
act, and sipping something smooth can ease the But today, more of us need the relief of a buzz than
strain. The trouble is, now that booze has become ever. “The pace at which most women live is punish-
so linked with relaxing, many of us don’t even think ing,” says Ann Dowsett Johnston, author of Drink:
to question our consumption. “Drinking has a The Intimate Relationship Between Women and
Alcohol. “You race home from a busy day at the office
and have emails from work waiting for you and food
Has My Drinking to prepare and laundry piling up. The easiest thing
to do when you’re standing at the cutting board
Become a Problem? making dinner is pour yourself a glass of wine. It’s
the ultimate decompression tool.”
It’s easy to unwittingly slip into a pattern of
Anxiety over the times we’re living in may play a
overindulging. Here are some hints that your
role too. Helena Peterson,* 45, an editorial consultant
habit may be creeping into the danger zone.
and single mom in Danbury, Connecticut, says she
noticed her drinking increased when she became
You vow to have just has studied women and
one glass of wine drinking for 20 years.
freaked-out over the state of the world: “For a while,
but end up sipping more. it got to the point where I could barely watch the news
“If you have a hard time You wake up lots without a glass of wine,” says Peterson. “I had trouble
controlling the quantity you of mornings feeling sleeping and was gaining weight, so I cut back on both
consume, that can be a groggy and fuzzy. the news and the booze. Within a week, I had more
sign that you’re becoming Consuming so much in
more dependent on the evenings that it
energy and felt less anxious overall.”
alcohol,” says Sharon affects your performance Cultural forces surely fuel our consumption as
Wilsnack, PhD, adjunct or energy the next well. “Since the mid-1990s, there’s been a ‘pinking’
professor of clinical day is cause for concern. of the alcohol market, with skinny cocktails and
neuroscience at the berry-flavored vodkas,” Johnston says. “Now there’s
University of North Dakota You used to get a nice
School of Medicine & buzz from a single
surround-sound messaging in movies and on TV
Health Sciences. G&T. Now you need two. that alcohol is the best way for women to relax and
“Being able to drink reward themselves.” Consider Olivia Pope’s appre-
Friends mention things more indicates you’ve ciation for fine wine on Scandal, and all the happy
you said or did that developed a tolerance,” hours on the Real Housewives franchises. “It has
you don’t remember. Wilsnack explains. That’s
Alcohol disrupts activity worth noting because
reached a saturation point.”
in the hippocampus, escalating use raises the A few glasses of cabernet may make you feel warm
a region of the brain that risk of liver damage. and fuzzy, but the consequences of routinely over-
plays a key role in the imbibing are anything but. Women are more suscep-
formation of new memo- You tried to cut back tible than men to the effects of alcohol, not only
ries, and the more you for a month but
drink, the more impaired couldn’t stick with it.
because we’re smaller but also because we have less
your memory becomes. “If you find it uncomfort- fluid in our bodies. As a result, alcohol is more con-
Blacking out can happen if able to give up alcohol centrated when it hits the bloodstream. What’s more,
you imbibe on an empty temporarily—or you really our stomachs have lower levels of alcohol dehydro-
stomach or you down can’t do it—that’s a red genase (ADH), the enzyme that breaks down alcohol
several drinks in quick flag,” says Wilsnack. Before
succession. But when it’s a you try again, check out the
and reduces absorption, and the ADH in our livers is
regular occurrence, take advice and resources in less active. That means our blood alcohol levels rise
notice, says Wilsnack, who “Dialing Back” (opposite). more quickly and stay elevated longer, making us
more prone to short-term effects, like slurring and

48 H E A LT H
 Dialing Back
These strategies can help you take a more mindful approach to alcohol.

Most women who drink
regularly don’t have a
diagnosable substance use
disorder—even those who
drink daily or binge on four
or more drinks on one
occasion, according to the
Centers for Disease Control
and Prevention. But it
makes sense to approach
your alcohol use as
conscientiously as you do
your diet or exercise routine,
says Ruby Warrington,
author of Sober Curious.
“Many of us go along
without thinking about our
consumption. Being sober
curious means stepping
outside that contract and
questioning yourself: ‘Do I
really want to have a drink
right now? What’s the
impact to my mental,
emotional, and physical
health; to my work life; and
to my relationships? What
would happen if I chose not
to drink?’ ”
If you feel it’s time for
a change, here are
some tips from experts.
Set specific limits.
Saying, “I’m going to cut
back” is too vague, says
Nowinski. Instead, define
your terms: I will have
alcohol no more than four
nights a week. On Friday
and Saturday, I won’t have
more than two glasses,
and the other nights, I’ll
stick with one.” Nowinski
notes that “being specific
gives you a greater sense of
control—and you can pat
yourself on the back every
time you meet your goal.”
Pay attention.
Noticing alcohol’s in-the-
moment effects may help
you regulate your consump-
tion, says Gabrielle Glaser,
author of Her Best-Kept
Secret: Why Women
Drink—and How They Can
Regain Control. “I chatted
with a woman who tracked
her mood and realized that
one or two drinks made her
feel happy, but a third made
her feel morose, angry, and
sloppy,” she says. “Tuning
in to how you feel can help
some people stay within
reasonable limits.”
Get guidance.
Look into CheckUp &
Choices (checkupand
choices.com), an online
fee-based program
that can help you assess
your drinking and develop
skills to scale back. “Our
studies have shown that
with a few simple tools,
you can reduce consump-
tion by about 50 percent,”
says Reid Hester, PhD,
director of research at the
organization.
Join a community.
Moderation Management
(moderation.org) is a
free program that starts
with 30 days of abstinence
and includes a “mutual-
help” environment with
meetings that you can
attend in person or dial into
by phone as you work on
changing your habits.
See a therapist.
Research shows that
cognitive behavior therapy
is particularly effective
at helping people curb
their drinking. You’ll strive
to identify situations
and emotions that trigger
your desire to drink—
and learn tools to avoid
or cope with them.
Socialize in
new ways.
While women are drinking
more, there are signs that
as a culture, we may have
reached a turning point.
There are new options for
alcohol-free social
gatherings. For instance,
Warrington founded Club
SÖDA NYC (clubsoda.nyc),
an event series for the sober
curious that includes
parties, meet-ups, talks,
and workshops. Likewise,
the Loosid app can help you
find sober events as well as
groups in your community
that promote sober living.
Getting together at a
bar may be the most
obvious way to socialize,
but it’s far from the only
one. “You can meet friends
for coffee or tea or exercise
or alcohol-free meals,”
says Warrington. The
experience may surprise
you, she adds. “I was
worried about my first
sober wedding, but I
actually felt good—and,
ironically, more confident.
I realized I had been
outsourcing my confidence
to alcohol for years.”

stumbling, as well as longer-term health dangers—
including liver damage, heart disease, and cancer.
There are social hazards, too, of course. That’s what
led Allie McCormick,* 36, to rethink her habit. She
had started drinking more to cope with stress from
work and her 90-minute commute on Los Angeles
freeways. “If I was home alone, I’d often open a bottle
of wine and finish it. I told myself, ‘I’m an adult, and
I can relax in a way that feels good to me,’ ” she says.
But there was a downside. “I’d get so drunk I’d
start bickering with my husband over something
silly or text a friend I hadn’t seen in months at
midnight saying, ‘You’re my best friend.’ I behaved
in ways that made me cringe the next day.” On top
of that, McCormick didn’t feel great. “I was often
tired, and I had this chronic, low-grade depression.
I just felt blah,” she says.
In December 2017, she decided to give up alcohol
for 100 days—and hasn’t had a drink since. “A few
weeks in, my mood lifted, and I started hopping out
of bed in the morning, ready to tackle the day,” says
McCormick, who soon after joined a gym and took
up yoga. “I had no idea how much alcohol was affect-
ing me, until I quit drinking.” ●

H E A LT H 49
 THE HARDEST
DRUG TO QUIT
The aggressively addictive power of
nicotine makes smoking (and vaping) one
of the most difficult habits to break.
BY CHRISTOPHER TKACZYK

PETER L aRUSSA began smoking at the age of 13 and continued the

habit for more than 20 years. But in January 2020, at age 35, he decided
to up and quit, with the assistance of nicotine patches. “I realized that
I’d smoked for more than half of my life,” he says. “While I didn’t have
any complications from smoking, I knew the long-term effects would
get worse the older I got and if I continued smoking. So I quit.”
LaRussa’s story isn’t unusual. Like many Americans, he started
smoking as a teenager and continued the habit into adulthood. But
many smokers don’t consider quitting until they begin to experience
tobacco-related health problems or diseases, such as lung cancer,
COPD, and heart disease. LaRussa was lucky that he quit before he
began having health complications—although complications may
still develop in later years.
What is unusual is the fact that LaRussa used to be a registered
nurse. He continued smoking throughout nursing school and
into the first few years of his nursing career. Despite the known
warnings about tobacco use, he kept smoking because nicotine—
a chemical that is naturally produced by the tobacco plant—is
one of the most addictive drugs in existence, alongside cocaine
and methamphetamine.

50 H E A LT H
H E A LT H 51
 THE ADDICTION

Nicotine is so addictive because it feeds the
alpha-4, beta-2 receptors in the brain, which is the
human body’s pleasure/reward system that pro-
duces dopamine, a feel-good neurotransmitter
(chemical messenger). “Using nicotine replaces
the body’s natural process of producing dopamine,
which we naturally get from exercise, laughter,
and other stress-management techniques,” says
Jennifer Folkenroth, the national senior director of
tobacco at the American Lung Association (ALA).
“The dopamine triggers the brain to send you a mes-
sage that you need to dose it again with nicotine in
order to release more dopamine in those receptors
to feel good and to experience pleasure. The need to
repeat that physical activity [of smoking] is what
makes it so addictive.”
The difficulty in quitting smoking has continued
to increase drastically over the past few decades, as
tobacco companies have steadily increased the
amount of nicotine in their products, Folkenroth
explains.
TOBACCO AND SMOKING-RELATED illnesses kill
roughly 500,000 Americans each year, according
to the Centers for Disease Control and Prevention
(CDC). While nicotine is the trigger for the addic-
tion, it isn’t the actual cause of the illnesses that
result from smoking or vaping/e-cigarettes. “The
damage being done through these products are
linked directly to the additive carcinogens,”
Folkenroth says. “Cigarettes have more than 7,000
chemicals in them, 200 of which are classified as
toxic poisons and, of course, consistently dosed
within the body, is what is creating the damage that
we see.”
In spite of the distressing statistics, the tobacco
industry has remained undaunted. In 2019,
cigarette companies spent a staggering $8.2 billion
on advertising and marketing in United States
alone. “The marketing is really working,” says
Folkenroth. “About 40 percent of adult e-cigarette
users continue to also use traditional cigarettes. So
we’re seeing a lot of dual use of tobacco products.

Smoking in the United States

Fourteen percent of Americans (34.1 million) smoke regularly, according to a 2019 CDC
report. Here are the percentages of adults 18+ who smoke every day or some days.

By gender
Male: 15.3
Female: 12.7

By age
18–24: 8.0
25–44: 16.7
45–64: 17.0
65 and up: 8.2

By race
White: 15.5
Black: 14.9
Asian: 7.2
American Indian/
Alaska Native: 20.9
Hispanic: 8.8
Other: 19.7

By region
Northeast: 12.8
Midwest: 16.4
South: 15.4
West: 10.4

52 H E A LT H

Among youth, even though we are seeing a decline
[since the COVID-19 pandemic began], we are
consistently seeing that there are still 1.6 million
more kids using the products than even three
years ago.”
And though overall tobacco use among American
adults has dropped by 68 percent since the CDC
began tracking usage in 1965, roughly 13.7 percent
of adult Americans were still smoking in 2020.
Nearly 9 percent of youth are smokers, but there has
been a significant drop in tobacco consumption
among that population during the pandemic. Home
schooling and increased supervision under the
watchful eye of parents could potentially be a reason
for the decrease, though a thorough study has not
been conducted.
The ALA found in a recent study that in 2020,
disposable e-cigarette use skyrocketed by 1,000
percent among high school students (from 2.4 percent
to 26.5  percent) and 400  percent among middle
schoolers (from 3  percent to 15.2 percent). And
Tips for Quitting
How to get started
1. Consult with your doctor.
Your primary care physician is the
first step on the road to recovery
from nicotine addiction. They know
your medical history and can advise
you on your best possible plan for
recourse and help you kick the habit
completely.
2. Consider your options.
If you’re planning to quit on your own,
do some research. Nicotine cessation
drugs, gums, and patches are all
available over the counter, so choose
the one that suits you.
3. Seek out resources.
Whether you’re a smoker or someone
who is trying to help a loved one
stop smoking, there are many
helpful online resources, including
smokefree.gov and the American
Lung Association (lung.org).
23.6 percent of high school students in the U.S. use at
least one tobacco product, including e-cigarettes,
according to the ALA’s 2020 National Youth Tobacco
Survey.
In its efforts to reduce the use of tobacco among
American youth, the ALA has been lobbying mem-
bers of Congress to pass a bill that prohibits tobacco
companies from producing flavored e-cigarettes,
which have seen the biggest growth among teenage
users. Last year, such a bill was passed by the U.S.
House of Representatives, but it eventually died in
the Senate.
After a successful lawsuit filed by the ALA last
year, the U.S. Food and Drug Administration (FDA)
is currently engaged in a process to review many
types of e-cigarettes on the market. “While the FDA
has authority to enforce the youth access provisions,
it has seriously failed to take meaningful action
against the e-cigarette manufacturers who intend
to market these tobacco products to kids, including
flavor products,” Folkenroth says.
H E A LT H 53
 THE ADDICTION
THE POWER OF ADDICTION isn’t purely a chemical
process. Michael M. Miller, MD, a clinical psychol-
ogist and former president and board chair of the
American Society of Addiction Medicine, who refers
to himself as a “addictionologist,” says that “addic-
tion is not about the drugs you take—it’s about what
happens to your brain when you use drugs and then
how that changes your behavior and your thoughts
and your emotions.”
Dr. Miller points out that most people who use
addictive drugs do not develop addiction. But for those
that do, their brains undergo changes when they are
rewarded by the drug. “One of the things that we know
affects how addictive something is, is the frequency
of the reward, or the rapidity of the reward, or even
the half-life of the agent,” Dr. Miller says.
Tobacco smokers become addicted so quickly and
need to feed the habit so often because smoked
drugs work faster than ingested or injected drugs.
“Smoking gets it to your brain faster because it gets
54 H E A LT H
into your lungs, where there is a huge interface with
the circulatory system. And so drugs transfer from
smoke into the bloodstream very efficiently.
It goes into your brain superfast. Smoking is an
extraordinarily efficient way to deliver a powerful
reward to the brain,” explains Dr. Miller.
For those trying to quit, FDA-approved medications
like Chantix (varenicline tartrate) and Zyban (bupro-
pion hydrochloride), over-the-counter treatments,
and counseling offer the best possible rate of success.
And it’s important to remember that failure is not
necessarily due to a lack of willpower or dedication.
Folkenroth points out that quitting can be challenging
and urges patience and encouragement for those who
are seeking to kick the habit. It may just be that the
initial treatment plan wasn’t the right one. Patience
is key. “More than 50 million ex-smokers are proof
that it is absolutely possible,” she says. “A failed quit
attempt isn’t a failure at all. It is an opportunity to gain
the resources and tools for the next climb.” ●
 The Growing Threat of Vaping
E-cigarettes are just as addictive as their traditional
counterparts—especially for teenagers.
BY MAGGIE O’NEILL

Much is still unknown

about vaping—especially
what type of long-term
effects using e-cigarettes
may have on the body.
Something we do know,
however, is whether or
not vaping is addictive—
but the answer is still a
little complicated. If you’re
using an e-cigarette, such
as a JUUL, that heats up
nicotine, the answer is yes.
“When [the nicotine] goes
into your bloodstream, it
will release substances in
your brain that can initially
give you a pleasure
sensation,” says Humberto
Choi, MD, a pulmonary
medicine specialist at
Cleveland Clinic. (Not all
vaping devices heat up
nicotine—some also heat
up marijuana or other
vaping liquids.) this nicotine addiction. time,” says Brian Barnett, Dr. Choi explains, when
That pleasure sensation “Teenagers especially— MD, who works at you vape you “could
comes from nicotine their brains are still Cleveland Clinic’s Center be inhaling a higher
stimulating the release of developing,” Dr. Choi says. for Behavioral Health. concentration of nicotine”
the neurotransmitter “They’re more susceptible Yes, you read that right: than you would from a
dopamine in your brain, to this kind of stimulation.” Vaping addiction can regular cigarette, since
according to the National It may also take less also lead to withdrawal levels of nicotine can
Institute on Drug Abuse. time to become addicted once you stop. Over time, vary between vape
As with traditional to vaping, particularly for your brain starts to crave juices—and more nicotine
cigarettes, those feel-good teenagers. “It may not take it, says Dr. Choi, and could mean a quicker,
chemicals keep you a lot of exposure to begin once you stop, your body stronger addiction.
coming back for more and the cycle of [vaping] goes through symptoms Overall, vaping is
even change your brain’s addiction,” says Dr. Choi. In like typical nicotine something you can get
sensitivity to dopamine, fact, teenagers specifically withdrawal, including hooked on—just as much,
leading your body to need may cycle through the weight gain, irritability, if not more than, regular
more and more nicotine to addiction process at a and restlessness. cigarettes. “Previous
satisfy it. faster rate, becoming But, while experts know research has shown that it
Vaping has become hooked on e-cigarettes, vaping is addictive, they’re takes the average smoker
increasingly popular with going through withdrawal, not sure how addictive— 30 or more attempts to
teenagers, who are often and then turning to or if it’s any more addictive quit smoking,” says
the target demographic for e-cigarettes again “within than smoking regular Dr. Barnett. “We shouldn’t
e-cigarettes and are more only a matter of weeks cigarettes. The scientific expect vaping to be any
at risk for succumbing to after vaping for the first data isn’t there yet, but, different from that.”

H E A LT H 55
 CHAP TER

The
Response
Addicts and their loved ones often
feel they have limited options. But
traditional treatments have evolved
into multifaceted therapies, and
many families are finding hope.

● Beyond the 12 Steps

● Treatments at the Fringes
● A Father’s Fight for His Son

56 H E A LT H
 BEYOND
THE 12 STEPS
The Alcoholics Anonymous model has
worked for drinkers and drug addicts for
decades. But there are other options.
BY LISA LOMBARDI

WILLIAM NELSON, NMD, a naturopathic medical doctor in Scotts-

dale, Arizona, never intended to get involved in addiction medicine.
But then his stepdaughter, Lauryn, became hopelessly dependent on
heroin. She overdosed multiple times (“Her heart stopped twice—
they had to use the paddles on her”). As the 20-something cycled in
and out of rehab and the ER, Dr. Nelson lived in fear of the inevitable
tragedy. But one day, he stumbled upon a drug called naltrexone, an
old FDA-approved medication that treats opioid addiction by blocking
opiate receptors in the brain. After Lauryn received naltrexone
implants, which slowly infuse the drug into the system, “she was able
to remain sober for the first time,” says Dr. Nelson.
Lauryn’s story could have had a far different ending. Every
day, 250-plus people in the U.S. die from opioids, including heroin
and prescription painkillers such as OxyContin, fentanyl, and
Vicodin. Unintentional overdose deaths from these drugs have shot
up almost 500 percent since 1999. The odds are not good for a quick
recovery from addiction: 85 percent to 90 percent of people who kick
opioids start using again (officially known as the “recidivism rate”)
within one year. Relapse is now considered to be part of recovery,
which can take many years. Drinking problems, meanwhile, affect

58 H E A LT H
H E A LT H 59
 THE RESPONSE
nearly 15 million Americans, according to the 2018
National Survey on Drug Use and Health, and can
be extremely difficult to overcome. Studies show
that it’s not a quick fix. Only one-third of those who
get help for a drinking problem are free of alcohol
one year later.
But there is some encouraging news on the recov-
ery front. Old medications are being given a second
look and used in new ways to curb cravings for drugs
and alcohol. Programs are springing up that empha-
size holistic approaches to recovery, including cog-
nitive behavior therapy—retraining the brain to build
healthier neural pathways. The biggest change of all,
though, is a rethinking of what recovery even means.
“There’s a paradigm shift going on in our field,”
says Vonnie Nealon, clinical director of Warriors
Heart, an inpatient substance-abuse treatment pro-
gram for military veterans and first responders, in
San Antonio, Texas. “We’re realizing that there may
be some people with a substance-abuse problem who
are able to recover; however, they may still need to
take medications like benzodiazepines—or others—
for…co-occurring disorders.” Some of the people
treated at Warriors Heart, for instance, may plan to
return home and continue using a different chemi-
cal, such as alcohol, in moderation. This is not rec-
ommended, though, as it eventually leads back to
their substance of choice.
Of course, this goes against everything we’ve
ever heard about addiction and recovery. For almost
90 years, Alcoholics Anonymous has ruled the recov-
ery landscape, preaching a gospel of total abstinence.
You’re on the wagon or you’re off. More than 2 million
members worldwide maintain sobriety through
AA’s 12-step program with its emphasis on surrender
to a higher power and acceptance that you are pow-
erless in the face of your demons.
Yet in recent years, the program has come under
fire. Critics argued that the scientific evidence to
back up the 12-step approach was inconclusive,
despite its ongoing popularity. In 2020, however, an
influential Cochrane review declared that AA was,
in fact, supported by research, for 42 percent of the
population. Nealon, who used AA herself to get sober
decades ago, says she knows that AA works—just as
clearly as she knows that it doesn’t work for everyone.
“Recovery is not one-size-fits-all, with everyone fit-
ting comfortably into a 12-step program,” she notes.
Part of the issue with abstinence is that it leaves
out problem drinkers who are unwilling or unable
60 H E A LT H
to give up booze entirely. Presented with a binary
choice (keep drinking heavily or never have another
drink), they choose the former. That may be why
only about 10 percent of problem drinkers seek help.
Given that heavy alcohol use puts people at increased
risk for disease and early death, the goal is to get
more of the other 90 percent to get control of their
drinking even if they can’t fully quit.
Drugs for Drug Problems?
Medication-assisted treatment (MAT) is a potent
tool in the fight against addiction, yet it isn’t used
often enough, with fewer than half of treatment
programs offering drugs for opioid addiction, accord-
ing to a study in the Journal of Addiction Medicine.
Naltrexone—the drug that Lauryn used to break free
of the grip of heroin—is actually a well-established
medication that won FDA approval in the 1980s to
treat opioid addiction. In the early 1990s, it was also
approved for alcohol use disorder.
So how does it work? Naltrexone is an opioid
antagonist: It blocks opiate receptors in the brain.
That means it’s impossible to get high while naltrex-
one is in your system. The drug also curbs cravings
for opioids, which may be the real key to why it’s
making a difference in the fight against addiction.
“It takes away the uncontrollable cravings that make
sobriety so difficult and relapse so common,” says
Dr. Nelson.
The first step to starting naltrexone treatment is
to detox from the opioids, because if there are still
drugs in the system, addicts will experience a rapid,
much more extreme, and potentially dangerous form
of withdrawal. Once the body is opioid-free, there
are a few ways to take naltrexone. The first is via an
FDA-approved injection. In 2015, the pharma com-
pany Alkermes won approval for Vivitrol, a long-
acting injection of the drug. Vivitrol stays in the
system for 28 days at a time, so it involves monthly
trips to a doctor. According to the company’s
research, people who get Vivitrol are one-seventeenth
as likely to relapse as those given a placebo.
Another option is the naltrexone pellet. Made in
a compounding pharmacy and implanted in the
backside, generally by an alternative practitioner,
the pellet keeps the opiate-blocking drug in the sys-
tem for three to six months. According to Dr. Nelson,
naltrexone has been nothing short of miraculous
for his patients. “If done correctly, it’s virtually
impossible to relapse,” he says. He recommends that
An AA attendee, circa 1950, speaks at a local meeting after three months without a drink.
patients get pellets implanted (and replaced) for the
first 18 months to two years of recovery and then
switch to the oral form of naltrexone, which they’ll
take for the rest of their lives.
Rx for Booze
You can also take naltrexone pills and the Vivitrol
shot to help you give up alcohol. But it actually seems
to work better when the person continues to drink.
This approach is known as the Sinclair method,
named for the Stanford physician who discovered it
in the 1970s. John David Sinclair found that taking
naltrexone one hour before drinking chemically
disrupts the body’s reward system, taking away the
desire for alcohol. “It causes an extinction of the
reward system,” explains Dr. Nelson. The addict
slowly cuts back on drinking as the reward of drink-
ing is slowly unlearned. Remember Pavlov’s dog, who
stopped salivating after the food was no longer pro-
vided when the bell was rung? That phenomenon,
known as extinction, is what’s at work here. A study
published in the Journal of Clinical Psychopharma­
cology on the Sinclair method found that a group that
was given naltrexone before drinking drank signifi-
cantly less than a placebo group.
Dr. Nelson himself was a skeptic before he started
using this method on his patients. “I thought it had
to be a hoax,” he says. But he has since seen it help
hundreds of people; in his clinical experience, it
works 90 percent to 95 percent of the time. “One
patient went from drinking 30 or 40 beers a day to
being able to come home from a hard day at work and
have a single beer,” he says. Another went from being
a hard-core alcoholic to having just the occasional
glass of champagne at a wedding. It can take any-
where from a short time to a year and a half for prob-
lem drinkers to reduce their drinking to that of a
social drinker. The only downside is that you need
to take the pill before drinking for the rest of your
life (or for as long as you choose to drink).
There are other meds that help in the battle with
the bottle. Common prescriptions such as the nerve-
pain drug gabapentin, the anti- smoking drug
Chantix, and the seizure drug topiramate are being
used off-label to dull cravings and help drinkers cut
back. Another FDA-approved drug, Antabuse (disul-
firam), is an aversion therapy that chemically turns
drinkers off of alcohol. Drinking while taking
Antabuse yields miserable feelings (vomiting, chills,
crashing headaches). The upside is it works. The
downside is it works so well—making people so
miserable—that it’s hard to stay on the drug.
H E A LT H 61
 THE RESPONSE
Cognitive Therapy
Even if a person goes the medication route, therapy is
also critical. Cognitive behavioral therapy (CBT)
focuses on changing both behavior and thought
process—reframing the need to drink and the central
role alcohol plays in a drinker’s life. Many programs
employ it and help people start new behaviors that
change their brain and set them up for future success.
SMART Recovery is an AA alternative program that
emphasizes CBT. “It’s not like a 12-step where they ask
you to rely on a higher power,” explains Nealon. “They
still do meetings, but they leave the God part out.”
Also key: getting help for any coexisting mental
health issues. At Warriors Heart, patients are assigned
two counselors: one to help treat their addiction, and
the other to help them work through mental health
challenges such as PTSD and depression. “The truth
is, a lot of people who use drugs and alcohol do so
because it has become a coping mechanism. And
somewhere in their journey, they found if they drank
they could forget their problems for a while,” says
Nealon. Or they found that if they drank before a
meeting at work, their coworkers wouldn’t realize
Holistic approaches to recovery, such as tai chi, can complement other treatment modes.
62 H E A LT H
they had PTSD. “The longer you use that coping
mechanism, the more it’s going to affect your brain
chemistry and the more you’re going to have to depend
on it,” she adds. If people don’t get help for those issues
while at rehab, she adds, “when they leave the pro-
gram, the co-occurring disorder is going to raise its
head. You can’t control depression with willpower.”
In addition, many treatment programs incorporate
mindfulness and wellness. From yoga of 12-step
recovery classes and tai chi to emotional-support
animals and hypnotherapy, holistic approaches give
addicts tools to help cope when they’re back in the
real (often stressful) world.
Not everyone will respond to chimes and medita-
tion, however. The best way to help someone recover
from addiction, experts say, is to find an individual
approach that suits the person.
And that means never giving up. Dr. Nelson wants
the world to know about the medication that is help-
ing so many of his patients and that saved his step-
daughter while there was still time. Lauryn now
works at one of the rehab programs she attended.
Dr. Nelson says, “She’s treating her former self.” ●
 Getting the Cures to the Patients
Several drugs already exist that can help fight some addictions,
but there are still obstacles to widespread treatment.
Although there are
numerous medications to
treat drug and alcohol
addiction, better access
and more research are still
needed. The urgency of the
current U.S. opioid crisis is
causing more of often-
scarce federal dollars to be
spent investigating drug
addiction than alcoholism.
At the same time, says
Joshua D. Lee, MD, an
associate professor of
population health at NYU
School of Medicine, we are
not using enough of the
drugs and other resources
we already have.
Generally, two mainstay
drugs have been used
in addition to naltrexone
to treat opioid disorder.
Methadone, which has
been prescribed for
decades to treat heroin and
other addictions, is
delivered only in specialized
addiction clinics operating
under strict regulations that
may require patients to
show up for treatment five
or six days a week. In some
parts of the country, clinics
are not easily accessible.
Buprenorphine, itself a
form of opioid, is another
option. It can be prescribed
and administered by
physicians in their offices,
but only by those who have
undergone special training
and have received a waiver
from the FDA allowing them
to prescribe. Most doctors
have not. Naltrexone, not
a controlled substance
like the other two, has no
BY BARBARA SADICK
special requirements for
administering, but the Naltrexone, methadone, and
buprenorphine are all common drugs
formulation most often used to treat opioid addiction.
approved for treatment of
opioid use disorder
necessitates an injection
once a month for as long as
a patient is benefiting.
Partly as a result of all of
these requirements, says
Jennifer McNeely, MD, an
addiction medicine
physician at NYU Langone,
only 20 percent of those
who have opioid use
disorder are receiving any
treatment and less than
10 percent are being
treated with medications.
Perceptions matter too.
The fact that alcohol is legal,
widely used, and culturally
accepted contributes to the
low numbers of alcoholics
seeking treatment. There’s
not the same social stigma
associated with drinking as
there is for drugs such
as heroin and cocaine. By
its very nature, says James
Garbutt, MD, a researcher
at Bowles Center for Alcohol
Studies at the University
of North Carolina, addiction Experts agree that abuse requires tolerance
is an obstacle to seeking several policy changes for trial and error. To be
help. Substance abusers need to be made to help effective, says Dr. Garbutt,
want to keep using; if the curb the national addiction treatment for alcohol
culture tells alcoholics their crisis. Special prescribing addiction requires working
particular substance isn’t requirements, for example, with patients on an
so bad, that can be all the should be eased, and ongoing basis and being
permission they need. The clinics should be more open to treatment changes
same phenomenon can widely available. “We do along the way. “What we
have a subtle impact on have incredibly good need,” he says, “is for
pharmaceutical companies, medications; they just doctors and patients to
which feel less demand to aren’t getting to enough educate themselves
develop new drugs to treat people,” says McNeely. about addiction, including
alcoholism than to treat Finding more medications paying attention to the
opioid abuse. to treat opioid and alcohol problems of access.”
H E A LT H 63
 TREATMENTS
AT THE FRINGES
Two promising techniques may be able
to help manage addictions by targeting key
regions in the brain itself.
BY LAURA ENTIS

ADDICTION IS an intractable disease, driven by a
complex network of biological, psychological, and
environmental contributors. It’s widespread—nearly
half of Americans report having a close friend or
family member who has been addicted to a
substance—and it’s deadly. In 2020, drug overdoses
in the U.S. claimed more than 93,000 lives, exceeding
the national toll from car crashes, AIDS, or guns.
The scale of the addiction problem is huge. And
yet there remain few effective solutions beyond
12-step programs, support groups, and medications
to treat opioid, tobacco, and alcohol use disorders.
(There are no FDA-approved treatments for cocaine,
stimulant, or hallucinogen use disorders.)
Medications can work well, “but it depends on the
person,” says Anna Lembke, MD, the medical direc-
tor of addiction medicine at Stanford University. “We
don’t consider it strange that people who have cancer
might respond to one chemotherapy rather than
another…but for some reason, when it comes to
addiction, people get all up in arms, as if there should
be one magic wand that would solve the problem for
everybody.” Alternative therapies could provide bet-
ter options to patients who are ill-suited for current
treatments—and options are what addicts need.
Enter neurostimulation procedures, in which
areas of the brain receive targeted energy through
either an implanted electrical device or pulses of
magnetism applied to the skull or forehead. On its
surface, treating as stubborn a problem as addiction
with energetic intervention sounds improbable. But
preliminary research has been encouraging—to
the point that researchers are beginning to conduct
clinical trials. “It’s all coalescing,” says Allen Ho, MD,
a neurosurgery resident at Stanford.
FOR DECADES, DOCTORS have applied electronic
charges to the brain to treat a range of diseases, most
notably movement disorders. Among the wide vari-
ety of techniques, the two most heavily researched

64 H E A LT H
 DEEP BRAIN
STIMULATION
HAS BEEN USED TO
TREAT PARKINSON’S,
DEPRESSION, OCD, AND
ADDICTION USING AN
IMPLANTED PULSE
GENERATOR.
 THE RESPONSE
have been deep brain stimulation (DBS), a surgical
procedure in which an electrode is threaded into the
brain and connected to a small device similar to a
pacemaker, and transcranial magnetic stimulation
(TMS), in which electronic magnetic coils are
applied to the surface of the skull.
Each has its benefits. TMS is noninvasive, while
DBS reaches areas in the brain that surface currents
can’t; together they are approved for conditions
including Parkinson’s, essential tremor, dystonia,
obsessive-compulsive disorder (OCD), epilepsy, and
depression. In general, side effects are rare and mild.
We owe much of our understanding of how neuro-
stimulation works—and how it could work in cases
of addiction—to movement disorders. In the past,
patients with Parkinson’s often received lesion ther-
apy, in which a spot in the brain was burned away to
regulate tremors and other motion and alleviate
rigidity. Starting in the 1970s with
the advent of neurostimulator
technology and its resulting
experiments, it became evident
It’s possible
that targeted electrode pulses
that aberrant
were capable of providing the
activity
same relief in a reversible and less
brain
risky way. In 2002, DBS was
compensating
approved to treat Parkinson’s,
addiction
followed by essential tremor and
than causing
dystonia. Approval next came for
other conditions that stem from
regulation issues, such as depression, OCD, and
attention deficit hyperactivity disorder.
Addiction has also long been a target. Whereas a
healthy brain is able to control and override urges to
satisfy cravings and pursue pleasurable activities—to
know, in essence, when enough is enough—in an
addicted brain, that “circuit is hijacked,” Dr. Ho says.
“Addiction is a disease process through which people
have a deranged ability to self-regulate.”
In movement disorders, hyper-specific targets in
the brain have been well established over time. Not
so for addiction, although general regions associated
with the brain’s reward circuitry, including the
nucleus accumbens, prefrontal cortex, and insula,
have been established.
“The brain essentially activates these areas to help
reinforce future behavior,” says Benjamin Walter,
MD, the medical director of the Cleveland Clinic’s
Center for Neurological Restoration’s Deep Brain
Stimulation program. Such reinforcement is an
66 H E A LT H
important function that aids in habit formation. It’s
believed that OCD and addiction are caused, at least
in part, by the dysregulation of these circuits.
Brain stimulation works by disrupting malfunc-
tioning circuits and replacing the dysfunctional
activity with a steady current. The idea is that by
overriding aberrant wiring with a constant bland
signal, the brain is able to “readapt and achieve a
more normal state,” Dr. Walter says. For Parkinson’s
patients, this means the regulation of movement.
For those with substance use disorders, the hope is
that the artificial stimulation will alleviate the
“abnormal need” that characterizes addiction.
Surgeons have identified which parts of the brain
to target with the curative current based on both
animal studies and functional magnetic resonance
imaging (fMRI) of human subjects, in which
addicted and nonaddicted brains are watched in real
time and compared with locate
correlates of the disease. In mice,
scientists not only have identified
brain structures that cause addic-
tive behavior but also are able to
in certain reverse them through targeted
regions is stimulation, essentially turning
for addiction on and off. But such a
rather clean, direct causal link has not
it. been established in more complex
human brains. That’s because
even if fMRI has identified where
the addicted human brain differs from the non-
addicted brain, it still doesn’t reveal what is causing
these changes to occur. It’s possible that aberrant
activity in certain regions is actually compensating
for addiction rather than causing it, in which case
well-intentioned stimulation therapy could worsen
the condition, says Michael Fox, MD, an associate
professor of neurology at Harvard Medical School
and the director of the Center for Brain Circuit
Therapeutics at Brigham and Women’s Hospital.
Researchers have some idea of neuromodulation’s
ability to treat addiction in humans by targeting
regions associated with the reward circuitry and
watching the result, but most of the data has come
from open trials. Unlike in double-blind studies,
subjects and investigators can bias the results when
they know which group is receiving real treatment.
For movement disorders, a causal relationship has
been established between circuits and symptoms.
Dr. Fox has seen wheelchair-bound patients with

Transcranial magnetic stimulation is a noninvasive
addiction therapy utilizing magnetic pulses.
terrible tremors stand up, walk across the room, and
write on a chalkboard after their device is activated:
“It’s dramatic,” he says.
Yet even in movement disorders, researchers
aren’t sure how neuromodulation enables the brain
to regain control of runaway circuits and help
patients, in turn, regain control of their bodies. “Are
we shutting [the circuits] down? Are we slowing
them down? Are we reversing them?” Dr. Ho asks.
“These are questions that no one has a very good
answer for.”
FOR ALL THE question marks, it’s not hard to see
why investigators are excited about brain stimula-
tion’s potential in treating substance use disorders.
Even if the results don’t come from double-blind
trials, there’s plenty of evidence that neuromodula-
tion can treat addictive behaviors at least in certain
patient populations. For instance, a 2015 paper pub-
lished in Addiction examined cigarette smokers who,
as a result of a stroke, suffered brain damage. Some
patients experienced an unexpected side effect of
the ordeal: reduced tobacco-withdrawal symptoms
and cravings, an effect that was statistically more
likely to occur when the damage was to the insula.
Brain stimulation could provide the same therapeu-
tic effect by targeting the same area, Dr. Fox says.
In two clinical trials, Nolan Williams, MD, direc-
tor of the Interventional Psychiatry Clinical
Research and the Brain Stimulation Laboratory at
Stanford Medical Center, is exploring TMS’ ability
to treat alcohol dependence and opiate cravings in
adults with substance use disorders.  
Although the evidence that comes from studies like
these may be compelling, establishing a true causal
relationship between brain stimulation and reward
circuitry regulation requires large double-blind trials.
Conducting them, however, presents real challenges.
DBS and TMS trials involve modulating circuits
to change desire and behavior. Whether addicts are
able to fully consent remains an open ethical ques-
tion, Dr. Ho says. And then there are the logistics.
Double-blind neuromodulation trials, in which
patients and investigators are kept in the dark about
who is receiving treatment rather than a placebo,
can be tricky to pull off, particularly for DBS, a sur-
gical procedure.
What’s more, even if DBS and TMS prove effective,
addiction is a multifaceted disease that isn’t exclu-
sively caused by changes in the brain. Unless under-
lying societal, social, and environmental factors
are also addressed, it’s likely many patients will
continue to engage in addictive behaviors even fol-
lowing treatment.
For now, neuromodulation remains a promising
potential tool to treat addiction but needs to be
patiently refined and vetted via many trials over
time. After all, scientists may more or less know the
parts of the brain involved in addictive behaviors,
but they are still working to pinpoint the exact cir-
cuits at work in those regions. “I think it’s a matter
of good large studies looking at the data carefully
and, probably most importantly, identifying the
right patients to offer the therapy to in these clinical
trials,” Dr. Walter says.
It’s essentially an educated game of trial and error.
Success depends on whether researchers select
the correct targets straightaway. If they don’t—a
real possibility—the first batch of clinical trials will
fail. That doesn’t necessarily mean that the treat-
ments don’t work, only that “we didn’t use the right
therapy at the right target,” says Dr. Fox. From there,
researchers must start again—armed, crucially, with
more data for more trials.
For addicts facing a viselike disease with limited
options, new solutions can’t come fast enough.
“Treating addiction is never going to be one-size-
fits-all,” Dr. Lembke says. “To build an effective
infrastructure to treat patients who have serious
addiction problems, we need to make sure they have
access to all the available tools.” ●
H E A LT H 67
 A FATHER’S FIGHT
FOR HIS SON
In his memoir Beautiful Boy and the film that is based
upon it, writer David Sheff tells the raw tale
of his son Nic’s addiction to methamphetamine, his
frequent relapses, and his eventual recovery.

In the latter portion of the book, Nic has relapsed and
is at large in the world with his girlfriend, identified in
the book only as Z. His family does not know his where-
abouts, nor does his former recovery sponsor, Randy.
David Sheff lives in Northern California with his wife,
Karen, and their children, Jasper and Daisy. Nic is the
child of David’s marriage to his first wife, Vicki.
Another week.
Vicki, with whom I speak daily, says that she is
numb. I am, too. It’s not that I don’t worry about
Nic—I think about him all the time—but for the
moment I am not incapacitated.
Is this where parents wind up?
I walk past more people on the streets… I walk
past them and step over them, people alone and
abandoned, and, when I do, as always, I think, Where
are their parents. But this time I wonder, Is this the
answer? Am I becoming one of them—a parent who
has accepted defeat? My agonizing has not helped
Nic in the slightest.
I am not pretending that this isn’t happening.
I am doing all that I can do.
I wait.
A downward spiral.
It’s a degenerative disease. I imagine the down-
ward spiral.
No, I am not numb. I wish I were. Sometimes I feel
overwhelmed.
I brace myself.
Randy continues to call Nic and leave messages on
his dead cell phone. Randy was Nic’s lifeline.
Using Z.’s phone, which is still working, Nic calls
and leaves more messages. “I just want you to know
we’re safe. We’re going to meetings. I’m getting sober.”
He claims that the relapse was a one-shot, three-
day mistake and he’s fine. But the longer he talks, the
more it becomes obvious that his voice is the voice of
Nic on something.
I wait.

68 H E A LT H
 NIC (LEFT)
AND DAVID
SHEFF WROTE
JOINT MEMOIRS ON
NIC’S STRUGGLE
WITH ADDICTION
AND DAVID’S
CHALLENGE TO
COPE.
 THE RESPONSE

It’s like watching from afar, perhaps through bin­ Nothing for two more days, but Nic is in the desert,
oculars with imperfect lenses, the moments before a writing in the shade. There are drugs in the desert, too.
train wreck. All of us who love him commiserate. At night, Karen and I switch off reading to the kids.
Karen and I. Vicki and I. Randy. We all know. And yet We are nearing the end of Harry Potter. Professor
there’s nothing we can do. I call Nic back. “Nic, don’t Dumbledore died. He is dead. More than one of the
forget how dangerous it is when you aren’t attending children we know cried for hours when they read
meetings,” I say. “Don’t forget when you listen to the this—Albus Dumbledore, Harry’s protector with
logic of your brain when it’s under the influence.” whom these children grew up, is dead. Evil is winning,
In recovery, working with Randy, Nic was the one and I feel weakened by the ceaseless battle.
who explained the insidiousness to me: “A using
addict cannot trust his own brain—it lies, says, ‘You ON THURSDAY, JASPER has a soccer game after
can have one drink, a joint, a single line, just one.’ It school. Daisy has swimming. Karen and I divide the
tells him, ‘I have moved beyond my sponsor.’ It says, driving.
‘I don’t require the obsessive and vigilant recovery I have found a quiet place in a corner of the club­
program I needed when I was emerging from the room near the pool to write. Looking up, out the win­
relapse.’ It says, ‘I am happier and more complete than dow through the slats of shutters, I see a dark form
I have ever been.’ It says, ‘I am independent, alive.’ ” curve up and break the water, followed by a pair of
And so Nic said he couldn’t trust his own brain and kicking feet: Daisy doing her laps. The coach, poised
needed to rely on Randy, meetings, and tanned and lithe, a former
the program, and prayer—yes, All­American swimmer who has
prayer—to go forward. taught all three of our children,
Nic, you have come so far.
“An alcoholic will crouches at the end of the lane,
Let me quote you: “Everything
steal your wallet. encouraging Daisy and the other
I have will be gone if I don’t stay
A drug addict swimmers. I lose sight of her
with the program.”
will steal your among the lines of bodies in their
wallet and blue suits until she returns back
TWO DAYS LATER, on Wednes­
then help you down the lane in the opposite
day, Nic calls up slurring and asks
look for it.” direction, her powerful arms pull­
for rent money. No. He says that he ing in arching freestyle strokes. I
knew I would say no. He saved it for remember when it was her big
the end of the conversation, after, “I love you so much. brother Nic in the water, his lean dolphin body cutting
I’m safe. We really f­­­ed up but we’re going to be fine through the pool.
now. I just took a little something to help me come
down from the meth and coke and smack and…” THERE IS NO NEWS. Some of the panic in which I
Vicki says no, too. lived during these crises seems to have lifted. I worry,
Now it is Friday. Nothing on Saturday. Nothing on but I am not sick with worry. I’m getting better. I’m
Sunday. letting go. I’m in abject denial.
Nothing until Monday when an email arrives. It must be like a soldier in a trench during a bomb­
“hey pop, we’re in the desert. Z is doing a commer­ ing raid. I’ve shut down every nonessential emotion,
cial, out by joshua tree…my phone doesn’t get any concentrating every neuron in my new brain on the
reception here and I just borrowed this computer moment in order to stay alive.
for a second from some guy on the set…sorry…this I am in a silent war against an enemy as pernicious
came up really suddenly…anyway, i’ll call you when and omnipresent as evil. Evil? I don’t believe in evil
i find a phone that works…it’s hot, hot here and bor­ any more than I believe in God. But at the same time
ing…z just doing wardrobe and i’m writing in the I know this: only Satan himself could have designed
shade here…don’t fret…i may have some exciting a disease that has self­deception as a symptom, so
news too…love ya…nic” that its victims deny they are afflicted, and will not
Joshua Tree. seek treatment, and will vilify those on the outside
A respite. An oasis. Maybe Nic will stop on his own. who see what’s happening.
Maybe he’ll be OK. After dinner, Jasper asks me to quiz him on math

70 H E A LT H
and his words of the week. Then he and I read a Mad
magazine together.
In bed, I grab one of the novels on the tottering
stack on the night table. I will never get through all
the books. I’m so tired at night that I read a page,
maybe two, and fall asleep. Karen joins me.
The telephone rings. I ignore it. In my half-
consciousness I have decided that it’s a serviceman
we called for an estimate on some repairs. I think, It
will wait until morning.
The phone rings again. I’ll get the messages tomor-
row. No, Karen says, you had better check.
The first call is Nic’s godfather. Nic just called him
and left a message. “He’s in Oakland.” My friend’s
voice is in a state of alarm. “He says he’s in trouble and
needs help. I don’t know what to do.”
My heart pounds.
The next message is from Vicki. Nic called her, too,
leaving a similar message. “I lied about Joshua Tree
because I didn’t want you to worry that I was in
Oakland. I’m sober. Please, we’re in trouble. We need
plane tickets back to L.A.” He tells a convoluted story
about how they got there, but the bottom line is that
he and Z. are at the home of a crack addict in Oakland
who is out of his mind and they have to get out.
I return Vicki’s call. She is unsure what to do—
whether or not to pay for a plane ticket. I understand,
but, no, I say. If it were me, I would not help unless he
wants to go into rehab. Then maybe.
I hang up. I call my friend [Nic’s godfather]. He is
calmer than when he left the message. He says,
“Listen,” and plays the message on his answering
machine over the telephone. We hear the slur in Nic’s
voice. “I need help. I can’t call my dad. I don’t know
what to do, please give me a call.” He leaves Z.’s cell
phone number.
“It’s so sad,” my friend says. “Part of me wants to
drive to Oakland to get him and part of me wants
to wring his neck.”
Once again, Nic is here and he is high. For some
reason, I’m aberrantly calm as I think, If he is here,
what might he do? Might he come to our house? What
do I do if he does? Where else might he go?
The next day, Nic leaves another message for his
godfather and one for his mother, this time saying
that the girlfriend of the crack addict with whom they
were staying showed up and gave Nic and Z. money
to fly home.
I’m working at the Corte Madera library, a stack
of books at my side.
I have brought my laptop and I’m writing and
writing, an attempt to contain something that is fast
(once again) spiraling out of control.
The phone is on vibrate because of the library and
it starts its mad shaking and rattling as if possessed.
I pick it up from the table so the noise doesn’t disturb
anyone. On the screen, in sickly green letters, I see
that it’s Nic’s girlfriend’s phone.
I have no desire to hear more lies. I turn it off.
Later, as I am driving to pick up the kids from
school, I listen to the message. Nic says that he and Z.
are driving back from Joshua Tree and are finally in
cell phone range. He says, word for word:
“Hey, Pop, we’re driving back from Joshua Tree and
we’re finally in cell phone range again…”
I am struck not just by the lie, but by its intricacy. He
could have said, “I’m back in L.A.” He could have
checked in without saying any more than hello. But he
thought through the original lie and built on it, bejew-
eling it with detail so that I would never question it.
And I would not have if I didn’t already know it was a
lie. By now I have heard about the web of lies by addicts.
“Substance abusers lie about everything, and usually
do an awesome job of it,” Stephen King once wrote. “It’s
the Liar’s Disease.” Nic once told me, quoting an AA
platitude, “An alcoholic will steal your wallet and lie
about it. A drug addict will steal your wallet and then
help you look for it.” Part of me is convinced that he
actually believes that he will find it for you. I listen to
the message a few times. I want to remember it.
Did he forget that he called his mother and his god-
father and told them that he was in desperate peril in
Oakland? After everything, does he assume that my
dear friend would not call me if he was worried about
Nic, if Nic was desperately in danger in an Oakland
crack house? Does he not know by now that his
mother, with whom I have ridden this hellish roller
coaster, will of course call to check in with me to talk
about what, if anything, we should do? And not only
about what to do. Just to talk to the other person who
loves Nic the way she does.
The message continues. He’s not slurring. He
sounds fine. He says he misses and loves me. O
EXCERPTED FROM BEAUTIFUL BOY: A FATHER’S
JOURNEY THROUGH HIS SON’S ADDICTION BY
DAVID SHEFF. COPYRIGHT © 2008 BY DAVID
SHEFF. REPRINTED BY PERMISSION OF MARINER
BOOKS, AN IMPRINT OF HARPERCOLLINS
PUBLISHERS. ALL RIGHTS RESERVED.
H E A LT H 71
 CHAP TER

The
Stories
Addiction is pervasive on movie and
TV screens and between the lines of
novels. However, these stories also
play out in real life, among great
innovators hiding struggle behind
their spotlights.

● The Addictive Creative

● “My Son Is Always With Me”
● Battling the Odds
● Fictional Addicts, Real Pain

72 H E A LT H
 THE ADDICTIVE
CREATIVE
Creativity and addiction have long
seemed linked. Why do great art and great
pain so often come together?
BY EILEEN DASPIN

IT IS A DISTRESSINGLY familiar ritual in America. A famous

musician or writer or actor admits to an addiction and checks into
a rehab facility—or, more tragically, dies of an overdose. A flurry of
media coverage follows. The stories include lists of other creative
types who’ve fallen prey to the addiction at hand—whether drugs
(Prince, Philip Seymour Hoffman), alcohol (Carrie Fisher, Stephen
King), sex (actor David Duchovny, comedian Russell Brand),
gambling (Deadwood creator David Milch, singer Gladys Knight)
or shopping (journalist Buzz Bissinger, Michael Jackson). In the
aftermath, there may be an autobiography chronicling the road to
recovery. Or an interview. Or an appearance on a public service
announcement. Or a relapse.
And always, an implied question arises: Is there a link between
addiction and creativity? Given the frequency of such tragedies, it’s
impossible not to wonder. Not all celebrities who overdose are addicts,
but between 2000 and 2015, the number of drug-related celebrity
deaths nearly doubled, a spike that researchers have tied to the rise
of prescription opioids. In 2018, rapper Mac Miller, Dolores O’Riordan
of the band the Cranberries, and actor Verne Troyer, all self-admitted
addicts, died from drug use or incidents related to alcohol abuse. Brad

74 H E A LT H
H E A LT H 75
 THE STORIES
Pitt indicated in an interview that alcoholism was
part of what led to the demise of his marriage to
Angelina Jolie. And in 2013, after spending more
than half a million dollars on designer clothing,
Bissinger detailed his “Gucci addiction” in an essay
in GQ. “I see the collection, and the pheromones of
hot clothing defeat the part of the brain that rations
rationality,” Bissinger wrote of attending a Gucci
fashion show in Milan. “There is the deliciousness of
desire…I have to have it. I don’t have to have it. I need
it. I don’t need it.”
Bissinger, the author of Friday Night Lights, a non-
fiction best seller that chronicled the experiences of
a small-town high school football team in Texas and
was later made into a popular film and hit television
series, could likely afford to
indulge his impulses. And like a lot
of celebrities, he did.
There certainly are unique
High-profile
pressures on high-profile creative
types
types that can lead to addictive
themselves
behavior. Celebrities’ daily lives
comparisons to
are scrutinized by the media,
their peers,
as are their relationships, work,
unfavorably,
successes, and failures. They may
equally
see themselves in acute compari-
comparisons to their
sons to their peers, often unfavor-
younger
ably, and in equally painful
comparisons to their younger
selves. Some have to overcome stage fright or conquer
writer’s block. Others may feel the need for solitude
to create their work.
Unfamous creatives may feel that kind of pressure
too. In 2017, reacting to media reports of drug abuse
among artistic types, researchers from Eötvös
Loránd University in Budapest surveyed a group of
university art students and a group of non–art stu-
dents about their drug habits to see how the two
compared. The art students, presumably the more
creative group, reported that they had tried more
types of illegal substances than their non-art peers,
that they began taking them younger, and that they
used them more frequently. The survey’s authors
offered theories on why creatives might turn to illegal
drugs—to reduce anxiety, to see the world from a
different perspective—but said there is no evidence
that creative ability by itself leads to drug abuse.
In fact, hard science says there is no confirmed
causal link between artistry and addiction, according
to neuroscientist David Linden, PhD, of Johns
76 H E A LT H
Hopkins University, who has researched the topic.
But there are hints. Studies of heredity, most signifi-
cantly between twins, show that 40 percent to 60 per-
cent of a predisposition to addiction is genetic. There
is no single addiction gene, just as there is no single
creativity gene, but scientists are beginning to under-
stand that a specific genetic suite sets the stage for
these traits. The ones associated with addiction are
connected to the release of dopamine, the neu-
rotransmitter that plays a role in motivating behavior.
It is dopamine that rewards us with good feelings
when we eat something delicious, when we have sex,
or when we have positive social experiences.
Addicts become addicted not because they derive
pleasure strongly from gambling or drugs or sex, but
because they feel pleasure more
weakly—a theory referred to as
the “blunted dopamine” hypoth-
creative esis. They may drink more, shop
may see more, do more drugs because
in acute that’s what it takes to bring them
joy. Linden, the author of The
often Compass of Pleasure: How Our
and in Brains Make Fatty Foods, Orgasm,
painful Exercise, Marijuana, Generosity,
Vodka, Learning, and Gambling
selves. Feel So Good, put it this way in a
conversation with Scientific
American: “Addicts seem to want
[pleasure] more but like it less.”
In this scenario, creative types may similarly be
seeking a rush that comes to others more easily.
People with low-functioning dopamine systems are
more inclined to take risks, seek novelty, and act
compulsively. None of these behaviors are explicitly
creative, but they can be a catalyst for creativity,
Linden said in the same interview. “Novelty-seeking
might be a spur to creativity. Risk-taking might lead
you to go more out on a limb,” he said. “If you’re
compulsive, you might be more motivated to get your
art, science idea, or novel out into the world.”
LITERATURE ON THE LINK between creativity and
addiction lends support to the connection, with
reports dating back at least to the beginning of the
19th century. One early record is that of Thomas
De Quincey. In 1804, De Quincey, then 19 and a stu-
dent at Oxford University, had been prescribed opium
to relieve excruciating pain from facial neuralgia. It’s
uncertain whether the drug had the desired medicinal
Like addiction, creativity cannot be isolated by just one gene or catalyst—both are unique.
effect, but De Quincey nonetheless kept using it. For
eight years, it heightened his enjoyment of books,
music, solitude, and urban wandering. But inevitably
he succumbed to addiction. “Oh! Heavens!…what an
upheaving, from its lowest depths, of the inner spirit!
What an apocalypse of the world within me!”
De Quincey wrote in what might be the first modern
drug memoir, Confessions of an English Opium-Eater,
published in 1821.
About the same time that De Quincey was battling
opium dependency, there was a wave of Europeans
experimenting with hashish, compliments of
Napoleon Bonaparte. Expelled from Egypt in 1801,
the general and his troops returned to France with
samples of what the Egyptians called dawamesk, a
jam made from cannabis, vanilla, pistachios, almonds,
and musk. By the early 1840s, dawamesk—with its
sensory- expanding qualities—was catching on
throughout the French population, and psychiatrist
Jacques-Joseph Moreau wanted to understand its
impact on the nervous system. In Moreau’s view, the
drug fostered an “intellectual intoxication” that was
superior to the “ignoble heavy drunkenness of alco-
hol,” but he needed to test his theories on others.
To do so, Moreau sought out artistic-minded vol-
unteers, according to the book Cannabis by Jonathon
Green, and contacted Théophile Gautier, a French
philosopher and writer. Gautier in turn recruited a
group of his friends to take the experiments a step
further. It was quite the circle: Among them were the
writers Alexandre Dumas, Victor Hugo, and Honoré
de  Balzac; poet Charles Baudelaire; and painter
Eugène Delacroix. The group called itself the Hashish
Club, and from 1844 to 1849, they gathered monthly
at a Parisian hotel, dressed in Arab clothing, to drink
coffee laced with hashish or eat dawamesk spread on
bread and discuss their reactions.
While the dawamesk made an impression on
H E A LT H 77
 THE STORIES
members, heightening their senses and filling them
with “languorous wonder,” as Baudelaire put it, they
were clear-eyed in their assessment of the drug. In
an article titled “Artificial Paradise,” Baudelaire
captured hashish’s allure and dangers. “At first, a
certain absurd, irresistible hilarity overcomes you.
The most ordinary words, the simplest ideas assume
a new and bizarre aspect,” the poet wrote. But in the
end Baudelaire concluded that the hashish taker
would likely suffer consequences. “Wine exalts the
will,” he wrote. “Hashish annihilates it.”
Ironically, although Baudelaire and his confreres
avoided hashish addiction, the poet later succumbed
to laudanum, alcohol, and opium. And he had plenty
of addictive company among the 19th century’s cre-
ative class. After playing roulette for the first time,
while on vacation in Germany, Fyodor Dostoyevsky
gave in to a debilitating gambling problem that
almost ruined his life. He was forced into debt more
Singer Dolores O’Riordan
died in 2018 of drowning
after excessive drinking.
78
than once and had to write as quickly as possible to
secure the money needed to pay creditors. He pawned
his wedding rings and his wife’s valuables. A fellow
novelist, Leo Tolstoy, was a sex addict, whose diaries
painfully chronicle the illness: “I’m disgusting,” he
wrote, flatly and brutally.
BISSINGER MAY NOT be Tolstoy or Hugo or
Dumas—something he would likely concede—but in
his GQ essay, he sounds similar themes to those of
the writers who came before him. He needs stimu-
lation “to create, to survive,” he wrote. “Without it I
feel dead, useless, overcome by the worst anxiety of
all, nothingness, dead man walking.”
Friday Night Lights was published when Bissinger
was 35. Twenty years later, he said, “the words were
harder to find,” and he grew anxious he would never
repeat his earlier success. That’s when he discovered
the power of clothing, which, as he put it, was “hot
and beautiful and transformative, a new sense of
self-expression that I finally had the courage to
realize. I hated khaki pants. Clothing became the
stimulation and attention I craved.”
Bissinger started binge-shopping online as an
antidote to any mood: “feeling anxious, feeling
depressed, feeling flat, feeling excited, and desper-
ately wanting another excitement hit.” He shopped
his favorite websites constantly, clicking “Buy”
during the workday instead of writing, in bed before
going to sleep, or while waiting to meet a friend at a
bar. Sometimes he bought the same item twice, hav-
ing forgotten he owned it already.
After the GQ story was published, he checked
himself into rehab for various addictions. But he has
yet to conquer his compulsion. In a 2018 interview,
Bissinger said that his shopping tab was more than
$1 million and that he was seeing a therapist. He
continues as a contributing editor to Vanity Fair and
is working on a new book, about football, the Marine
Corps, and World War II.
Generally, as with Bissinger, addiction erodes focus
and discipline, which isn’t conducive to the creative
act. But there are great works that have come out of
binges. The Beatles experimented extensively while
on LSD, and John Lennon spoke openly about com-
posing some of the trippy 1967 song “I Am the
Walrus” while high on the hallucinogen. Some of
Willem de Kooning’s most famous paintings were
fueled by alcohol, and Stephen King has admitted
that he wrote Cujo, his 1981 horror classic, while in a
Rapper Mac Miller struggled with substance abuse throughout his career before his death in 2018.
spiral of cocaine and alcohol addiction. He has said
he barely remembers writing the best seller about a
once-friendly Saint Bernard bitten by a sick bat.
“I don’t say that with pride or shame, only with a
vague sense of sorrow and loss,” wrote King, now
sober, in his memoir, On Writing. He added: “Creative
people probably do run a greater risk of alcohol and
addiction than those in some other jobs, but so what?
We all look pretty much the same when we’re puking
in the gutter.”
There are factors aside from low dopamine that
may push an individual toward creativity. Creative
people tend to process information differently than
the rest of us, according to Harvard researcher
Shelley Carson, PhD. Most people, Carson says, have
filters to block out the vast amount of data that
streams into our minds. But highly creative people
let a lot more information in, so they have to process
and organize the information in unusual ways, a trait
referred to as “cognitive disinhibition.” Business-
people, who bring a different kind of creativity to
their work, might call it thinking outside the box.
In Portrait of an Addict as a Young Man, celebrated
literary agent Bill Clegg (his clients included The
History of Love author Nicole Krauss and Pulitzer
Prize finalist Susan Choi) detailed how he binged
on crack cocaine to overcome an inferiority complex
and feelings that he was an impostor among New
York’s accomplished literati. (Example: “I am not
nearly as bright or well-read or business savvy or
connected as I think people imagine me to be.”) Over
a period of a few years, Clegg lost everything, includ-
ing his clients, his apartment, his partner, and his
sanity. In the two-month binge during which he hit
bottom, Clegg blew through some $70,000 on crack,
Ketel One vodka, and pricey hotel rooms. He turned
paranoid, convinced that cabs and helicopters were
following him.
After writing a second memoir, Ninety Days, about
his attempts to get sober, Clegg relapsed, but he has
apparently righted his life again. He wrote Did You
Ever Have a Family, a 2015 novel that was long-listed
for the National Book Award and Britain’s prestigious
Booker Prize, followed that up with the well-reviewed
novel The End of the Day in 2020, and has resumed
work as a literary agent. “Recovery is an ongoing
project that is really discrete from everything else in
my life,” he said in an interview during a book tour.
“It allows me to be an agent, allows me to write,
allows me to be married, allows me to be part of a
family. The writing is not a support beam of recovery,
but a happy consequence of it.” ●
H E A LT H 79
 “MY SON IS ALWAYS
WITH ME”
Rock star Melissa Etheridge opens up about the pain of
watching her beloved son Beckett die of an opioid
overdose—and how she hopes to help other families.
BY JEFF NELSON

ON MAY 13, 2020, Melissa Etheridge received the
phone call she had been dreading: Her 21-year-old
son Beckett had died of an opioid overdose. The
singer had been steeling herself for the call since their
final conversation. “Four days before he died, he
called me and said, ‘Mom, I’m really scared,’ and he
mentioned fentanyl,” Etheridge says of the synthetic
opioid that is 50 to 100 times more potent than mor-
phine. “I tried to get him [treatment]. I tried to get
him to let me call an ambulance for him, then he
stopped calling me. He didn’t call me for four days,
and twice we sent a wellness check on him. The sec-
ond time, they found him dead.” Etheridge learned
the devastating news from her former partner Julie
Cypher, Beckett’s other mother. “I hadn’t heard from
him, so I had four days to think, ‘Oh my God, what if
he’s dead?’ ” Etheridge says now. “It wasn’t a shock.
It was, ‘Damn, he just slipped away.’ ”
Etheridge is still coming to terms with Beckett’s
death. “It gets better. It’s been eight months—feels
like two weeks. I miss him. It’s something that you
have to grow with every day,” she told People in early
2021. Leaning on her wife, Linda Wallem, and finding
joy in daughters Bailey and Johnnie and son Miller,
Etheridge hopes to raise awareness about the opioid
crisis as she heals. According to 2018 data from the
Centers for Disease Control and Prevention, 128
Americans die of an opioid overdose each day. “It’s a
nightmare so many families go through,” the singer
says over Zoom from her home studio, “and it just eats
away at good people.”
Beckett was just 17 years old when he got hooked
on opioids. An avid outdoorsman, he was away from
home, training to become a pro snowboarder at Aspen
Valley Ski and Snowboard Club in Colorado. “He was
100 percent happy when he was on his snowboard
or out on a hike or riding his mountain bike,” says
Etheridge. But in 2016 Beckett broke his ankle on the
slopes, “and it gave him a whole lot of pain. It kept him
from being a professional snowboarder,” she says. “He

80 H E A LT H
 “IT’S A
NIGHTMARE
SO MANY FAMILIES
GO THROUGH,”
ETHERIDGE SAYS
OF THE OPIOID
CRISIS.

H E A LT H 81
 THE STORIES
Etheridge and 12-year-old Beckett in 2011.
was on that path, and he got lost then—because if he
wasn’t going to do that, what was he going to do?”
Beckett was prescribed painkillers to manage the
injury, and he became dependent on the medication.
When Etheridge realized he was addicted, she got him
into treatment, but he left when he was 18. “The drug
abuse really turned him into someone I didn’t know,”
Etheridge says of Beckett, who eventually began using
heroin, then fentanyl. “He was quicker to anger or
mistrust. He stole money from me. The last couple of
weeks, he was paranoid, and all of a sudden he was
involved with guns. It’s sad because it’s not who he
was before that.”
Over the years, Etheridge says, she often felt helpless
as Beckett fell deeper into substance abuse. “When
you have a loved one who is battling opioid addiction,
it’s horrific. You don’t know what to do. You want to
help them, but ultimately they have to help them-
selves,” she says. “It’s a journey for anyone around the
loved one. You realize the only way to help them is to
take care of yourself. You can’t do anything for them;
you can’t make them be sober.” Before he died, Beckett
was trying to build a life for himself in Colorado, where
he was in the process of getting a job. But addiction
held too tight a grip on him. “You would think, ‘Okay,
82 H E A LT H
he’s doing better.’ Then you would find out he slipped,”
says Etheridge. Months before his death, Beckett
entered a detox facility. She feels certain her son
yearned for sobriety but ultimately couldn’t reconcile
his demons. “He wanted to get off [the drugs],” she
says, “but he wasn’t looking for help not to do them.”
Since Beckett succumbed to addiction, Etheridge
has refused to feel at fault. “I could only do so much,”
she says. “You constantly think, ‘If I had only done
this; had I only done that.’ That doesn’t help you.
That’s making yourself sick with guilt and shame.”
In June 2020, the Grammy- and Oscar-winning
rocker launched the Etheridge Foundation, which
supports research into the causes and effects of opioid
addiction. And she’s sharing Beckett’s story to help
others, as she did when she came out as gay and
released her mainstream breakthrough album, Yes I
Am, in 1993, and then again when she revealed her
breast cancer diagnosis in 2004. “When opioid addic-
tion took my son, I wasn’t going to hide that. It feels
better to be open about it, to be truthful about it,” she
says. “We’re here to be an example.”
As she grieves the loss of her son, Etheridge has
found solace in her spirituality (she listens to inspira-
tional speaker Abraham Hicks’ podcast) and, of
course, music. After Beckett died, she started her
at-home streaming service, Etheridge TV, on which
she plays covers and concerts and does a chat show
with Wallem, a TV producer whom she wed in 2014.
“I told Linda, ‘I’m going out in the garage, and I’m going
to change that into a studio.’ She looked at me like I
was crazy, but she kept coming out here every day with
me. It took us about four weeks to build it all,”
Etheridge says of the project, which gave her purpose
during one of the hardest times of her life. Performing
during the pandemic and connecting with fans has
been “very healing for me,” she says. So too has spend-
ing time with Wallem, Bailey, and her twins, Johnnie
and Miller (whom she shares with ex-wife Tammy
Lynn Michaels). “We were all in this house together
when we found out [about Beckett’s death], so we were
able to grieve together,” Etheridge says of Beckett’s
siblings. “My youngest son is growing up. His voice is
changing, and he sounds so much like Beckett. There’s
times I look at my Linda, and we’re like, ‘Oh my God,
he laughs like him.’ ” As Etheridge continues to cope,
she finds comfort in knowing Beckett is now finally
at peace. “I believe he’s out of pain, which does bring
me relief,” she says, as does another thought: “My son
is always with me, and I will see him again.” ●
 A Careful Approach to Opioid Use
There may be times when you need to take powerful prescription painkillers,
but it’s crucial to proceed with caution.
BY KRISTIN CANNING

It might not seem like

a big deal to take a pain
med prescribed by your
doctor. But if the drug falls
into the opioid category,
you may want to have
a deeper conversation
with your physician.
Opioid medications—
such as codeine,
oxycodone, and fentanyl—
work by attaching to
opioid receptors in the
body and brain to lower the
perception of pain. They
can be very effective, but
also highly addictive. The
longer you take an opioid,
the more you may need to
get the same painkilling
effect. “They aren’t an
appropriate long-term pain
management option,”
says Antoine Douaihy, MD,
a professor of psychiatry
and medicine at the
University of Pittsburgh
School of Medicine. But have contributed to in crippling agony after you’ve had with drug or
in recent years, there’s this public health crisis an accident. alcohol abuse, and the risks
been a dramatic increase over the past two And in general, you involved in taking these
in the acceptance of decades,” Dr. Douaihy should limit your use of powerful drugs.
opioids to treat conditions says. “We underestimated an opioid as much as As many as 1 in 4
like osteoarthritis and back the addictive potential possible: “Most of the time, people who are prescribed
pain, according to the of opioid painkillers for acute injuries, you opioids long term (for
Centers for Disease Control [at first], and they’ve been don’t need it for more than noncancer pain) by a
and Prevention (CDC). overprescribed.” a few days,” Dr. Cidambi primary care physician will
We are in the middle So when does it says. If your doctor struggle with addiction,
of an opioid overdose actually make sense to suggests you take an opioid according to the CDC. But
epidemic. In 2019, there take an opioid? Only for longer than a week, the risks go beyond
were more than 14,000 when you really need it, ask if there other options. addiction and overdose.
deaths in the United States says addiction specialist The CDC also They may include vomiting,
involving prescription Indra Cidambi, MD, recommends talking with dizziness, depression,
opioids, accounting medical director of the your doctor about non- itching, and even increased
for 28 percent of all Center for Network opioid alternatives, such as sensitivity to pain.
opioid-overdose-related Therapy in Middlesex, physical therapy and And if you do ultimately
fatalities, according to New Jersey—if you interventional therapies decide to take an opioid,
the CDC. “Unfortunately, just had major surgery, (injections). Other matters be sure to follow up
health care practitioners for example, or you’re to discuss: any problems regularly with your doctor.

H E A LT H 83
 THE STORIES

BATTLING
THE ODDS
These celebrities have fought
against their own addictions
and have been vocal champions
of the journey to recovery.
BY COURTNEY MIFSUD

Robert Downey Jr.

“For some folks it’s just a function
of age,” the Avengers star told
Vanity Fair in 2014 about
overcoming his demons. “It’s
perfectly normal for people to be
obsessive about something for a
period of time, then leave it alone.”
When asked about the public
incident in 1996 in which Downey’s
neighbors came home to find the
actor passed out in their 11-year-old
son’s bed, he says it was “an
uncommon occurrence for me.
Happened to be a very public one.
I was not a guy who blacked out.”
Police had earlier found heroin,
cocaine, crack, and an unloaded
.357 Magnum in Downey’s car
when he was stopped for speeding.
He dropped out of rehab twice and,
in 1999, served just under a year in
jail. After two more arrests, he
checked into rehab again and got
clean. “Job one is get out of that
cave. A lot of people do get out but
don’t change,” said Downey. “So
the thing is to get out and recognize
the significance of that aggressive
denial of your fate, come through
some crucible forged in a stronger
metal. Or whatever. So many things
have become less certain. I swear
to God. I am not my story.”

84 H E A LT H
 Gladys Knight
Gladys Knight, the “Midnight Train
to Georgia” singer and Rock & Roll
Hall of Fame inductee, said in an
interview with the Los Angeles
Times in 2011 that she had once
been powerless to stop her
gambling addiction. “Winning is
how they get you,” she said.
“Because you think you’ll win
everything, and you won’t… I had
gotten $2,000. And within 25,
30 minutes, I had won 60 grand.
And I sat right at that table and gave
every dime of it back. And I just got
sick at the table.” Right after leaving
the card table, Knight called
Gambler’s Anonymous and got
help. “The lady on the phone said,
‘Where are you? We’ll come get
you.’ That was about 15, 20 years
ago. And I went to one meeting.
Demi Lovato
That was all I had to go to.”
Demi Lovato was suddenly hospitalized in July 2018 after an unspecified
overdose. “I have always been transparent about my journey with addiction,”
the singer wrote in a statement posted to Instagram that August. “What I’ve
learned is that this illness is not something that disappears or fades with time.
It is something I must continue to overcome and have not done yet.” Lovato
(who came out as gender nonbinary in 2021) opened up about their struggles
with drug abuse and addiction in a 2017 documentary, Simply Complicated.
In it, the singer shared that they started using cocaine at age 17. “I was with
a couple friends, and they introduced me to it,” they said. “I was scared,
because my mom always told me your heart could just burst if you do it, but
I did it anyways. And I loved it.” Lovato’s journey has been complicated,
but they are working to get better. “I look forward to the day where I can say
I came out on the other side,” Lovato wrote, adding, “I will keep fighting.”

a big problem with alcohol and

Matthew Perry
For 10 years it seemed as if Matthew
Perry was living the actor’s dream.
He had an iconic role as Chandler
Bing on the sitcom Friends and
was making $1 million an episode.
But Perry was struggling. “I had
pills, and I couldn’t stop,” he
told People magazine in 2013.
“Eventually things got so bad that
I couldn’t hide it, and then
everybody knew.” After years of
public struggles, with three
stints in rehab, Perry became
a vocal advocate for people
struggling with addictions,
appearing before Congress in
2011. In 2013, he turned his
Malibu, California, beach home
into a men’s sober-living facility
for two years. That same year,
he shared the ongoing
challenges of remaining sober
with The Hollywood Reporter:
“You can’t have a drug problem
for 30 years and then expect
[it] be solved in 28 days.”
THE STORIES

Wynonna Judd
Throughout nearly 40 years as a
recording artist, Wynonna Judd has
had numerous addiction-rooted
struggles. When, in 2003, Judd’s
cholesterol put her at risk of a
heart attack, the singer spoke
about her emotional-eating issues
for the first time to Oprah Winfrey.
Three years later, she checked into
a treatment center for food
addiction. “I was a people pleaser—
I had trouble asking for what I
need,” Judd told People magazine
in 2009. “I learned I can’t do it
alone.” A year later, she told
country-music website the Boot:
“Reaching out for people, not food,
was my greatest challenge. I was an
isolating kind of person. And being
more active was a challenge—
forcing myself to show up when
I didn’t feel like it, and being the
participant in my recovery and
healing. You have to be willing to
step outside your comfort—not use
food, but call somebody instead.”
When her daughter, Grace Pauline
Kelley, was sent to prison in 2018
Edie Falco
at age 22 for meth-related charges,
In Nurse Jackie, Edie Falco plays an ER nurse who is addicted to pills before
Judd became an advocate for
seeking sobriety by going to 12-step meetings. But this character was
criminal-justice reform.
not Falco’s first experience with addiction; the actress had struggled with
it in the early 1990s. “I was drunk all the time!” she told New York
magazine in 2008. “My life was an absolute mess, and I was hanging out
with very scary and dangerous people and behaving in ways that I was
horrified by. And after one particular night of debauchery, where I woke
up—I won’t get into it. But I realized, OK, I’m done.” Falco drew on that
experience in Nurse Jackie, saying that she was fascinated with all of the
facets that surround an addict’s life: “the helplessness around [addiction],
and learning to deal with that, and all the various 12-step programs I’ve
been a part of over the years, and how much they’ve helped me.”

Terry Crews
In 2016, actor Terry Crews revealed
in a Facebook post that he had
once entered rehab to treat a porn
addiction after wife Rebecca
King-Crews threatened to leave.
“Some people say, ‘Hey, man…you
can’t really be addicted to
pornography.’ But I’m gonna tell you
something: If day turns into night
and you are still watching, you
probably have got a problem. And
that was me,” the Brooklyn
Nine-Nine star said. “It changes the
way you think about people.”
Michael Phelps
As part of the 2018 Kennedy Forum
in Chicago addressing depression,
suicide, and mental illness, swimmer
Michael Phelps spoke about coming
to terms with his depression and
related substance abuse. “Really,
after every Olympics I think I fell into
a major state of depression,” he said
when asked to pinpoint when his
trouble began. He noticed a pattern
of emotion “that just wasn’t right” at
“a certain time during every year,”
around the beginning of October or
November, he said. “I would say ’04
was probably the first depression
spell I went through.” That same
year, Phelps was publicly charged
with driving under the influence. In
the fall of 2008—weeks after he’d
won a record eight gold medals at
the Beijing Olympics—a photo
surfaced of Phelps smoking from a
bong, behavior he later described as
regrettable. Drugs were a way of
running from “whatever it was I
wanted to run from,” he said. “It would
be just me self-medicating myself,
basically daily, to try to fix whatever it
was that I was trying to run from.”

Eric Clapton
In early 1982, despite having
overcome a heroin addiction, Eric
Clapton still had a serious alcohol
problem. But the people around the
musician would not call him out on
his problems, with one exception:
Clapton’s manager, Roger Forrester.
“He packed me up and sent me off to
[the rehab facility] Hazelden. When
I got to Hazelden, I had to sign this
thing saying who is your significant
other,” Clapton told Rolling Stone
in 2017. “I was married. But I put him.
Because he was the only one who
would stand up to me and call me
out.” In the 2013 documentary
Beware of Mr. Baker, Clapton said
that getting sober saved his life.
“I thought that if I stopped drinking
and I stopped using drugs…I would
not be able to play anymore,” he
said. “[But] my experience now tells
me, in a long time of being in
recovery, that I can be a good
musician with or without that.”

H E A LT H 87
 THE STORIES

Bradley Cooper
When Bradley Cooper headlined and
directed the latest remake of A Star
Is Born, the actor’s painful past
paralleled his character’s arc. “The
stories that exist in this story, it
comes from a very deep personal
place, and that’s the only way that I
know how to communicate with
many people,” he told The New York
Times. In 2012, Cooper told The
Hollywood Reporter that he had been
sober for eight years. He said that the
effects of his drug and alcohol use
became unbearable. “I don’t drink or
do drugs at all anymore,” he said.
“Being sober helps a great deal.”
In A Star Is Born, Cooper played an
alcoholic musician named Jackson
Maine who struggles with fame.
“Anytime you’re trying to tell the
truth, you need to go to places and
use things that have happened to
you, or you’ve read about or
experienced,” Cooper told Variety in
2016. “And that’s all part of the
beauty of turning whatever things
you’ve gone through into a story.
I find that to be very cathartic.”

Elton John
Despite being clean for more than
three decades, singer and pianist
Elton John remains haunted by his
drug- and alcohol-fueled past. “I still
dream, twice a week at least, that
I’ve taken cocaine and I have it up my
nose,” John told NPR in 2012. “And
it’s very vivid and it’s very upsetting,
but at least it’s a wake-up call.”
Throughout the 1970s and ’80s,
the exuberant rock legend lived life
through a drug-altered haze. The
performer credits his sobriety to
meeting Ryan White, a teenage
hemophiliac who had contracted
HIV through a contaminated blood
transfusion. “I had the luck to meet
Ryan White and his family,” he
said in 2017. “I wanted to help them,
but they ended up helping me
much more. Ryan was the spark
that helped me to recover from
my addictions and start the AIDS
foundation. Within six months [of
White’s death], I became sober and
clean, and have been for 27 years.”

88 H E A LT H

Russell Brand
“The drug problem: I’m still recovering from it, aren’t I?” Russell Brand, the
star who has famously struggled with heroin, alcohol, and sex, said on
The Jonathan Ross Show. “There’s the old [whistles] problem, the craving,
the lust,” he said, referring to his struggle with sex addiction. “I have used my
life as a sort of greedy experiment, gorging myself on all manner of
phenomena. There were some brilliant bits, of course there were—some of
the bits were really, really brilliant. But mostly, what I discovered, nothing has
made me feel as good as the kind of connection that I find with people.” Brand
published a book about his battles with addiction called Recovery: Freedom
From Our Addictions. “The instinct that drives compulsion is universal. It is an
attempt to solve the problem of disconnection, alienation, tepid despair,”
Brand wrote. “The problem is ultimately ‘being human’ in an environment that
is curiously ill-equipped to deal with the challenges that entails.”
People magazine in 2018. “I had a
10-year run, stealing, conniving.
No one knew. No one.” The Curtis
family has a long history of
struggles with addiction. Her father,
actor Tony Curtis, abused alcohol,
cocaine, and heroin. Her half
brother Nicholas Curtis died from a
heroin overdose in 1994. Curtis
started her recovery in 1999 and
opened up about her addiction to
her husband, actor Christopher
Guest, the same day as her first
recovery meeting. “I’m breaking the
cycle that has basically destroyed
the lives of generations in my
Jamie Lee Curtis family,” Curtis said. “Getting sober
The Halloween actress, who has remains my single greatest
been sober for more than 20 years, accomplishment…bigger than my
hid her addiction to painkillers for a husband, bigger than both of my
decade. “I was ahead of the curve of children and bigger than any work,
the opiate epidemic,” Curtis told success, failure. Anything.”
Rob Lowe
Rob Lowe marked his journey to
sobriety with an inspiring message in
2019. “Today I celebrate 29 years of
sobriety. Thank you to all those who
have inspired me on this wonderful,
challenging and life-changing
journey,” he captioned the Instagram
post. “If you, or someone you know,
are struggling with alcohol or
addiction, there CAN be a future of
hope, health and happiness. And it
comes one day at a time.” The West
Wing star has talked openly about
his struggles since deciding to get
sober at the age of 26, including how
he problematically replaced his
substance addictions with exercise.
“It became an outlet for all of the
tension, stresses, compulsivity,”
Lowe told Men’s Health. “I funneled
the addiction, frankly, into that.”
He was awarded the Brent Shapiro
Foundation’s Spirit of Sobriety
award in 2015 for being alcohol- and
drug-free for 25 years. He said upon
being presented with the award:
“Being in recovery has given me
everything of value that I have in my
life.… It’s given me a beautiful family
and an amazing career. I’m under no
illusions where I would be without
the gift of alcoholism and the
chance to recover from it.”
 SHERLOCK
HOLMES (HERE
PLAYED BY BASIL
RATHBONE IN 1939)
IS ONE OF THE
EARLIEST ADDICTS
IN FICTION.
 FICTIONAL ADDICTS,
REAL PAIN
In literature, television shows, movies, and elsewhere,
we have been captivated by characters struggling with their
addictions—and have learned a lot from them, too.
BY EMILY JOSHU

AS JACK KEROUAC cranked out the first draft of
the postwar classic On the Road on 120 feet of taped
sheets of paper in 1951, in what is said to have been a
three-week, Benzedrine-and-wine-fueled mania, his
melancholy protagonist, Sal Paradise, slipped into
despair. Echoing the buzz, if not the frenzied mood,
of his creator, Paradise’s voice unfolded on the scroll.
“I forgave everybody, I gave up, I got drunk,” he
laments. “Everything was falling apart.” Two years
later, as Kerouac tore through more drafts, William
S. Burroughs published his semiautobiographical
Junky, in which his drug-peddling antihero declares
that heroin is not “a means to increased enjoyment
of life.… It is a way of life.”
Stories about addicts—sometimes penned by
addicts—are not a phenomenon exclusive to the Beat
generation. In the decades before and after Kerouac
and Burroughs, addiction has been one of the most
prevalent and romanticized flaws with which writers
have plagued their characters. From tales of cocaine
dabbler Sherlock Holmes to unraveling alcoholic Fiona
Gallagher, of TV’s Shameless, their lives have played
out in turns of triumph and downward spirals.
Sherlock Holmes
In the early 1880s, during the emergence of psycho-
analysis, Sigmund Freud began utilizing a radical new
tool in his practice: cocaine. Prescribing it to patients
during a career rut, Freud pioneered the normaliza-
tion of cocaine as a painkiller and tool for (fleetingly)
energizing mental function. Around the same time,
his acquaintance Sir Arthur Conan Doyle began craft-
ing the tales of infamous literary enigma and cocaine
addict Sherlock Holmes. “I suppose that its influence
is physically a bad one,” the famed Victorian detective
tells his partner, Dr. John Watson, of the drug in the
1890 short story “The Sign of the Four.” He was right,
but he added: “I find it, however, so transcendently
stimulating and clarifying to the mind that its sec-
ondary action is a matter of small moment.”

H E A LT H 91
 THE STORIES
The self-proclaimed independent consultant and
unmatched master of deduction Holmes injects him-
self with a “seven-percent solution” of cocaine, his
“forearm and wrist all dotted and scarred with innu-
merable puncture-marks,” Watson narrates. The
choice to give an otherwise unflinching and prag-
matic detective a drug problem could be attributed
to Conan Doyle’s medical background and supposed
familiarity with cocaine as an anesthetic. Similar to
the cases he unravels, the sleuth’s own perception of
cocaine is shrouded in mystery and is often contra-
dictory. Holmes refers to his syringe as an “instru-
ment of evil,” but he succumbs to its ability to help
him “escape from the commonplaces of existence.”
Though Holmes’ addiction was a sign of the era’s
ambivalence toward cocaine, many literary critics
believe it sheds light on the character’s moral ambi-
guity. With such a fatal weakness part of a character
with almost superhuman deduction, the drug human-
izes Holmes and shatters his veneer of perfection.
Rebecca Bloomwood
Wannabe fashion journalist Rebecca Bloomwood
(played by Isla Fisher) owes her redemption arc to a
green scarf and irony. In the book series and later
movie Confessions of a Shopaholic, Rebecca finds her-
self with a maxed-out credit card and an obsession
over the $20 scarf (which she borrows money to pay
for) that she insists is necessary for an upcoming inter-
view with her dream fashion magazine, Alette. After
being rejected for the job, she finds herself interview-
ing with the editor of financial magazine Successful
Savings, who had given her the money for the scarf and
soon gives her her own column, too. Despite the edi-
tor’s belief in Rebecca’s money-saving habits, she is
buried in $16,000 worth of credit card debt.
Unlike many fictional addicts, Rebecca navigates
her redemption relatively easily. She manages to
downsize enough to pay her debt off in its entirety and
even strikes up a romance with her editor. However,
she never actually admits to having an addiction and
instead merely acknowledges that the high from suc-
cumbing to an expensive price tag fades, but the bills
remain. “When I shop, the world gets better. And then
it’s not, and I need to do it again,” she states. Upon the
film’s release, about a year after the 2008 recession
hit, critics deemed the narrative unrealistic and bland.
Entertainment Weekly’s Owen Gleiberman said in his
review: “The disreputable, spangly-headed joy of
Confessions of a Shopaholic is that…the movie makes
92 H E A LT H
no apologies about its heroine’s addictive craving for
clothes. (It has no illusions about it, either.)”
Rebecca’s compulsive shopping did, at the time,
offer insight into an insatiable consumer culture that
would drastically alter modern retail habits over a
decade after the movie hit theaters. Today, when 6 per-
cent of Americans have been estimated to be shopping
addicts, her addiction may have been a portent.
Alexei Ivanovich
A giant of 19th-century Russian literature, Fyodor
Dostoyevsky was a master narrator of vice, aristoc-
racy, and games of chance. In his 1866 novella The
Gambler, Dostoyevsky follows nobleman Alexei
Ivanovich’s financial and moral descent in a fictional
gambling spa in the aptly named Roulettenberg. A
tutor to a general’s children, Alexei falls madly in love
with the general’s stepdaughter, Polina. At Polina’s
request, he places a bet in a game of roulette and wins.
He slips further and further into the habit until he
loses his job, the love of his life, and all sense of finan-
cial security. His urge becomes irresistible, as he says,
“Even on my way to the gambling hall, as soon as I
hear, two rooms away, the clink of the scattered
money I almost go into convulsions.”
The general also has a mound of gambling debt to
tackle. He agonizes over the inheritance he expects
his wealthy great-aunt to leave him, falling into
despair when the aunt has also lost much of her wealth
to roulette. Both Alexei and the general fall into a cycle
of gambling to keep themselves afloat—precisely the
pattern too many real-world compulsives adopt—and
never quite get ahead. Alexei explains the deeper
appeal of risking it all on games of chance: “No, it was
not the money that I valued. What I wanted was to
make all this mob of Heintzes, hotel proprietors, and
fine ladies of Baden talk about me, recount my story,
wonder at me, extol my doings, and worship my win-
nings.” That too is a painful echo of the real world.
The Gambler not only creates a portrait of greed but
also dovetails the writer’s own vice. Per a formal con-
tract, Dostoyevsky finished the project in 1866 under
a strict deadline to pay off the gambling debt he owed
to prominent publisher and editor F.T. Stellovsky. If
he didn’t deliver the novel on time, Stellovsky would
acquire the rights to his works for nine years without
compensation. With the assistance of a stenographer,
he met the deadline with just hours to spare. But writ-
ing about characters with a crippling roulette addic-
tion did not help Dostoyevsky cure his own. Writing

to his brother, Mikhail, he said, “I believed in my sys-
tem…within a quarter of an hour I won 600 francs.
This whetted my appetite. Suddenly I started to lose,
couldn’t control myself and lost everything.”
Don Draper
Manhattan, the 1960s, a Madison Avenue high-rise.
It was an era of dry martinis, thick cigars, expensive
suits, and promiscuous late nights. For Mad Men
antihero Don Draper (Jon Hamm), this landscape is
familiar—and destructive. The charismatic advertis-
ing executive is considered by his colleagues the great-
est among them at pitching copy, but as the series
unfolds he ends up in a downward spiral of alcohol,
cigarettes, and sex. The drinking, however, is the
smooth talker’s most suffocating vice.
While drinking serves mainly as part of the ambi-
ence of after-hours socializing and glossy business
deals in early seasons, as the series progresses, Draper
slips deeper into alcoholism, shown most notably
when he gives a drunken pitch to Life cereal. He even-
tually gets suspended from his job, is tossed in jail, and
punches a minister. In addition to drinking, he shows
consistent signs of sex addiction throughout the series,
cheating on his wife as early as the first episode.
Eventually, life mirrored art, as Hamm fell prey to
While Confessions of a
Shopaholic and Mad Men
show addiction in subtler,
more understated veins,
The Gambler is a grim
tale that dovetails its
author’s own struggle
with excessive gambling.
his character’s vice and checked himself into rehab for
alcohol abuse in 2015, after eight years in Don’s shoes.
In an interview with Variety, Hamm said: “Playing this
guy does not come without its own difficulties. It’s not
fun to live in this guy’s headspace year after year.”
Don Draper has been cited by TV critics as a symbol
of 1960s power-hungry decadence in a culture of over-
consumption. Full of promise and power, the intoxi-
cated adman ultimately collapses under extreme
pressure, narcissistic ambition, and the fallacy that
he can have it all. “He’s not a malicious, uncaring guy,
but he’s very defended. And that’s alcoholism—when
the feelings get even a little bit intense, boom: bottle.
Happy, sad, painful, whatever,” Scott Bienenfeld, CEO
and medical director of Rebound Brooklyn, told
Esquire. “He represents this era of excessive consump-
tion and a bottomless search for fulfillment.”
Fiona Gallagher
Fiona Gallagher (Emmy Rossum) spends the first few
seasons of the Showtime hit Shameless swearing to
be better than her father, lifelong junkie and alcoholic
Frank Gallagher (William H. Macy). After her mother
abandons Frank and the six children, Fiona assumes
the role of primary caretaker at just 16 years old. But
in the whirl of keeping her siblings out of trouble in
H E A LT H 93
 THE STORIES
seasons eight and nine, she succumbs to several of
her parents’ toxic habits, including occasional cocaine
use, casual sex, and clubbing.
Her self-destructive decisions cause her to get
wrapped up in an unraveling string of odd jobs, crim-
inal charges, and sexual exploits, and in later seasons,
Fiona begins to replicate her father’s alcoholism. After
a night of heavy drinking, she stumbles to the doorstep
of her newest flame, only to be greeted by his wife and
child. Hysterical, she crashes into a parked car. This
causes her to plunge further, going as far as stealing
her father’s alcohol when she finds him passed out on
the floor, losing her job, drinking in the shower, getting
arrested, and assaulting a woman who harasses her
brother Liam. The first step on her road to recovery?
Waking up hungover and passed out next to her father.
Horrified by the idea of turning into Frank, she starts
attending Alcoholics Anonymous meetings.
Beyond Fiona’s descent into addiction, Shameless
portrayed addiction as a family disease. Critics asso-
ciated five of the Gallagher siblings with personality
subtypes found in adolescent and adult children of
alcoholics, diagnoses validated by two studies from
the National Institute of Mental Health. The subtypes
include the Enabler (Rescuer), the Hero, the Scapegoat
(Rebel), the Lost Child, and the Mascot. Fiona’s ulti-
mate fate, however, remains uncertain, as Rossum
departed the series at the end of season nine and
viewers were never given an update on Fiona’s status
when the show concluded in 2021.
Dr. Gregory House
Considered a 21st-century homage to Holmes,
Dr. Gregory House (Hugh Laurie) combines deduc-
tion and medicine as a diagnostician in the television
show House. Used as a nod to “home” and a play on
“Holmes,” as confirmed by show creator David Shore,
not only is House named for the famous detective, but
its titular character also shares the same apartment
number, 221B, draws support from just one true
friend—Dr. James Wilson (Robert Sean Leonard)—
and possesses an unrivaled talent for cracking unsolv-
able cases. He seems to be impaired only by a sour
attitude and an addiction to pills.
After suffering a blood clot in his leg five years before
the series pilot, which resulted in muscle death, House
rejected the idea of amputation and instead, per the
instructions of his partner while he was in a medically
induced coma, had the dead muscle removed, leaving
him with excruciating pain and a reliance on Vicodin.
94 H E A LT H
Top: Shameless’ Fiona
Gallagher descended
into substance abuse
much like her father,
whereas Gregory House
of House mirrored the
behavior of detective
Sherlock Holmes.
House acknowledges that he has lost control and can-
not function without the pills, whereas his Victorian
counterpart Holmes does not, mainly using drugs as
a boost to his detective skills and a way of combating
boredom. Still, concealed by his usual veil of sarcasm,
House remains unsympathetic toward other addicts,
stating, “On average, drug addicts are stupid.”
House says that the pills merely “let me do my job,
and they take away my pain,” yet he often goes to
extreme lengths to get a fix—punching another doc-
tor, committing forgery with Wilson’s prescription
pad, and stealing medications from dead patients,
among other ugly incidents. Although House has
admitted to using drugs before his injury, his col-
leagues often wonder whether his arrogance and
callousness are the product of addiction or part of a
dark, unhappy personality that drove him to drugs
in the first place. It’s a cause-or-effect question that
comes up among real addicts, too.
Despite his cynicism, House ultimately regrets not
having his leg amputated, which likely would have
prevented him from taking Vicodin. In season six, he
warns a woman refusing amputation against making
the same choice he did. “I’m in pain. Every day,” he
says, “and it changed me. Made me a harder person.
A worse person. And now, now I’m alone.” ●
 Editor in Chief Amy Conway
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Title Page and Contents
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Introduction
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Chapter 1
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H E A LT H 95
 HOW TO
GET HELP
If you or someone you know is
struggling with an addiction, don’t
wait. Find treatment programs
for drug addiction and alcoholism
near you at samhsa.gov/find-help/
national-helpline, or speak with a
trained counselor confidentially
at 1-800-662-HELP.

96 H E A LT H
 The rise in addictions has had an impact on
so many lives and families. It has also led to a rise
in knowledge, compassion, and hope.