What Addicts Need

Annie Fuller knew she was in trouble a year ago, when in the space of a few hours she managed to drink a male co-worker more than twice her size under the table. Of course, she'd been practicing for a quarter of her life by then; at 47, she was pouring a pint of bourbon, a 12-pack of beer and a couple of bottles of wine into her 115-pound body each day. She had come to prefer alcohol to food, sex or the company of friends and loved ones. Her marriage had ended; she had virtually stopped leaving the house, except to work and to drink. Fuller had tried and failed enough times over the years to know that she would not be able to sober up on her own. The last time she'd stopped drinking her body went into violent seizures, a common and terrifying symptom of alcohol withdrawal. But the single mother and mortgage-company VP refused to sign into rehab. "I live in a small town," she says. "And when you go to a hospital for something like that, everybody knows about it." So when a family doctor told her about Vivitrol, a monthly injection that prevents patients from drinking alcohol by obliterating its ability to intoxicate, Fuller agreed. She took a sabbatical from work, sent her 15-year-old daughter to stay with relatives and hunkered down to weather the painful, frightening blizzard of detoxification in the comfort of her own living room.

What does it mean to be an addict? For a long time the answer was that someone like Fuller "lacked willpower," a tautology that is pretty much useless as a guide to treatment. In the current jargon of the recovery movement, addiction to alcohol, drugs or nicotine is a "bio-psycho-social-spiritual disorder," a phrase that seems to have been invented by the treatment industry to emphasize how complex the problem is and how much more funding it deserves. But the word itself comes from the Latin addictus, a debtor who was indentured to work off what he owed; someone addicted to alcohol or drugs is powerless over his or her fate in the same way—except debtors-as-addicts can never fully balance the books. It had been years since the pleasure of drinking outweighed the pain it caused Fuller. Looked at that way, the "social" and "spiritual" aspects of her problem seem insignificant compared with the contribution of biology. If you weigh advances in neuroscience over the last few decades against social and spiritual progress, it's clear which field is more likely to produce the next breakthrough in treatments.

While the roots of addiction remain a dark tangle of factors—most experts agree that addicts trying to quit will always need psychological support—the old white-knuckle wisdom that addicts simply lack resolve passed out of fashion decades ago. The American Medical Association recognized addiction as a disease back in 1956. But only now are we beginning to see treatments that target the underlying biochemistry of that disease.

The emerging paradigm views addiction as a chronic, relapsing brain disorder to be managed with all the tools at medicine's disposal. The addict's brain is malfunctioning, as surely as the pancreas in someone with diabetes. In both cases, "lifestyle choices" may be contributing factors, but no one regards that as a reason to withhold insulin from a diabetic. "We are making unprecedented advances in understanding the biology of addiction," says David Rosenblum, a public-health professor and addiction expert at Boston University. "And that is finally starting to push the thinking from 'moral failing' to 'legitimate illness'."

In laboratories run and funded by the National Institute on Drug Abuse (NIDA), fMRI and PET scans are forcing that infuriating organ, the addicted brain, to yield up its secrets. Geneticists have found the first few (of what is likely to be many) gene variants that predispose people to addiction, helping explain why only about one person in 10 who tries an addictive drug actually becomes hooked on it. Neuroscientists are mapping the intricate network of triggers and feedback loops that are set in motion by the taste—or, for that matter, the sight or thought—of a beer or a cigarette; they have learned to identify the signal that an alcoholic is about to pour a drink even before he's aware of it himself, and trace the impulse back to its origins in the primitive midbrain. And they are learning to interrupt and control these processes at numerous points along the way. Among more than 200 compounds being developed or tested by NIDA are ones that block the intoxicating effects of drugs, including vaccines that train the body's own immune system to bar them from the brain. Other compounds have the amazing ability to intervene in the cortex in the last milliseconds before the impulse to reach for a glass translates into action. To the extent that "willpower" is a meaningful concept at all, the era of willpower-in-a-pill may be just over the horizon. "The future is clear," says Nora Volkow, the director of NIDA. "In 10 years we will be treating addiction as a disease, and that means with medicine."

Volkow's vision of the future, however, is being greeted warily by big pharmaceutical companies, reluctant to develop products that would associate their brands with drug addicts. It is also facing resistance from some elements in the addiction-treatment community, who are wedded to the 12-Step model pioneered by Alcoholics Anonymous in 1935. Twelve-Step programs traditionally discourage members from using any psychoactive substances, on the ground that addicts will simply trade one dependency for another. That rationale has some unfortunate history on its side; both opium and cocaine were first introduced to the United States as cures for alcoholism in the late 1800s. More recently there is the example of methadone, the synthetic heroin that turned out to be addictive in its own right, and Antabuse, a drug that makes you throw up when you drink alcohol—which suffers from the shortcoming that an alcoholic planning a binge can just skip his dose.