Q&A: Is Addiction a Learning Disorder?

Maia Szalavitz drew on years of research, as well as her own battles with cocaine and heroin, in writing her new book, Unbroken Brain: A Revolutionary New Way of Understanding Addiction. Szalavitz, a 2015 Soros Justice Fellow, spoke to Thomas Watson, senior editorial advisor, about her work and what’s wrong with drug policy today.
Maia Szalavitz
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Maia Szalavitz is a 2015 Soros Justice Fellow.

Photo credit: Ethan Hill/Redux for the Open Society Foundations
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Your new book argues that addiction is a learning disorder, as opposed to a brain disease or a criminal decision. What does this mean, in a nutshell?

Addiction is compulsive behavior that occurs despite negative consequences. This is the most widely accepted definition of the problem in medicine and psychiatry. However, policymakers and others haven’t really understood the implications of this. What it means is that, in essence, addiction is difficulty learning from punishment.

By recognizing the role of learning in addiction, we can better understand its sometimes paradoxical qualities. For example, people with addiction often look like they are deliberately planning their own self-destruction. But from our point of view, we are simply doing what we need to do to survive emotionally. We’re not zombies—we’re making choices, but those choices are biased in a way that is not obvious to people on the outside. 

It’s similar to what you see when people fall in love: a person’s priorities change dramatically, and people may lie or hide certain behavior in order to protect the relationship. This doesn’t mean that people with addiction are inherently liars or manipulative, or that we have no free will. It’s just that we are under a type of stress that often pushes us to become self-protective in this way. It is critical for policymakers to understand this because it means that punitive treatment and punitive criminal justice policy are doomed to fail.

What are the biggest obstacles to advancing policies that treat addiction as a health care challenge rather than a criminal justice issue?

One huge obstacle is the way we see addiction, and how that view is rooted in our racist drug policies. To move forward, we need to understand that our laws are not based on science, but on bizarre, racist, and anti-immigrant campaigns of the 20th century.

These campaigns shape the way we see addiction even now. Every time you hear a white person saying, “I’m not your typical addict,” you hear the echo of the racism that originally drove drug prohibition. And every headline about heroin hitting the “middle class”—by which is meant white people of any class—has the same backdrop.

To recognize addiction as a learning problem—driven by self-medication to deal with trauma, mental illness, and other sources of despair—requires letting go of the idea that our drug laws are rational and accepting that they were made to control certain groups of people. That’s the only reason you can have alcohol and tobacco be legal while marijuana is illegal; no one can make a rational argument for that. 

What I’m arguing is that we need to treat addiction like a real medical problem, not one that is uniquely moral. This will allow us to recognize that decriminalization of all personal drug possession, and complete legalization of some drugs, is the only policy that can genuinely help people with addiction while minimizing harm to everyone else.

What’s the most surprising thing you’ve learned about addiction and drug policy during the course of your fellowship? 

That it is sometimes possible to have a rational discussion of these issues that actually changes people’s minds. For decades, the entire drug policy debate was stalled. Harm reduction was a fringe concept. And needle exchange was so stigmatized that President Clinton saw the need to block it in order to avoid the dreaded “soft on crime” label, even though the data was already crystal clear at the time that it saved lives and didn’t encourage drug use.

Now, we have USA Today endorsing safe injection facilities and the New York Times supporting marijuana legalization. Four states actually have legalized, and it’s increasingly difficult to find someone to quote who favors arresting and jailing users, or who opposes access to the overdose antidote naloxone on moral grounds.

Yes, it’s true that the “whiteness” of the opioid problem has helped move the debate, but so has the quiet, persistent work of thousands of harm reduction advocates who made compassionate treatment of people who use drugs an idea whose time has come.

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wow, how do i get a copy of the book?

Try your local library. It's available through ours. The same may true for you.

I found it on Amazon, no problem. It is available for Kindle and I got a copy that way.

No one should ever have to suffer what i suffered as an addict to heroin in the UK for 20yrs, i've been drug free for a decade now but that was my own doing not a rehab or anything else, it was circumstances that heped me make the choice to stop but not before my health was so badly damaged that i still could lose both legs because of problems caused my injecting into my groin area, i'm a good girl and was never into hurting people i only ever got in trouble for shop lifting and that wasn't personal for me at all but me and many others have been treated worse than dogs, it may be to late to make a difference to me and my life now but i welcome the changes being made right now, i just hope the UK follows suit because heroin addiction, cocaine addiction, Ecstacy tablets, legal highs are rampant in my country now....these changes are long over due and I applaud this lady and others from the substance misuse services that are fighting for these changes....

To stop addition you get to the children. You train them in the universal practice of Mindfullness. To center the brains activity to pause and dispurss agitation without reaching for some chemical to find relief is the simple answer. By repeating this process from a young age an educational defense will be built to compensate for inherited weaknesses in the brain. In one generation we taught kids that you must use seatbelts to save lives. My Grandchildren forced me to use them or they wouldn't get in my car. The practice of Mindfulness costs nothing when offered in preschool. It is the secreat sauce to cure addiction, and it's practice costs nothing. Look no further, let's just organized. WW Gilman

What a clear thought base you have on the "real world," rather than the antiquated thought base found so frustratingly in our government, much of our population and now the media, who are damaging peoples' lives. I hope your words go viral over and over again so we can make some progress and look toward "fixing" things in the only way we can, by global understanding of the truth, the problems and how they need to be handled, and the people involved. Let this be a part of our education system, from grade school to medical school. Treat all sick people with whom addictive drugs are a part of their lives. And this must include putting much, much more focus on patients in intractable, life-long pain who use the same class of drugs addicts use, but for their reason, medicine. By mis-diagnosing addicts and ignoring people who suffer with pain, we are losing and will continue to lose, and therefore, we will keep creating bigger and bigger problems. Thank you for your refreshing and clear-headed ideas. Now can this be expanded and put to use?

I thought that I loved the high bought on by the injection or after my veins "collaspe" that feel of "horse" as it was called in my body. The pain of addiction struggles was minimized as I lit a cigarette to "boost" the high. The slamming of jail and prison doors slowly awakened me as I got older and my body got older even faster. Detox was not the place for me. I thought I didn't need that or a methadone program. I'm going to die using. Then I began to realize that there was no fun in going to jails and being dope sick. Choices had to be made and I made them about twenty years ago. My love for the drug "captured" my ability to really love myself and the family that loved me then and now. While I still like the thought of nodding, I will not because of the consequences involved and I just love having some say as to what goes on in and with my life. I'm writing children's books and plays that have been produced and advocating for Veterans as I am a Veteran and if I used, I would lose the credibility. It's about choices.

I concur with Ms Dolly Flop. Treating a drug addict as a medical patient is the right way to take.

UK is the major supporter of the UN Drugs Holocaust, because the 52.000 euros I paid to Gilead Pharma is now in UK and this profit is the biggest reason to keep killing 100.000 Persons just in USA and 1 Million slaved in jail by year.. Called it HR, called HIV cal it HCV billions and trillions that organizations as HRI manipulate and control for mantain the profit. If drugs were not Criminalized, the UK Nazi Army wouldnt pay for all queens birthdays. But 4.500 million slaves made too many movies, History will remember 100 Million Human Beings Killed. The US/ Anglo Saxonic Drugs Criminal Holocaust will stay record for all eternity! Regards. Jovision

it is a nice book by introduction, please even me i would like to get it, where, i wanna know.

So, what specific treatment implications would it have to treat addiction as a learning disorder rather than a medical diagnosis? How would we do treatment (or prevention) differently? What is the utility of the distinction?

Fascinating perspective on perceiving the issue as a “Learning Disorder”. I suppose I could support that idea for particular instances of addiction for certain substances, at the beginning-to-intermediate stages of what might end up being a “Severe Addiction”. I think the “Learning Disorder” aspect of an addiction becomes irrelevant, proportionately to the chemical dependency increase and severity, for example, in the case of the big three substances: Cocaine, Meth, Opiates. I would tend to think that a person actually “Learns” rather quickly from the negative consequence of withdrawal alone, without even needing to consider any of the additional consequences that may accompany it, and actually “Knows” exactly what steps they would need to remedy their situation. But, in considering taking the necessary steps towards remediation, the Individual has a Clear, Present, and Immediate chemical need to act otherwise and consume the temporary cure now, hence resulting in even more potential and increasing devastation and suffering in the future, as a “Side-Affect Consequence” of their short-sighted choice to avoid the current pain/suffering, and in many cases, to be able to function at all. Many people have not experienced the absolute and dire need to consume a particular substance, to be able to function at all, or stop vomiting/diarrhea, and/or to keep from going temporarily insane. I think the absolute most imperative thing to do to minimize the harm of the whole “Addiction Phenomenon” is to draw a major moral distinction between “Addiction” i.e. less-than-stellar self-choices, and true “Ethical/Moral Trespass”, which is “Deliberate, Intentional and/or Wanton Harm” towards others. For many years, these two were lumped together. Big Mistake. Reason? Anyone who has studied anything, even at Dime-Store level, about Psychoanalysis, knows that Self-Imposed Guilt, thrust into an individual by His/Her own Super-Ego, is far more self-destructive than any substance known to Humanity. This kind of destructive guilt ought to be reserved for True Moral Trespass, and not for some irrational and unjustifiable negative perception of one’s self, brought about by a society that tolerates and even promotes the Deadly/Gluttonous consumption of some substances, but not others. Society and Humanity in the Western World (and to the extreme in the Muslim World), in general, is far too hypocritical, and ridden with denial, still, in its perception of itself, and again, in its estimate of what behaviors might justify shame, and what behaviors really should not. In conclusion, we ought to really be critical and cognizant of any “Obsessive/Compulsive” behavior and motivate ourselves to understand the cause, whatever it might be in varying cases, instead of simply demonizing certain “Obsessions/Compulsions”, whilst ignoring others, even as we know that any runaway obsession, nearly always causes unnecessary suffering.

Check out the book High Price by neuroscientist Carl Hart. In it he does experiments where people that are "addicted" to crack cocaine quit spontaneously when offered better choices (like a way to make money). His work shows that the "chemical addiction" model is not supported by facts. It is purely moral and is because of our religious devotion to "free will" and a misunderstanding of agency.

Developments like use of Nalmefene and Naltrexone to detrain opoid receptors are old work but simply not widely known.
The attempt to blame racism here is indicative that this is a concern troll article.

So when RP President Duterte says "If you know of any addicts, go ahead and kill them yourself as getting their parents to do it would be too painful" he is systematically targeting a population based on their learning disorder.

Although the rational conclusion of the article is refreshing, it forgets to bring up the morals behind addiction classifications. Typically, illicit drug use is often concluded to be the result of addiction of the used drugs. Opiate use is rare compared to, for example, hallucinigenic drug use. I occassionally use mushrooms to maintain mental growth and cultivate my metacognitive skills in order to manage my ADD. Is that an addiction?

To label people as addicts is oversimplifying things. Not saying people may suffer from addictions, but in most cases it's nothing more but unacceptable routes to achieve happiness or growth.

Just like drug abuse should be judged separate from drug use, judge addictions separate from hobbies by any damage the habit causes.

Addiction is not entirely a learning disorder, although there is a memory component to it. Check out Dr. Kevin McCauley's video on the neuroscience of addiction on youtube.

Racism didn't cause cannabis prohibition. That is an urban myth. But I do support legalized medical marijuana and coca leaves.

Your statement: "Racism didn't cause cannabis prohibition." is factually incorrect.

Explicit evidence for the racist basis of drug laws is in the Congressional Record of the sessions when the laws were passed. You can look it up or google Dr. Tod Mikuriya, " Marijuana Medical Papers: 1839 - 1972"

Is addiction "a learning disorder?"

Interesting question.

My first response was: I thought
my addiction was a learning aid.

Maybe it is a learning disorder in the sense that:
"What we won't do for ourselves will be done to us."

But ultimately I would conclude after dealing with US drug policy intimately, both professionally and personally, for precisely 50 years this year, the learning disorder is that of those lawmakers who refuse to see drugs as primarily an issue of public health not of criminal justice and refuse to admit that the fault lines of race and social class make reasonably equitable enforcement of laws against personal drug use and user-dealer level sales to be existentially impossible.

I agree, it is possible to change people's mind, through rational discourse, but without a tectonic shift in US politics that is not going to change the balance of those in power who think this injustice is just fine.

You are right in your argument.

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