The question is inspired by a recent article in the Huffington Post, by Dr Allen Frances, Emeritus Professor of Psychiatry at Duke. His thoughtful critique asks whether we are seeing a trend to “medicalize normality out of existence” — with the inclusion of behavioral addictions in the new psychiatry handbook Diagnostic and Statistical Manual of Mental Disorders (DSM-5.) Gambling and the popular frenzy around the recent half-billion dollar lottery is our jump-off point for a wide-ranging discussion of addiction.
Transcript (edited):
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. There is a lot in the news today, so we’ll see what we have time for. One article in the Huffington Post implies we all have behavioral addictions. Just before the podcast we were talking about the big lottery jackpot and how everyone gets all excited, even people that dont normally play the lottery or gamble get all excited and run out and buy tickets. And of course, that just increases (decreases) the odds of winning because more people are participating. And so does that mean everyone is susceptible to the gambling bug, Darryl?
DARRYL: Well, Howard, no. I think the author of the Huffington Post article and a lot of other writers really dont understand addiction. They dont understand that theres a difference between recreational gambling or sports gambling or fun gambling or, you know, innocuous gambling versus pathological gambling. The Huffington Post article was actually taking pot shots at the DSM5, which is adding a category to the addictions and related disorders section that focus on behavioral addictions of which gambling is on the fast track to be included.
HOWARD: Yes … including Internet addiction and sex addiction also.
DARRYL: Internet, sex, shopping/buying addiction…that kind of stuff. The people who promote these activities know how to impact the brain and psyche of individuals in order to attract them to participate. One way is “the big win.” The first hit is usually free and a person experiences a big feeling or a great feeling from say smoking pot or from snorting cocaine. Its not always the first one for most people for many people who participate in those activities, thats the one that then attracts you to do another one, and another one.
HOWARD: There was another story, a different story about about how certain experiences can change your brain inexorably and permanently.
DARRYL: There are some genes involved with addiction, but it is not across the board. That first big hit on a drug your first big drunk, your first big win in gambling is going to affect your brain. Its sometimes going to cause some permanent changes, but not everyone is prone to become an addict and addiction involves a whole different process. A lot more people are going to buy a lottery ticket when the pot is up to 500 million bucks – everyone runs to their corner store to buy a ticket because its a lure. Its a big win. I mean, Id be happy with a 2 million dollar win! But then you sit back and think, Oh my God, theres a 500 million dollar pot – maybe I should buy a double ticket or triple ticket. And its going to attract a lot of people. Now heres the difference…a few not everybody and Im not sure what percentage of people in America are vulnerable to gambling addiction, …but those who are vulnerable might wager their house, they’ll put up their car to get money for tickets thinking that the more tickets they buy will increase their possibilities of winning. And its like flipping a coin, no matter how many times you flip it, each individual ticket you buy has a 50/50 shot so the odds of winning the 500 million dollar lottery is astronomical. People are more likely to be hit by lightening or all kinds of other bizarre things eaten by sharks or whatever than winning this Lotto. But people see 500 million dollars and figure somebodys got to win, why not me! So people are going to go out and buy tickets. What Im saying is that if you are a pathological gambler if you have an addiction, you have no control you act beyond normal systems and are willing to suffer catastrophic consequences in order to keep in the action, and its not about winning as much as its about being in the actual game of gambling and being active in that process, so a pathological gambler will sacrifice a lot of really important things maybe even food – in order to put all their money toward gambling because they believe they have a better chance of winning. And thats the difference. When we talk about behavior or addictions and we look at things like sexual addiction, its not about a normal sexual drive, or even your average philanderers drive. Its the point at which a person must be involved in sexual activity despite the fact that it is causing a tremendous negative impact on their relationship, their job or anything else yet they continue despite suffering negative consequences. That means theres a disconnect in the brain. That means there is a biological process and gambling is an addiction because as we image the brain and study it, we see a difference between a gamblers brain – a pathological gambler and maybe you and me – someone who might buy a lottery ticket now and then or go to Reno now and then and play a game theres a totally different brain process that resembles someone on cocaine or methamphetamine.
HOWARD: Now one of the stories was about sex addiction, the article said that it was less of a classic addiction than others and I dont know if there are any image studies scans done on this, but the story indicated that it is more of an excuse for people who are philandering and that have some kind of infidelity issues. Do you know of any studies on this? Behavior is much trickier than drugs, but it seems that with the evolution of scanning it has made it possible to take a different look.
DARRYL: Yes, it’s just beginning so there arent a lot of convincing studies about sexual addiction, about Internet addiction, about buying addiction and things like that. There was a lot of work done on gambling because the pathology was so dramatic. I imagine that like all addictions, there are many people who are going to abuse that to justify whatever they want to justify or to help them with a pending criminal case. I’ve had clients who really didnt have a drug addiction, but when they got caught trafficking drugs, it was a much lighter sentence if they claimed they were an addict and referred into treatment. It is much easier than to sit there and take the wrath and take the punishment for being a person whos not addicted, but is trafficking drugs to those who are addicted.
HOWARD: Addicted to money!
DARRYL: Horrible crime yes, maybe theyre addicted to money and that is their crime.
HOWARD: Which is possibly you know, assignable as a crime.
DARRYL: You know, its funny you mention that because I think that is what is happening in America right now. The rich are getting richer. The disparity between the haves and the have-nots is the highest its ever been in our country and something our society should realize is that once people get into money as a commodity rather than simply as a means of exchange the disparity will become greater. When money becomes a commodity, it doesnt enter back into our economy and our economy suffers for it.
HOWARD: Trickle down fails.
DARRYL: Yes that doesnt work when people look at money as a commodity and that seems to be happening in our society right now promoting greed and amassing money just for moneys sake. I think were headed for more economic problems, not less. We need to take a different turn on this and look at it differently. But from just an addiction standpoint people who are sex addicts have a different reaction to that addiction and to the substance or the behavior, than normal people everybody may participate in sex, but when youre sexually addicted, you participate in a compulsive way without caring about how its going to impact you or anybody else and without thought of disease or anything.
When people who are referred because they were caught driving under the influence, they may lose their license, but if they participate in treatment for 90 days and show that they can stay fairly sober in that 90 days, then they get their license their privileges back and theyre not on probation. On a national basis, about one-third of people in treatment after their first DUI dont drink during that 90 day period. They dont drink and drive after that 90 day period. Those are probably normies or super normies who understand how important their driving privileges are. They might have had a little bit too much at a party and had to drive home and got caught in a sting or whatever – and those are the people who want to save their license, and they rarely go back to that behavior. Another third of the people who come for treatment won’t drink and drive during the period that theyre being scrutinized. They graduate and they may occasionally slip and do it again, but theyre not compulsive. They dont go heavy into their drinking and they are usually normies or social drinkers or whatever. Then there are the third who drink and drive on their way to treatment classes – and they drink and drive on the way home. They get 15 DUIs and are going to lose their license for life. They might have had an accident or hurt somebody already, or might have been involved in a fatal accident with because of their drinking and driving, but they dont stop and thats pathological. Thats beyond the norm and they have an addiction. And it’s the same with gambling or Internet addiction where people continue to participate, where kids starve themselves because they dont eat because theyre playing an online game or their Avatar gets deleted from a game or something and they commit suicide, thats beyond normal activity.
HOWARD: Thats well beyond.
DARRYL: And thats what were talking about. Were talking about the “well beyond” people who really are different. Theyre not like a normal person participating in pleasurable things like sex, gambling .
HOWARD: Rock and roll!
DARRYL: Rock and roll! Theyre not normally participating theyre pathologically compulsive and they continue beyond the point of suffering catastrophic, horrendous, life consequences – and thats what addiction is. And so that Huffington Post article was just taking a stab at the DSM5 for including gambling and assuming … were all addicted to something. We all have these behaviors. Thats incorrect. Thats a very, very narrow view of what addiction is and it doesnt appreciate the horror story of people who have an addiction, because addicts contrary to popular belief are miserable in their addiction. Pathological gamblers are gamblers, but theyre not happy doing what they are doing. They want to stop. They want to quit. They cant keep themselves from doing it. When we did a study of the addicts coming in for treatment at our center, all of them had a tremendous amount of shame, tremendous amount of guilt, tremendous amount of depression and some of them …..a good third of them were suicidally depressed because of their inability to control their use of alcohol or drugs and even had tried committing suicide because they couldnt stand themselves. Thats what addiction is. You dont want to do it. Youre not getting any benefit or joy out of it. Youre suffering tremendous negative consequences, but you don’t have the ability to stop and thats what the author of the Huffington Post article and other people have to recognize that addiction is a true pathology.
HOWARD: Well, thats why I wanted to talk about this because it seemed like it needed some clarity and it seems like addiction in general has been in the news lately. Of course, whenever celebrities are involved, it allegedly becomes news worthy and so .its been in the news more and the distinction I thought needed to be made as to whether or not everyone is truly, by definition, addicted.
DARRYL: Another unfortunate result of a person not being able to control their addiction is that entrepreneurs, corporations, you name it – take advantage and make a lot of money – no matter how much cigarettes cost or how much negative advertising smoking gets – those who are addicted are going to smoke and spend whatever it takes. With drug use – addicts will do whatever to get the money to buy what they are addicted to – sometimes that results in killings and other horrendous crimes. And even if they legalize drugs, I submit to you that tobacco is legal and its our biggest killer weve got.
HOWARD: And alcohol.
DARRYL: Alcohol is legal. Its the next biggest killer so its not a matter of legality, its a matter of how addiction affects those people who are vulnerable to it and how people take advantage and make money off of it. Theres that story out of Washington this week about a woman who had swallowed something like 180 pellets of heroin to smuggle it into the country. Total weight of the heroin was 5 pounds. Thats going to kill her dead.
HOWARD: Why didnt it kill her? It wasnt dissolved? It was in some kind of wrapper?
DARRYL: Most likely the drug was stuffed into condoms or a balloon. In the old days you swallowed it in a balloon and then…when you get to where youre going, you just let nature take its course or you take a laxative and it comes out. She smuggled in heroin with a street value of something like 150,000 dollars – 5 pounds of heroin. And thats a lot of money, but that also means that there is a risk because once in awhile the condom melts, the balloons pops and there are many people who end up dead in airports and in bathrooms. I remember when I was working in the clinic years ago …a very nervous young man came in and waited until nobody was around me and came up and said, “Doc you know, I swallowed a bunch of balloons. I was bringing stuff in from Mexico and now Im getting loaded.” And you should have seen the panic on his face. This meant that the balloons had burst somewhere in his stomach and the drugs were entering his system and he had enough in him, he knew, to kill him, so we had to treat him right away with Narcan or whatever to make sure he wasnt going to die from the amount of the drug that was in his system. Drugs are a dangerous threat in this country and opiates are a big part of that and why I think parents across the nation are buying aerosol Narcan and Naloxone and Naloxone injections to keep at home so they can treat their kid’s overdose of heroin. Its an amazing statement of where drugs are headed and what drugs do to the people in the United States I think.
HOWARD: And, you know, we talk about the cycle of uppers and downers, certainly seems like it is pointing towards an increase in the downer cycle. This is certainly exacerbated by prescription drug abuse. Anyway, thats all the time we have for this week. I thought that was a good discussion of a lot of the different stories. Until the next time, as ever, we value your thoughts and appreciate you listening. If you do have a comment, question, or a suggestion, please drop us a note here on our website. Darryl, until next time.
DARRYL: Hey, thanks Howard for a great podcast.
HOWARD: That wraps our pod for today. Thanks for visiting and check back soon for the next in the series.