Breaking the cycle: Changing how we deal with addiction

A hospitalist gained insight from a neuroscience journalist.

For most hospitalists, admitting someone with addiction-related medical problems often brings a sense of ineptness, futility, and dread. We have a couple of days and a peashooter to try to stop—or at least slow—this freight train of disaster.

Ms Szalavitz
Ms. Szalavitz

In search of a better solution, I recently spoke with neuroscience journalist Maia Szalavitz, author of the book Unbroken Brain.

Having spent part of the 1980s using and dealing cocaine while attending Columbia University, Ms. Szalavitz understands the tendency of clinicians to see such patients as lost causes—”unreachable and unteachable”—but knows firsthand that this is not the case. The basic tenet of her philosophy is that addiction isn't a “bad habit,” something to be treated with derision or shame. Rather, it is a learning disorder that will only resolve when the behavior is unlearned.

Dr Bowron
Dr. Bowron

She also builds a case for what people with substance use disorder are and what they are not. For any hospitalist who wants to do better, to see these patients differently, the following list might kickstart that change.

People with substance use disorder are not:

Low IQ

It may be “stupid” to misuse drugs, but most people with addiction aren't “stupid.”

“People at both ends of the IQ spectrum are at elevated risk,” Ms. Szalavitz said during our interview. “So some of these patients may genuinely be low IQ, but some of them will also be extremely high. It's a U curve. And similarly with class, the extremely rich are at risk, as are the extremely poor. The middle class would be at the lowest risk.”


Patients with addictions are not habitual liars, although it can sure feel that way. We've all seen it: Day 1 they deny using, and also the results of the urine drug screen. Day 2 they admit to being in the room with someone who was using. Day 3 they admit to using.

“There's one exception—which is that there is an elevation of anti-social personality disorder in people with addiction—but the vast majority of people with addiction will only lie the same way somebody lies about having an affair,” Ms. Szalavitz said.

Like “normal” people, those with substance use disorder will be honest when they are not punished for their honesty. “They won't lie in situations where they can be anonymous and where they feel comfortable. In other words, somebody may not want to apply the name ‘addict’ to themselves, but if you ask them how many times a day do you inject, they'll say ‘Oh you know, three to four,’” Ms. Szalavitz.

In denial

Most of those with substance use disorders are absolutely aware of their addiction. Their denial is faux and driven by either feelings of hopelessness or concerns of criminality.

“You have to realize the context in which people are telling you things. If you believe that addiction is hopeless, of course you're going to deny having it, because then it means the rest of your life is hopeless. And if they tell you certain things, they are admitting crime, and they've been punished in the past for that. So it's really a very difficult situation,” Ms. Szalavitz said.


They do not have a death wish. As Ms. Szalavitz learned first-hand, those with substance use disorder regularly go to great lengths to stay alive. They understand that their behavior takes them to the edge of the cliff, but almost no one really wants to jump off.

“Again, there will be exceptions, because there are many people with substance use disorder who also have depression. With that exception, addiction is not a sign of suicidality. Addiction is a sign of survival, of trying to heal one's self,” she said.

Inherently criminal or violent

“Simply being addicted does not make you into a mugger, or any other kind of criminal. We don't see a billionaire one-percenter who gets addicted going and sticking up drug stores. They don't have to. They have the money. They just buy their drugs,” Ms. Szalavitz said.

But when out of money, someone with substance use disorder will use whatever skills he has to get more.

“An accountant, for instance, might embezzle but would be unlikely to start breaking into homes,” Ms. Szalavitz said. “whereas someone who comes from a situation where they previously had been exposed to doing other criminal activities is more likely to turn to them.”

People with substance use disorder are:


It takes more than just a weak moment to become addicted. As Ms. Szalavitz chronicles, it takes the right sequence of wrong events to block a person's normal healthy brain development, to learn to seek this ultimately punitive behavior.

“As you get older you are less at risk, but if you put enough extreme situations together you could probably create it in anybody,” she said. “There's genetics involved, there's environmental stuff. Your genetics might give you an oversensitive temperament, and then you get abused, and that turns into depression, and then you find drugs and they work. ‘Yay!’ And that's an unlucky series of events that may seem lucky to the person at first.”

As a physician standing at the bedside, a little dose of “it could have been me” certainly expands one's compassion.

People with control issues

If you look at a physically, financially, and socially ravaged homeless patient who is addicted to heroin, and you're befuddled by how her life got so out of control, the answer is: she has control issues.

“There isn't an addictive personality that fits all people of addiction, but impulsivity is definitely elevated in a lot of people with addiction. So is compulsivity, which is kind of the opposite. But they are both problems with executive control—that is, self-regulation,” said Ms. Szalavitz.

“This doesn't mean they are like zombies with no free will; it's more that there's difficulty in managing emotions and choices. They have difficulty starting things, or difficulty stopping things. Sometimes both. The impulsivity is a huge thing for some people, not much for others.”

People with emotional and sensory regulation problems

Being sick and hospitalized stirs up all kinds of emotions, but for patients with substance use issues, the emotional problems started well before becoming “the patient in room W4360.”

“Certainly there are plenty of people with addiction who got there via bipolar disorder, which is a form of extreme emotional dysregulation,” Ms. Szalavitz said. “But that's definitely not all people who are addicted. Usually there's some issue in coping with emotions and a lot of times that will involve difficulty controlling anger or sadness, or just sensory stuff where you will get into a situation that makes you very anxious because it's very loud or something.”

People who have to ‘use’ just to feel normal

For empathy purposes, this point cannot be overstated. These patients are not seeking nirvana; they are seeking “norm-vana.”

“People think, ‘Oh, people with addiction just want to be high all the time, they just want to be euphoric and they don't want to do any work.’ The reality is that in most cases, you're coming from a below-normal mood, and you just want to be OK. And getting there for you looks like pleasure-seeking for other people,” Ms. Szalavitz said.

People whose problem is primarily emotional and psychosocial, not physical

Consciously or unconsciously, physicians do this all the time—we get an alcoholic patient through withdrawal and figure the hard part is over and the rest is simple: Don't drink again. Voila!

But for many, trying not to drink (or use) again is where the suffering truly begins. It's only for patients with healthy self-control (neither too impulsive nor too compulsive) and healthy emotional/stimulus regulation where physical dependence is the primary hurdle.

“If you have a patient using opioids to get through a painful cancer treatment and they get physically dependent, when they quit, they don't experience the hell that people with addiction tend to experience. There are some exceptions, but generally they taper very slowly, they associate the drug with a horrible experience of having cancer, and they feel like ‘Hey, no more pain? Don't need that drug anymore,’” said Ms. Szalavitz.

People who are going to recover

The hopelessness that both patients and clinicians often feel about substance use disorder is not warranted by the statistics.

“You're going to see some extreme cases where this is less true, but most addictions end by the time the patient is 35. Smoking is an exception, but more than half of all people using alcohol or opioid or cocaine stimulants will not be addicted by their 35th birthday. On average, without any treatment at all, about 5% of people are getting better each year,” Ms. Szalavitz said. “The fentanyl thing is more complicated because they have to be able to live through that in order to recover. That's why staying on methadone or buprenorphine cuts the death rate in half.”

So the next time a patient with substance use disorder ends up on your census, remember what they typically are not—unintelligent, inherently criminal or deceitful, suicidal, or in denial—and what they are: people with problems self-regulating their behavior and emotions, people getting “high” just to feel normal, people whose addiction is driven far more by emotional and psychosocial issues than physical dependence, and people who have a good chance of recovering no matter how bad it looks.

If addiction is a learned behavior (as Ms. Szalavitz argues in her book), it makes sense that it can also be unlearned. That's a hopeful message for a disease that deserves one. We can all do better.