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Survival"Gotta have it" is the driving thought of an addict. "Gotta have it." A drink, a drag, a hit, a line, a pill, another piece of chocolate. "Gotta have it." Getting it is all that matters. Scrounging in the garbage for cigarette butts, stealing pills from a friend's medicine chest, driving into a dangerous neighborhood at night to meet a drug dealer, wiping out a child's bank account. Nothing is more important than smoking, swallowing, snorting, shooting, somehow securing and consuming it, and feeling its effects, now. Not health or physical safety. Not love or work or sex or money or relationships or responsibility. Not commitment or common sense or self-respect. Not the law or the truth. This urgent inner demand overrides all others, undermines reason, resolve, and will. It is relentless. It does not stop until it is satisfied. And then, it starts again. "Gotta have it!" What drives this madness?
"It's not the physical withdrawal," Tom Krause insists. "It's the craving that kills you." With his blond hair and blue eyes, button-down collar and crewneck sweater, he looks more like the quintessential college boy back in town for his twenty-fifth reunion than the hard-core codeine addict he was until four months ago. "I can take physical pain," he says. "I'm an athlete. I've had plenty of injuries and broken bones. I've handled withdrawal so many times it's absurd. I can take stomach cramps. I can take my head feeling like it's in a vice. What I can't take is standing in the shower at seven o'clock in the morning thinking I'm okay, and all of a sudden, out of the clear blue sky, I'm saying, 'I have to buy a drug.' The next thing I know,I'm calling my dealer. I could walk out of an NA meeting feeling great and three blocks later say, 'I gotta have a drug.' Where does that come from?"
What perversion of our instincts for self-preservation and independence spawns such powerful and self-destructive dependency? How does it develop and why in some people and not in others?
"In college, honest to God, I never even took a drink," Tom continues. "That's how serious I was about sports. I played football and baseball. I was an all-American, if you can believe that. When I got out of graduate school in the mid sixties, I smoked grass for the first time. And I liked it. Then I understood what people meant by a 'mind-altering' drug. I thought it was terrific. Everybody was doing it—not everybody, but eighty percent. I've got friends—guys who are running companies now—who were smoking marijuana every day before they went to work. They stopped, and I kept going, switching from drug to drug."
What compels someone to cross the line from user to abuser to addict? Why can one person have a drink or two and feel satisfied, while another keeps drinking until the bottle is empty? Why, for some, does eating, one of life's most basic needs, become all-consuming? Why do different people get addicted to alcohol and others to cigarettes?
Why do some find barbiturates, painkillers or heroin, cocaine or chocolate more appealing? Is the answer in the abused substance or the substance abuser? What, if anything, do they have in common with activities like exercise, gambling, shopping, work, and sex when they are pursued compulsively? Are they addictions, too? And finally, where do the roots of the addiction lie: in our genes or our environment; in our chemistry or our character?
"I know my psychiatrist thought I had some kind of moral defect," Tom reveals ruefully. "He would say, 'You're too impatient. Tough it out. It will get better.' But it didn't. So he'd tell me to do the NA thing, take it hour by hour. That's easy to say. There are twenty-four hours in a day, every day. You miss one of those hour-by-hours, and you're right back! I toughed it out for eighty-seven days once before I called him and said, 'If you don't write me a prescription, I'm going to get it illegally, because I can't take this anymore.' He said, 'You are babying yourself, Tom. You have to develop a higher threshold to pain.' So what happens? Your self-esteem goes down even more. You think, 'Oh my God, a shrink can't help me. NA can't help me. A clinic can't help me. I've tried them all and I'm still failing. What's wrong with me?' That on top of the physical stuff, on top of the 'I-gotta-have-the-drug I-want-the drug'—it's too much. You're going to lose all the time."
Obsessive thoughts, the inability to resist and the inability to stop, accompanied by feelings of powerlessness and inadequacy are the elements of individual stories of addiction, no matter what the substance or activity involved.
Sandy Scopek, a married woman in her forties and the mother of two teenage girls, echoed and amplified Tom's words. Sandy's substance of abuse is food, an even more insidious and difficult choice to understand. It is the constancy, intensity, and insatiability of her urge to eat that set Sandy apart.
"If I'm in the kitchen, I have to eat something," she says. "If I'm walking down the street and I pass a grocery store, I have to go in and buy some candy. When I come out, I'll have a pretzel on the corner and a hot dog on the next corner. If I go out to dinner and there are eight pieces of bread on the table, I'll eat six of them. If the hors d'oeuvres are being passed around at a party, I'm running after them. It's humiliating! Not just the fact that I crave food so badly, I can't even control it in front of other people. It isn't a hunger issue. I can be full, and ten minutes later I'm stuffing something else into my mouth. It's as if someone else is bending me to their will. No amount of discipline or strength can stop the craving. It's on my mind all the time.
"But this isn't about being thin," Sandy insists. "First of all, I'm not fat. I've never been fat. I've fluctuated between forty to sixty pounds overweight all my life. Of course, I'd rather be thin. I know I look better when I weigh less, but honestly, that isn't the issue. It's the compulsion. It's the slavery. It's the feeling that you can't help it, and no one understands why, and no one believes you. My husband is one of those truly disciplined, self-controlled people. He would say, 'Oh, yes, I understand, but you know, Sandy, if you can just eat a little less you probably wouldn't have this problem.' They think, 'Look what she's doing to herself. We're in control of our lives. If she really wanted to change, she could. Therefore, she must like the way she is, or else she's really weak.' It's very upsetting and demoralizing. You sit down and think, 'What am I in for, for the rest of my life? Am I always going to be eating this way? Are people always going to be looking at me disapprovingly or patronizingly or pityingly. Why can't I stop?'"
Ultimately, for Sandy and Tom, it is impossible to override their most fundamental drive . . . to survive. Gotta have it—or perish—is the message that the brain sends out. Perish without a piece of cake? Without a fifth drink? Yes. Ancient biology underlies their behavior. That "gotta have it" message races along neural pathways hardwired into the brain hundreds of millions of years ago, designed to ensure that the organism it inhabits continues to exist. No thought, no intention, and no consequences are involved. When this system developed, no parts of the brain capable of such sophisticated cognitive functions had yet evolved. The "mind" was still millennia away. There was only the "old brain," the one we have in common with reptiles, rodents, snakes, snails, and every other organism that has managed to survive on this demanding and dangerous planet.
This message was sent only when the organism had to be motivated to act in the interest of its own survival or the survival of its species. To accomplish this, nature designed internal systems to sense and monitor our bodies. By altering the levels of substances called neurochemicals and glucocorticoids, these systems brought our perceived needs to our immediate attention. If the need became life-threatening and our survival depended on the performance of a certain behavior, these systems made our thoughts involuntary and irresistible. Actions had to be taken . . . or we'd perish.
In the case of addiction, abnormal levels of these substances appear to sustain the individual in a perpetually activated state, a survival mode. Highly responsive to stimuli, much of it well below conscious awareness, we react as if our lives are at stake. Understanding how and why this occurs could provide a way of treating addiction. We therefore begin our story by first exploring the elegant and extraordinarily effective survival system devised by nature eons ago, when life on Earth began.
In the Beginning Why are we here?
Philosophy yields to biology.
We are here because we survived. We each survived because we made it through gestation and the birth canal into the care of people who, whatever their strengths or shortcomings, managed to feed and protect us. We survived because, as a group, science and society collaborated to shield us from diseases that a century ago would have killed us before we emerged from childhood. We survived as individuals by being fortunate enough to avoid both the natural and unnatural disasters that threaten us as we navigate the minefield that is life.
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