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Addiction

 

If you place a thing in the center of your life
that lacks the power to nourish
It will eventually poison everything you are and destroy you.
-"Liontamer" by Faithless

 

 

What is addiction?

    "Addiction" is one extreme of the normal range of human behavior. It comes in a thousand degrees of severity and can apply to almost anything. Loosely defined, it's a compulsion that keeps drawing you back to something. In the range of reasonably healthy addictive behaviors is the absolute commitment of many young boys to get home from school so they can log more hours on a video game. Less healthy sorts of compulsive behavior involve food (some people just can't say no to chocolate) or sex (extreme promiscuity, sense of self-worth through sexuality.) Sometimes it involves chemicals like caffeine, cocaine, etc.

     What all these things have in common is that the person is strongly motivated to repeat a certain behavior (whether it's playing a game, eating a cake, or taking a drug.) Sometimes these compulsive behaviors have a component of physical addiction (the user will suffer physical/mental problems if the drug is withdrawn, such as can occur with heroin, prescription drugs like Paxil, and even caffeine.) However, it has become clear over the years that the more powerful aspect of addiction is psychological: There is something about the behavior that is rewarding. The adolescent video game junkie gets a rush of adrenaline and sense of accomplishment as well as entertainment. The "comfort food" addict gets a release of serotonin to calm anxiety and depression. The coffee drinker gets an increase in alertness and motivation to help face their day. The heroin user gets to emotionally shut out the world and feel liberated from all earthly cares and traumas. What all of these manifestations of addictive behavior share is that the user wants what the behavior gives them. The gamer really wants to play that game: The game does not enslave them against their will. The heroin addict really wants the release and escape of the drug: They are not simply compelled by some sinister chemical.

     That's not to say that addicts aren't paying a high price for what drugs give them. The heroin addict can escape the physical and emotional pain of their life, but pays a high price financially, risks overdoses, diseases if they inject the drug, arrest, and becoming an outcast in an anti-drug society. Yet they continue to do it. If you put them in a lock-down 'de-tox' program, get them past the agony of opiate withdrawal and let them go, most will go back to heroin in short order. The physical addiction was powerful, but the psychological dependence, their reliance on it to provide something they emotionally needed, probably wasn't affected by the de-tox process. Taking bananas away from monkeys for a month doesn't make them stop wanting bananas.

So what is it about MDMA that might appeal to a user so strongly that they would be willing to put up with the negative aspects of frequent use?

     Emotional release. MDMA is an antidepressant and anti-neurotic drug of almost unparalleled power. If you are under severe emotional strain, MDMA can provide an escape. How compelling returning to the MDMA state will be to a given person largely depends on how rotten their lives otherwise are (a common theme to drug dependency.) To a reasonably healthy, happy person the MDMA state is often a great gift; a transcendent experience to be remembered fondly as they go on with their normal lives. To somebody suffering from depression or other emotional problems, MDMA can easily become an escape; a way to run away from reality.

What's so wrong about that? People have a right to try to be happy.

    Perhaps, but the MDMA state is not sustainable. While high, your serotonin system is being powerfully strengthened by the MDMA. When the high fades, there is a price to be paid: Your brain's supply of serotonin (and sensitivity to it) has been reduced. Not only do you lose the serotonin enhancement of the MDMA, you get dropped down to below-normal levels. It can take weeks to fully recover from this effect, and it can add up. The more frequently you use, the less time you give yourself to recover between uses, the more badly your serotonin system will be disrupted. Hangovers grow longer and more severe, simple post-use fatigue gives way to anxiety, depression, memory problems, and more. This isn't a game you can win: You can cheat on your boyfriend, cheat on your taxes, even cheat death...but you just can't beat your own biology (at least in this case.) The user that seeks frequent escape in MDMA will be ground down; the problems they sought to escape will only be made worse by frequent use.

So what happens when somebody becomes compulsive in their use?

    Compulsive users seem to follow one of two possible patterns. The first (and typical) pattern is one of escalating use until the side effects and hangovers become so severe that the user reaches a crisis point. They crash, swear it off, perhaps seek psychiatric help and prescription medications instead of more MDMA to deal with their problems. It's not a pretty process, but the dependency is self-limiting by the severity of drug side effects.

     In the second (apparently very rare) pattern of abuse, the user 'makes peace' with MDMA, accepting severely and chronically suppressed serotonin function by propping themselves up with massive frequent doses. Under this scenario, the MDMA becomes much more like methamphetamine: Its ability to draw a strong serotonin effect from the brain has been largely lost, but it retains the ability to release dopamine in significant amounts if the dose is high enough. This too is not a very sustainable condition; the longest case I've heard of is about a year. The fate of such users is not well known; it is likely that they too eventually crash and seek help.

     In the first case, full recovery is generally expected, although it may take months for the user's brain to get back to normal (depending on how severe the pattern of abuse was.) Frightened users may assume that the lingering effects are the result of brain damage (neurotoxicity). There is no need to assume the worst; although their brains have clearly undergone temporary changes, it is unlikely that true structural damage has occurred.

     In the second group, there isn't enough data to even speculate. If anybody is a good candidate for neurotoxicity, it's somebody who was taking thirty pills in a night.

Is there any treatment for MDMA abuse?

     Yes! Pharmacologically, popular antidepressants like Prozac, Paxil, etc. can provide the enhancement of the serotonin system the abusing user is seeking without the severe side effects and disruption of life caused by heavy MDMA use. In mild cases, serotonin-elevating supplements like 5-HTP may be enough to suppress drug cravings. However, this sort of maintenance treatment doesn't really address the underlying question of why they became abusers in the first place. If they were motivated by emotional problems, those issues must be addressed to prevent a return to drug abuse. Drug addiction is not a criminal problem. It isn't a law enforcement problem. It isn't even primarily a physical health problem (although that can be a side effect.) At its core, drug abuse is usually a matter of people with psychological issues trying to treat themselves with the tools available to them (prohibited drugs which, in spite of all government efforts, are still often easier to get than common antidepressant prescriptions.) Putting addicts in prison for their drug use is vicious and unproductive: About all you can hope to accomplish is to reduce the chances of them using drugs while behind bars.

     For the sake of clarity, let me repeat that drug use (occasional, controlled) is not the same thing as drug abuse (frequent, compulsive, destructive to the user's regular life.) The person that enjoys a few beers on a Friday night is not an alcoholic, nor is the occasional user of prohibited drugs an addict. Whether the law approves of a particular drug or not is irrelevant when the question is one of responsible vs. unhealthy patterns of use. Treating most users of prohibited drugs as addicts is not justified; the vast majority of users are not dependent, and neither want nor would benefit from treatment programs.

How addictive is MDMA compared to other drugs?

     There's not as much data to go by as I would like, but what we do have suggests that MDMA is one of the less addictive recreational drugs. In spite of MDMA being used recreationally in the US for over thirty years, the first addicts weren't documented in the literature until 1999.[1]

     We also have some field research evaluating how dependent users were to different drugs. Severity of Dependence scores (a scale used to gauge how addicted a user is) have been gathered for a number of popular drugs: [2]

Drug
Severity of Dependence (contact)
Severity of Dependence (no contact)
Marijuana
2.6
3.4
'Ecstasy'
1.3
1.5
Amphetamine
6.1
2.3
Heroin
12.9
5.6
Crack
5.5
5.7

     The "contact" group was drug users who were known to police or getting services (needle exchange programs, etc...'addicts' in the traditional sense.) The "no contact" group was users who were not seeking or getting treatment, were not known to police, etc. Perhaps the most interesting finding is that the "ecstasy" scores for severity of dependence (addiction) were actually half those of marijuana. I only wish they had included alcohol (I expect it would score at least as highly as marijuana.) Also missing are cigarettes, which some research has suggested are similar to heroin in addictiveness.

     In a large German study, ecstasy was found to have a lifetime rate of abuse (patterns of use that interfere with normal activities/obligations) of roughly one in five users, comparable to that of other psychedelics such as LSD. The same study claimed that, over the lifetime of users, about one in ten would meet the DSM-IV requirements for dependence.[3] The latter number may be somewhat inflated due to some of MDMA's unusual characteristics, such as the common occurrence of a 'hangover' period that can last for several days (which might be inaccurately identified as a withdrawal symptom.)

     Also of interest, animal behavioral research has found that rats in a social environment (with other rats to play with and interact with) do not find MDMA addictive, but socially isolated rats do.[4] This fits very well with anecdotal reports of human abusers; it seems likely that a major factor in the development of MDMA dependence is an underlying emotional need for a sense of connection and acceptance.

Avoiding addiction.

     The first step in avoiding addiction is understanding that it does happen, and can happen to you. Some people are at very little risk of addiction while others are at high risk, but anybody can become addicted under the right circumstances.

     Second, be sensitive to what your mind and body are telling you. Pay attention to drug cravings; the more you want a drug, the less wise it is to give in to that urge. The worst of addiction problems always start with "well...just one more time/line/pill can't hurt." Drugs can be a lot of fun, so it's understandable that people can get carried away when they discover a new one...but if you don't control your use, it may end up controlling you.

     And finally, don't be shy about asking for help. If you feel drugs have become too big a part of your life, talk to a friend, doctor or psychologist. Sometimes just talking helps, and they can prescribe medications that can help with anxiety, depression, or other issues that may be contributing to the problem. Drug addiction happens. It's not a sin, and doesn't mean you were weak or are a bad person. Never be afraid to ask for help; medical professionals are there to help you, not to judge you.

 

 


[1] Jansen KL, "Ecstasy (MDMA) Dependence", Drug and Alcohol Dependence, 1999;53,2:121-124. Abstract.

[2] Robson P, Bruce M "A comparison of 'visible' and 'invisible' users of amphetamine, cocaine, and heroin: two distinct populations?" Addiction, 1997;92(12):1729-1736. Abstract.

[3] Schuster P, Lieb R, Lamertz C, Wittchen HU "Is the Use of Ecstasy and Hallucinogens Increasing?" European Addiction Research 1998; 4:75-82. Abstract.

[4] Meyer A, Mayerhofer A, Kovar K, Schmidt W "Rewarding effects of the optical isomers of [MDMA] and [MDEA] measured by conditioned place preference in rats", Neurosci Lett 2002; 330(3):280-4. Abstract