The tipping point in addiction


Editor’s Note: This op-ed/editorial was written by Lance Dodes, MD, Training and Supervising Analyst Emeritus of the Boston Psychoanalytic Society and Institute and former Assistant Clinical Professor of Psychiatry at the Harvard Medical School. We’re grateful to Dr. Dodes for sharing his perspectives.

A "tipping point" is a moment when there is a sudden change in a system, caused by an event that itself may be small. A recent example was the abrupt shift in attitude toward the comedian Bill Cosby. After years of allegations that were mostly ignored by the mainstream press and the public because of Cosby's upstanding image, suddenly the tide turned when one person spoke up about it. It was no longer improper or implausible to question him; indeed, this quickly became the dominant view. A much more important example occurred in recent years with the relatively rapid shift from overwhelming public opposition to same-sex marriage to widespread acceptance. Quoting a 2013 article by Andrew Nathan in the Journal of Democracy, Wikipedia sums up the tipping point concept this way:

Regime transitions belong to that paradoxical class of events which are inevitable but not predictable. Other examples are bank runs, currency inflations, strikes, migrations, riots, and revolutions. In retrospect, such events are explainable, even overdetermined. In prospect, however, their timing and character are impossible to anticipate. Such events seem to come closer and closer but do not occur, even when all the conditions are ripe—until suddenly they do.

Addiction has suffered severely with two major errors about its nature and treatment, and is just now coming to a tipping point for one of them, though the other is still almost universally accepted as gospel.

The mistake now coming closer to being challenged is this country's wildly unscientific acceptance of the value of 12-step programs in the treatment of addictive behavior. In our recent review of 40 years of academic studies of 12-step outcomes, we found that the overall success rate of AA is between 5% and 8% (The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry; Beacon Press, 2014). AA has, of course, claimed since its inception in the 1930's that everybody who "honestly commits" to the program does well, a statement that was never true. In fact, as we pointed out, the harm from people believing this myth has been incalculable. Everyone in the addiction field knows of people who have spent years and decades of their lives going back and back to 12-step programs while their lives were ruined. They returned because they were told, by people in AA and out, that their failure to be helped was their fault. They had to work the program harder. Nowhere else in psychiatry, psychology or medicine is the patient blamed when the treatment fails.

But now there have been a series of books, articles and movies that have begun to shatter the AA myth. I've been honored to be a part of two of these films (“The Business of Rehab” and “The Thirteenth Step,” which won as best documentary at the 2015 Beverly Hills Film Festival and was accepted to the Cannes film festival). There is still tremendous resistance to challenging the 12-step hegemony, in part because people make a great deal of money from it (not AA itself, but all the 12-step-based rehab centers), and in part because nobody likes to hear that what they've been doing actually may cause far more harm than good.

The other giant error in addiction is the neurobiological "chronic brain disease" hypothesis, created and widely publicized by the National Institute on Drug Abuse. This idea, derived from studies with rats, has nothing to do with addiction in humans, as has been shown by an overwhelming body of evidence.   The NIDA researchers found that rats are temporarily excited by release of dopamine in their reward pathways upon exposure to drug cues, and that they over-secrete dopamine once having been exposed to high doses of heroin. Humans are almost exactly the reverse. As everyone who has worked with our species knows, people are typically quite calm during the time between deciding to visit a bar and having a drink, or during the 90 minute drive from Boston to the casinos in Connecticut, or between starting to prepare food and actually eating it. Human behavior is not based on release of dopamine; it is a psychological solution to feeling overwhelmingly helpless or trapped, a psychological compulsion. When the decision is made to finally do something within one's own control (the compulsive drive to repeat a specific behavior), people feel relieved. And, of course, we've known for 40 years from the famous Robins study of Vietnam veterans that taking large amounts of heroin over a long period of time does not, in fact, turn people into addicts. The ex-soldiers Robins studied may or may not have had hypersecretion of dopamine when they saw cues associated with heroin, but regardless, they did not become addicts. Nor did decades of smoking create a chronic brain disease making it impossible for people to simply decide to stop using cigarettes, nor did taking opiates for pain turn patients into permanent addicts. People are very different from rats. Addictive episodes in humans are precipitated by psychological factors: loss of relationships, humiliations, grief, loss of self-esteem and so on. We are not rats, and even if our brains change upon exposure to drugs that is simply not what causes or sustains human addiction. Finally, it is well-known that there are many non-drug addictions and compulsive behaviors which are regularly substituted for drug addictions (including compulsive gambling, eating, Internet use, and even compulsively cleaning the house). Non-drug addictions are often named "compulsions" (as with gambling or sex), which is accurate; we should have learned long ago that just because some compulsions are focused on drugs they are no different, and have nothing inherently to do with, the effects of drugs on brains.

Sadly, there is currently so much blind acceptance of the neurobiological myth that we are not yet near a tipping point for this notion, despite the overwhelming evidence against it. But we can hope that day will come.

Lance Dodes, M.D.
Training and Supervising Analyst Emeritus
Boston Psychoanalytic Society and Institute
Asst Clinical Professor of Psychiatry (retired)
Harvard Medical School
Author: The Heart of Addiction; Breaking Addiction; The Sober Truth

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7 thoughts on “The tipping point in addiction

  1. Elizabeth George Reply

    The most interesting article I have read in years

  2. Ramon Ortiz Reply

    Dr. Dodes is a psychoanalyst and as such his bias is toward the “psychological.” Addiction is a BioPsychoSocial illness
    with components of all three working in syndrome in the addict.
    If, as Dr. Dodes states, “People are very different from rats” then tell Joseph LeDoux, one of our leading researchers on Anxiety to stop using the little fellas because he is just wasting his time.
    Dr. Dodes has been on this Anti-AA campaign for some time now. In psychological terms we might say that he is “fixated” or stuck in the “oral stage” of badmouthing AA.
    If there is an “overwhelming body of evidence showing that rat studies disprove the neurological ‘chronic brain disease’ hypothesis he should cite the evidence, put it forth and let us with non-rat brains decide for ourselves.
    Finally, if there is anything that we can say, with some degree of certainty, it is that Psychoanalysis is more suspect than AA as to its efficacy in helping people get better. However, as Dr. Dodes says about the 12 Step rehab industry, “People make a great deal of money from it.” Is he talking about Psychoanalysis?

  3. Mike Ashton Reply

    Lance – with you on the brain disease theory – see our analysis of the Vietnam studies at:
    and more on the implications in an instalment of our online addiction treatment course at:
    Have not read your book The Sober Truth so can’t comment on that, but as you may know, 12-step approaches are not part of wallpaper here in the UK as they are in the USA.
    Mike Ashton

  4. Patrick kariuki Reply

    the most affected area on this is Africa kenya

  5. Martin Buuri Kaburia Reply

    A lot needs to be done

  6. Daniel Nyukuri Reply

    Good to learn that the “tipping point” in addiction is a moment when there is a sudden change in a system, caused by an event that itself may be small.

  7. Martin Buuri Kaburia Reply

    It certainly will,hopefully

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