For as long as people have struggled against the bonds of addiction, there's been a theory that a major basis of addiction is the chemical properties of the substance being used. Opiates, we might say, are highly addictive because that's how opiates are. The same is true for methamphetamine, alcohol, or tobacco. It's all about the chemical properties of these substances and how they bind to various neurobiological connections in the body, many pharmacological experts would say.
But what if an extremely large study advanced a different agenda for the cause of addiction? What if such a study stated plainly that what we see as the problem of addiction isn't really the problem at all, but a manifestation of a deeper pain caused by a damaging incident within the life history of an individual? What would this understanding of the cause of addiction mean for its diagnosis and treatment? What would it mean for the process that we call detoxification? Could it change the industry's history high levels of treatment failures and relapses?
Not all of the answers are clear yet, but a powerful Sunday Behavioral Healthcare Leadership presentation by Vincent Felitti, MD certainly suggested that traditional theories about the origins of addictive behavior and the so-called "addictive personality" could be more than a little off the mark.
In "The origins of addiction: Evidence from the Adverse Childhood Experiences (ACE) Study," Felitti, a co-author of the landmark study, gave Summit attendees something very interesting to think about.
He suggested that signs of addiction that might be seen as "obvious," such as obesity, frequent smoking or drinking, or abusive use of illicit or prescription medications "aren't the essence of the problem." Instead, he suggested, the ACE study offers evidence that such obvious addiction is "actually an individual's flawed solution to the real problem, which is the lingering and often nearly forgotten impact of a series of adverse incidents that happened in childhood, sometimes decades before.
He cited the example of a woman whose obesity presented a major health problem, a problem that was to kill her at age 42. After successfully losing more than 200 lbs on a medically managed fast, a weight loss that eliminated her need for supplemental oxygen therapy (she never smoked, but suffered from scarring of the lungs), the woman inexplicably put on 37 pounds in just two weeks.
Further investigation showed that the woman's weight gain began at age 11. But what caused it? The woman's answer shocked Felitti and other obesity experts. The woman gained weight as a protective mechanism, she admitted, a means of making herself less attractive to a sexual molester - her grandfather - who began abusing her, and continued to abuse her, before the age of 11.
After similar inquiries with other patients, "we stumbled into all sorts of child abuse and markedly dysfunctional households," said Felitti. "The ACE study was developed to see if what we discovered in weight loss programs had any relevance in the general population."
Years of evidence accumultated through the study showed that it did. The result showed a consistent pattern of "adverse events" in the childhoods of thousands of educated, middle class Kaiser patients in California. And, the study showed that as the number of these events increased in an individual's life, so too did significant health impacts (risk behaviors, behavioral health disorders, addictions, suicide attempts, even cancer and other diseases) with life-shortening consequences.
ACEs reported/incidence in lives of ACE study group (N=17,000)
- Major psychological abuse--11%
- Physical abuse--28%
- Sexual contact--sexual contact/abuse--22% (28% women, 16% men)
- Emotional neglect 15%
- Physical neglect 10%
- Alchoholism 27%
- Loss of parent before 18 (death, divorce, abandonment)--23%
- Depression or MI in another family member--17%
- Domestic violence directed toward mother--13%
- Member of family incarcerated--5%
Through a scoring system, the study compared the number of ACEs reported in the life of individuals (retrospectively), and compared them to the incidence of health problems.
Then, after explaining that most people have one or two ACEs, the adverse impacts grow steadily as the number of ACEs grows. With regard to addiction, he reports that individuals with ACE scores of 6 or higher have a 4,000-fold increase in the incidence of intravenous drug abuse, and a risk of death by suicide that is at least 3,000 times greater than those with one or fewer ACEs.
To bolster his claim about the power of ACEs, rather than the chemical characteristics of substances as the key to addiction, Felitti cited another study, this time about the incidence of heroin use among US servicemen in Vietnam. Of nearly 900 who admitted to an addiction -- regular use of heroin while "in country" -- 95% were able to quit without treatment within months of returning home.
The answer, inexplicable in terms of traditional understanding of addiction as a conjunction of substance characteristics and "addictive" personality traits, was that the removal of the stressor - their rotation home after a traumatic period of service in Vietnam - took away the GIs perceived need to use heroin to feel better.
One individual asked Felitti to then explain an obvious confound to the theory that ACEs drive addictive behavior. "What about those who succeed, despite the prevalence of ACEs in their personal histories?" Felitti replied that although some individuals may have escaped addictive behaviors, high ACE scores also correlated with the incidence of stress-related breakdowns in the human immune system, often leading to premature deaths due to cancer or other chronic diseases.