MARCH 12, 2007
In 1981, Representative Jim Ramstad thought his political career was over. Seven months into his first term as a state senator from Minnesota, Ramstad found himself in a jail cell in Sioux Falls, South Dakota. His trip had started out innocently enough. The young pol had gone to Sioux Falls with members of the Minnesota Vikings football team to raise money for youth sports. But a fun night with friends turned sour quickly. "The last thing I remember," says Ramstad, "is dancing at the discotheque across the street from the Holiday Inn." Others have told Ramstad that he eventually left the discotheque alone and went to the Holiday Inn's coffee shop. That sounds like a pretty smart move--except Ramstad refused to leave when the manager asked. The police were called, and Ramstad was arrested on a host of charges ranging from disorderly conduct to resisting arrest. It was the first time Ramstad, who was 35 years old at the time, had ever been arrested.
"It's not exactly the kind of publicity one wants as a new public official," Ramstad chuckles bitterly, thinking back to that day when he woke up "feeling a fear I'd never felt before." Though at the time the young senator "wanted to be dead," July 31, 1981, would turn out to be "the beginning of a new life." Ramstad was lucky. He credits the Sioux Falls Police Department with his untraditional "intervention." Ramstad, who regularly drank to "black-out proportions," had access to treatment and support. The now nine-term Republican congressman has been sober now for more than 25 years.
Though addiction has been considered a disease by the American Medical Association since 1956, most insurance companies still don't cover addiction the same way they cover other diseases: Co-pays are artificially inflated, and coverage for treatment is often spare at best. For many, treatment is a luxury they cannot afford. That's why Ramstad is still trying to pass legislation he initially proposed ten years ago with his Minnesota colleague, the late Senator Paul Wellstone, to force insurance companies to create a parity in the treatment of addiction with other diseases. It's also why Ramstad is excited about the new documentary from HBO, "Addiction," which takes a searing look at the long-stigmatized disease afflicting more than 23 million Americans.
Every few years, HBO's documentary department tackles a new public health crisis (the last few efforts dealt with cancer and eating disorders); when it came to addressing addiction, says HBO producer John Hoffman, the project became bigger than expected. In addition to the documentary series, the first episode of which airs tonight at 9:00 p.m., HBO, together with the Robert Wood Johnson Foundation, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), has created the largest website it has ever built for a program (including extra videos, podcasts, and treatment information), written an expert book, and is selling the 14-part series simultaneously on DVD. "We realized that the people watching would probably be those affected by addiction," says Hoffmann, "and we think that's a very big number."
Given that one in four adult Americans knows someone suffering from addiction, that's a very large number indeed. Which makes it all the more staggering that addiction is still so heavily stigmatized; it is, after all, the only disease you can get yelled at for having. But, according to Dr. Nora D. Volkow, director of NIDA, who is featured in "Addiction," that needs to change.
Addiction is a disease of adolescence. Your disposition for addiction up to age 25 may be considerably higher than later in life because your brain is not yet fully developed and your levels of impulsivity are peaking. Unfortunately, that can be a dangerous combination at exactly the wrong time: During college and times of heavy drinking and drug experimentation, some of us with specific genetic markers will actually train our brains to get addicted. Dr. Mark L. Willenbring, director of NIAAA's Division of Treatment and Recovery Research, also featured in "Addiction," says that once initiated, "the addiction itself bathes the brain--and changes the brain." When that happens, the adult addict is hard-wired for dependence.
Using new brain-imaging technology, Volkow has been able to show that the brain of an addict is different from that of a non-addict. Many people do not realize that we are quite literally of two minds all the time. We are driven by the limbic sytem--often called the pleasure center--for basic needs, from food to sex. And those impulses are kept in check by the frontal cortex, which is used to make sensible judgments--judgments like when to stop drinking or whether or not to have a puff--and to perceive consequences. In the brain of an addict, however, the limbic system is given an unnatural advantage when confronted with drugs or alcohol. "The frontal cortex of an addict does not intervene to inhibit at that point," says Volkow. In fact, the frontal cortex may not even have the chance to intervene. In "Addiction," a patient, William, is shown images of drug paraphernalia at such a fast rate that he cannot consciously perceive them, and yet his limbic system immediately lights up on the MRI. The part of the brain that wants the drug responds seconds faster than the frontal cortex in an addict. For William, and other addicts, the ability to exercise choice or control over the addiction is robbed from them.
That's not to say that addiction is a fait accompli. Willenbring is quick to point out that, while making rational choices becomes very difficult for an addict, choice is still operative. This is particularly important in a legal context. If your brain "made" you drive drunk, for example, it would be hard to invoke the right punishment. "You may be hard-wired," says Stephen J. Morse, professor of law and psychiatry at the University of Pennsylvania, "but it doesn't mean that you are sleepwalking."
As far as any "my brain made me do it" defenses go, Morse is not concerned. First, he says, most addicts have moments of "quiescence," when they are not high, when they can choose to get help to avoid the situations whereby they may become harmful. Just like a driver who kills a pedestrian after a seizure can be held culpable if said driver knew he was subject to seizures, similarly addicts can be held responsible--as can we all--for any unlawful acts committed under the influence. Secondly, the fact that many addicts do quit using drugs or alcohol is proof that choice exists.
So should we get mad at all the addicts who don't quit? Not so fast. Holding people accountable for their destructive actions does not mean that addiction itself is a moral failing. Millions of us leave college addicted; millions more don't. Are those addicts to blame for their genetic make-up? For American culture? For a brain that doesn't function accurately when faced with a drug? Or even when faced with just a cue for a drug? "Fifty percent of people with high blood-pressure don't take their medication as directed," says Willenbring. "We don't call that a moral failing."
"The ability to control yourself under situations of need is different" from how we approach other situations, points out Volkow. Imagine you are given a piece of meat, she says. You don't have to eat it. "But if you are starving, you don't have any choice but to eat the meat." In fact, you'll go through hell to get to the meat. And that's how an addicted brain responds to his or her drug of choice: as a matter of life-and-death.
Which invites the question: Why does a large chunk of society cast blame on the addict? Willenbring argues that people have trouble understanding because they actually relate to the addict--at least a little. Some people might see a person with depression and not understand why she needs medication because "we all get depressed sometimes." We also all have cravings and desires that we resist everyday through rational decision-making. So when we see an addict, it's easy to say: Hey, I face temptation too, and I make my life work; what's your problem? "People don't understand because they have never felt it," says Volkow. "They think, steal from my husband to buy drugs? I would never do that." They don't understand something so powerful.
"We're still dealing with stigma because too many policy-makers still hold to the old-fashioned idea that addiction is a moral weakness or failing," barks Representative Ramstad. He's angry, he says, because addiction costs our country $400 billion a year by some estimates; that's a result of everything from on-the-job accidents to absenteeism to jail cells and health care costs (addicts' health care bills are "100 percent higher than non-addicts'," says Ramstad). Enforcing parity in insurance coverage would certainly help. According to The New England Journal of Medicine, parity would in fact be very cost-effective. Meanwhile, of course, more people seeking treatment would actually get it and not be turned away or priced out--a problem faced by nearly every addict in "Addiction."
So why hasn't the life- and money-saving legislation that Ramstad has been pushing for ten years not yet passed? Ramstad blames a lack of understanding, but another Hill official told me that "when insurance companies and the U.S. Chamber of Commerce don't back something, it's hard to pass it." But Ramstad thinks this is his year; more insurance companies are cooperating, and the Democrats are more sympathetic to this veteran Republican's favorite cause.
Watching tonight's documentary on HBO might just help, too. It does not toil in the nasty morass of addiction's grip. And that is to HBO's great credit. The film follows the science and sheds light on new and important treatments and drugs for a crippling disease all too many of us are deeply affected by. "Addiction" does not make the viewer a voyeur, but rather a participant in the need for more and better solutions. After all, whatever your judgment of addicts, addiction is a $400 billion problem. And that's not something any of us have a choice about.
By Sacha Zimmerman