Are we all addicts?

Our May issue is out on newsstands now and after reading it, you may never think about addiction in the same way. But just what is an addiction anyway? Read our interview with Dr. Andreas Heinz and then pick up a copy of our print edition.

Image for Are we all addicts?
Photos by Jason Harrell

Does getting hooked happen in the body or the brain? Is being addicted to your phone the same as being on drugs? And what about the new “magic pill” that treats alcoholism? We asked Charité researcher Andreas Heinz.

In the middle of the Charité campus in Mitte stands a rather beautiful brick building from the 1900s. Above the elaborate arched entryway, the words “Psychiatrische u. Nervenklinik” hearken back to the early days of brain science. Inside, the neo-gothic vaulted ceiling, elliptical semicircular stairwells and maze of narrow off-white corridors, abandoned closets and spooky corners reek of bygone times when women were diagnosed with hysteria and shock therapy was the treatment of choice.

It is tempting to label behaviours that we don’t like as addictions.

Now, 115 years later, all is quiet in the psychiatry department of Charité. The bust of eminent psychiatrist Carl Westphal – the man who coined the term “agoraphobia” – is missing from its pedestal and you hardly pass a breathing soul in the long corridor separating neurology from psychiatry, just one man stomping through, soliloquising on politics at the top of his lungs, completely unaware of the pretty view over the walled garden with century-old trees and rose bushes.

On the third floor of a rear building is the office of Professor Andreas Heinz, who has headed the psychiatry department for the last 13 years. Potted plants and Rothko paintings make for a congenial atmosphere, but the padded doors remind the visitor that some 78 patients are still treated here, in the quiet muffled atmosphere of Berlin’s reputable psych ward…

You’re about to release the results of a highly publicised trial about baclofen, a controversial drug that’s been hyped as a cure against alcohol addiction. The results are encouraging – what’s next?

Usually you need two positive studies in a country to get a medication approved. So, the results would be a strong argument to do another study, and if that was also positive, it would be possible to apply to the authorities to use baclofen as a regular drug in the treatment of alcohol abuse disorder. For now, it is only approved as a first-line treatment for muscular spastic paralysis, its original indication.

Why haven’t there been more studies like yours?

The problem is that when a drug is already on the market as a generic, like baclofen, the pharma corporations have no interest in financing a study for a new indication. Baclofen is not patented anymore, so it doesn’t earn any money when you bring in a new indication.

How did you manage to finance this trial, then?

We were lucky to have some public funding which made the study possible. We are part of a Cluster of Excellence, a network of researchers applying for funds to cure neurological and psychological disorders. Altogether, some €60 million went to Charité, and we were able to use about €120,000 or so for this study. It was a very cheap study, which is why there were relatively few patients, but it was successful and that makes it worthwhile.

The medication is now used in France, apparently pretty successfully. Why is the German medical establishment so sceptical about it? Is this to do with the personality of Dr. Ameisen and the way he hyped his discovery as “the magic pill that can cure alcoholism”?

That was not very helpful. I liked Ameisen a lot, but he said that with baclofen, you don’t need any treatment anymore. That was unnecessarily polemical. A medication might reduce cravings and relapse risk. But it doesn’t mean that if you’re in debt and you have no friends and you’re sitting home alone, it will magically solve everything. People need a reason to stay abstinent. They may need a self-help group and support, they may need to fix their relationships, all of these things. Medication can simply reduce certain aspects of your problem, like your craving for alcohol.

Ameisen was not only a cardiologist, he also was a pianist who drank to overcome his stage fright. Baclofen, as a muscle relaxant, probably also calms you down and replaces the need to drink alcohol by giving you a similar relaxing effect without addiction. It may be particularly effective for people who drink alcohol to reduce anxiety. It will not help everybody, and it will not replace self-help groups and therapy.

Many of your colleagues I talked to say that alcoholism is too complex an addiction to be cured with pills…

But then, nobody would say that depression is so complicated that you shouldn’t take a medication just because it doesn’t alter your original problems. The idea is to help you reach some sort of plateau. In my view, medication should never be given alone without psycho-social treatment – referring a patient to a self-help group and having him regularly see a consultant. This doesn’t need to be a doctor; it could be a social worker.

In America, people still stand by Alcoholics Anonymous and the 12-step programme. It is almost heretical to think that one could get rid of alcohol addiction easily – with the help of a pill, for example.

We have had similar discussions here, in some Berlin consultation offices. Counsellors saying, “We don’t need doctors to treat our patients” – quite an interesting comment!

So is alcohol abuse a disease? Or about some demon inside yourself that you have to defeat, as purported by the likes of AA?

There is a South Park episode called “Bloody Mary” – it’s about AA meetings and it makes a joke out of the concept that alcohol is a disease. They nail down a few problems associated with this religious idea behind AA: “I have a very bad disease, I need a higher spirit to help…” Many anti-Church jokes come up. I still believe it is a disease, but stating that you are helpless and need a higher power only fits for some patients, not all.

It’s a pretty puritanical dogma.

It’s very puritanical – you should control yourself, you shouldn’t do this and you shouldn’t do that. I don’t want Bible Belt fanatics to tell me that having sex before you marry is sex addiction, reversing all the liberties we have developed over the past 30, 40 years in Western societies. This is why I am very careful about labelling too many social or behavioural problems as addictions.

Are rehabilitation programmes as popular in Germany as in the US, where it is a huge business?

Rehab clinics work quite well, but only 3-4 percent of alcohol-dependent patients in Germany are in them. Another four percent are in psychiatry departments for detoxification. And all the rest never see a specialist. They see general practitioners for somatic issues, like liver problems.

How does the prevalence of alcoholism compare to other drugs in Germany?

About three million Germans have alcohol abuse disorder, mostly men – women more often suffer from depression, but alcoholism affects 5-7 percent of the male population. The most common addiction in Germany is still smoking, which a lot of my colleagues don’t see as an addiction, but as a bad habit. In my view, it’s the most dangerous addiction – about 100,000 patients per year die due to smoking. About 40,000 people die of alcohol problems, mainly in combination with nicotine – it’s a good match. Then about 1000 die of illegal drugs. Even if you compare death rates, nicotine and alcohol are above heroin.

With alcohol and smoking, there is the matter of what one considers the threshold: addiction or bad habit? Where do you draw the line?

The line for addiction as dependence is rather clear: there was a British alcohol researcher called Edwards whose main idea, which I think is correct, is that you have dependence when you have tolerance development, when the brain is in a state of equilibrium with the drugs and you get withdrawal symptoms, like shivers, shaking and sweating, if you stop. This is the core of the dependence construct. The other part is that you have a strong craving, and reduced control.

You actually fulfil DSM5 criteria for alcohol abuse disorder for just liking a glass of wine.

Unfortunately, in the States they have mixed the concept of dependence up with the much less defined construct of abuse or harmful use. Because classifying something as ‘harmful’ depends very much on society. When I was in Kabul, Afghanistan, my hotel was blown up and I wanted to drink a glass of wine in the evening – that would be harmful alcohol use. It’s absolutely forbidden, and you get into a lot of social trouble if you do it. You actually fulfil DSM5 criteria for alcohol abuse disorder for just liking a glass of wine. In Germany you are allowed to drink from the age of 16; in the States you have to be 21. So there are lots of cultural differences.

Are you in favour of legalisation, or at least decriminalisation, of drugs?

It’s a difficult discussion. I think society could legalise cannabis. To my understanding, the medical risks of cannabis are not really worse than alcohol. The problem with legalisation is how to protect the youth. In Germany, a 12-year-old can get strong spirits in the supermarket… so if we treat cannabis like alcohol, we will have a disaster. Also, the one percent of the population that is prone to schizophrenia will be at a higher risk of triggering their psychosis. So it would have to be carefully regulated.

Pro-liberalisation champions claim that prohibition doesn’t help – quite the contrary…

In the case of alcohol, the idea that Prohibition didn’t work is wrong. Alcohol consumption during Prohibition went down. Of course crime went up, as we all know. But I am concerned about cocaine and heroin. I really wouldn’t want my kids or anyone getting addicted to these drugs.

So you feel that if they were legal, more people would get addicted?

That’s my concern.

Do you make a distinction between psychological addiction and physiological addiction?

 don’t think so, because every psychological procedure has a physiological correlate. Everything you do has a correlate in your brain. I am a strong opponent of separating what they call the somatic and psychological parts of an addiction. They say craving is psychological and withdrawal is somatic, but that’s nonsense. They both originate in the brain.

What about the difference between substance addictions, like tobacco, alcohol and drugs, and behavioural addictions, like computer games?

The problem with defining behavioural addictions is that they don’t usually have a strong sedative effect on the brain. When you stop them, you don’t usually have withdrawal symptoms. So many passions are characterised by cravings and reduced control. A scientist who is having a breakthrough will probably cut out eating or talking with his family to do his experiments. I am strongly against labelling passionate forms of living as pathologised addictions.

But at Charité you have groups working on gaming addiction…

I think you can, carefully, use the concept that you lose degrees of freedom when you’re really into behavioural addiction. It boils down to whether playing games for hours and hours really cuts down on your ability to interact socially. But you have to be careful about labelling a behaviour an addiction just because it’s socially undesirable.

It’s kind of a slippery slope…

Absolutely. My example is always “drapetomania” – this was the supposed addiction of African American slaves to running away. They supposedly had a ‘craving’ to escape. It was labelled a disease 160 years ago. It is tempting to label everything that you don’t like as an addiction.

Is there such a thing as an ‘addictive personality’ – people who really thrive on extreme behaviour?

I don’t think there is a personality that makes you safe against addiction. Everybody can find something that excites them enough so that everything else pales in comparison.

There are personality differences, but everybody can become addicted if the drug is strong enough. When you’re on cocaine, you release about six times as much dopamine as you do in the most exciting social interaction, including sex. Drugs can be overwhelming. Of course there are predispositions, but I don’t think there is a personality that makes you safe against addiction. Everybody can find something that excites them enough so that everything else pales in comparison.

What about internet and social media addiction? Are they just buzzwords? Trendy concepts?

You have to see what people actually do on the internet. You can be addicted to gambling on the internet – it’s rather well-described that with gambling you can not only have craving and reduced control, but you can also develop withdrawal symptoms and tolerance rather similar to substance abuse addiction. There are actually people who stand next to a gambling machine and sweat and shiver if they can’t play. When it comes to social media, like relentless posting or chatting, I’m not really convinced that this should be called an addiction. There is a strong desire to not be lonely and to stay in contact with friends, and with all these internet connections we can do that faster and with more people at the same time. It’s very typical of our time, but I don’t think it’s an addiction – there would have to be some tolerance development and withdrawal symptoms, otherwise you’re not talking about the same concept.

So social media might not be an addiction, but gambling is?

We can say gambling resembles alcoholism in certain ways, but there are lots of differences with respect to the reward system. One thing is important: I don’t think addiction is a thing in the brain. Addiction is a concept one uses to describe similarities among behaviours, but these behaviours are very heterogeneous. There’s no symmetry in that every addiction alters dopamine in the same measurable way. Everything that interests us, as far as we know, interferes with our neurotransmitter systems, including dopamine. It’s a question of degree – it’s not a categorical difference where you can say, okay, now the addiction has started.

But are we all equal before substances? Does alcohol work in the same way for everyone, for example?

We do know that all addictive drugs activate dopamine transmission, but the degree to which they alter it is different. Many alcohol-dependent patients look like the normal controls – it’s just a few that really stick out. Again, you can understand patterns and alterations, but people are different from one another. Some people might profit from an anti-alcoholism medication, while others won’t. It’s the same with anti-depressants – they work in about one out of six to eight patients.

What about the genetics?

The genetic component explains about 50 percent of what goes on. But the most clear-cut genetic finding is that people who can drink a lot, do drink a lot. In Asia, a lot of people get these flush reactions because their alcohol metabolisation is genetically different. In Europe, genetic variation in serotonin neurotransmission influences how much alcohol you can drink before you get intoxicated. If you don’t have strong side effects, then you tend to drink more. It doesn’t make you an addict automatically, but it helps you drink too much. Then neuroadaptation and tolerance development starts – at that point, some patients could drink a bottle of vodka and not be comatose, while I would be.  

Image for Are we all addicts?
Photo by Jason Harrell

Born in 1960 in Stuttgart, Andreas Heinz studied medicine, philosophy and anthropology at the Ruhr University in Bochum, the Free University in Berlin and Howard University in Washington, DC. Since 2002 he’s been the director of the Department of Psychiatry and Psychotherapy at Charité Hospital in Berlin. He is the author of several books on migration and mental health and more than 500 scientific articles on many topics, including addictive disorders. He has also contributed to a guideline on group therapy for alcohol addicts and other works on alcoholism. After meeting Olivier Ameisen in Berlin (they appeared on Stern TV together), Heinz decided to pursue further evidence on baclofen as an alcoholism treatment and initiated Charité’s study of the compound (BACLAD) in 2011.

Originally published in issue #138, May 2015