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An Interview with Steven Hyman, M.D.

The following is the edited transcript of an interview by Bill Moyers with Steven Hyman, M.D., on the brain and its role in addiction. Hyman directs the National Institute of Mental Health. Portions of this interview appear in the CLOSE TO HOME series.

Moyers: You've said in the past that we have to stop thinking about the brain as an impenetrable black box, a bag of chemicals that we can never comprehend. How should we consider it?

Hyman: We now have the tools to begin to understand how the brain works. There's a great deal we still don't know, but what we're finding is really remarkable. As we learn to understand the brain, we're going to increasingly understand how we as human beings work. How we learn and also how we get sick. How we get mental illnesses, including addictions.

Looking at the brain as a black box separates us from our brains, in essence. It leads to this kind of thinking which separates body and mind. And we have to understand how things go wrong in the brain, if we're going to understand how things go wrong in our mental life and our behavior.

Moyers: You've also referred to the brain as a universe. What do you mean by that?

Hyman: The brain is the most complex structure we've discovered. It has a hundred billion cells, but by itself that fact isn't particularly remarkable. Unlike other organs in the body, however, those hundred billion cells are made up of thousands of distinct cell types. Different kinds of cells with different shapes and different chemical natures. And those cells communicate with each other in a marvelously precise, but marvelously complex, network of intercommunication. And they communicate using more than a hundred different chemicals.

Moyers: Chemicals which in a way are the equivalent of our words, our language?

Hyman: Yes, that's a good way of putting it. The only thing is that the brain has different ways of decoding each word or each chemical. And the decoders are called receptors. So for a chemical that people have probably heard about like serotonin -- which has been in the news because many modern anti-depressants work on it --  there are at least fifteen different kinds of receptors or decoders. Obviously that's a very rich and complex signal. But besides the fact that the brain is so complex in its wiring and in its chemistry, in many ways the crowning complexity of the brain is that it changes. It changes with experience. Every time you learn something your brain is physically changed. There's this old idea that the brain is some kind of hardware and thoughts, for example, might be considered software running on it. But that's not quite right.

Because literally the physical nature of the brain itself is changed by experience. By drugs, by chemicals, by all kinds of things.

Moyers: On the plane earlier, I saw an ad for a long distance phone call company. And I make a lot of long distance calls from the road. Over time I've come to punch in their number automatically, without thinking. My brain changed to learn that?

Hyman: Absolutely. How else could it be? How is that you could take a random fact that you've come across somewhere in your world and carry it with you for days or weeks or years, maybe for a lifetime? Memory is not written in the clouds or on some ghostly material. It literally is recorded by changes in the brain. What's happened is that some of the specialized connections between nerve cells, called synapses, have been altered.

To store a memory, some synapses have a stronger connection. Maybe more chemical signal is being transmitted across that synapse. Others perhaps have a weaker connection. But there is a literal, physical change in your brain for every memory.

Moyers: What are things like the PET scan and other brain imaging techniques doing for your research?

Hyman: Modern noninvasive neuro-imaging, PET scans, MRIs are very important. They're allowing us to see the living, thinking, feeling, human brain at work. In the past, there were certain experiments that could only be done on animals. But there are lots of things we can't ask a rodent or a monkey because they can't describe their subjective experiences. These techniques allow us to take what we've learned from animal models and look at what happens in the human brain. What happens when we experience fear? What happens when we formulate a sentence or remember something? And I have to tell you it is really with a certain amount of awe that I experience some of the results that we're getting.

Moyers: Can you look at these PET scans, these images, and see this communication taking place?

Hyman: Yes. We can image desire in the brain.

Moyers: And see the receptors all engaged in this lively conversation?

Hyman: Well, I'm afraid we can't quite do that yet. Because things in the brain are so small. Inside our heads we have maybe a quadrillion synapses. A number that is hard to even imagine. And looking from the outside even with these wonderful tools we can't literally see individual synapses or even small assemblies of cells. What we see are many cells working together. And that's why we have to go back and forth between human research and animal models where we can use much finer methods, to see what's happening at the synaptic level.

Moyers: What's the most important thing we're learning about addiction from brain research?

Hyman: Well, one very important insight is the recognition that in vulnerable individuals, the disease of addiction is produced by chronic administration of the drugs themselves. Drugs of abuse appear to commandeer circuits in the brain that are involved in the control of motivation, which means the addicted person's will can be impaired.

Moyers: OK, now we're back to addiction and the brain. So there's solid evidence that alcohol, tobacco, cocaine, and heroin physically change the brain?

Hyman: There is incontrovertible evidence that these drugs physically change the brain. At all levels, beginning with molecular and chemical changes. In many cases we can actually see changes in the structure of synapses and in the shape of cells. Above all, what we're seeing are the kinds of changes in the way nerve cells communicate with each other that would impact our subjective life and our behavior.

Moyers: You mean drugs change not only the physical size and shape of the cell but the psychological operation of the brain as well?

Hyman: Yes. The psychological operation of the brain -- how we feel about ourselves, what we do -- reflects the workings of networks of nerve cells. And these drugs change the way that these networks function. And therefore, they can change our behavior.

Moyers: Do these four main drugs all change the brain in the same way?

Hyman: There are some shared properties and some differences. The shared properties have to do with a particular brain pathway -- sometimes called the reward circuitry -- which is where all drugs of abuse, directly or indirectly, have their effect. This pathway is rather deep in the brain. It extends from a structure called the midbrain and sends projections of nerve cells (they are called axons) to a part of the brain called the nucleus accumbens. In Latin, that means "leaning nucleus," and it's named because of its shape. The nucleus accumbens is in an area involved in the processing of emotions. This circuit has to do with, among other things, learning what's good for us. You see, learning that occurs in the presence of strong emotion is very different from trying to remember something that seems dry as dust. Let's say a child touches a hot stove. Well, that child certainly doesn't have to study or practice the idea that you don't touch a hot stove twice. The child will learn in a profound way and carry that for the rest of his or her life.

Moyers: Mark Twain said that when a cat sits on a hot stove it won't sit on that stove again.

Hyman: [CHUCKLES] That's right.

Moyers: But neither will it sit on a cold stove.

Hyman: And the difference between the human and the cat is that we can learn about different contexts.

Moyers: So what happens when a child touches the hot stove?

Hyman: Well, part of the brain which is involved in emotion, in this case something called the amygdala, basically says, "Ouch. This is bad, we're not going to do this again." And the child has a subjective response to the hot stove, which is very negative: aversive, we call it. And all kinds of things are happening in the brain. Among them is something called emotional memory. The child is going to associate anything now that looks like a stove with a negative consequence. And the next time the child encounters a hot stove, the child is not going to have to say, "Hmm, now let me recall . . . did I do my homework? Do I or don't I touch this?" Quite the contrary. The child may actually recoil. And anyone who's suffered a terrible accident -- we see this in post-traumatic stress disorder -- can be reminded in a full-blooded way of the entire scene by just one cue. The entire emotional panoply, including changes in heart rate and all kinds of negative feelings, can be evoked. That's on the negative side. We also have circuits, not quite as well understood, on the positive side. And these are the circuits that are used by drugs of abuse. In the 1950s in Canada, two scientists named James Olds and Peter Milner did a very crucial and famous experiment. They wanted to know whether there were areas of the brain which would respond positively to electrical stimulation, which would feel good when stimulated. So they put electrodes in the brains of rats. And there were levers for the rats to press which would let them stimulate themselves.

Not surprisingly, there were some locations where the rat treated the lever with a great deal of respect, as if perhaps it had caused something very painful. Most locations of the electrode were really quite neutral. The rodent would treat the lever as just another piece of furniture in its cage.

But there were a small number where the rodent would literally push the lever tens of thousands of times in succession until exhaustion supervened and the rat fell asleep. That electrical stimulation was apparently very pleasing, very exciting to the rat. Now, in the pop-psych literature, this area got called the pleasure center. It is the same evolutionarily very old meso-accumbens projection that I've been discussing. And the nucleus accumbens seems to have a particular role in telling us what might be pleasing, what might be good for us. What we want. What we desire.

Moyers: So the rat pushed the lever over and over because the stimulation was giving something of a "high?"

Hyman: Yes, it hit that spot which said, "That feels good, do it again and remember how to do it." And we as humans have a spot like that as well.

Moyers: Drugs, alcohol, tobacco, all converge on that same brain region?

Hyman: Yes, they do. The brain communicates with chemicals, it uses chemicals as its "words" and those chemicals control the brain's electrical activity. And what all the addictive drugs have in common is that they are mimics. They masquerade as natural chemicals in these reward circuits. Drugs like cocaine, for example, are like Trojan horses. In essence, what coke does is it gets into the apparatus that usually turns off the dopamine signal. And this apparatus recognizes that "Hey, this thing isn't dopamine at all," but it's already blocked. So it can't send the signal "no more dopamine"  -- it's quite literally a Trojan horse.

Moyers: The cocaine tricks the brain into making dopamine more active?

Hyman: That's exactly right. Now, let's think about this brain reward circuit and what it might be doing. Say that you have discovered a delicious and wonderful new food. You don't have to study this, you remember it right away and you remember it with pleasure and with indeed a certain amount of desire. When this memory is laid down, a certain amount of dopamine is probably released in this brain reward circuit, in this meso-accumbens circuit.

Moyers: So why doesn't the brain get addicted to broccoli?

Hyman: The simple answer is that broccoli doesn't have chemicals in it which short-circuit the system and provide abnormally elevated rewards. Because what people who use cocaine or amphetamine discover is that they can circumvent all of the work it normally takes to get some natural reward. I've talked about discovering the good taste of a new food. But imagine that you've just finished a marvelous documentary. And you feel a certain amount of pride and reward and you get a certain amount of dopamine for that.

Moyers: Till I read the review.

Hyman: Till you read the review, exactly. Then your amygdala (which codes fear and anger, amongst other things) starts firing.

Moyers: [LAUGHS]

Hyman: Basically the drug abuser finds that these drugs, at least initially, give them a kind of euphoria. A kind of self confidence. A feeling that they can achieve only with extreme difficulty using natural stimuli.

Moyers: There's no natural high quite as high as a drug high?

Hyman: No, because the drugs really do trick the brain. Cocaine and amphetamine put more dopamine in key synapses over a longer period of time in this brain reward pathway than normal. And because they are so rewarding, because they tap right into a circuit that we have in our brains, whose job it is to say something like, "Yes, that was good. Let's do it again and let's remember exactly how we did it," people will take these drugs again and again and again.

Moyers: What about tobacco? I mean, a lot of times when children smoke that first cigarette they will cough and choke because they don't like it. But they'll have another cigarette and another. What's going on there?

Hyman: With drugs that are harder to like at first, like tobacco, people teach each other to enjoy them. The peers of a child trying his first cigarette create an atmosphere where that act receives approbation, where toughing it out is respected and cool. And pretty soon they get over the initial irritation and cough. And soon after that, they find out they're hooked.

Moyers: And are they hooked because nicotine has done for this pleasure pathway what the cocaine has done for the user?

Hyman: Yes, though maybe not as profoundly. All of the most addictive drugs, either directly like cocaine and amphetamine or indirectly, like nicotine, alcohol, opiates, cause release of dopamine in this brain reward pathway.

Moyers: And because the dopamine is released I have the impression that something really good is happening to me?

Hyman: Yes, and here's the important thing. You have a subjective feeling of euphoria. You feel when you take these drugs that something really good is happening to you. You feel, as I've said, either high or in the case of cocaine and amphetamines, that you have great confidence. The world is bright. The problem is that these drugs are like a sledgehammer in the brain. While the person is feeling this euphoria, other things are happening. You see, our cells have all kinds of mechanisms to adapt to powerful environmental stimuli that they see as a stress. It's called homeostasis, trying to keep functioning well under constantly changing environmental conditions.

Perhaps the best example I can give you is going to the gym and lifting weights. The first time you go, you strain your muscles, right? You have sore arms after you lift weights. But if you go back to the gym and lift very heavy weights, (think drug dose), you do it enough times a week (think frequency of drug administration), and you do it for long enough (think chronicity), what happens? A signal goes from these poor strained muscle membranes to the very nucleus of the cell, which contains the genetic material. And it says basically, "We've got to adapt, we're under a lot of stress here." And the muscle cell turns on the genes that make structural proteins and over time we get what a body builder considers a very positive adaptation -- big muscles.

Moyers: The gene is saying, "Hey, guys, I need more protein."

Hyman: Exactly, "Give me more protein." Now let's go to the drug addict's brain. Here's this poor synapse which has never seen so much dopamine for so long in its life, what is it going to do? The dopamine on the one hand may be helping the drug user feel euphoria, but at the same time, the receptor cell isn't very happy. It's stressed. What happens? First, it's trying to decrease the efficacy of this dopamine signal so it won't hit it so hard, and it's saying "Enough, too much." It sends signals to other cells to say, "Turn this off." So adaptation occurs, and we see the clinical realities of this when somebody ends a cocaine binge. At that point, there might be less dopamine in the brain or the dopamine that's there might be less effective than prior to drug use. So after a cocaine binge, the brain is physically changed -- it's adapted. But that adaptation, less dopamine now, means that the drug user feels bad. The drug user can't feel pleasure. The drug user might feel depressed and is craving more drug.

Moyers: His body is saying it wants more dopamine, he can't get it, so he physically gets depressed.

Hyman: In effect, yes. But the addict doesn't know that that's what's happening. What the addict knows, or thinks is correct, is, "I will feel better if I put myself back in this precise context where I felt good and use my drug." This is the learning side of it, the emotional memory. It may not be true that taking the drug will make him feel better, but that's what using the drug teaches him. And part of that memory is not only the emotion, but the whole context. The friends that they see when they are using drugs, the paraphernalia, the kind of room they are in or the kind of alley, all become attached to the ritual and the feelings of getting high. They become part of the brain's "emotional memory."

Moyers: That's why AA talks about "people, places, and things." Avoid the people you used with, avoid the places you used, and avoid the things associated with use like the pipe.

Hyman: That's absolutely right. Remember, the dopamine in this brain reward circuit is still saying, "That was good, let's do it again, and let's remember exactly how we did it." So there's this emotional learning that goes on which is in many ways the longest lived change in the brain.

Moyers: Perhaps this is what we mean when we talk about indelible memories.

Hyman: I think that's right. And one of the things that Alcoholics Anonymous says is that alcoholics are not recovered, they are recovering. I think they're right because there are many things in the brain that make it likely that once addicted you're at high risk of relapse and one of the most important is this indelible memory. We know that when people are detoxified and then they're back in a situation where they used to use drugs, they may experience certain feelings. In the case of the cocaine user, they might feel a little bit high. Which makes them want more. In the case of the heroin addict, some of them actually feel a little bit of withdrawal, and that makes them want the drug. A common experience for ex-smokers is that they'll have a festive meal and be reminded that they used to enjoy a cigarette at such times and they will feel waves of craving. These are cues which are awakening these powerful memories. When something is highly rewarding, we are likely to remember it vividly and also to remember the circumstances under which we encountered it. Even after years of abstinence, people may experience profound cravings and risk relapse if placed in the surroundings of their former drug use.

Moyers: You've referred to the reward circuit as part of the "old brain." What do you mean, the "old brain," and why might we have a reward region in the first place?

Hyman: Well, the idea of an older part of the brain really comes from study of comparative neuroanatomy that looks at lizards and evolutionary older mammals and compares them to primates and humans. And what we see is a very developed neocortex in humans, which is the outer layer of our brain and has been linked with reasoning. Our cerebral cortex appeared relatively recently in evolution. But some of the emotional circuits in the brain have been around for a much longer time. That's why they have gotten the moniker "the lizard brain," because of their evolutionary history. But it's unfair to equate all of our emotions with lizards because after all, they do a lot of good things for us as well. What makes us fundamentally human is not thinking alone or emotion alone but a combination of the two. In fact, what makes us different from computers is certainly emotion. And some of the highest human feelings like love or altruism are human, as well as fear or anger or pain which we share with lizards. It's the interweaving of emotion and cognition that allows us to make any decision that we make in life. The important thing is that we have dedicated circuits in the brain which are involved in emotion. I mean, imagine the world without emotion. All meaning would drain out of it -- it would just be a world of cold facts. The world comes to us instead, full of rich meaning. Things have a valence. They make us happy or sad. Some things are fearsome, some things are enjoyable, some make us curious. Some are edible. And the emotional part of our brain is making appraisals. It's saying this can hurt us, this is good for us. And in making those appraisals, the emotional parts of our brain start all kinds of downstream reactions. The emotion of fear, for example, starts our hearts racing.

Moyers: But what does this have to do with that old lizard brain? Why would the lizard have eveloped a brain that would assign priorities of value?

Hyman: Well, probably not so that it could write philosophical texts about value. The circuit most likely developed to control behavior quickly. At the simplest level, any animal needs to be able to judge what to avoid and what to approach. It needs to evaluate situations and react to them immediately. It can't be sitting there thinking, "Hmmm. Is this food or is this something that will eat me?" It has to react as soon as a threat is spotted, otherwise it won't live very long.

Emotions really are circuits in our brain that allow us to survive. Now this is speculation, but just imagine some of the roles for this reward circuit in evolution. Without something to make sex appealing, nature's experiment with sexual reproduction would have been a great failure. We would have been perhaps budding like yeast or something, with no need for a sexual partner or the sex act. And while that sounds kind of silly, the fact is there has to be something extremely compelling about reproduction in order to get the job done because, as any parent knows, the process of having a child is not always easy. If sex gave no pleasure, or you didn't remember or desire that pleasure, you wouldn't reproduce yourself. But also, evolution couldn't hardwire every possible response into our brains. We're going to encounter all kinds of new and unexpected situations in our world. And so this reward circuit has to be able to learn. And when it's something like a new food that's good for us, or something that is healing or useful, then we've learned about something that's going to be adaptive.

Moyers: Let me make sure I understand this. In terms of survival, the more relevant something is to survival, the more likely we are to remember it?

Hyman: That's very well put. The more relevant something is to our survival, the more likely we are to remember it. Again, let's contrast having to study some dry as dust material in the classroom, where you have to rehearse and rehearse to remember it, and compare that with something that's really emotionally charged. You just don't forget your first love, but most of us forget the Pythagorean theorem. The other thing which is very important is that key parts of memory are not necessarily conscious. They are memories that get us to control behavior -- that motivate us, if you will. So, for example, if you encounter something that has hurt you badly in the past -- let's imagine you have been bitten by a snake once, and you're now hiking along and you find yourself in just the kind of country where you were bitten before -- before you even realize it, you might find that your heart is racing, that your palms are sweaty, and that you're vigilant and ready to escape. I think the important point here is that emotion paints the world with meaning. Emotion says this is important, that is dangerous, this is good. And it paints the experience in such a way that our conscious minds may be involved but all kinds of unconscious processes are also involved.

I think some of the stigma of addiction results from a misunderstanding of these unconscious processes. Because the illness is largely invisible, but also because when people look inside themselves, they don't realize they can't see everything that motivates their own behavior. We don't recognize, for example, that when I reach over to point my finger at you, all kinds of things have happened in the background of my brain. It calculated a trajectory, it stabilized my shoulder girdle, it told certain muscles to fire up so many hundred milliseconds and opposing muscles to fire up so many hundred milliseconds. If I had to calculate the trajectory and do the fine tuning as I approach my target, I don't think I would be very successful in pointing at you; in fact, I might well hit you instead. And it's the same thing with emotional processing. Lots of things which we aren't wholly aware of are going on in the background, telling us about the emotional valence of the world. For the addicted person, it's saying, "You know, you better get another drink now because we're running out here and the world's getting pretty bleak." Addicts aren't willfully choosing those background thoughts and feelings and drives, and non-addicted people don't have to contend with them.

Moyers: Are those background thoughts predetermined?

Hyman: Well, with reproduction, for example, the desire is very much hardwired. Witness all of the hard work that people have to do in order to avoid sexual desire when in certain religions they decide they're going to be celibate. It takes a great act of will to overcome, in this case, these very hardwired desires that evolution, interested as it was in reproductive success, put into us.

Moyers: What do you mean, "hardwired"?

Hyman: Certain responses in our brain, like sexual desire, develop through pre-existing genetic programs which we are born with. We may experience aspects of sex and find them good or rewarding or disappointing or what have you, but we are born to find sex pleasurable. If people were designed to avoid sex, there wouldn't be too many of us around, would there? But because the world is complicated and unpredictable, nature could not have built in a list of everything that was going to be good, of everything that could hurt us, of everything we ought to be afraid of. And so these emotional circuits have some built in functions, but perhaps the most important thing they do for us in our lives is, they learn. But there can be a danger here because in many ways emotional circuits take our higher processing out of the loop. They literally cut it out, by bypassing those pathways and -- crucially for our understanding of addiction -- push our behavior before we've really had time to look rationally at all its implications. And so when you've learned to like a drug, you find you're already going after it before you've thought about it. If you talk to an alcoholic or a drug addict, they will tell you they often wake up in the morning and they say "I'm not going to use today. Right. In fact, I'm never going to use again." And then they go out in the world and they see their drinking buddies and the sight of them taps into these emotional memories. The voice of reason, of conscious control, becomes a rather small voice in competition with this intense emotional sense of craving and need.

Moyers: So while the rational brain has said "never again," the emotional brain circumvents it?

Hyman: That's right.

Moyers: So which part of the brain ultimately determines our behavior?

Hyman: Well, it's both really, but this emotional brain has an awful lot to say about our behavioral priorities. As I said, emotional circuits are survival circuits. And when they get literally perverted by drugs, they still have an awful lot to say about what we should do first and what we should think about. Just consider the behavior of an alcoholic or a drug addict. First of all, many long term alcoholics stop enjoying alcohol, either because of tolerance or physical illness, so they're not even getting pleasure from it anymore. And they may recognize that they have wrecked their family life. Their job is in question, or it's gone. They've lost their social status, and yet they keep drinking. How is it possible for people to do that? What I would say is that the critical circuit in the brain, which is involved in setting our behavioral priorities, has been usurped by the drug. The long term interest of the person -- rationality -- is barely audible in the calculations of a drug-impaired brain.

Moyers: It's no longer driving the assigning of value, the creation of motivation?

Hyman: Right. And we can sit here and talk about it, but it's actually people's stories that really take your breath away. I mean, when you hear the story of a woman ignoring or even selling her children to get more crack cocaine, it's easy to say this must be a bad person, but that's not necessarily the case. This is someone whose behavior has been totally usurped by drugs, whose ability to set priorities has been totally deranged by drugs.

Moyers: Is this why you call addiction a disease of the brain?

Hyman: This is exactly why I call addiction a disease of the brain. What happens is, in the vulnerable brain -- not everyone who experiments with drugs is going to get addicted -- in the vulnerable brain, if you use drugs at a high enough dose, frequently enough, and for long enough, you literally change the way the brain works, you change the way nerve cells communicate in such a way that you develop this compulsive, out-of-control use despite knowing that all kinds of terrible things can happen to you, and despite even experiencing many of those things.

Moyers: Do you have any hope that we might be able to identify the vulnerable person early enough to intervene?

Hyman: I think that we're going to be able to identify vulnerability, and then it's a different question as to how we intervene. For alcohol, I think it's pretty clear that those people who have the early-onset, severest forms of alcoholism are genetically predisposed.

Moyers: But even when we say it's genetic, there's still more to say, isn't there? My brother became addicted to cigarettes. He died very early because of his addiction. But I never felt addicted to tobacco.

Hyman: Well, you might not have shared all of the same genes, but what you're saying is actually quite important. Which is that for things as complicated as behavior we don't have any situation that I know of where genes have all of the say. Where we have total genetic determinism. Rather, for behavior what we have is a complex dance of genes and environment building a brain as we develop, creating us as we experience the world, and as we behave. It's a very complicated dance that we're only just starting to unravel. But I don't think that we are ever going to find a piece of DNA that will make someone an alcoholic 100% of the time. Rather, what we're going to find are pieces of DNA that are part of the instructions for building a brain. These instructions are read out in the context of our environment. Starting before we're born, in utero, and continuing well after we're born. And in combination with many other genes, we emerge as people with certain traits that the genes give us a bias toward. For reasons that we don't yet understand, some genes create a risk of alcoholism -- in some young men a risk that may be as much as tenfold greater than in people who don't have those genes.

Moyers: What's your response to someone who says to you, "Sure, Doc, I'd like to quit, but my DNA won't let me?"

Hyman: That question gets to the heart of the controversy over the disease model. We know that addiction looks every bit like a disease. But the problem is that the disease model can be misinterpreted. An addict could retort, as you suggest, "Gee, I'd like to say no, Doc, but I'm just a helpless tool of my DNA." But the disease model doesn't mean that we can't ask people to be responsible for themselves. Because the brain doesn't have only one pathway. It has this remarkable complexity of myriad circuits and trillions and maybe quadrillions of synapses.

Moyers: It's a universe.

Hyman: Yes, and it divides up tasks -- it's redundant, if you will. So while part of the brain may be perverted by the drug, and one set of circuits may be really out of whack, there are other circuits at work. People who are addicted still remain engageable. Other parts of their brain are still working. Now, it's not easy to engage them. And it's not easy because in addiction, literally, the organ of compliance, the part of the brain that's involved in setting behavioral priorities, is affected.

Moyers: Well, if the brain has been compromised by the drugs, and if the desire to use has become a commanding motivation, is that person capable of responsible choices? Is the addict still a moral agent, capable of free choice?

Hyman: I believe that the addict is still a moral agent, but his ability or her ability to exercise free choice is very much compromised. And I believe it is the job of the family, the employer, the doctor, the community, to serve almost as a prosthesis.

Moyers: Explain that.

Hyman: Everyone around the addict needs to work together to bolster what's good and capable in the patient. To prop up his motivation to change and help this addicted person to recover. People need help to counter the intense desire for another drink or "hit."

Moyers: I see so many mothers and fathers and sisters and brothers and friends and employers get so angry and frustrated at somebody they love or care about who just won't stop. The addict seems to willfully disregard all of our efforts to help.

Hyman: Well, yes, in the beginning picking up a drink is a voluntary act, but we have to look past that and ask about the motivation. The addicted person is not able to select his or her motives. The part of the brain that is selecting behavioral priorities is compromised. So the motor behavior, picking up a drink, seeking drugs, smoking cocaine is really the downstream expression of something that's broken, which is this whole set of motivations. We can't see them -- from the outside, an alcoholic taking a drink looks like anyone else engaged in that behavior. But what's happening in his head is different. The important thing for us to remember is just how hard it is for the addicted person to stop. And how much support they need in order to be able to stop. Take heart patients. We don't blame them for having heart disease, but we ask them to follow a certain diet, to exercise, to comply with medication regimes. So it is with the addicted person -- we shouldn't blame them for the disease, but we should treat them as having responsibility for their recovery. One critical difference between addiction and heart disease is that the substance -- illicit drugs or alcohol or nicotine -- can markedly diminish the ability of the patient to follow through on medical advice. So the patient's family, friends, employers, etc., must shore up whatever strengths the patient has in order to help him stop. We have to help addicts get treatment, and support them in staying with it.

Moyers: So even though drugs have changed the brain, it can be changed back?

Hyman: I don't think that you can have your brain back just the way it was, but I certainly believe recovery is possible. There are some changes in your brain that may be irreversible, especially the kinds of emotional memories that we talked about, they may really be indelible. But people who have a stroke are able to recover by using other parts of their brain which weren't affected. It seems extreme, but you might think of someone who is addicted almost as if they've had a peculiar kind of stroke, which affects their motivation and self-will.

Moyers: What can we expect from the addict?

Hyman: Well, my experience as a clinician is that many addicts are just not ready to give it up. Drugs are too important. They still are experiencing mostly positive consequences from using. But eventually, people very often get into a position where the negative consequences of their addiction begin to outweigh the positive.

Moyers: They hit bottom, in the language of AA.

Hyman: Yes. Now, some of these people actually stop by themselves. It's really quite remarkable. But many people, perhaps most, need treatment. And when you address somebody like this, often you're met initially with anger or denial. After all, what you're saying is, "I'm going to ask you to give up the central thing in your life. That thing without which you think you can't go on." So it's not surprising that people don't say, "Sure, Doc, fine. Where's the nearest treatment program?" You have to be persistent. And non-judgmental. I think what you really have to do is sit with the addicted person and face the problem together and say, well, "How about the traffic accident you caused? How about this abnormal liver test? What are we going to do about it?" You start to engage the person, but recognize that it might well take time before he or she quits entirely.

Moyers: If I were your patient, and I relapsed once, you would not consider our relationship a failure?

Hyman: Absolutely not.

Moyers: If I relapsed a second time?

Hyman: I would not consider it a failure. But if you keep relapsing and we sit here and talk about your alcoholism at every session and you do nothing to get treatment, then we're not doing something right. It would be easy for me to say that you're so sick that I can't help you. It would be easy for me to say, "I've done my job because I've issued a stern warning." But what we really have to do when somebody either doesn't get treatment or keeps relapsing is to ask, "What am I not mobilizing to get this person into treatment?" Maybe I have to get the family and the employer involved. Maybe I need to approach you differently. This disease is a terrible enemy once it is dug in.

Moyers: Do you think we will ever eliminate the desire people have to try drugs?

Hyman: No, I don't think so. I think that part of our humanity is that many people are curious about transcending themselves. People are curious about new experiences. Some people are suffering and looking for ways of feeling better. And people will experiment with drugs. In a healthy society we can help people avoid the most dangerous drugs and we can help people get well if they become hooked.

Moyers: If addiction is about learning, why doesn't the addict learn that withdrawal in certain cases is so painful, so abominable, so awful that the brain says, "I don't want to go through that again, so I won't use."

Hyman: One of the really striking things about human beings is that we have a lot of trouble thinking about long-term risk. We are very short-term creatures indeed. Also, you see, withdrawal is very painful, but it's not actually associated with the drug. What's associated with the drug is pleasure and relief. The withdrawal syndrome is occurring in isolation and without the drug. Indeed, it is accompanied by intense craving for the drug. So the withdrawal does not in any way extinguish or do away with the impulse, the craving, the desire for drugs. Indeed, one of the important challenges to us as a species is how we can figure out ways of dealing with our inability to conform our behavior to our long-term best interest.

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Alan Leshner | Steven Hyman | George Koob





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