Escalating numbers of people in South Africa and worldwide are addicted to substances and destructive behaviours. What causes addiction? Why is it on the increase? What can be done about it?
It’s year-end – a time when most of us feel licensed to let go and indulge. The pact we make with ourselves is that we will commit to restraint and balance in the new year. With addictions, the new year is perpetually deferred.
Counsellors talk about how increasing numbers of people across the socio-economic spectrum are engaging in addictive behaviour, from gambling, to eating; from porn to sugar; from drugs to shopping. Addiction is defined as a physical or psychological need for a habit-forming activity or substance.
If we look at drugs, the range and availability, is staggering. In South Africa, as little as R10 buys a hit of nyaope – a combination of heroin and marijuana. Like all drugs, cheap or expensive, for a few moments it offers a feeling of contentment, happiness, of having no cares in the world. You want to repeat this, but soon you no longer feel contentment or happiness from taking more; now you need the hit just to cope and avoid withdrawal..
It’s the same with most addictions, and many addicts convince themselves that they will start phasing out the substance or activity. This approach inevitably fails and, sooner or later, they come crashing down.
If the addict is a child there are other complexities because they don’t understand that what they are doing will have negative, long-term effects.
WITSReview spoke to a range of counsellors, doctors, psychiatrists and scientists, about the different perspectives on addiction.
Definition of Addiction
The American Society of Addiction Medicine (AMSAM) is a professional society representing over 4,000 physicians, clinicians and associated professionals in the field of addiction medicine.
It defines addiction as:
Short Definition of Addiction:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterised by an inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
Dr Hashendra Ramjee –
We do not like the term “social drinking”
Wits alumnus Dr Hashendra Ramjee (MBBCh 1997) is an executive member of the South African Addiction Medicine Society. After completing his medical degree at Wits, Dr Ramjee worked and trained for two years in the United Kingdom in the field of specialised addiction medicine. He returned to South Africa in 2005 and is currently a consultant for the Intensive Inpatient Programme at the Houghton House Group of treatment centres, and at the Akeso Psychiatric Clinic.
The extended inpatient care programme at Houghton House, known as the GAP, was established by two Wits alumni, psychologist Dan Wolf (BA 1995, MEd 2001) and psychiatrist Dr Charles Perkel (MBBCh 1985), together with psychologist Allan Sweiden. Houghton House was founded by Alex Hamlyn who was a drug addict for 17 years, has been clean for 22 years and is part of the counseling team at Houghton House and The Gap in Joburg.
The most pervasive addictive substance
He starts the discussion with South Africa’s most pervasive addictive substance: alcohol. “It is legal and available, and we associate it with socialising and celebration. The effect of this is to sanction drinking and mask potential addiction, which is why we do not like the term ‘social drinking’,” Dr Ramjee says.
South Africa is not one of the world’s highest-consuming countries. However, South Africans who drink, drink very hard, according to the World Health Organisation.
When does drinking become an addiction? Is it only if you are a very hard drinker? “Not at all,” says Dr Ramjee. “We quantify a person’s alcohol consumption in terms of the units they drink, with 12gm equating to one unit of alcohol. For women we limit alcohol consumption to one or two units a day and men to two units. Anything more can indicate a drinking problem.”
We need to ask the hard questions
He explains that addiction is not restricted to the stereotype of someone hitting rock bottom. There is a very important “in-between phase” that people need to be aware of, with red flags lining the way. “We need to ask the hard questions, such as why someone is regularly out drinking, including late at night, when they have a family at home.”
While some addictions are obvious, others are difficult to pick up until they are far down the line. An example is the person who is addicted to over-the-counter painkillers or the person whose work revolves around drinking and socialising.
Highly defensive reaction
When asked about their behaviour, he says, many people will become highly defensive.
He believes that “a multi-disciplinary approach gives people in recovery the best chance of staying clean”. It’s important to monitor the physical and the mental progress of patients as they move through treatment, from detoxification and stabilisation to medication management and relapse prevention.
“I work closely with a psychiatrist, neurologist, psychologists and social workers and occupational therapists, as well as the patient’s family and the judicial and policing services as they all have an important role to play.”
A routine problem for GPs
Dr Ramjee says all forms of substance abuse, including stimulants and anabolic steroids used by sports people, have become so prevalent in South Africa that GPs regard it as a routine problem.
“It is therefore extremely important for Health Sciences students and professionals to thoroughly understand substance use disorders and how to identify the various forms, as well as other co-existing mental health disorders and medical disorders, which can lead to significant dysfunction in an individual’s social, psychological and physical wellbeing. This includes behaviour that puts the person at life-threatening risk.
“Doctors, medics, pharmacists, paramedics, nurses and community health workers all need more training in addiction. The treatment-providing community in South Africa is small and therefore it is all the more important to expand the awareness and prevention side. People need to be able to go to their clinic or doctor and ask for help, just as if they had diabetes or any other issue.”
Addiction affects everyone
Dan Wolf, the Director of the Houghton House Group of Treatment Centres, has a Master’s in Psychology from Wits. In 2000 he pioneered the first intensive outpatient addiction recovery programme, called First Step, and is recognised as a national expert on addiction treatment.
“Addiction, substance abuse, avoiding reality or whatever you want to call it affects everyone, all ages, all cultures, all socio-economic groups, and we have seen a significant increase over the past couple of years,” he says.
Fuelling this is the accessibility of a wide range of drugs, including cocaine, heroin and methamphetamine, as well as other potentially addictive avenues, such as online porn and online affairs.
Wolf says: “Addiction is not a clinical term; the more clinical term used today is ‘substance use disorder’. The term addiction also applies to certain behaviours and can therefore be understood as getting stuck in a place of dependence, or, in some instances, getting stuck in adolescence. This is indicated by behaviours that display resistance to independence.
“True independence isn’t about being an outsider or backpacking around India, it is a stage of adult life that requires delaying gratification, taking responsibility, facing emotionally challenging situations, making sacrifices to achieve goals and meeting commitments. These are consciously developed qualities that draw on our higher human potential, as opposed to living in a more unconscious, instinctive way.”
Part of the problem, he elaborates, is that too many people expect life to be easy and the more our society moves towards technology and convenience, the more people become predisposed to instant gratification and living a life that doesn’t require ongoing effort and resilience.
“It is easy to become addicted in our society but it is not easy to decide it’s time to leave the party because it requires far-reaching changes in the person’s life, and it literally requires re-training neural pathways in a life-affirming direction.”
Rehab – a minimum of three weeks
“Inpatients come to us for a minimum of 30 days and we have a strong 12-step recovery programme, which originated from the Alcoholics Anonymous 12-step approach, but it is not about forcing people to believe in God or a specific religion,” he explains.
“A major issue in South Africa is that while people with medical aid insurance can be referred to private, inpatient treatment centres, there is a critical shortage of state facilities and facilities for adolescents.”
Is addiction genetic?
“As a neuroscientist I’m interested in the mechanisms of addiction. What has always fascinated me is why people would do such harm to themselves and commit offences. It reflects how powerful the addictive behaviour must be that it takes over your judgement,” says Professor William Daniels, Head of the School of Physiology at Wits.
A key research area in this field for Prof Daniels is the inheritability of addiction. If a child’s mother or father is an addict, will the child be predisposed to addiction? And what role does the social context of an individual play in fostering addiction?
To research this he is part of a group of South African and Moroccan neuroscientists who are collaborating with the University of Zurich in Switzerland. They are observing mice which have access to good food, water, liquid cocaine and alcohol, each offered in an accessible container, respectively situated in the four corners of a cage.
Prof Daniels explains: “It’s long-term research and we are not ready to report on the findings, but what we are researching is whether any patterns can be observed over time. For example, do any of the mice start drinking the beer and progress to the cocaine, in other words, demonstrate the gateway theory of addiction? Or do they show an addictive preference for either, or do they avoid them altogether and stick to the food and water? We are also looking at whether any of the mice adopt the behaviour of their more experimental or addictive peers.”
Is addiction a brain disease?
This is the question posed by Yale University psychiatry lecturer Dr Sally Satel in an article in The Conversation on 10 May 2016. She says brain changes do occur as a result of addiction, but “it is a problem of the person”.
She elaborates that addiction cannot be said to be beyond the control of an addict in the same way as the symptoms of Alzheimer’s disease or multiple sclerosis are beyond the control of the afflicted person.
“That is why recovery from addiction is possible.
“Take, for example, the case of physicians and pilots with drug or alcohol addiction. When these individuals are reported to their oversight boards, they are monitored closely for several years. They are suspended for a period of time and return to work on probation and under strict supervision. If they don’t comply with set rules, they have a lot to lose (jobs, income, status). It is no coincidence that their recovery rates are high. They choose their job, income and status over the addiction.”
Satel says people choose to take addictive substances because “at the start of an episode of addiction, the drug increases in enjoyment value”. At the same time, once-rewarding activities such as relationships, job or family recede in enjoyment value.
“The appeal of using inevitably starts to fade as consequences pile up – spending too much money, disappointing loved ones, attracting suspicion at work – but the drug still retains value because it now salves psychic pain, suppresses withdrawal symptoms and douses intense craving.”
While the use of medication can help patients in the withdrawal phase, the patient has to exercise choice in turning away from the addiction for recovery to be successful, she says. To imply that they are merely helpless victims of a brain disease takes choice away from them.
Ancient circuitry, anticipation, addiction
The familiar routes we follow to our bottle store, shopping centre, drug dealer, illicit affair, online porn site … these are physical or electronic routes but at the same time they create well-trodden mental pathways in our brains with powerful feelings of anticipation.
The nature of well-trodden pathways is that we will follow them again and again. We literally have to re-route our brains to new pathways and redirect our feelings of anticipation.
Johannesburg-based counsellor, life coach and author Stephanie Vermeulen explains this in her latest book, Personal Intelligence: Future Fit Now (EQ+IQ).
“We have been led to believe that the rational brain rules our lives, but the ancient circuitry of our brains defies this in its constant seeking of a ‘feel good’ response,” she says.
“The ancient circuitry developed when we first roamed the earth and pursued activities that ensured our survival, notably finding food and procreating. As part of the evolutionary process, our brains developed a feel-good circuitry response to these activities, with an associated surge of the neurochemical dopamine, known as the ‘reward chemical’.”
Dopamine doesn’t surge when we achieve the activity: it surges in anticipation of it.
“Our brain is much the same piece of kit as the one our ancestors used all those aeons ago, only it has to deal with far greater complexity today. The anticipation of food or sex has expanded into a wide range of tempting activities with an equally powerful anticipatory response, which can lead to harmful addictions.”
The effect of the addictive substance or activity compounds the problem – we might enjoy the effect or we might dislike the dark places to which it takes us, but this is secondary to the wanting, to the anticipation.
“Complicating this response is socially imprinted reinforcement that something will make us feel better,” Vermeulen continues. “We know the feel-good factor is short-lived and should be avoided, but the wanting circuit overrides all sensible thoughts.
“It is the same for any addiction; the familiar circuitry dominates,” Vermeulen says. “We see this in young boys and girls who grow up with easy access to online content, such as porn. If a young boy or girl takes a look at porn and if it sets off some form of sexual response or fantasy, the wanting circuitry is laid down.”
She says the ancient wanting circuitry has many outlets, including religion. Replacing alcohol or drug addiction with religion has helped many people, but unless the underlying issues are addressed, there is the risk of relapse.
As American transformational behaviour specialist Dr Judith Wright says, to manage our emotions and our mental circuitry we need to become far more conscious of what we are doing and why. We need to recognise our patterns and understand the rush is in the pursuit; even the most exhilarating effect is short-lived.
With the help of a therapist who understands addictions, we need to retrain our brains to seek out new, healthy feel-good paths, such as exercise or having fun with our friends and families. Behaviour modification is key, says Vermeulen, who believes that “getting back to basics is far more fulfilling than chasing tinsel”.
The instant gratification, consumerist society of “I want it and I deserve it now” has fuelled our addiction circuitry and the result is many people land up in debt, in rehabilitation centres or deeply unfulfilled, anxious and depressed.
Addiction at work
Experienced counsellor Carolyn Dugmore, whose Wits degrees include a Master’s in Social Work (2014), counsels for ICAS (Independent Counselling and Advisory Services) in South Africa, which focuses on employee wellness and behavioural risk management for corporates. She says dependence on substances, including drugs (illegal or legal), alcohol and sugar or food, is a notable problem in the corporate sector. There has also been a rise in technology-related dependencies, such as internet addiction disorder, internet gaming addiction, cyber relationship addiction and cyber porn addiction.
“In the corporate sector, life is highly pressured at all levels and people are using various avenues to manage the pressure, ease anxiety, lift depression and escape from daily worries.”
Addictions can lead to disciplinary issues such as absenteeism, late-coming, injuries and accidents, lying, theft and conflict with colleagues.
Denial and facts
When confronted about their addiction, people tend to deny it, minimise the problem, rationalise it or project it onto other people, says Dugmore. “Emotional confrontations often do not work because feelings can be debated. Confronting the person with facts is usually essential. Facts include being arrested for drunk driving, abuse of a spouse while drunk or on drugs, receiving a protection order, and being blacklisted due to debt problems.
“If I am seeing a person with an addiction problem who is defensive about it, I often ask them to write down over a week or two what they are using and how much. I find that this method, if they are honest about their use, helps to bring about the recognition of the impact on their life, and then to make the choice to change their actions.
What family and friends can do
“One approach is to ask the person with the problem to meet with a group of two to four people who have influence in his or her life. They each present some facts connected to the person’s dependency in a concerned and respectful manner, with the goal of assisting the person to accept reality and, if possible, to make a firm commitment for treatment.”
Dugmore says the problem might need to be assessed by a social worker, psychologist, psychiatrist or GP. Support groups such as Gamblers Anonymous, Overeaters Anonymous, Alcoholics and Narcotics Anonymous are also excellent sources of support.
What causes addiction?
Astrid Bleazby-Hodgetts, MA Clinical Psychology, Wits:“There are many factors that can contribute to the development of addiction. For some it starts as experimentation through curiosity or peer pressure. Other contributing factors include unresolved trauma, poorly developed coping mechanisms, low self-esteem, a genetic predisposition or a pre-existing mental health problem. Getting to the root cause for each individual is essential in understanding and addressing their addiction.
“Early intervention and prevention programmes that target the youth and provide education on substance abuse may help in addressing addiction and preventing the youth from experimenting.”
How a drug addict reclaimed his life
The founder of addiction treatment centre Houghton House is Alex Hamlyn. He was a drug addict for 17 years, has been clean for 22 years and is part of the counseling team at Houghton House and The Gap in Joburg. This is his story:
I started using drugs at the age of 13 and used to a greater or lesser extent until I was 30. There didn’t seem to be anything in my life that drew me towards drugs; I came from a reasonably functional family, I think I was a popular, reasonably well-adjusted adolescent.
I smoked my first joint quite excitedly and a little bit cautiously. I enjoyed the experience and there didn’t seem to be anything negative about it, and so I continued to do it. I think it was availability. Somebody would say ‘I can get you some magic mushrooms’, and I would say, okay, good, and then someone would say ‘I can get you some amphetamine’. There wasn’t even a hesitation; it was if you can get them, I want them.
When I was 16, I was introduced to cocaine and I thought that was very smart and very fashionable, associated with the jet set lifestyle, which was a million miles from where I was but it was a taste of it. So looking back at what was happening, I was spending all of my spare time, all of my social life getting hold of and using drugs, to the exclusion of everything else.
We called it partying
At the time we called it partying and I was only interested in partying, I didn’t do anything much else and even when I started properly using heroin at the age of 18, I still didn’t think it was a problem, I thought it was a lifestyle choice and kind of cool. There was a club where everyone was using heroin and these were the cool guys and I wanted to be part of that.
I liked getting high
I liked getting high. I liked being able to alter the way that I felt from one minute to the next, I liked the power and the control that it gave me. If I was feeling happy, I could feel happier, if I was feeling bad I could tune it out; it felt as if it gave me control and it felt nice. Until that changed.
On one particular evening I’d taken two microdots (LSD) and I had gone with a friend to a club where we were looking in the mirror and pulling faces, freaking each other out and it was all fun, but my friend had obviously upset somebody and grabbed his ear and tried to cut it off, or that is what appeared to happen. There was blood everywhere and I was scared and tripping really heavily. I just lost control and I tipped over the edge into this kind of nightmare of paranoia and panic.
I persuaded some friends there to put me in a taxi and send me home to my parents’ house. They asked me what had happened and when I said I had taken too much acid, they took me to hospital.
I thought he didn’t know what he was talking about
A psychiatrist there asked me what I had taken, and I thought he meant in my life, so I said marijuana, hashish, ecstasy, amphetamines, poppers, heroin, cocaine … I gave him this long list of drugs. He told me it wasn’t normal for a boy of 17 to be taking the drugs I was taking, but I thought he didn’t know what he was talking about.
I was so convinced that what I was doing was okay that I carried on. Age 26 to 30 was just a nightmare, I was so hooked I couldn’t find a way out. I had been injecting heroin for eight years, my veins had collapsed, I had abscesses, I was really looking the part, and not only was there a problem finding the money to get the drug I couldn’t get it into my system, I couldn’t find a vein.
I wasn’t under any delusion that this was fun anymore; this was painful and difficult. I felt angry and sorry for myself and this allowed me to commit crime and to be unpleasant, to not care that I was hurting my parents or my friends or anybody who cared about me.
My self-respect had degenerated
My self-respect had degenerated to such an extent that I would stop in the nearest public toilet and catch the water from the toilet to cook up the heroin and I didn’t care. I was self-destructing and at some level I knew it. I was getting more and more overtly suicidal. So much so that the last memory I have of using was with a lethal dose of heroin in my hand and thinking death would be so much better than what I was doing. But I couldn’t find a vein to get the dose into my body. I couldn’t even kill myself.
The moment of surrender
I knew I could not carry on using but the desperation was that I didn’t think I could stop using either. Today I understand that to be the moment of surrender where I stopped trying to control what was going on and made a decision that I wasn’t going to shoot heroin anymore, no matter what. I went cold turkey; I just lay in a bed and withdrew. I had gone cold turkey before but returned to using. This time, however, I just lay there thinking I don’t care if I die, but I am not going to use heroin again.
Over the years I had been intermittently attending a support group, a twelve-step fellowship where I met a group of people who understood how difficult it was and who supported me in making better choices and through just getting through one day at a time without using. If I could do that then I was in the game.
Having found a way out, and once I had managed to stop using I was a bit evangelical about sharing the news with people and helping other people to stop. One of the constants in my recovery is that no matter how bad it is, there is always hope, you can always get out of it, you can still stop the nightmare. And I still feel passionate about that today and that is what led me into working in rehabilitation.
It’s not a conscious process of denial where the addict knows they are in denial. In order for denial to work it has to be subconscious. You only know you were in denial once you’ve come out of denial, in the same way that you only know you were asleep once you’ve woken up. A huge part of recovery has been in sharing this message with people all these years and I love my life now. It’s been 22 years since I last took a drink or a drug.
I have a family and children and I enjoy the work that I do. I have a very fulfilling life and from where I came, it’s literally chalk and cheese. And for me every step of the way has been wonderful. I often feel I went to sleep at some point in my teenage years and I only woke up once I put the drugs down, and I know it sounds corny but the colours are brighter, music is better, everything is better, clean. And it was such a surprise because I was taking drugs initially because I thought that was making everything better, and in fact I love not using drugs, I love being clean and I love the fact that I am out of hell.