THE ORIGINS OF ADDICTION: Evidence from the Adverse Childhood Experiences Study
NOVEMBER 07, 2014 by Vincent J. Felitti, MD ABSTRACT
My intent is to challenge the usual concept of addiction with new evidence from a population-based clinical study of over 17,000 adult, middle-class Americans. The usual concept of addiction essentially states that the compulsive use of ‘addictive’ substances is in some way caused by properties intrinsic to their molecular structure. This view confuses mechanism with cause. Because any accepted explanation of addiction has social, medical, therapeutic, and legal implications, the way one understands addiction is important. Confusing mechanism with basic cause quickly leads one down a path that is misleading. Here, new data is presented to stimulate rethinking the basis of addiction.
Purpose:
My intent is to challenge the usual concept of addiction with new evidence from a population- Basedclinical study of over 17,000 adult, middle-class Americans. The usual concept of addiction essentially states that the compulsive use of ‘addictive’ substances is in some way caused by properties intrinsic to their molecular structure. This view confuses mechanism with cause. Because any accepted explanation of addiction has social, medical, therapeutic, and legal implications, the way one understands addiction is important. Confusing mechanism with basic cause quickly leads one down a path that is misleading. Here, new data is presented to stimulate rethinking the basis of addiction.
Background:
The information I present comes from the Adverse Childhood Experiences (ACE) Study.2 The ACE Study deals with the basic causes underlying the 10 most common causes of death in America; addiction is only one of several outcomes studied.
In the mid-1980s, physicians in Kaiser Permanente’s Department of Preventive Medicine in San Diego discovered that patients successfully losing weight in the Weight Program were the most likely to drop out. This unexpected observation led to our discovery that overeating and obesity were often being used unconsciously as protective solutions to unrecognized problems dating back to childhood.3, 4 Counter intuitively, obesity provided hidden benefits: it often was sexually, physically, or emotionally protective.
02/16/2004 page 2 Felitti ACE-Addiction article, DE
Our discovery that public health problems like obesity could also be personal solutions, and our finding an unexpectedly high prevalence of adverse childhood experiences in our middle class adult population, led to collaboration with the Centers for Disease Control (CDC) to document their prevalence and to study the implications of these unexpected clinical observations. I am deeply indebted to my colleague, Robert F. Anda MD, who skillfully designed the Adverse Childhood Experiences (ACE) Study in an epidemiologically sound manner, and whose group at CDC analyzed several hundred thousand pages of patient data to produce the data we have published.
Many of our obese patients had previously been heavy drinkers, heavy smokers, or users of illicit drugs. Of what relevance are these observations; do they imply some unspecified innate tendency to addiction? Is addiction genetic, as some have proposed for alcoholism? Is addiction a biomedical disease, a personality disorder, or something different? Are diseases and personality disorders separable, or are they ultimately related? What does one make of the dramatic recent findings in neurobiology that seem to promise a neurochemical explanation for addiction? Why does only a small percent of persons exposed to addictive substances become compulsive users?
Although the problem of narcotic addiction has led to extensive legislative attempts at eradication, its prevalence has not abated over the past century. However, the distribution pattern of narcotic use within the population has radically changed, attracting significant political attention and governmental action.5 The inability to control addiction by these major, well-intended governmental efforts has drawn thoughtful and challenging commentary from a number of different viewpoints.6,7
In our detailed study of over 17,000 middle-class American adults of diverse ethnicity, we found that the compulsive use of nicotine, alcohol, and injected street drugs increases proportionally in a strong, graded, dose-response manner that closely parallels the intensity of adverse life experiences during childhood. This of course supports old psychoanalytic views and is at odds with current concepts, including those of biological psychiatry, drug-treatment programs, and drug-eradication programs. Our findings are disturbing to some because they imply that the basic causes of addiction lie within us and the way we treat each other, not in drug dealers or dangerous chemicals. They suggest that billions of dollars have been spent everywhere except where the answer is to be found.