Adapted from an essay first published in Social Policy Magazine (Vol. 27, No. 2, Winter 1996).
Both America’s war on drugs and our own private struggles — with everything from compulsive eating to heroin — are hampered by a single flawed assumption: that addiction is one thing, varying only in degree. In practice there are two fundamentally different kinds of addiction, simple and complex, and they call for entirely different responses.
Two Contradictory Truths
The public atmosphere around addiction is one of alarm. We are told that dependence can seize anyone, on almost anything, and that the way back is long, agonizing, and uncertain. Cigarette makers stand accused of boosting the nicotine in a product already tied to some 400,000 American deaths a year. The message is that addiction is a merciless force, and that once hooked, escape is nearly impossible.
Yet other facts sit uneasily beside that story. Over roughly 25 years, 50 million Americans quit smoking, and about 90 percent did it on their own — no doctor, no medication, no group. A 1990 Gallup poll found that 70 percent of people who changed their drinking habits did so without doctors, therapists, or AA. Most people who gamble or overeat never become addicted at all; there are heavy drug users who never escalate, and studies of heroin addiction find that a meaningful share remit on their own — famously, more than 90 percent of Vietnam veterans who returned addicted broke the habit within a year.
If those were the only numbers, the alarm would seem overblown. But the other side is just as real: problem drinkers in this country outnumber the population of New York City; the abuse of alcohol, tobacco, and other drugs costs Americans hundreds of billions of dollars a year; the majority of smokers who try to quit fail. So which is it — is the grip of addiction exaggerated or supreme? That is the wrong question. The better move is to rethink the category itself.
Defining the Two Kinds
The American Psychiatric Association describes addiction in terms of tolerance, using a substance to relieve withdrawal, unsuccessful efforts to cut down, and continued use despite known harm. That description captures one form well. It captures the other poorly.
Simple addiction is a surface dependence. It can involve genuine physical craving and withdrawal, but the evidence suggests it can be undone without long-term group programs or professional treatment — through willpower and individual effort. Simple addiction touches only part of the person; another, often larger part, opposes it and can win.
Complex addiction is another animal. In The Selfish Brain: Learning From Addiction, DuPont describes four hallmarks: the substance produces powerfully good feelings and blots out bad ones; the user loses control; the behavior continues despite mounting consequences; and the person denies there is a problem at all. To that we would add a driving mechanism — complex addiction is an attempt to use an external substance to manage, mute, or repress an inner psychological state. It reflects deeper trouble that users are usually unaware of, and it resists rational intervention. It typically requires long-term, intensive help: AA and other 12-step programs, professional recovery centers, or therapeutic communities.
Smoking and Depression
Nicotine is unusual: even its simple form is among the hardest habits to break, and users of heroin or cocaine often say quitting cigarettes is harder still. But the complex form has a psychiatric shadow. When Alexander Glassman’s team set out in the mid-1980s to test a smoking-cessation drug on people free of serious mental illness, they were startled to find that 60 percent of the habitual smokers they selected had a prior history of major depression. Smokers with that history were about twice as likely to be unable to quit as those without it.
Follow-up work has repeatedly linked smoking to depression and other disorders. A CDC survey of high school students found that those who smoked were far more likely to report a suicide attempt than nonsmokers. Nicotine helps release dopamine — the same reward chemistry involved in opiates and cocaine — which helps explain why, for some people, a cigarette becomes an “anchor in the storm” rather than a casual habit. For the person who can quit easily, smoking is simple addiction in its clearest form. For the person who cannot stop despite knowing it is killing them, it is masking something deeper.
Alcoholism
A small share of former problem drinkers can return to moderate social drinking; for them, alcohol was only a social lubricant and a mild high — simple addiction. The complex alcoholic drinks for something else entirely. James Milam’s biologic theory holds that some people are born unable to process alcohol normally: “It is addictive for only a minority of its users, namely, alcoholics,” he writes. For such a person, a socially ordinary start quietly tips into an irresistible craving rooted in biology rather than personality — and for them, as AA insists, light social drinking is never again a safe option.
Seen this way, the contradictory claims about addiction — that it is curable and not curable, a disease and not a disease, overblown and supreme — each hold a kernel of truth. Which one applies depends on whether the addiction is simple or complex.
Food, and a Personal Case
Sugar makes the point cleanly. Many people eat sweets daily and never form an attachment; the taste is the whole appeal. For others, a candy bar or a bowl of ice cream carries a charge — comfort, security, self-reward — laid down in childhood. One of us knows this firsthand. A committed nightly drinker for years, Riessman was diagnosed with diabetes and told to give up both alcohol and sugar. He stopped drinking gin that same day, without withdrawal or craving. Yet he could not give up the half-pint of ice cream he ate each night, even knowing the danger. The gin had been mere relaxation — simple. The ice cream, like Proust’s madeleine, summoned birthday parties and summer nights and the lost security of childhood. Laden with that meaning, it became the harder drug.
What This Means for Treatment
Much of the high failure rate in treatment comes from a mismatch: complex addiction treated by simple means, or heavy, in-depth programs aimed at mild, self-treatable habits. Successful intervention depends on accurate diagnosis.
- For simple addiction, modest, self-applied methods are appropriate — willpower, meditation and religious practice, exercise, better nutrition, self-hypnosis and guided imagery, acupuncture and acupressure, and various stress-reduction routines. Statistically, most people who overcome a simple dependence do so without outside help.
- For complex addiction, the work must be long-term and intensive, with an emphasis on total abstinence, personality change, participation in mutual-support groups, and sustained rehabilitation. By definition it is out of control, and it yields only with the help of others.
Complex addiction tends to be indicated when a person finds it impossible to stop, is in deep denial, is doing real damage to work and family, or keeps using even after addiction-related illness sets in. It is worth noting that fear of creating complex addiction through medical pain relief is largely misplaced: when morphine is given for severe pain, the resulting dependence is almost always simple and readily reversed.
Conclusion
The two types of addiction call for different interventions, and the real challenge is to tell them apart before treatment rather than after — through questionnaires, interviews, life histories, and behavioral indicators that could predict which form a person is facing. Why not simply treat the underlying depression or biology and be done with it? Because the addictive elements themselves — withdrawal, rising tolerance, compulsion — have a power of their own. A depressed person is one thing; a depressed smoker is quite another. When the whole person is addicted, the whole person must be treated — and the form of help must be matched, as precisely as we can manage, to the kind of addiction in front of us.