or there are unsuccessful efforts to cut down or control substance use.
5.A great deal of time is spent in activities necessary for obtaining the substance, using the substance or recovering from its effects.
6.Important social, occupational, or recreational activities are given up or reduced because of substance use.
7.The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption).
As it gathers momentum, alcohol addiction inevitably affects the drinker’s physical and social selves, visibly damaging the architecture of their life. Jobs are lost. Relationships spoil. There may be accidents, arrests and injuries, or the drinker may simply become increasingly neglectful of their responsibilities and capacity to provide self-care. Conditions associated with long-term alcoholism include hepatitis, cirrhosis, fatty liver, gastritis, stomach ulcers, hypertension, heart disease, impotence, infertility, various types of cancer, increased susceptibility to infection, sleep disorders, loss of memory and personality changes caused by damage to the brain. As an early researcher into alcohol addiction wrote in the American Journal of Psychiatry back in 1935: ‘The striking and inescapable impression one gets from a review of acute alcoholic intoxication is of the almost infinite diversity of symptoms that may ensue from the action of this single toxic agent.’
Not everyone who drinks alcohol, however, becomes an alcoholic. This disease, which exists in all quarters of the world, is caused by a multitude of factors, among them genetic predisposition, early life experience and social influences. In a 2011 paper entitled ‘The role of early life stress as a predictor for alcohol and drug dependence’, Mary-Anne Enoch, a long-term researcher in the field, wrote:
It is well established that the hereditability of alcoholism is around 50% . . . Therefore, genetic and environmental influences on the development of addictive disorders are equally important, although the proportions of risk may vary according to societal groups.
Later, when I was transcribing my interview with Dr. Petros Levounis, the Addiction Institute’s director, I realised that I’d asked the question of what causes alcoholism several times over, in varying formulations, and that each time his answer was slightly different. This isn’t to say that he was imprecise. On the contrary, he was a meticulous speaker. His understanding of alcoholism involved balancing a succession of models like spinning plates. The disease was primarily genetic, but social and psychological factors were very much involved. There isn’t an alcoholic personality per se, as early theorists suggested there might be, but alcohol does bring with it a constellation of behaviours (lying, stealing, cheating; the usual car crash) that will in all probability subside or disappear entirely when sobriety is attained; although – and here he laughed a little – there are plenty of jerks who become alcoholics and continue to be jerks after they’re dry.
Near the beginning of the conversation he used a phrase that intrigued me. He mentioned a process called the brain switch. If someone is particularly prone to alcoholism – if the genetic and social and psychological factors are all stacked against them – then they are likely to experience a change in brain function. As Dr. Levounis put it, ‘it seems that they engrave the addiction at the more primitive part of the brain, the mesolimbic system, and from that point on the addiction tends to have a life of its own, to a large extent independent of the forces that set it into motion to begin with’. He called this lively, liberated monster the big bear, and later the big beast. ‘Unfortunately,’ he added, ‘the majority of people do not really see that and have the false hope that if they go back to the root of the problem and yank out the root cause of what happened then they will be addiction-free for the rest of their lives.’
The brain switch wasn’t a concept I’d come across before. It was initially proposed about fifteen years earlier by Alan Leshner, then director of the National Institute on Drug Abuse. He suggested that neurobiological changes took place around the nucleus accumbens, the part of the mesolimbic system that deals with pleasure and reward, where addiction takes hold most strongly. These neural pathways, Dr. Levounis explained, ‘don’t only signify for pleasure and pain; they also signify for salience. Essentially, they tell us what is important and what is not. So instead of having all kinds of things that are pleasurable and rewarding and salient in your life, all these things start becoming less and less important and the one that remains is primarily the drug of abuse. It’s alcohol.’
The permanence of this hijack is due primarily to the geography of the pleasure-reward pathways, their anatomical position within the nutshell of the human skull. He mapped it out for me with his hands, showing how the mesolimbic system is sandwiched between the hippocampus, which is the memory centre of the brain, and the limbic system, which is its emotional core. It made sense to me. Memory and emotion. How else do we make decisions, except by cognition, by the pure application of reason? But that region of the brain, the frontal lobes, is far away, anatomically speaking, and imperfectly connected, especially in the young. Little wonder that alcoholism was once characterised as a failure of will. The frontal lobes weigh right and wrong, apportion risk; the limbic system is all greed and appetite and impulse, with the hippocampus adding the siren’s whisper: how sweet it was, remember?
I shifted in my seat. I could see The Line of Beauty on the shelf in front of me, filed among the blue books. There were pigeons outside. The city was hammering against the window, insistent as a drill. Dr Levounis was talking now about the long-term picture: how the pleasure-reward pathways stay hijacked even in sobriety, so that although the alcoholic might stop drinking they remain vulnerable to addiction. For how long, I asked, and he replied: ‘Although a lot of people manage to beat the illness, the risk of using stays with you for a long, long time, if not for the rest of your life.’
We turned then to a discussion of treatment. Dr Levounis outlined the two basic options for recovery: the abstinence-based model and the harm-reduction model. In the abstinence-based model (the version favoured by Alcoholics Anonymous), the alcoholic stops drinking entirely, concentrating on the maintenance of sobriety. In the harm-reduction model, on the other hand, the focus is on improving the conditions of one’s life and not necessarily on stopping drinking. He thought, pragmatically, that both were efficacious, depending on the individual’s circumstance and needs.
There was a lot to think about in this conversation, but it was the big beast that stayed with me when I went down into the street. What would Tennessee Williams have made of it, the idea that addiction has its own momentum, its own articulated presence within the skull? I’m not sure he would have been surprised. He had a gut sense of how people are driven by irrational cravings. I thought of poor Blanche DuBois, sneaking shots of whiskey in her sister’s house in New Orleans; of Brick Pollitt, hobbling back and forth to Echo Spring, saying to his dying father, ‘it’s hard for me to understand how anybody could care if he lived or died or was dying or cared about anything but whether or not there was liquor left in the bottle’. Williams might not have known where the frontal lobes were located (although he probably did, being a dedicated hypochondriac whose sister’s lobotomy left him with a lifelong terror of psychiatric care), but he certainly understood how a human being can navigate without the use of reason. I’m not sure Cat on a Hot Tin Roof is about much else besides irrational compulsions – alcohol, money, sex – and how they can unshape a life.
The AA meeting was on the Upper West Side at 6 p.m. I slept a while at the hotel and then cut across Central Park, eating a hot dog on the way. The trees were maybe a fortnight away from coming into leaf and as I walked I saw a red cardinal in a bush beside the path. Nothing except changes in climate and language communicate so thoroughly a sense of travel as the difference in birdlife. A week later, on the way to Key West, I’d see vultures circling
