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The personal and social consequences of this widespread and relentless urge are almost too large to grasp. In the United States, about 16 percent of the population twelve and older meet criteria for a substance use disorder, and about a quarter of all deaths are attributed to excessive drug use.

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Each day, ten thousand people around the globe die as a result of substance abuse. Along this path to the grave is a breathtaking series of losses: of hope, dignity, relationships, money, generativity, family and societal structure, and community resources. Worldwide, addiction may be the most formidable health problem, affecting about one in every five people over the age of fourteen.

In purely financial terms, it costs more than five times as much as AIDS and twice as much as cancer. In the United States, this means that close to 10 percent of all health-care expenditures go toward prevention, diagnosis, and treatment of people suffering from addictive diseases, and the statistics are similarly frightening in most other Western cultures.

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Despite all this money and effort, successful recovery is no more likely than it was fifty years ago. There are two primary reasons for the incredibly broad, deep, and persistent costs of drug addiction. First, excessive use is remarkably common, cutting across geographic, economic, ethnic, and gender lines with little variation. It is also highly resistant to treatment. Although reliable estimates are hard to come by, most experts agree that no more than 10 percent of substance abusers can manage to stay clean for any appreciable time.

As far as illnesses go, this rate is almost singularly low: one has about twice as good a chance of surviving brain cancer. Despite a statistically bleak outlook, there are some reasons to be encouraged. Some addicts, once desperate cases, do get clean and stay clean, and even go on to live productive, happy lives.


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We know, for instance, that addiction results from a complex web of factors including a genetic predisposition, developmental influences, and environmental input. I say complex because each of these factors is very dense. That is, hundreds of genes and innumerable environmental contributions are involved.

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The factors also depend on one another. For example, a particular strand of DNA may enhance a liability for addiction but only in the presence or absence of other specific genes and along with certain experiences during development either pre- or postnatal and in specific contexts. So, while we may know a lot, the complexity of the disease means that we are still unable to predict whether a particular individual will develop an addiction. While in the end there might be as many different paths to addiction as there are addicts, there are general principles of brain function that underlie all compulsive use.

What was once a normal state punctuated by periods of high, inexorably transforms to a state of desperation that is only temporarily subdued by drug. At the point where pathology determines behavior, most addicts die trying to satisfy an insatiable drive.

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Or as a bird hatched in a cage would feel upon being unexpectedly set free. Just as light is revealed by darkness, and joy by sorrow, alcohol provided powerful subconscious recognition of my desperate strivings for self-acceptance and existential purpose and my inability to negotiate a complex world of relationships, fears, and hopes. At the same time, it seemed to deliver, on a satin pillow, the key to all my blooming angst. Abruptly relieved from an existence both harsh and lackluster, I had finally discovered ease.

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So I began with enthusiasm, even determination. From the start, I consumed as much and as often as I could—literally through most of seventh grade, because school afforded the best opportunities for freedom from parental oversight in my suburban, middle-class world. Drinking before, during, and when I could after school, I seemed to possess an admirable innate tolerance. I was almost never sick or hungover—perhaps it was my youthful liver—and appeared presentable despite what would surely be deemed legal intoxication.

Though I never achieved the overwhelming sense of wholeness that I experienced the first time, alcohol continued to confer muted contentment. Any altered state seemed a dramatic improvement over a drab and tedious life toeing the line. As far back as I can remember, I felt hemmed in, frustrated by imposed limits and my own limitations.

Longing for other, for something else, is at the core of my experience of self. Even today, below the persona of nurturing friend, committed partner, determined scientist, and adoring parent is a heartbreaking desire to embrace oblivion. Like in a dream, time flows by as I futilely pursue a series of inane tasks, all the while suppressing a growing sense of panic. I fantasize about disembarking at an unfamiliar exit, or pushing aside a broken gate into a foreign sanctum, somehow entering a world where we all at least agree not to pretend things are different than they seem.

What is going on? What am I doing? Questions like these must have been among my first conscious thoughts. My first time getting drunk seemed to offer an easy way through the difficulty of growing up, and it was a long while before I had enough awareness to look back and wonder about the causes of my trajectory.

In the end, the very effect I loved so much about alcohol—its ability to mute existential fears—utterly betrayed me. The chief of the National Institute on Alcohol Abuse and Alcoholism, George Koob, has said that there are two ways of becoming an alcoholic: either being born one or drinking a lot. Koob is not trying to be flip, and the high likelihood that one or the other of these applies to each of us helps explain why the disease is so prevalent.

I agree that many who end up like me have a predisposition even before their first sip but also appreciate that enough exposure to any mind-altering drug will induce tolerance and dependence—hallmarks of addiction—in anyone with a nervous system. Unfortunately, though, no scientific model can yet explain my quick and brutal slide to homelessness, hopelessness, and utter desolation.

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