Maté argues that addiction is an adaptive response to pain – whether physical, emotional, or psychological. In other words, all addiction can be classed as coping mechanisms developed to alleviate suffering. In my experience, sometimes addictions manifest in ways that are so far removed from the source of pain that it is hard to see them in this context.

This perspective is powerfully illustrated through his work with patients at the PHS. Throughout the book, there is a vivid correlation between addiction and hardship. The book is filled with accounts of pain and trauma from those at the PHS: stories of rape, humiliation, rejection, abandonment, violence, and many others. It was humbling and emotional to read them and as much as I’d want to, it doesn’t feel right to share them here. They are only included in Maté’s work with the permission of those he supported and whose voices he carefully listened to.

Wider literature reinforces Maté’s link between pain and addiction. Addiction rates are highest among vulnerable, often socially marginalised communities (Robards et al., 2020; Kreek, 2011). The Adverse Childhood Experiences (ACE) study looked at the incidence of ten categories of painful circumstances, including family violence, parental divorce, family drug/alcohol abuse, death of a parent, physical/sexual abuse, across thousands of people from diverse backgrounds. They then correlated these figures with substance abuse later in the subjects’ lives. For each ACE, the risk for early initiation of substance abuse increased 2-4 times. Subjects with 5+ ACEs had 7-10 times greater risk for substance abuse than those with none. The researchers concluded that around two-thirds of injection drug use can be attributed to abusive and traumatic childhood events.

Not all addiction is rooted in some explicit trauma like those of the ACE. Stress, in general, and the suffering it produces is a powerful driver of addiction. The most potent stressors are uncertainty or loss of control, whether personal (such as a chronic illness), professional (losing a job), economic (debt), or psychological (grief). Stress has been shown to powerfully increase the need for external sources of dopamine, and as such, is a major trigger for initial substance abuse, addictive behaviours, and likelihood of relapse. Interestingly, stress hormones can themselves be addictive which contributes to the earlier idea I mentioned about how addictions may manifest in ways far removed from their cause.

Given that childhood adversity and external stressors are almost entirely out of our control, if you don’t happen to struggle with addiction, be grateful for your fortune, be respectful and aware of others’ pain, and be non-judgemental about how it may manifest.

Addiction is Not Caused by the Substance.

One of the greatest misconceptions about addiction – and a fundamental premise of the War on Drugs – is the belief that addiction is caused by the consumption of a substance. It’s a misconception for several reasons. First, it fails to account for the wide range of non-substance based addictions: sex, shopping, work, gambling, or in Maté’s case, collecting music. When someone is addicted to eating, nobody blames the inherent addictive potential of food.

You may say, ‘but some drugs affect neurochemistry in a way that increases addictive potential more than food or shopping!’. This is true, but for two reasons the distinction is not as important as you may think. First, neuroimaging has shown the remarkable neurological similarities between addictions to substances and non-substances. It may be that the intensity of the addiction and manifestations of behaviours may vary, but the underlying mechanism is universal.

Second, not everyone who consumes addictive substances becomes addicted. Consider how around 20% of American soldiers returning from the Vietnam War met the criteria for drug addiction. Before they left, fewer than 1% did. Yet, the remission rate when people returned was 95%. This suggests that the addiction did not arise from the drug itself, but from the specific needs and circumstances of soldiers during the horrific conditions of the war. This is of course a more extreme example, but the psychological states of many people in the world is not far removed from the strain of wartime. The point here is that addiction is tied more to the circumstances in which it arises than the addictive substance/behaviour itself.

It’s important not to downplay the potential powerful interactions of drugs on our individual neurochemistry –  opioids, amphetamines, and other such drugs have powerful interactions with our brain. However, reducing addiction to a mere chemical dependence overlooks the complex web of personal, emotional, and environmental factors that contribute to addiction.

A final point worth mentioning is how this misconception is rooted in observations of animal behaviour in experimental conditions. However, these results are drawn from lab animals that live in unnatural circumstances of captivity and stress. These results offer more insight into environmental stressors result in addiction, rather than anything about the inherent addictive potential of a substance. When researchers created a natural, friendly environment to study addiction in rats, addiction rates were far lower, even after having consumed the drug previously and having free access to it.

Ok, So What is Addiction Then?  

Maté expands on our current definition of addiction, arguing that it involves:

• Compulsive engagement with the behaviour, or a constant preoccupation with it
• Impaired control over the behaviour
• Persistence or relapse, despite evidence of negative consequences
• Dissatisfaction, irritability or intense craving when the object is not immediately available

Notice that in this more expansive definition, it need not be an addiction toward a substance. Any pursuit, natural or artificial, that induces a feeling of increased motivation or reward will activate the same brain systems as drug addictions. 

Notice also that there is no mention of ‘disease’ or ‘illness’. The common pathologisation of addiction reduces it to something external – a condition that you have, rather than a part of who you are. This over-medicalised view (a strong, and in my opinion, highly flawed tendency in western psychology) neglects how tied addictive behaviours are to our internal and external environments. Addiction is not an illness but an adaptive response, an aspect of ourselves that represents some unmet need.

Some addicts never recognise the harm of their addiction, staying in denial, rationalisation, or avoidance. Others accept them willingly, resolving to live and die by it. Maté’s definition of addiction expands the definition beyond the severe turmoil that pop culture suggests, arguing that for many, addiction manifests in more subtle ways like our day-to-day vices. Often we build our lives around these vices, rather than through them. Regardless of the intensity of manifestation, the journey towards resolving those vices, not avoiding them, is not easy or natural. Those who undertake it, bravely facing the truths and inner pain that drives their addictions, are worthy of respect and admiration.

There is an important distinction to be made between ‘dependence’ and ‘addiction’. Dependence can be understood as the powerful attachment to harmful substances or behaviours. An addict comes to depend on something, but addiction encompasses the deeper emotional and psychological dynamics at play.

Why Don’t Addicts Just Stop?

A friend asked me this once, and I remember feeling frustrated, not just because it seemed to neglect the very real struggles of addicts, but also because I didn’t know the answer myself. From this book and other reading, addicts don’t stop because a) neurological mechanisms of control are impaired, b) their addiction serves an adaptive function, and c) the capacity to exert free will is limited.

Addiction is both cause and consequence of neural impairment

Addictive behaviours are the result of a dysfunction of brain tissue, the same way that cardiac insufficiency is a dysfunction of heart tissue. Conclusive evidence has shown that in regions of the brain responsible for impulse control and making rational decisions, what we call ‘choice’, addicted brains have reduced activity.

Two reasons contribute to this in a cyclical fashion, First, extensive evidence shows ACEs have tangible, physical consequences for our neurological development. People mistreated in childhood have smaller white matter than non-mistreated children (Eluvathingal et al., 2006). Women abused in childhood show a 15% decrease from normal in the size of the hippocampus (Bale et al., 2005). Increased ACEs result in impaired systems of stress regulation (Felitti et al., 1998). Addicts tend to have reduced activity in the orbitofrontal cortex, an important area in charge of weighing up short-term objectives and long-term consequences (Volkow et al., 2003).

Second, addicted brains have less dopamine receptors, particular those affected by repeated drug use (the dopamine-based orientation to addiction is endorsed by neuroscientists such as Huberman and Lembke). As the brain adjusts to the higher-than-normal levels of dopamine in the brain, it downregulates, which then means in the absence of that drug people experience withdrawal. Chronic use means the brain damage is significant, making relapse more likely, and abstinence more painful. In the same way a smoker’s lungs become damaged and adapt to function pathologically, so does the brain in response to repeated drug use, although instead of lung disease or heart disease, the manifestations are pathological emotional and psychological behaviours.

The neuroscience of addiction is particularly interesting with regards to opiates like heroine, codeine, fentanyl. Endorphins, the brain’s natural opioids, are produced to relieve pain, reduce stress, and improve mood. Most importantly, they are essential for the emotional bonding between mother and infant. Infants need their maternal figure (main caregiver) because they can’t regulate their own stress apparatus. If left alone, they will literally stress themselves to death. Given the essential nature of this chemical in our emotional and psychological regulation, it’s not a stretch that if faced with a lack of proper maternal bonding during infancy/childhood, many turn to drugs as the next-best, and often only, option. 

“Opiates are the chemical linchpins of the emotional apparatus in the brain that is responsible for protecting and nurturing infant life: Addiction to opiates like heroin and morphine arises in a brain system that governs the most powerful emotional dynamic in human existence: the attachment instinct. Love.”

Current neuroscience and developmental psychology cannot stress this idea enough: emotional nurturance, via endorphins, is an absolute requirement for healthy neurobiological brain development. This is most clear in the fact that the majority of chronically, hardcore substance-dependents adults lived, as infants or children, under conditions of severe adversity. Their predisposition towards drugs was programmed way before they had a chance to prevent it. 

This was maybe the most profound bit in the book – it broke my heart and showed me the humanity, pain, and misfortune of the struggling addict. Maté talks about a 27 year old who has recently died of an overdose. Maté recalls from one of her early interviewa: ’The first time I did heroin,’ she says’ it felt like a warm, soft hug.’ How much addiction is rooted in people not feeling loved; how painfully ironic that addiction then hijacks the very systems used to express love.

Addiction Serves an Adaptive Function

From this, it’s clear that people carry on engaging with their addictions because, despite the potential harm, they serve some purpose. Usually the purpose revolves around alleviating the strain of a dysregulated internal environment. As Maté describes, addicts aren’t addicted to the substance itself but to the physical, emotional, or spiritual relief it provides. On a fundamental (albeit highly reductive) level, our lives revolve around avoiding pain. As one patient put it, ‘I’m not afraid of dying, sometimes I’m more afraid of living’. Importantly, the emphasis here is not that they don’t care about life or are existentially detached. They are not suicidal (although some certainly may be). They fear life because they have been shown that life is worth fearing. It causes pain and suffering. Our most instinctive drives seek to avoid these dynamics by whatever means necessary.

The capacity to exert free will is impaired

The final reason why addicts don’t just stop is related to the concept of free will. In the world of the psyche, freedom is a relative concept. Determinists argue that there’s no such thing. However, I and others subscribe to the idea that freedom can exist, but only when our automatic mental mechanisms can be transcended and engaged with through conscious awareness.

The distinction between automatic mechanisms and conscious free will can be made clear in these three different responses to a situation where you are angry: 1) Punching a wall out of anger 2) Thinking: ‘I am so angry I could punch this wall’, and 3)  Reflecting: my mind is telling me I am so angry that I should punch this wall’. At each level you gain a capacity to transcend the determined forces that govern that momentary instinct, and gain free will/the capacity to choose. For addicts, the neurological systems governing the 1/10 to 1/5 of a second between the awareness of the impulse and activation of the muscles to engage that impulse, i.e., the time in which we are able to exert conscious control, are impaired. We are all faced with moments where we are guided by impulse. Observing, reflecting, and letting go of that impulse is a skill I am increasingly practicing, and I have noted how it can be improved through practice.

However, this is not saying that addicts bear no responsibility for their actions. Merely that in reality, free choice and responsibility are not absolute concepts. People choose and decide and act within both an internal and external context. The internal context develops through experience, and is influenced by conditions over which the individual, particularly as a young child, had no choice whatsoever. In this respect, addicts don’t ‘just stop’ because they were never given the option to.

The War on Drugs 

The war on drugs is not a war on drugs, it is a war on people. More specifically, it is a war on those most likely to be involved with drugs. Who are these people? All the data suggests it’s those who are most neglected and oppressed in childhood. In effect, the ruthless criminalisation of drug consumption punishes those who have suffered trauma, and as is often the case, are trying to solve their pain in worlds devoid of psychological or social stability. Maté’s stance on the War on Drugs is aggressive, but not unfair. He refers to a GCDP report that showed that it had not only failed to reduce drug use, but increased drug-related crime and violence, strained law enforcement, judicial systems and economic systems, undermined human and civil rights, and all with a disproportionate effect on poor people and people of colour. While some of these are inherent to any criminal industry, the War on Drugs has been built upon the notion that drugs are an inherent evil and must be destroyed. This is far removed from both logic and science. It completely ignores a large part of the reasons why people are doing drugs in the first place, which ironically, have no doubt been made worse by militant anti-drug policies.

Part of the historic issue of social policy regarding drug addicts is that they are often met with contempt, judgement, and an overarching resentment at their incapacity to just stop. But consider the irony in how much sympathy society has for a mistreated suffering child, and how much contempt we show as that suffering child then seeks survival and comfort using the only mechanisms they have been afforded.

How Do We Heal Addiction?

Maté’s mantra for treating the addiction is asking not ‘why the addiction?’ but ‘why the pain?’. When considering an addiction, don’t ask about the the addictive substance/behaviour itself, like when it started, how frequent the use is. Instead ask, ‘what does it offer you? What do you like about it?’ Often, as Maté concludes from his extensive work with those struggling with addiction, it is as an escape, a coping mechanism, a source of peace, or a sense of control. From there, the root of the addiction can be dug up and its perceived necessity removed.

Addiction can’t be treated as the single-individual, accidental misfortune, genetic predetermination, or poor decision making. It’s a product of development in a particular context, and subsequent adaptive mechanisms developed in response to that context. Treatment must take into account the internal climate: beliefs, memories, mind-states and emotions that feed addictive impulses, as well as how the external environment precipitates and perpetuates this climate. This latter part is harder as its often less under the control of the individual.

Despite this, the individual is still front and centre in the treatment of their own addiction. Maté outlines five key steps that, while not a comprehensive treatment for addiction, may serve as a useful path to disengagement with maladaptive behaviours.

Re-Label: Observe your compulsive thoughts, with compassion, and begin to redefine them. Instead of thinking, ‘I need this now’, recognise the emergence of the compulsive thought created by automatic mechanisms in your mind which have created a false sense of urgency. While difficult, I’ve found with time and practice this recognition becomes easier, and as does the ease of relabelling.

Re-Attribute: Understand that circumstances beyond your control contributed to the development of these automatic, compulsive mechanisms. By recognising the lack of agency in their creation, you can begin to separate yourself from them and observe them without the usual self-critical narratives. I’ve recently observed some Compassion Focussed Therapy, and have witnessed how much of an impact a compassionate approach to the self can have.

Re-Focus: When compulsions arise, shift your attention. This helps delay the conversion of compulsive thought to addictive behaviour, training your brain to resist automatic impulses. Though hard it first, the plasticity of the brain allows for rewiring on even the most fundamental levels.

Re-Value: After practicing these steps, reflect on the true value of the addiction. What does it serve you vs. how it has cost you. Writing these down as you go may help.

Re-Create: Get in touch with your values, passions, intentions. If there is love in you somewhere, that’s perhaps been lost along the way, make contact with it and find ways to express it. Whatever it is, create a life that’s more aligned with who you are beyond the circumstantial compulsions that derail you. I believe, and hope to practice one day as an existential psychotherapist, that many of our psychological ailments may be resolved through living authentically, in a life aligned with our essential being.