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The Hacking of the American Mind Chapter 6. The Purification of Addiction
Author: Robert H. Lustig Publisher: New York, NY: Penguin Random House. Publish Date: 2017 Review Date: Status:⌛️
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Substances of abuse used to be scarce—a luxury for most of us—and dopamine was at low ebb. Prior to the eighteenth century, virtually every stimulus that generated reward was hard to come by, due to either its scarcity or its expense. You had to go out of your way to obtain the various illicit drugs. There were no stores, no internet, and there was very little porn. We’ve always had gambling and prostitution, but they weren’t on every street corner. Hedonic substances were once rare, limited to alcohol from the Triangle Trade, which allowed for the transfer of slaves from Africa, sugar and rum from the Caribbean, and money from New England.1 Slowly but surely, advances in technology, commodity crop farming, and globalization have made various rewarding substances readily available, and the ability to engage in rewarding behaviors not just possible but almost constant. Pleasure is now easy and cheap, if nothing else. In the twenty-first century, substances of abuse have become easier and cheaper to obtain all over the world. Whereas these substances were once something to savor and ponder, now they come a dozen to a box
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When did substances of abuse first appear on the scene?2 Archeological digs support the contention that Central Asia’s Yamnaya people (one of the three tribes that founded European civilization) had discovered and were trading cannabis as early as ten thousand years ago.3 The first literary reference to recreational drug use was from 5000 B.C.E., when the Sumerians chronicled the use of opium.4 The first reference to alcohol in the form of wine goes back to 4000 B.C.E., and the first mention of commercial production dates to 3500 B.C.E. in the form of an Egyptian brewery.5 But addiction didn’t really become a societal problem until we started purifying these substances. The first reference to addiction comes from China at around C.E. 1000, when opium became widely used.6
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In Western society, however, addiction and addicts remained a relative rarity through most of the second millennium. We’ve had wine since the time of the Romans, but we had to rely on natural fermentation for its production. In early times wine spoiled rapidly, because early vintners couldn’t get the alcohol content up past 5 percent, just like beer, which was equally likely to spoil. Although commercial beer production dates back to European monasteries in the seventh century C.E., succumbing to alcohol addiction wasn’t an option: the alcohol content was just not high enough. Alcoholism remained a matter of availability. Once it could be easily bottled, we were awash in hard spirits. Distilled alcohol became the obvious choice of most addicts, because you could ferment and distill just about anything. Alcoholism became a major societal problem throughout Europe in the 1700s once it became available and cheap. Prohibition turned out to be the anvil on which our current American society was forged. If anything, the dopamine rush from alcohol was increased tenfold by the fact that it had to be consumed in backroom speakeasys. It’s not an accident that 1933 saw the passage of the Twenty-First Amendment, which just happened to coincide with both the nadir of the Depression, and with Franklin Roosevelt’s New Deal of 1933. The government needed the tax money. But despite our affinity for alcohol, the dopamine rush still remained a luxury, out of the reach of most people, either due to religion, morality, reputation, or expense.
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Times have changed. Currently, the National Institute for Drug Abuse (NIDA) puts the U.S. binge-drinking rate at 30 percent for men and 16 percent for women, while alcoholism rates are 9.5 percent for men and 3.3 percent for women.7 Considering the use rate for alcohol is 67 percent of the U.S. adult population, that means that between one-quarter and one-half of Americans are binge users. That’s a pretty high take rate. And this is worth $212 billion in annual revenue to the U.S. alcohol industry.8 Kids today aren’t just bingeing on alcohol, they’re also popping uppers, downers, and everything in between. In adolescents over the last thirty-five years, the binge-drinking rates, as well as use of virtually every other illicit substance, has continued to increase.9 Alcohol is but one example of substances being purified and manufactured to suit the whims of societal addiction and bludgeon our dopamine receptors into submission. Marijuana is bred to be stronger than ever before, the coca leaf continues to provide both line cocaine and its cheaper cousin, crack, and opium poppies are still grown to make heroin. There’s big money to be made. Just ask Walter White from Breaking Bad (2008–2013). Those who distill, bottle, and sell these substances know what they’re doing and how to capitalize on our dopamine pathways (see Chapter 3).
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It’s no secret there is big money in the pharmaceutical industry. The annual profit margin of Big Pharma is 18 percent, with five companies making 20 percent or more.11 But even this profit margin is minuscule when compared to the money being made on the cheapest thrill possible. The processed food industry grosses 657 billion is gross profit, for a gross profit margin of 45 percent. And what drives such profits? The drug that isn’t a drug. Or is it? In America, circumcision of males at birth is relatively common. When the Jewish mohel (trained circumciser) performs the ritual called the Brith Milah, what alleviates the pain? He dips the pacifier in wine. But when the obstetrician performs this procedure in the hospital, what alleviates the pain? The pacifier is dipped in Sweet-Ease (a 24 percent super-concentrated sugar solution)12 that activates both dopamine and opioids in the brain. Just as we all have motivation to obtain pleasure, virtually all humans have a sweet tooth at some level. It’s inscribed into our DNA. The world loves sugar. There’s not a race, ethnic group, or tribe on the planet that doesn’t understand the meaning of “sweet.” This can be traced back evolutionarily, because there are no foodstuffs on the planet that are both sweet and acutely poisonous. Sweet meant that it was safe to eat. Jamaican ackee fruit, when immature (and not sweet), contains a compound called hypoglycin that can cause Jamaican vomiting sickness and can be life-threatening. But once the mature ackee fruit blooms, all the hypoglycin is metabolized, and it is the Jamaican national dish, canned and shipped worldwide.
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Despite our sugar love, the cost of sugar prevented its overconsumption until about fifty years ago. Prior to World War II, sugar was a condiment, something you added to your coffee or tea—“one lump or two?” But shortly after World War II, refined sugar became the drug of abuse for the masses. It was ratcheted up first with the advent of processed foods, which included added sugar. Then it was given another hike with the advent of high-fructose corn syrup in 1975, which provided competition for cane and beet sugar. This lowered prices further, and suddenly sugar started appearing in everything. And finally, the first Dietary Goals for the United States,13 published in 1977, told people to eat less fat, but it didn’t say anything about sugar. Now we have a choice: we can get our fix either from cane or beet sugar, or its cousins high-fructose corn syrup, maple syrup, agave, and honey. There’s a quick fix waiting for you on every street corner and in every refrigerator.
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Rats, like humans, love sugar. Feed them a little, and they will want more. Let them at it, and they will increase their intake, drinking loads of sugar water just to maintain their fix. Columbia neuroscientist Nicole Avena showed that within just twenty-one days, their NA looks whipped, as would happen with any other drug of abuse.14 And even more so when given binge access.15
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Until recently, scientists were locked in a vehement debate as to whether it was sugar or fat that caused your reward pathway to fire. Eric Stice in Oregon conducted a neuroimaging study that looked at fat and sugar separately, and together, in milk shakes that were calorically equivalent.16 Using four different combinations of high-and low-fat and high-and low-sugar milk shakes, he found that the high-fat variety caused greater activation in oral somatosensory regions (i.e., where you experience mouthfeel), while high-sugar more effectively recruited reward-related and gustatory (taste) regions. Increasing sugar caused greater activity in the reward pathway, while increasing fat did not. In other words, it’s the sugar that drives the dopamine, which drives the motivation for reward.
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Dietary sugar is composed of two molecules: glucose and fructose. Glucose is the energy of life. Glucose is so important that if you don’t consume it, your liver makes it (gluconeogenesis). Conversely, fructose, while an energy source, is otherwise vestigial; there is no biochemical reaction that requires it. Yet, when consumed chronically and at high dose, fructose is similarly toxic and abused.17 Not everyone who is exposed gets addicted, but enough do to warrant a similar discussion. These two molecules, glucose and fructose, activate different parts of the brain. On functional MRI (fMRI) scanning, the glucose molecule lights up areas associated with consciousness and movement, while the fructose molecule lights up the reward pathway and several sites in the stress-fear-memory pathway as well.18 These studies suggest that sugar is uniquely capable of driving the reward pathway and altering emotional responses.
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Not everyone subscribes to this expanded view of addictive substances. Drugs are a luxury. Food is a necessity. How can a food—like sugar—that is necessary for survival also be addicting? Because certain “foods” are not necessary for survival. We need essential nutrients that our body can’t make out of other nutrients, or we get sick and die. But there are only four classes of essential nutrients: (1) essential amino acids (nine out of the possible twenty found in dietary protein), (2) essential fatty acids (such as omega-3 and linolenic acid), (3) vitamins, and (4) other micronutrients, such as minerals. None of the foods that contain these essential nutrients are even remotely addictive. Of those substances that also contain calories, only alcohol and sugar have been shown to be addictive. The other addictive consumable found in food is caffeine.
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Wait, I can hear it—you’re saying, sugar? A drug? How is that possible? It’s part of other foods. It’s in fruit. It provides calories. It’s an energy source. Moreover, it’s a commodity! We subsidize it! OK, let’s try an analogy. Can you name a substance that: (1) has calories, (2) is an energy source, (3) is not required by any biochemical reaction in the body, and (4) is not nutrition by anybody’s estimation, (5) when consumed in excess causes damage to cells, organs, and humans, (6) we love anyway, and (7) is addictive? Answer: alcohol. Alcohol’s got calories and is an energy source, but alcohol is not a food. Alcohol is not nutrition. There’s no biochemical reaction that requires it (40 percent of Americans don’t consume alcohol, and they’re not sick).19 Alcohol does not hurt you because it has calories or because it can cause weight gain. Alcohol is dangerous because it’s alcohol. It can fry your brain and your liver. It’s a drug and it’s addictive in a percentage of the population. Same with sugar: it meets each one of these same criteria. Fructose, the sweet molecule in sugar, contains calories that you can burn for energy, but it’s not nutrition because there’s no biochemical reaction in any eukaryotic (animal) cell on the planet that requires it. It’s a vestige from when we split off the evolutionary tree from plants. And when consumed in excess, sugar fries your liver, just like alcohol.20
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And this makes sense, because where do you get alcohol from? Fermentation of sugar: it’s called wine. Sugar causes diabetes, heart disease, fatty liver disease, and tooth decay. Sugar’s not dangerous because of its calories, or because it makes you fat. Sugar is dangerous because it’s sugar.21 It’s not nutrition. When consumed in excess, it’s a toxin. And it’s addictive. Fructose directly increases consumption independent of energy need.22 Sucrose establishes hardwired pathways for craving in these areas that can be identified by fMRI.23 Indeed, sweetness surpasses cocaine as a reward in rats.24 Animal models of intermittent sugar administration induces behavioral alterations consistent with dependence, i.e., bingeing, withdrawal, craving, and cross-sensitization to other drugs of abuse.25
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The naysayers will still say, “But sugar is natural. Sugar’s been with us for thousands of years. Sugar is FOOD! How can food be toxic? How can food be addictive? This begs the question: What is food? Is sugar food? Webster’s Dictionary defines “food” as “material consisting essentially of protein, carbohydrate, and fat used in the body of an organism to sustain growth, repair, and vital processes and to furnish energy.” Well, sugar furnishes energy, so of course that makes it a food! For instance, a group of European academic researchers have joined forces into a political action group called NeuroFAST, which maintains that humans can succumb to “eating addiction” (it’s the person’s fault) but argue vehemently against the concept of “food addiction” (it’s the food’s fault).26 This is not a semantic difference. If it’s “eating addiction,” the food industry bears no responsibility. If it’s “food addiction,” they bear at least some corporate responsibility for our current medical and behavioral health debacle.
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Something I see in most psychology in general. The blame is always put on the person
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NeuroFAST categorically insists that even though specific foods can generate a reward signal, they can’t be addicting, as they are necessary for survival. In their own words: In humans, there is no evidence that a specific food, food ingredient or food additive causes a substance based type of addiction (the only currently known exception is caffeine which via specific mechanisms can potentially be addictive) … Within this context we specifically point out that we do not consider alcoholic beverages as food, despite the fact that one gram of ethanol has an energy density of 7 kcal.27 Interesting. NeuroFAST recognizes caffeine as addictive, yet they give it a pass. Caffeine is present in many foods (e.g., coffee), yet it is classified by the FDA as a food additive. It is also a drug; we give it to premature newborns with underdeveloped nervous systems to prevent apnea (stoppage of breathing). NeuroFAST then goes on to give alcohol a pass as well. Natural yeasts constantly ferment fruit while still on the vine or tree, causing it to ripen,28 yet NeuroFAST recognizes that purified alcohol is not a food. Alcohol is also a drug; we used to give it to women to stop premature labor. It is also addictive.
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So what is the difference with refined sugar? The sucrose in your sugar bowl is the same compound as what is in fruit, but the fiber has been removed, and it’s been crystallized for purity. It’s this process that turned fructose from food into drug. And it’s the purification that made it addictive. Just like alcohol. So in a convoluted sort of way, NeuroFAST got it half-right. They state that food can’t be addictive, but they recognize that food additives can. But that means when these additives are added to our food, they can make our food addictive. Like sugar.
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The sine qua non of this argument is soda. Is soda a food? Is there anything in soda that you need that could make it a food? Sugar—that’s an additive. Caffeine—another additive. Both addictive. Phosphoric acid, caramel coloring? No. Sodium? We’re all consuming triple what we need as it is.29 Water? Water’s necessary, but it’s not a food—it’s water.
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In the Middle Ages, sugar was a spice. Up through the mid-1900s it was a condiment. Only in the last fifty years has it become a diet staple. And it’s addictive for exactly the same reasons and via the same mechanism as alcohol. Sugar is not a food; it’s a food additive, just like alcohol. That’s why the FDA proposed changing the Nutrition Facts label to include “added sugar” (although the current administration may revoke this change). And that’s why children are getting the diseases of alcohol—type 2 diabetes and fatty liver disease—without alcohol.
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The DSM-V says all you need for addiction is tolerance and dependence (engaging despite conscious knowledge and recognition of their detriment), with resultant misery. Behaviors and substances that used to be excluded from the definition now qualify under this rubric. Can you honestly look yourself in the mirror and tell yourself that you have no addictions? Ben & Jerry’s, eBay, Facebook, porn, video games, coffee? How long did the rush from the new iPhone last? Or the new car? Or the new wife? As a society we’ve become tolerant by obtaining new stuff at a moment’s notice. We don’t just want, we need the newest, fastest, shiniest, classiest, coolest. You might call dopamine the dark underbelly of our consumer culture. It’s the driver of desire, the purveyor of pleasure, the neurotransmitter of novelty, the lever that business pushes to keep our economy going, but at a clear, perceptible, and increasing cost. We’ve purified our substances to concentrate their effects, and we are perpetually in need of the next shiny object.