The Fix

The science of pleasure is playing a greater role in the marketing strategies of all sorts of companies: the people who waft the smell of freshly baked doughnuts at you in the shopping mall have fine-tuned their recipes in the laboratory, not the kitchen. But Apple is in a class of its own. No other company has managed to mix such a finely balanced cocktail of desire, in which the crude flavour of compulsion is disguised by a deliciously minimalist aesthetic.

‘More than any other product, the iPhone has encouraged the tech industry to concentrate on getting people hooked on things,’ says Yiannopoulos. ‘Apple’s marketing genius, and the incredible attention to detail paid to the design of their devices, filters down into the iPhone developer ecosystem.’

He cites the example of Angry Birds, a simple computer game app that, by May 2011, had been downloaded 200 million times.13 (#litres_trial_promo) The premise of Angry Birds is simple: players launch birds across the screen with a slingshot, judging the trajectory of flight and altering the force and initial direction accordingly. It sounds harmless enough. But type ‘Angry Birds addiction’ into Google and you’re presented with 3.24 million results. So many people complain about being addicted to the game that it has spawned self-help pages all over the internet. Some of these pages ask whether Angry Birds addictions are changing people’s brains. Self-described addicts say they don’t know why they can’t put the game down, and talk about compulsively tracing their fingers on tables as they subconsciously recall the catapult action of the game. These sound suspiciously like the little rituals associated with alcoholism and drug abuse.

Again, perhaps a degree of scepticism is called for: it can only be a matter of time before some opportunistic researcher diagnoses ABAD – Angry Birds Addiction Disorder (which would presumably be a particular strain of IAD, since the game is played mostly on iPhones). No doubt the Angry Birds craze will fade, as these crazes always do. But it may well leave behind a residue, in the form of the compulsive instinct to perform repetitive actions.

It’s not a conspiracy theory to suggest that the primary task of iPhone game developers is learning how to manipulate our brains’ reward circuits. They cheerfully admit as much. At the 2010 Virtual Goods Summit in London, Peter Vesterbacka, lead developer for Rovio, the company behind Angry Birds, described how they make the game so addictive. ‘We use simple A/B testing to work out what keeps people coming back,’ he said. ‘We don’t have to guess any more. With so many users, we can just run the numbers.’14 (#litres_trial_promo)

We can just run the numbers. Remember those words. Where previously advertising and marketing were more creative disciplines that involved a huge element of risk, a new generation of manufacturers doesn’t need to guess what will keep us coming back for our fix: they already know.

Viewers of House, America’s most popular medical drama – and at one time the most watched television programme in the world – are familiar with the sight of Dr Gregory House, the snide, sexy, crippled antihero, tipping back his head and tossing a couple of Vicodin into his mouth. He’s even been known to throw a pill into the air and catch it like a performing seal. The screenplays go out of their way to portray House as an addict: several times we’re shown him shivering and sweating his way through opiate withdrawal. But, in the end, the Vicodin is as integral to his charm as his twisted humour. The one fuels the other.

Although Dr House, played brilliantly by Hugh Laurie, is prescribed the drug to dull the pain of a leg injury, he also uses it to stave off boredom and stimulate his work as a diagnostic detective. Any similarity to the cocaine-injecting Sherlock Holmes is surely intentional. But only the very earliest Holmes stories actually depict drug abuse: Arthur Conan Doyle, worried that he might encourage addiction, quickly made his hero abandon the vice. Not so the makers of House, who have sustained the central character’s dependence on Vicodin despite criticism from some medical professionals (and, reportedly, the Drug Enforcement Agency).

‘Since the first episode I have been concerned with the show’s message and have attempted several times to educate the writers and producers regarding the danger of Vicodin abuse,’ wrote one physician, coincidentally named Dr John House, who specialises in hearing loss, a devastating side effect of Vicodin.15 (#litres_trial_promo) He lobbied long and hard for this symptom to be recognised in House and eventually it was, albeit in a throwaway line. (As I write, the series is coming to an end, and so far one symptom that hasn’t been mentioned, so far as I can tell, is the awful constipation it causes: a truly realistic scenario would force the good doctor to spend most of the season straining on the lavatory.) The fictional House does succeed in giving up Vicodin after suffering rather implausible hallucinations caused by the drug and completing a period of rehab, but after a couple of seasons he is shown relapsing.

Vicodin was already a fashionable recreational drug when the show first aired in 2004. It was passed around like after-dinner mints at Manhattan dinner parties. In 2001, USA Today described Vicodin as ‘the new celebrity drug of choice’. Matthew Perry, one of the stars of Friends, had already gone into rehab for his addiction to it – twice. Eminem had a Vicodin tattoo on his arm. David Spade joked about it at the Golden Globes. ‘Who isn’t doing them?’ asked Courtney Love. ‘Everyone who makes it starts popping them.’16 (#litres_trial_promo) Celebrities favoured it for the same reason other users did: it was (and is) relatively easy to persuade doctors to prescribe it. In the US, Vicodin falls into the Schedule III category, less tightly controlled than stronger opiate painkillers such as Oxycontin, classified as Schedule II. You can phone in a prescription for Vicodin to a pharmacy; for Oxycontin, you have to hand over a physical script.

So by the time the first House screenplays were being written in 2003, Vicodin was already as famous for its recreational buzz as for its painkilling properties. When the show became a hit, Associated Press writer Frazier Moore suggested that its success was thanks to the way it ‘fetishises pain’. In other words, millions of Americans on painkillers could identify with Dr House’s suffering.17 (#litres_trial_promo) If true, that’s only part of the story. The scripts often refer to Greg House’s pain, caused by the removal of leg muscles after a thigh aneurysm. But much of the sharpest humour centres around House’s schoolboy naughtiness in trying to score more pills than he has been prescribed. That isn’t the fetishisation of pain: it’s the fetishisation of Vicodin. An unofficial range of House T-shirts, still on sale in 2011, includes one that reads: ‘Wake up and smell the Vicodin’. The same logo, accompanied by a photo of Hugh Laurie looking spaced out, is also available as desktop wallpaper for your computer.

Meanwhile, the embedding of the drug in other parts of popular culture continues apace.

‘The Vicodin Song’, by singer-songwriter Terra Naomi, has been watched on YouTube more than half a million times. It’s an appropriately sleepy ballad which begins: And I’ve got Vicodin, do you wanna come over?

The most popular comment on the thread underneath the YouTube video reads: ‘When I listen to this I think of Dr House :)) This song is really cool.’18 (#litres_trial_promo) Many of the 2,000-plus comments, however, aren’t about the song or the show. They’re about how much Vicodin you can take recreationally without hurting your liver. It’s a vigorous debate:

FreeWhoopin1390: Well vicodin (aka hydrocodone) gives you a good calm high. It’s a super chill high to be honest. Now some people might try and tell you that 20–25 mg gets you high, let me start by saying those people are idiots. 20–25 mg will give you a relaxed small buzz for the first time. If you want a really good calm high that lasts for a while take 35–40 mg. I say 40 for the first time but that’s just me. Word of caution tho, do not exceed 4000 mg of tylenol [paracetamol] which is in vicodin, in 24 hours.

Thebluefus: If you get 40 mg of hydrocodone by taking vicodin you have reached the max for tylenol. You don’t need that much to get high, especially as a first time. Just two vicodin will get you the feeling. Don’t be stupid.

FreeWhoopin1390: Are you fucking stupid? The max for tylenol is 4000 mg a day. I take 50 mg of hydrocodone at once (they are 10/500). Which means they have 10 mg hydrocodone and 500 mg tylenol. Which means I am taking 2500 mg of tylenol. Which is nowhere near the max daily dosage. But thank you for sharing what you don’t know.

There are also catfights about the respective virtues of Vicodin and Oxycontin and a discussion of the regional variations in street prices. From time to time someone interrupts to say that they take Vicodin for real pain and that these junkies should be ashamed of themselves. But there are also commenters who were legitimately prescribed the drug who are now junkies themselves. They may resent being a slave to Vicodin or they may enjoy the high; perhaps a bit of both. What should we make of a comment like this?

1awareness: Bragging about pills is lame. I’m using them to make fibromyalgia feel less intense. I also have seizures which cause a lot of pain. I enjoy Vicodin.

These are commenters who describe themselves as Vicodin ‘users/abusers’, a term that neatly captures the ambiguity of prescription drug abuse. All mood-altering drugs, from Scotch whisky to crack cocaine, can be abused: you can harm yourself by taking too much of them. But the vast majority are supposed to intoxicate, even when consumed in ‘safe’ quantities. The Vicodin abuser, on the other hand, is hooked on a drug that the manufacturers insist isn’t designed to alter moods. To further complicate matters, if the abuser is in real pain, it can be hard to tell whether he or she is merely over-medicating or enjoying an extra recreational buzz on top of the pain relief – Dr Gregory House likes to keep his colleagues guessing on this point. But that sort of confusion doesn’t make Vicodin dependence any less difficult to manage; it just means that, like so many 21st-century addictions, it is difficult to categorise and therefore difficult to treat.

As if these problems weren’t bad enough, it was revealed at the beginning of 2012 that several drug companies were working on hydrocodone pills that were potentially ten times as strong as Vicodin. The new pills would be ‘safer’ than Vicodin, according to Roger Hawley, chief executive of Zogenix, because they wouldn’t contain the paracetamol that harms the liver. Maybe so; but their time-release formula would also allow abusers to crunch them up for one hell of a hit. Zohydro, as Zogenix plans to call the drug, is scheduled for release in 2013.

This is just a guess, but it wouldn’t surprise me if, all over America, clued-up Vicodin users are already telling their doctors that their pain is getting worse and maybe they could use something a little stronger …

The addictive qualities of cupcakes, iPhones and Vicodin aren’t immediately obvious. Someone encountering a cupcake for the first time since childhood doesn’t think: uh-oh, I’d better be careful not to develop a sugar addition that triggers an eating disorder and end up washing the sick out of my hair. Likewise, people buying their first smartphone don’t worry about developing an obsessive-compulsive relationship with a computer game, and until recently the recreational use of painkillers was almost unheard of. In other words, as unqualified consumers we’re increasingly tempted by products about whose effect on our brain we know virtually nothing. We may not even notice the burst of tension-relieving pleasure they provide – at least, not until we realise that we can’t live without them.

Using substances and manipulating situations to fix your mood isn’t new. It’s the pace, intensity, range and scale of this mood-fixing that is unprecedented, irrespective of whether it involves drugs, alcohol, food or sex.

Put simply, both our need and our ability to manipulate our feelings are growing. We’re always searching for new ways to change the way we feel because, to state the obvious, we’re not at ease with ourselves. That’s a very broad-brush statement, so let me try to be more specific. Our ancestors were unable to insulate themselves from fear and despair in the way that we try to: certain forms of unhappiness, such as grief at the death of children, were more familiar to them than they are to us. Nor did they possess many fixes to address those feelings – and, in any case, experiences of such intensity aren’t easily fixed, even in the short term. We, on the other hand, struggle with small but inexorable and cumulative pressures in our daily lives. These produce a free-floating anxiety that is susceptible to short-term fixes.

The hi-tech world that ratchets up the pressure on us also yields scientific discoveries that speed up the flow of pleasure-giving and performance-enhancing chemicals in our brains. Indeed, producers and consumers collude vigorously in this process, which helps us cope with commitments that we feel are beyond our control. (Note, incidentally, how the verb ‘to cope’ has invaded so many areas of human activity: sometimes it seems that we need a ‘coping strategy’ just to go to the bathroom.) The jokey phrase ‘retail therapy’ has entered the language for a good reason. We, as consumers, know that the instant gratification of a purchase goes beyond simple pleasure at acquiring something new – it can change the way we feel about everything, albeit only for a short time. Manufacturers are well aware of it, too. They know they are the purveyors of fixes, and that the moment their fixes fail is the moment they start losing market share.

The problem is that these increasingly complex interactions between producers and consumers are also increasingly unpredictable, especially in their effects on the human body. It’s not possible to predict with any accuracy the sorts of relationships that people will form with the substances and experiences thrust at them. Neuroscientists are learning new things about our reward systems all the time, but they’ll admit privately that the attempt to turn these discoveries into drugs that target specific mental disorders have been shockingly hit-and-miss. Meanwhile, the rest of us know only one thing about those reward systems: how to stimulate them.

In other words, we are sitting in front of the controls of a machine whose workings are basically a mystery to us. And someone has just handed us the ignition keys.

2 (#u1b752989-d442-5211-8933-8d687b802192)

IS ADDICTION REALLY A ‘DISEASE’? (#u1b752989-d442-5211-8933-8d687b802192)

‘When people ask why I don’t drink, I explain that I’m allergic to alcohol. But really, it’s a disease. We all have it – everyone in this room.’

The speaker was Pippa, a former actress in her sixties with dyed auburn hair and scarlet lipstick applied so thickly that her mouth looked like a clown’s. This may sound rude, but of all the AA regulars gathered round the trestle table in the church hall she was the easiest to imagine as a drunk. She had what my father used to call ‘a whisky voice’, though she hadn’t touched a drop for 15 years. ‘I behaved in a very unladylike fashion,’ she recalled. ‘And I don’t know if you agree with me, but I think there’s something particularly undignified about the sight of a drunk woman.’

This produced a sniffle of feminist disapproval from a couple of young women in the room, who looked like business executives: the meeting was hosted by one of the Wren churches in the City of London. But no one argued with Pippa’s claim that she suffered from a disease. I attended those lunchtime meetings three times a week in the shaky few months after I stopped drinking, and never once did I hear alcoholism described as anything other than a physical illness. ‘Allergy’ was one description; much more common was the phrase borrowed from the ‘Big Book’, the bible of Alcoholics Anonymous – ‘a cunning, baffling and powerful disease’.

I had no doubt that I was an alcoholic. Alcoholism is the name for addiction to alcohol, and therefore I was also an addict – a useful word to describe someone who indulges in a pursuit so excessively that it harms them. The AA fellowship kept me away from alcohol thanks to the remarkable power of peer-group moral support, and especially the support of strangers, which has its own special potency. But I never thought my alcoholism, or any form of addiction, was a disease. Wisely, though, I kept that opinion to myself at those lunchtime meetings.

Lots of the attendees, Pippa included, seemed almost proud they had this ‘disease’. They talked about it in the defensive but boastful manner in which, years later, people would discuss their recently discovered ‘food intolerances’. They also referred all the time to ‘the alcoholic personality’, as if everyone who ended up in the rooms shared deeply rooted personality traits. Again, I couldn’t see it: on the contrary, I was surprised by how little the members of the fellowship had in common. But if I’d questioned any aspect of the AA worldview, I’d have been corrected immediately: ‘Don’t you dare tell me I haven’t got a disease!’ Or I’d have been fobbed off with words of wisdom: ‘Alcoholism is the one disease that tells you that you haven’t got it’ – an infuriating AA epigram designed to close down debate rather than open it up.

Alcoholics Anonymous dates its foundation from 1935, when it changed from a specifically Christian mission to drunks into an independent fellowship of self-help groups with a strong but deliberately all-inclusive religious ethos. Since then, AA has achieved two extraordinary things. First, it has saved the lives of innumerable drunks. I’m probably one of them, so I feel a bit churlish suggesting that its other major achievement – the dissemination of the disease model – has distorted the modern world’s understanding of addiction.

The fellowship’s first medical adviser, the psychiatrist Dr William Duncan Stillworth, declared: ‘Alcoholism is not just a vice or a habit. This is a compulsion, this is pathological craving, this is disease!’1 (#litres_trial_promo)

This disease is both incurable and progressive, according to AA. The only way to keep its symptoms under control is by a programme of total abstinence based on the famous 12 steps to recovery. In Step 1, sufferers acknowledge their powerlessness over alcohol. Other steps tell them to seek help from God, examine their character defects and make amends for the harm they caused when they were drinking. But – and this is the crucial point – AA reassures them that they cannot be blamed for the wreckage of their lives, because the disease robbed them of their free will.

This raises an obvious question. What about heavy drinkers who give up alcohol of their own accord, without any help from AA or the steps? The fellowship’s answer is a masterpiece of circular logic. Since these drunks exercised free will in stopping drinking, and since the disease of addiction robs you of your free will, they cannot have had the disease and were therefore never alcoholics in the first place.

That AA formula has had an extraordinary appeal for generations of ex-drinkers. The organisation has 1.2 million members in the United States who attend 55,000 meeting groups; there are over two million members worldwide. The fellowship is sometimes described as a religious movement, but it would be more accurate to describe it as a self-help group with religious overtones. The Big Book talks explicitly about God, though it adds that ‘God’ is shorthand for ‘a power greater than yourself’. That power can be a supernatural being or (for atheists and agnostics) simply the fellowship itself.

The disease model, enshrined in the 12 steps, has spread everywhere, perhaps thanks to the fact that AA has never attempted to copyright it. It’s happy for anyone to borrow its formula. As Brendan Koerner put it in Wired magazine, the 12 steps became ‘essentially open source code that anyone was free to build on, adding whatever features they wished’.2 (#litres_trial_promo)

As a result, there are around 200 separate 12-step fellowship networks covering all sorts of addictions. Narcotics Anonymous and Gamblers Anonymous have flourished since the 1950s, Overeaters Anonymous since 1960. Marijuana, cocaine, crystal meth and nicotine have their own 12-step programmes. (In Nicotine Anonymous, being tobacco-free is referred to as being ‘smober’.) There are fellowships dedicated to sex addiction and co-dependence. Online Gamers Anonymous was founded in 2002.

These groups have their own take on the 12 steps, but they leave intact the part of the open-source code that identifies addiction as a disease. Indeed, the vast majority of professional addiction specialists also embrace it. When Alcoholics Anonymous tells its members that medical opinion overwhelmingly thinks of addiction as a disease, it is telling the truth.

But that doesn’t mean that medical opinion is right. On closer examination, many specialists derive their ideas from 12-step groups rather than the other way round. Let me illustrate why I think the disease model is flawed by telling the stories of two addicts who were friends of mine.

In the late 1990s I got to know two young men, Robin and James, who had been inseparable at university. They were in their late 20s, bright, charming and socially ambitious. Both had been to minor public schools but neither had got into Oxford or Cambridge, so when they arrived at their redbrick university they had to settle for its wannabe Brideshead drinking societies. At least once a fortnight they would dress up in black tie and perform the charming party tricks they associated with Oxbridge – climbing up scaffolding and urinating on pedestrians, that sort of thing. When their hangovers allowed, they read Evelyn Waugh, whose cruel snobbery delighted them. They were less keen on textbooks and, despite fluent pens, did badly in exams.

After university they drifted from one undemanding job to another, in the process spending more and more time in the company of ex-public school wasters who used hard drugs. Neither Robin nor James was especially rich, but both had just enough private money to feed their dealers. Eventually they replaced their office jobs with ‘freelance’ occupations that didn’t require raising their heads from the pillow until the first of the afternoon soap operas. Both sets of parents were in despair, and raided their savings to pay for expensive spells in rehab that achieved nothing.

By 2000 the two men were boringly obsessed with getting high on any psychotropic substance they could lay their hands on, ranging from heroin to painkillers. At around that time I had a wisdom tooth taken out in the dentist’s chair and was given a supply of dihydrocodeine tablets that I didn’t take because they made me nauseous. I mentioned this to James, and within half an hour Robin was on the phone. ‘I hear you’ve got some DF118s,’ he said. I checked the label. Yes, that was what it said. ‘Since they make you puke, why not let me take them off your hands?’ he asked.

Robin and James were, or seemed to be, the most irredeemable addicts I’ve ever met. I was relieved when they drifted out of my life. I once caught sight of James hovering around the wines and spirits section of a supermarket in Bristol: this was the heyday of dirt-cheap own-brand vodka, and judging by the contents of his trolley he was taking full advantage of the special offers.

And now, five years later? Robin has a steady girlfriend, a baby daughter and a job in social media that has enabled him to start paying off his mortgage. He and his family are about to move to San Francisco, where he will work for an internet start-up. He gave up drink and drugs slowly, cutting out one substance after another, without relying on the 12 steps for guidance. ‘They just remind me of the bad old days in rehab,’ he explains. ‘My home-made recovery was a long and messy business, with plenty of false starts, but it did work in the end.’

James is dead. He killed himself by jumping from the fifth floor of an apartment block in Johannesburg in 2006. It seems to have been a spur-of-the-moment thing, but who knows? He didn’t leave a suicide note.