Special issue with the Sunday Magazine
From the publishers of THE HINDU

ADDICTIONS: February 25,2001

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Is it in the genes?

Dr. S. Mohan Raj

The author is a consultant psychiatrist based in Chennai.

Anantha Padmanabha Rao/Fotomedia

Dinesh* looked at the clock. His parents had gone to a party. For a change, the party was taking place in somebody else's house. Normally, about three parties took place in his house every week. He had seen father becoming less inhibited, singing and appearing happy. Even on days when there were no parties, father would sit alone and drink. "I've been drinking for 20 years. What is wrong with my health?" he would counter mother's advice.

Dinesh opened the fridge. Fancy bottles of various shapes were fighting for space with the foodstuff. He picked up a bottle. He was curious to find out what was in the drink that made elders root for more. He mixed a drink the way he had seen father do. He took a sip and didn't know any difference. After a few sips, he liked the experience. After a few months, he was taking alcohol daily.

Saravanan* doesn't remember any family member smoking or drinking. He resented being teased as a "sissy" by his friends for refusing to smoke or drink. He started to drink and felt that he was part of the group and was "macho". A few years later, he noticed that most of his friends had stopped drinking but he had progressed to drinking daily.

"Why do you take alcohol/ drugs?" Ask this question to those addicted to them and you will get a delightful variety of reasons. "Too much work, no work, to celebrate success, to mourn failure" etc. Critics point out that the theories regarding causes of addiction are as varied. The theories range from genetic to cultural factors. The fact is there is no single explanation for addiction. There are many factors that play a role. As clinicians, we look at the factors responsible for addiction in an individual patient and plan treatment accordingly.

Before becoming addicted to a drug, one has to start somewhere. Curiosity and availability were responsible for Dinesh trying his first drink. Peer pressure ensured Saravanan's initiation.

Not everyone who takes a drink goes on to become an addict. Some stop it after a while or limit it to certain occasions. This transition from "social drinking" to "alcohol dependence" (or addiction) is influenced by many factors.

Family

It is debated whether a complex process like addiction could be genetically determined. Research shows that it is partly true. Twin and adoption studies have shown that children of alcohol dependent parents have a higher risk of becoming alcohol dependent even when brought up by alcohol free foster parents.

The explanation given is the way a person's body metabolises (breaks down) alcohol. An enzyme called aldehyde dehydrogenase is crucial in metabolising acetaldehyde, which is a breakdown product of alcohol. Some people possess an inactive variant of this enzyme. For them, consumption of alcohol leads to high levels of acetaldehyde in the body, which causes a unpleasant reaction.

Japanese and Chinese have this variant enzyme. They develop an unpleasant flushing reaction with alcohol, popularly knows as "Oriental flush". This reaction protects them against heavy drinking and the incidence of alcohol dependence is low in these races.

It is easy to blame addiction on the genes. Is it only nature or does nurture play a role? Children look up to parents as role models. Parental behaviour and interests have a tremendous influence. If a parent smokes or drinks in the child's presence, the child sees it as normal acceptable behaviour, worth emulating.

G. Bharath Bhushan

A confiding relationship with parents and adequate emotional support from them are family factors that diminish the risk of adolescent initiation into drugs. These are influences which are nurtured over time. It is low in some families and parents try to make it up by suddenly increasing parental control or expressing love. This would only aggravate matters.

Pankaj who regularly takes cannabis and heroin says, "Suddenly my parents want me to tell them about my friends, my routine etc. Where were they all these years when I longed to tell them about many things? I would wait to tell them about what happened during the drama rehearsal at school or some funny incident but they had no time to listen. Why should I talk now?"

Some adolescents use drugs as an expression of independence or as overt hostility towards parents and society.

Drug factors

Paul has been drinking for five years. Gradually, he noticed that his usual quantity had no effect and he needed to take more to get the same "high" as before. Whenever he had to avoid alcohol for a day, he noticed that he was becoming irritable. His hands began to tremble and he couldn't fall asleep. He was constantly thinking about the next drink. These symptoms started appearing every evening and he drank to relieve them. A few months later, he would drink at noon to work without tremors.

Having to drink more to get the same "high" or "rush" is called tolerance. Unpleasant symptoms that appear on stopping a drug are called withdrawal symptoms. Most drugs of abuse share this property of causing withdrawal. The symptoms vary for different drugs.

Shankar's* shirt was dripping with sweat. "If only that peddler had delivered on time today," he thought as he tried to control yawning. Ever since he started abusing heroin, he had been diligent in his intake. He had seen a friend go through "cold turkey" and dreaded it. To avoid it, he had borrowed or stolen. But today, the supplier didn't turn up and none of his friends could be traced. A few minutes later, he developed goose flesh and abdominal cramps. He screamed with every cramp. Withdrawal symptoms ensure that a person goes back to the drug even if he attempts to stop it.

Individual factors

Psychiatric symptoms/ illness

Ajay lall

Jeeva* was sleepless and depressed for a month. He felt that he was worthless and was being a burden to others. His performance in office suffered as he felt very lethargic and had no interest in anything. He reported helplessness to a friend who in turn suggested, "Come and drown your sorrow in rum." Jeeva felt better after a few drinks and could even laugh. He had a severe hangover the next morning and decided not to drink again. By evening, boredom and sadness made him reach for the bottle again.

Persons with untreated depression or anxiety are prone to get addicted to alcohol/ drugs as they offer temporary relief. Ironically, in the long term, alcohol worsens the depression and anxiety. Certain personality traits like rebelliousness and novelty-seeking behaviour have also been implicated in drug abuse.

Environmental factors

Availability is a major reason for initiation rather than continuation of a drug. Recent relaxation of licensing in Uttar Pradesh, which enables beer to be stocked in grocery stores, has seen many adolescent take to it. Advertisements, which increase expectancy, also affect only the newbies. Those who are dependent will always procure the drug despite strict legislative control.

Stress: Stress comes in various forms. It could be occupational, financial, academic, marital etc, Alcohol/ drugs provide a maladaptive way of coping with or escaping from stress. In the absence of other healthy coping skills, alcohol/ drugs provide an easy way out. Alcohol helps Bahadur* to be assertive in the factory where he works but causes significant problems at home. "Drinking due to financial stress" is a logic that is difficult to fathom. Consuming alcohol due to marital stress is a hen and egg problem. It is often difficult to tell which begets the other.

Then there is the archaic "moral theory", which considers addiction as sinful, deliberate and due to a weak will. The logical remedy suggested is punishment. Traces of this concept persist in all of us despite alternate explanations and evidence.

A humane approach would be to consider addiction as a disease. A disease, which can be triggered and maintained by multiple influences. Treatment and preventive measures should, in addition to the individual, address these influences.

* All names in this article have been changed.