I’m, Dr. David Sack, an addiction psychiatrist. Ask me anything about drug and sex addiction

For years, people have stated that Marijuana is physically and chemically non-addictive. However, many people who smoke regularly do claim a form of "psychological" dependence. How do you reconcile this from a medical perspective? What do you consider the risks, if any, of prolonged marijuana use, and how much of this varies from person to person? And also, if you could, compare that perspective with the widespread use that we've seen of "legal" substances that have addictive qualities, like alcohol, cigarettes, coffee, and prescription drugs.

Most recent research indicates that marijuana can be both psychologically and physically addicting. Physical symptoms of withdrawal include anxiety, insomnia and loss of appetite. These tend to start within several days of stopping and peak during the first two weeks. Psychologically, people who chronically use cannibis are often observed to have low motivation, to be socially withdrawn, irritable and complain of memory difficulties.

This may be a bit off topic. How does television or video game addiction compare to the awful addictions you work with? Is the fact that the addiction has no physical dependence create a vaccume of respect for the matters in the professional community? Or rather is it the lack of severity and rates that cause less severe addictions to be less openly discussed?

Thank you for your AMA.

People have started to pay more attention to video gaming and compulsive TV watching and have put it on the spectrum with gambling. I have often seen young adults who started out as gamers but migrate to online gambling as they get older. There has been a lack of research at this point, but there is no question that many of the same behaviors (excessive involvement, disruption of relationships, interference with working) can occur with gaming.

When can you classify a "porn-addiction"? I watch porn everyday, but it doesn't really affect my day-to-day life outside of when I watch it. I definitely need to watch porn to sleep, am I addicted?

While medical specialists have yet to formally agree on when porn becomes an addiction, most experts would focus on how does watching porn affect other areas of your life. Does it disrupt your relationships? Does it interfere with getting other things done? Do you spend too much money on it? Your message suggests that your are starting to rely on watching porn to get sleep, and it makes me wonder if you are watching it at other times to control anxiety, improve mood, fight loneliness.

What advice would you give to someone dealing with a loved one who suffers from addiction?

Loved ones often struggle between fear (that the person will hurt themselves or someone else, overdose, do irrevocable harm to work or career) and anger (at being exploited, taken for granted, intimidated or abused). The first goal is to get your loved one to safety if possible. Sometimes safety is a place (rehabilitation program) at other times it is a process (90 meetings in 90 days). What a loved one shouldn't do is to continue to support an addicts habit.

Why are people addicts and some people not? I've done drugs a few times with my friends in a social setting but I've never desired to do it otherwise.

No matter which drug you choose, only a small proportion of the people who try it will become addicted. The risk is somewhere between 1 out of 8 to 1 out of 12. Genetic factors can account for up to 50% of the risk of becoming addicted but we have yet to identify the specific gene/genes are are involved. Two other factors that are often cited are the age of first exposure is another factor (the younger you are when you try a drug the more likely you are to become addicted) and a history of other psychological or emotional problems before you start using a drug.

Why does everyone get better looking when I’m drinking?

"They all look better at closing time, When a number 3 becomes a number 9."

Alcohol disinhibits impulsive and high risk behaviors. Someone who has been drinking becomes less selective and less worried about the problems that a casual sexual encounter may cause.

So I can't stop smoking weed currently, and I think it's exacerbated by the fact I have a ton of free time now. When I first wake up in the morning I feel fine, and tell myself not to smoke. The next thing I know I'm on the way to the library and lighting up a bowl. It's like my brain shuts off the voice of reason saying not to smoke. The worst part is that I'm studying for a major exam and I purposefully took off to study for this. What do I do in this case?

In my experience, pot is an insidious drug. People often don't realize the role that rebound anxiety and agitation may be playing when they light up that next bowl. Your pot use is starting to get in your way and your attempts to control it by yourself are not working. It is probably time to get help.

1. Are there differences between sex and drug addictions besides the object of addiction?

2. Is alcoholism counted as a drug addiction?

3. Is there a difference between compulsively over-eating and being addicted to food?

4. Does the prevalence of sex addiction vary culturally or ethnically?

5. When is an addiction an addiction and not just someone wanting to do something a lot? One thing I often hear bandied about is "when it starts to negatively affect the life of the person engaged in the (addictive) behavior or the lives of those around him" but this seems a strange rule of thumb if addiction really is a psychiatric condition. Is an autist only autistic when it negatively affects his life? Is someone with bipolar disorder? Someone with schizophrenia? Why does addiction get a special status?

Lots of questions here so I am going to see if I can get to all of them.

Sex and drugs are different. The reward value of sex in animal models is about half cocaine or amphetamines. In addition, the timing of the rewards is very different. With cocaine most of the reward occurs after you take the drug (anticipation or conditioned place preference mean you get some of the reward before). With sex most of the reward comes during the arousal phase when dopamine and other peptides (oxytocin) spike, before it is consummated.

1. Yes alcoholism is a drug addiction. It is a chemical that works in the brain by altering the effects of our own neurotransmitters (in this case GABA, glutamate, serotonin, and enkephalins are all affected).

2. Eating behaviors are complex and understudied. Some people would draw a distinction here given that more than half the population is overweight but most are eating is a way that disrupts other areas of their life.

3. I don't think we have a clear answer for that yet. What clearly varies culturally are sexual norms.

4. The colloquial use of addiction to loosely refer to anything people do too much of is confusing. The definition of pathological gambling gives some useful insights into how to think about this. It requires that the gambling behavior be accompanied by at least 5 of the following: loss of control, lying to family members, loss of job/school, increasing cost, chasing one's losses, irritable when cutting down, illegal acts to support the habit, needing others to provide money.

Have you ever seen someone with a porn addiction that affects their sexual drive? Basically they get all their sexual fulfillment from porn that they don’t need it from a partner?

This is a common observation among people with porn addiction and other forms of hypersexual behaviors. In addition to being aroused by an interested partner, mechanical stimulation, romantic encounters, memories of successful sexual experiences, men in particular are aroused by visual imagery. Much of the rewarding effects of sex on the nervous are mediated through the chemical dopamine. Dopamine release goes up most during the arousal phase of sex, not consummation. Pornography allows some people to extend this arousal phase, and may make sex with a partner seem less rewarding.

Any advice on slowly tapering off alcohol?

Stopping alcohol is among the most dangerous detoxes and should not be undertaken without consulting a physician who is knowledgeable about alcohol dependency and its treatment. Vitamin deficiencies (for example low magnesium levels or low thiamine), and other health problems make detoxing from alcohol even riskier.

What are your thoughts on food addiction?

Our new definition of addiction (ASAM) focuses on the idea that addiction is a disorder of the brains reward circuitry. Notice it doesn't say anything about drugs. This is because there is only one reward system in the brain - for both natural rewards and artificial rewards. The reward system plays an important evolutionary role because things that are important to our survival (food, water, sex) are experienced as pleasurable and the circumstances in which they occurred are remembered. Certain foods are inherently more pleasurable such as sugars, starches and salt. There was a time when these were hard to obtain. Now food manufacturers regularly 'design' food to be pleasurable. The resulting behaviors look very much like drug addiction. This has been extensively shown for sugar in animal models.

Hi Dr.

I've always had a slightly more philosophical (than psychological I suppose) view that much addiction is simply people trying to fill a void in their life with addictive substances and behaviour rather than address the root causes. Is there any truth to this that can be psychologically verified or is it nonsense?

Not all people come to addiction by the same path. People with a history of depression, anxiety, attention deficit disorder and certain personality disorders are more likely to become addicted. This forms the basis of the 'self-medication' hypothesis, i.e. that they are using drugs and alcohol to manage intolerable feeling and internal states. Childhood abuse and neglect are common antecedents. Successful treatment requires that the underlying emotional programs be addressed often through a combination of psychotherapy and medications.

what is the most effective way to quit smoking for good?

Quitting smoking (overcoming nicotine addiction) is one area of addiction where we've made a lot of progress in the last decade. There are now three classes of medications that can help people quit: nicotine replacement, buproprion (orginally developed as an antidepressant), and varenicline (which binds to the same receptor as nicotine and blocks craving and withdrawal). Varenicline is nearly twice as effective as the other two medications but can affect mood. Many people will need some combination of these medications. In addition quit rates improve when the medicines are combined with a behavioral program.

How have you been able to make the connection to medical professionals that addiction is a disease and not just a moral choice?

Doctors and other health professionals share many of the biases of the cultures they live in, including the idea that addicts are doing this to themselves. There has been an unprecedented willingness by people with drug and alcohol problems to come forward and discuss them and this has reduced the social stigma associated with addiction. The current opioid epidemic has brought heroin to the suburbs and there is a growing awareness about addiction among health professionals because more than ever it is touching their lives. We need to do more as part of the formal education process. Most medical and nursing programs offer very little formal education about drugs and alcohol or their treatment.

Is sex addiction something more phisical or psychological? Is it more dificult to treat someone that have sex addiction or drug addiction?

Sexual addiction has not been studied enough to give a definitive answer. Sexual arousal and consummation stimulate the brains reward system (mesocortical dopamine system) in ways that are similar to addicting drugs like amphetamine and cocaine. If fact, people who report having sexual addiction are 5 times more likely to have abused cocaine in the past. There are similarities in treating drug addictions and sexual addictions but there is one very important difference: with drugs the goal is to stop using them entirely; with sexual addiction the goal is to establish/re-establish a more normal pattern of sexual relations, not give it up altogether.

I am a recovering addict, myself. I just achieved one year of clean time and recovery on July 12th with the help and support of Narcotics Anonymous and the 12 Steps. I am curious, with your credentials, what you think of replacement substances like Vivitrol, Suboxone, Methadone, etc? Not that it matters, but my personal stance is i vehemently oppose them, but I am curious as to your thoughts?

Vivitrol (a long acting injectable form of naltrexone that is given one time per month), works very differently that suboxone (active ingredient buprenorphine) or methadone. Naltrexone acts as a blocker (antagonist) at the opiate receptor but has no rewarding properties. The other two have some rewarding properties. The problem today is that many people need more than one approach to solve their problems with opioid addiction. This means while many people will be helped by NA and do well, others will not. More people died from overdoses last year than in automobile accidents. The opiate epidemic is a crisis. As a physician, I want to get each patient the treatment that is right for them, but I don't think we can rule out entire classes of treatments as a matter of philosophy.

I wrote a long ass question I think I deleted so long ass question short.... I've cut down my method use over the course of numerous living nightmares and lack of access from literally all day everyday and sleeping 5 to 8 times a month to monthly or bi monthly use with the occasion runs.

I am far to ashamed to reach out for help on the true nature of my addiction which is actually Meth and porn cross addiction. I don't even have the desire to use Without access to porn. I can't really find a community dealing this this specifically and NA only goes so far. Plus the god-boner every one has there just makes me feel more alienated

Basically where do I start ending this shameful and seemingly inescapable demon I've created?

Straight up if my life is just gonna be this years and years, struggling in shameful meth use that negatively affects all aspects of my life, I'm just gonna check out now.

Any advice would be SO appreciated

I strongly recommend that you start by going into a treatment program where there expertise in both meth addiction and sexual addiction. It's a tough combination but you have to start somewhere. If you are not ready to start a program, commit to going to both NA and SAA, 90 meetings in 90 days, even if you don't think it can work for you.

Is addiction more a case of loving something a lot or an actual chemical inbalance?

Drugs of addiction are chemicals that mimic the neurotransmitters and neuropeptides that are naturally found in our brain. The repeated exposure to high does of these chemicals cases long term changes in the brain and the behaviors that are regulated by those brain regions. It is an actual chemical imbalance that can take months, and in some cases years to reverse.

Why do people think that they will never get addicted to a drug if they see that it happens to others on the same drug?????

In my experience, it is difficult for most of us to learn from others examples.