Understanding Addiction

Hi all. I haven’t been blogging for a while, partly because I wasn’t sure I had anything new to say. But the “opioid crisis” is obviously on everyone’s mind. So, I wanted to get the facts straight, and I pitched an article to The Guardian, published yesterday, based on what I found.

The response has been slightly overwhelming: more than 500 published comments in less than 24 hours (plus some emails to me personally). Most moving to me is the gratitude expressed by people in serious pain, people whose access to needed medication is being quickly cut off by the hysteria concerning the overdose epidemic. The point of my article was that most of the opioid panic is fueled by a misguided perception that opioid pharmaceuticals, prescribed and taken by patients in pain, is this diabolical force behind the wave of deaths.

I am in no way minimizing the tragedy of the overdose epidemic. But as most of you know, fentanyl and its analogues are the primary cause. But here — I’m pasting the article below, with a few additional thoughts, plus a graph from the NIH/NIDA website that helps tell the story. Or read the article in The Guardian and peruse the comment section. There’s a lot of painful reality (plus a lot of stupidity, as usual) revealed by these comments. Makes me feel good about what I wrote.

Pasted from The Guardian:

“The news media is awash with hysteria about the opioid crisis (or opioid epidemic). But what exactly are we talking about? If you Google “opioid crisis”, nine times out of 10 the first paragraph of whatever you’re reading will report on death rates. That’s right, the overdose crisis.

For example, the lead article on the “opioid crisis” on the US National Institutes of Health website begins with this sentence: “Every day, more than 90 Americans die after overdosing on opioids.”

Is the opioid crisis the same as the overdose crisis? No. One has to do with addiction rates, the other with death rates. And addiction rates aren’t rising much, if at all, except perhaps among middle-class whites. [See graph pasted below.] [And note that I should probably have added middle-aged middle-class whites.]

Let’s look a bit deeper.

The overdose crisis is unmistakable. I reported on some of the statistics and causes in the Guardian last July. I think the most striking fact is that drug overdose is the leading cause of death for Americans under 50. Some people swallow, or (more often) inject, more opioids than their body can handle, which causes the breathing reflex to shut down. But drug overdoses that include opioids (about 63%) are most often caused by a combination of drugs (or drugs and alcohol) and most often include illegal drugs (eg heroin). When prescription drugs are involved, methadone and oxycontin are at the top of the list, and these drugs are notoriously acquired and used illicitly.

Yet the most bellicose response to the overdose crisis is that we must stop doctors from prescribing opioids. Hmmm.

Yes, there has been an upsurge in the prescription of opioids in the US over the past 20 to 30 years (though prescription rates are currently decreasing). This was a response to an underprescription crisis. Severe and chronic pain were grossly undertreated for most of the 20th century. Even patients dying of cancer were left to writhe in pain until prescription policies began to ease in the 70s and 80s. The cause? An opioid scare campaign not much different from what’s happening today. (See Dreamland by Sam Quinones for details.) [I’ve updated this link.]

Certainly some doctors have been prescribing opioids too generously, and a few are motivated solely by profit. But that’s a tiny slice of the big picture. A close relative of mine is a family doctor in the US. He and his colleagues are generally scared (and angry) that they can be censured by licensing bodies for prescribing opioids to people who need them. And with all the fuss in the press right now, the pockets of overprescription are rapidly disappearing.

[I should probably have mentioned that advertising by Big Pharma also helped fuel the overprescription trend. But that’s kinda old news.]

But the news media rarely bother to distinguish between the legitimate prescription of opioids for pain and the diverting (or stealing) of pain pills for illicit use. The statistics most often reported are a hodge-podge. Take the first sentence of an article on the CNN site posted on 29 October: “Experts say the United States is in the throes of an opioid epidemic, as more than two million of Americans have become dependent on or abused prescription pain pills and street drugs.”

First, why not clarify that most of the abuse of prescription pain pills is not by those for whom they’re prescribed? Among those for whom they are prescribed, the onset of addiction (which is usually temporary) is about 10% for those with a previous drug-use history, and less than 1% for those with no such history. [Thanks to Maia Szalavitz for highlighting these statistics.] Note also the oft-repeated maxim that most heroin users start off on prescription opioids. Most divers start off as swimmers, but most swimmers don’t become divers.

Second, wouldn’t it be sensible for the media to distinguish street drugs such as heroin from pain pills? We’re talking about radically different groups of users.

Third, virtually all experts agree that fentanyl and related drugs are driving the overdose epidemic. These are many times stronger than heroin and far cheaper, so drug dealers often use them to lace or replace heroin. Yet, because fentanyl is a manufactured pharmaceutical prescribed for severe pain, the media often describe it as a prescription painkiller – however it reaches its users.

It’s remarkably irresponsible to ignore these distinctions and then use “sum total” statistics to scare doctors, policymakers and review boards into severely limiting the prescription of pain pills.

By the way, if you were either addicted to opioids or needed them badly for pain relief, what would you do if your prescription was abruptly terminated? Heroin is now easier to acquire than ever, partly because it’s available on the darknet and partly because present-day distribution networks function like independent cells rather than monolithic gangs – much harder to bust. And, of course, increased demand leads to increased supply. Addiction and pain are both serious problems, serious sources of suffering. If you were afflicted with either and couldn’t get help from your doctor, you’d try your best to get relief elsewhere. And your odds of overdosing would increase astronomically.

[A note to my readers: As you see, I’ve mentioned but somewhat underplayed the needs of people in addiction. Knowing my history and my sympathies, I think you must realize that I care very much about their needs as well.]

It’s doctors – not politicians, journalists, or professional review bodies – who are best equipped and motivated to decide what their patients need, at what doses, for what periods of time. And the vast majority of doctors are conscientious, responsible and ethical.

Addiction is not caused by drug availability. The abundant availability of alcohol doesn’t turn us all into alcoholics. No, addiction is caused by psychological (and economic) suffering, especially in childhood and adolescence (eg abuse, neglect, and other traumatic experiences), as revealed by massive correlations between adverse childhood experiences and later substance use. The US is at or near the bottom of the developed world in its record on child welfare and child poverty. No wonder there’s an addiction problem. And how easy it is to blame doctors for causing it.”

Here’s that graph that I should have pasted into the article, if I’d gotten permission and so forth. Note the almost steady rate of illicit drug use since 2002:

Pasted from a page on the NIH/NIDA website.

…by Bill Abbott, M.D….

Bill has been a long-standing member of this blog community and he has contributed his leadership and knowledge to the SMART Recovery movement. Thanks, Bill, for taking the time to share your thoughts here.

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I’ve recently completed two books. The first is Marc Lewis’s recent one and it is a winner. In this book Marc describes a “model” to explain addiction that is counter to the prevailing “disease model” and he does so in a very credible and lucid way that is based on neuroscience integrated with personal experiences of people he interviewed. A very effective approach indeed.

The second book, republished recently, is entitled Love and Addiction by Stanton Peele, which was first published in 1975 – 40 years ago. In this book (and other books of about the same vintage, such as Diseasing of America) Peele described the problem of addiction in very similar ways – obviously without the neuroscience available today — and showed the similarities between addiction and some forms of love, as Marc does also.

This has left me both frustrated and somewhat sad – that is, so much was clear forty years ago and yet we seem to have learned so little, and I can only come to conclude the following:

1. The current way we approach the problem of addiction in the United States is abysmal; it isn’t working because it is wrong.
2. We have failed to learn from our mistakes.
3. Much of what we really need to know to understand addiction has been known for a long time, but we haven’t paid attention.
4. We know enough about the problem to effectively deal with it.
5. And finally, the disease model is not only wrong; it is harmful.

Marc suggests that the disease model is harmful to a certain extent, but my purpose here is to expand on that idea. I feel justified perhaps because I am a medical doctor — and in long term recovery from alcohol misuse.

As a disclaimer, what I describe pertains to the United States, where I live… but probably to some extent to other western countries as well.

The harm stems from two sources:

The first is a practical issue. If addiction is a disease, doctors will be expected to “treat” it. That may not be too bad in theory, but unfortunately the medical profession (in the United States at least) is ill-prepared by virtue of knowledge, training, and — most problematic — insufficient time.

What about psychiatrists, you say? They are doctors. This is true (although many seem to forget clinical medicine)… but because they are doctors they treat patients by managing their patient’s diseases by prescribing medication, hoping for cure.

The underscored words lead to the second and greater problem with the brain disease model; and that is that it shifts the focus away from people with a problem to an outside entity, thereby mitigating personal responsibility. This position in essence means looking for an outside solution for an inside problem…that only an inside solution can help.

Let me expand on that a little.

Marc brings up two very important concepts in his book: what he calls “now appeal” (officially delay discounting) and ego fatigue or depletion (the depletion of cognitive resources for applying self-control). A related idea is the concept of locus of control.

This concept has been around for a number of years and has been described a number of ways. In general terms what it refers to is whether an individual believes in or relies on self-management or tends to look to outside resources for problem solving. This is not a fixed or constant trait but rather a tendency that varies with the problems and stresses people face. It often tends to be more on the external side in those encountering hard times – not uncommon in the addicted person. Some incorrectly call it low self-esteem.

So if addiction is a formerly useful coping strategy, now gone amiss, then one needs to look for other coping strategies that work better and be motivated to put them to use. And these work better if they are self-empowered. They don’t work if you rely on someone or something else. They just can’t.

The neuroscience points to the same conclusion; it is the “desire” that Marc is talking about that makes recovery work.

What is needed is a shift toward an internal locus of control. Something which the disease model tends to undermine because it fosters dependence on another power.

Surely you can and ought to seek help, advice, support, or what have you, if that can help. But ultimately you have to do it—for yourself

This is why the disease model is so insidious and counterproductive to successful recovery in many people. Although your doctor will encourage your participation, basically he is telling you what to do. This is prescription — be it medication or behavior. “You must stop drinking or you will die,“ my doctor said to me. I went home and poured a drink to think about that.

The evidence supporting the self-management approach is all over the place.

Consider so-called natural or spontaneous recovery — statistics show that as many as 80% of those who meet criteria for substance use disorder in the DSM-5 recover with no intervention or support whatsoever.

This is the epitome of self-management and empowerment.

For those who do need some help, self-management can be learned or better relearned in any number of ways… but I am skeptical that it will ever be learned in a doctor’s office, where you wait next to people with medical illnesses like hypertension and hemorrhoids.

A disease like cancer needs the doctor to manage it; addiction does not.

What those of us who solved the problem of addiction share is self-empowerment and then learning the skills to manage life’s many stresses in a different and ultimately less destructive manner.

The whole disease model concept is based on some really bad science and that in itself is harmful. But the fallout is potentially more damaging.

I only hope people start paying attention, because the problem is getting worse and we gotta do better. The people who suffer deserve that much, and if we help them to see what they can do for themselves, they may in fact do it — and feel good about the fact that they did.

Hello readers. Are you still out there? I haven’t gone near my blog for over two months. So no new posts, a few comments dribbling in, and of course not as many readers. Something had to give. Having to sell our house in the Netherlands, buy a house in Toronto, move goods, furniture, children, etc, from Arnhem to Toronto…all the crap you go through in moving, made so much more complicated by the pandemic, having to cancel services and contracts…in Dutch…was just overwhelming. So I took a break from non-essential duties. And that seemed to include the blog.

More than that, I wasn’t sure I had anything new to say about addiction — the science, treatment approaches…anything. I didn’t want to just recycle earlier topics. So my last post, on Internal Family Systems (IFS)  therapy for people in addiction, was looking like my last hurrah. But lately I started thinking I may have more stuff to share. IFS has changed the way I look at almost everything in psychology. It’s changed how I see emotional habits, “dysfunctional” behaviour patterns of all types, and of course the way I understand addiction. I’ve used it pretty methodically with myself — sometimes as an alternative to meditation. And it’s had a major impact on the way I practice psychotherapy.

So, moving on: the next set of posts will apply IFS theory and related ideas to our understanding of addiction — broadly — and find out where that takes us. If you haven’t read my last post — maybe take a look at that first to get the basic idea.

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I was talking with my wife about how common it is for people to feel inauthentic. It’s a big issue for adolescents in particular (that’s her field — adolescent development). Teens are always trying on different styles — different clothes, ways of talking, ways of seeing themselves. Who are they? Straight, gay, or bi — meaning what? — geek or jock, reserved or outgoing, serious or casual? And as they’re trying on these new identities, they often wonder if they’re being fake or real. It’s a big issue.

For people in addiction, the problem of “authenticity” is amplified and extended. We all know that stupid riddle: How can you tell when an addict is lying? His lips are moving. Insulting, of course, but there’s something to it. We addicts do lie. We lie because we don’t think we’re okay. We know that taking drugs is frowned on, to say the least. We lie because we continue to do something that most others disapprove of. Bye mom, I’m off to score some heroin, see you later. It’s just not something you’re going to hear.

My first big lie to my parents seemed necessary. I’d just used the money they’d given me for a winter coat to buy smack. I was 18, and I was anxious, depressed, and very lonely. Heroin helped. Gradually lying became habitual. I lied to romantic partners, parents, relatives, friends, work-mates, bosses — just about everyone — when the necessity arose. Being truthful about being a drug user — seriously? — is sure to invite heaps of social rejection, scorn, contempt, and often, serious consequences for one’s lifestyle and personal safety.

So addicts (I use that word to describe, not to shame) see themselves as inauthentic or untrustworthy. It’s a self-concept we acquire almost seamlessly. That’s not a great foundation for building self-esteem, and self-esteem can be crucial for developing self-care. In fact, seeing ourselves as inauthentic amplifies the shame and self-doubt that got launched in adolescence and boosted by drug use itself. What a drag.

But what if the idea of “being inauthentic” is just wrong. Like a map from the middle ages, what if it’s just totally inaccurate?

PLEASE NOTE THAT I AM HAVING SOME TECHNICAL PROBLEMS. TO GET AROUND THEM, I’VE DIVIDED THIS POST INTO TWO HALVES, PART 1 AND PART 2.

Please see Part 2 for the rest of this discussion!

…by Matt Robert…

We interrupt this broadcast for an important announcement from the fake news channel.  If you haven’t already heard, you are a worthless piece of shit who doesn’t have any business having a happy life, so you should just give up, say fuck it and use. You should just give up and settle for less, because this isn’t gonna get any better. Besides, nobody will know…or care.

Sound familiar?

One of the Trumpocalypse’s unintended contributions to the rational world was the reminder that not everything we hear on the news is real. Neither is everything we hear in our heads — especially the automatic negative thoughts blaring from our own fake news channel.

In some fake news stories of foreign origin the English is not quite right. In many of them, regardless of origin, the reasoning is not too solid. Likewise, sometimes the reasoning on our own fake news channel is a bit off: “So what if you got a degree in literature? You don’t know shit.”

Remember the fake news story about Hillary Clinton running a child pornography ring out of a pizzeria in NY city? And the guy who got a gun and drove hundreds of miles to the pizzeria to “save the children”? We too often act on the ridiculous messages that our fake news channel is sending us.

I’ve noticed that, when I was an in-patient or in a treatment program, the fake news network stopped broadcasting, or at least I couldn’t pick it up. I was always puzzled that whenever I was in treatment, I’d do great. Just being there sharpened my awareness. When I came out I’d go along great for a while and then tank. One likely reason: my fake news sources were back in action, broadcasting loud and clear.

So what to do? Well, you can’t change something if you don’t know what it is–and our fake news channel may always be there. Get to know yours — there may be more than one. My most popular channel is on the Self-Blame and Praise-Hater network.  “This just in: Everything bad that happens is your fault, and you don’t deserve any credit for a job well-done. And now a word from our sponsor: You suck.” I specifically and mindfully practice noticing when these subtle yet insidious rebroadcasts emerge unbidden.

Fake news triggers urges, and vice versa. The satellite feed for the lead story originated long ago and far away — for some of us the stories started in early childhood.  The stories can be as incessant as muzak playing over and over in your head. We have to change the channel to stay ahead of it…to stay in front of the fuck-its. Because when do the fuck-its happen? When terrorists demand action, now — no time to stop and think — or else.

Fake news is now not only a meme but an apt tag for the harmful diatribes that go off in our heads and often drive our behavior. But if we can recognize them, we can label them, and if we can label them, we can stop listening. If we can slow down enough to classify the news as real or fake, then, if it’s fake, we can turn down the volume — all the way down.

What are some things people do to change the channel on their fake news? Please let us know.

The heroin “epidemic” is a major concern all over the world right now. What are the various philosophies for dealing with it? In today’s post I’ll share some impressions from my recent visit to a harm reduction/methadone clinic in Belgium. Then I’ll post a piece by Percy Menzes who is dedicated to the use of naltrexone and policies that minimize access. Then we’ll see what Sally Satel has to say about programs that use punishments and rewards to get people to quit — so called incentives. That should keep us busy.

Last Thursday I took a train to a town in Belgium called Diest. It was two or three days after the attack on Brussels…so there were quite a few military guys standing around in the train stations with machine guns in their hands, ready for action. Not exactly reassuring.

But with all the chaos and pain that seem to infest the world right now, I felt a warm, cocoon-like embrace when I entered the Wit Huis  (The White House), a harm reduction clinic that provides prescriptions for methadone, counselling, and a place to hang out for a little while.

The waiting room was a pleasant lounge where people (mostly addicts) could relax with tea and cookies (and baked goods such as Easter cakes) and chat with their fellow travellers. It was clean, bright, and there was an air of positive energy: care, concern, and understanding. There were leaflets everywhere, outlining the dangers associated with different drugs. And there was always a staff person present, just being friendly, chatting, offering snacks. The staff consists of two social workers, two MA level psychologists, a criminologist (to help with charges, probation, as so forth), and the doctor, Carl, who wrote the methadone prescriptions. Carl was my host.

After being shown around — rooms for counselling, a play area for people with kids, a laundry room, showers, a medical area where wounds and infections were treated and clean needles and accessories were handed out (in exchange for used needles) — I mostly sat in a chair next to Carl in an office/interview room, while one client after another came for their methadone script. It was sort of fascinating.

Most were heroin addicts of course, but many also used meth and/or coke. Many of the heroin users balanced their methadone dose with heroin obtained on the street. And this was no secret. There wasn’t much lying or sneaking going on, according to Carl and the others. It was a tacit assumption that opioid addicts would fluctuate in when, whether, and how much heroin they used to spice up their diet. And there was no confrontation. There was no scolding, no pep talks, no condescension, no sense of a parent figure keeping tabs on the naughty children. Yet Carl was careful to balance the dosage of methadone against simultaneous heroin use: less methadone with more heroin, naturally, to minimize the odds of overdose. And overdose was rare with this population. So how did they manage that?

The clients seemed content to report honestly on what drugs they were taking, mostly because there was no censure or disapproval, either explicit or implicit, in the attitudes and behaviour of the staff — including Carl. But just to make sure, unanticipated urine tests were requested when people said they’d stopped using heroin and wanted to increase their dose of methadone to compensate. Again, it was the warmth and camaraderie that flowed between staff and clients that neutralized the temptation to lie. The smiles and hand-shakes, the invitations to chat about how things were going, the absence of demands. These people were leading lives that to some extent they were choosing and to some extent they were stuck in…and nobody was judging them. The purpose of the clinic was to keep users safe, healthy, and out of jail.

Nevertheless, despite all this sweetness and light, these folks were seriously addicted, both physically and psychologically, to a very powerful drug. They weren’t anywhere close to safe and stable in the big picture. About half were homeless, which generally meant they slept in different homes night by night, or in abandoned houses, or with relatives. They were not the happiest of campers.

And where I saw this most clearly wasn’t in the statistics — re homelessness, unemployment, co-occurring psychiatric disorders — but in the posture and facial expressions of the people sitting in the chair across from the doc. They often looked defeated and helpless. While some expressed enthusiasm, plans for the future, many looked dreamy or blank. Quite a few had the hunched over posture that expresses shame or remorse. Their eye contact might be sparse and fleeting, looking down a lot — the gaze pattern of people who live with a chronic level of shame or sense of inferiority. A sense of personal failure they’ve grown deeply accustomed to.

That part was sad. That aspect made me think that harm reduction and methadone provide a solution to the heroin epidemic, but it’s not a great solution. Something is still seriously wrong here, and this form of treatment, connection, and care can make it livable. But only just.

Clinics of this sort have sprung up in towns and cities throughout Belgium and other European countries. As always, I’d love to hear your opinions.