The opioid crisis as a disease of despair?

[Note: This is a repost from 1/19/18. This narrative has continued to gather steam over the past year. It’s not that this narrative contains no truth, it’s that it’s incomplete and misleading.]

The narrative that the opioid and overdose crisis is a product of despair has become very popular. The logic is that people in bad economic conditions are more likely to turn to opioids to cope with their circumstances, and that their hopeless environmental conditions make them more likely to die of an overdose. This model frames addiction and overdose as diseases of despair.

This model fits nicely with other writers who have garnered a lot of attention on the internet.

  • Johann Hari presents addiction as a product of a lack of connection to others.
  • Carl Hart frames sociological factors as causative and argues that there’s a rationality to escaping terrible circumstances via drug use and that a form of learned helplessness eventually takes root.
  • Bruce Alexander is frequently cited to support these theories. He did the “rat park” study that found rats deprived of stimulation and social interaction compulsively used drugs, while rats in enriched environments did not.

These understandings are so intuitive, but what if they are wrong?

These narratives make so much sense, and they support other beliefs and agendas many of us hold. Further, it feels like no one is going to harmed by efforts to improve economic, social, and environmental conditions, right?

Well, that’s not quite true. Bill White pointed out that how we define the problem determines who “owns” the problem, and that problem ownership has profound implications for addicts and their loved ones.

Whether we define alcoholism as a sin, a crime, a disease, a social problem, or a product of economic deprivation determines whether this society assigns that problem to the care of the priest, police officer, doctor, addiction counselor, social worker, urban planner, or community activist. The model chosen will determine the fate of untold numbers of alcoholics and addicts and untold numbers of social institutions and professional careers.

The existence of a “treatment industry” and its “ownership” of the problem of addiction should not be taken for granted. Sweeping shifts in values and changes in the alignment of major social institutions might pass ownership of this problem to another group.

With so many bad actors in treatment right now, there is not a great rush to protect the treatment industry.

To be sure, we’d be better off of a significant portion of the industry disappeared. However, the disappearance of specialty addiction treatment would be tragic for addicts and alcoholics in need of help.

Further, it just so happens that there’s good reason to doubt the “diseases of despair” narrative.

New study casts doubt on “diseases of despair” narrative

A new study looked at county level data and examined the relationship between several economic hardship indicators and deaths by overdose, alcohol-related causes, and suicide.

Mother Jones describes the findings this way:

Economic conditions explained only 8 percent of the change in overdose deaths from all drugs and 7 percent of the change in deaths from opioid painkillers—and even that small effect probably goes away if you control for additional unobservable factors. It explained none of the change in deaths from heroin, fentanyl, and other illegal opioids.

They quote the researcher as observing:

Such results probably should not be surprising since drug fatalities increased substantially – including a rapid acceleration of illicit opioid deaths – after the end of the Great Recession (i.e. subsequent to 2009), when economic performance considerably improved.

If it’s not economic hardship, what is it?

Vox describes the study’s conclusions this way [emphasis mine]:

. . . the bigger driver of overdose deaths was “the broader drug environment” — meaning the expanded supply of opioid painkillers, heroin, and illicit fentanyl over the past decade and a half, which has made these drugs much more available and, therefore, easier to misuse and overdose on.

Leonid Bershidsky from Bloomberg noted the following:

The absence of an opioid epidemic in Europe indirectly confirms Ruhm’s finding. European nations have experienced the same globalization-related transition as the U.S. In some of them — Greece, Portugal, Ireland, Spain, even France — economic problems were more severe in recent years than in the U.S. Yet no explosion of overdose deaths has occurred.

. . .

There’s also a notable difference in what substances are causing overdose deaths. In the U.S., heroin accounted for 24 percent of last year’s overdose deaths. In Europe in 2018, its share of the death toll was 81 percent. That should say something about how supply affects the outcomes.

Piling on

Then, as if to drive the point home, BMJ posted a study examining the relationship between opioid exposure and misuse. They looked at post-surgical pain treatment,

Each refill and week of opioid prescription is associated with a large increase in opioid misuse among opioid naive patients. The data from this study suggest that duration of the prescription rather than dosage is more strongly associated with ultimate misuse in the early postsurgical period. The analysis quantifies the association of prescribing choices on opioid misuse and identifies levers for possible impact.

The study “excluded patients with presurgical evidence of opioid or other non-specific forms of misuse in the six months before surgery.” (I would have liked more stringent exclusionary criteria, but it’s still instructive.)

Where does this leave us?

I’ll repeat (a modified version of) what I wrote in a post in response to Johann Hari’s TED talk that emphasized lack of purpose and connection as the cause of addiction and add economic factors to the mix.

  • Do economic/social/environmental factors cause addiction? No.
  • Are they important? Yes.
  • Could they influence the onset and course of addiction? Yes.
  • Is addressing those factors important in facilitating recovery for many addicts? Yes.
  • Do economic/social/environmental factors cause addiction? No.

Ok, but what about policy?

This leaves us with some uncomfortable (but obvious, to anyone paying attention to this crisis) findings to consider.

Much of the policy discussion over the last several years has been dismissive of supply as a factor in addiction. This poses very serious concerns about that stance.

I’ve never been dismissive of supply as an important consideration, but I am coming to believe that I’ve underestimated its importance.

A lot of that dismissiveness is in response to the drug war and the moral horror of mass incarceration.

The problem demands more of us than we are typically capable of. We need to figure out how to address illicit and licit supply without resorting to mass incarceration AND assure treatment of adequate quality, duration, and intensity.

The opioid crisis as a disease of despair?

The narrative that the opioid and overdose crisis is a product of despair has become very popular. The logic is that people in bad economic conditions are more likely to turn to opioids to cope with their circumstances, and that their hopeless environmental conditions make them more likely to die of an overdose. This model frames addiction and overdose as diseases of despair.

This model fits nicely with other writers who have garnered a lot of attention on the internet.

  • Johann Hari presents addiction as a product of a lack of connection to others.
  • Carl Hart frames sociological factors as causative and argues that there’s a rationality to escaping terrible circumstances via drug use and that a form of learned helplessness eventually takes root.
  • Bruce Alexander is frequently cited to support these theories. He did the “rat park” study that found rats deprived of stimulation and social interaction compulsively used drugs, while rats in enriched environments did not.

These understandings are so intuitive, but what if they are wrong?

These narratives make so much sense, and they support other beliefs and agendas many of us hold. Further, it feels like no one is going to harmed by efforts to improve economic, social, and environmental conditions, right?

Well, that’s not quite true. Bill White pointed out that how we define the problem determines who “owns” the problem, and that problem ownership has profound implications for addicts and their loved ones.

Whether we define alcoholism as a sin, a crime, a disease, a social problem, or a product of economic deprivation determines whether this society assigns that problem to the care of the priest, police officer, doctor, addiction counselor, social worker, urban planner, or community activist. The model chosen will determine the fate of untold numbers of alcoholics and addicts and untold numbers of social institutions and professional careers.

The existence of a “treatment industry” and its “ownership” of the problem of addiction should not be taken for granted. Sweeping shifts in values and changes in the alignment of major social institutions might pass ownership of this problem to another group.

With so many bad actors in treatment right now, there is not a great rush to protect the treatment industry.

To be sure, we’d be better off of a significant portion of the industry disappeared. However, the disappearance of specialty addiction treatment would be tragic for addicts and alcoholics in need of help.

Further, it just so happens that there’s good reason to doubt the “diseases of despair” narrative.

New study casts doubt on “diseases of despair” narrative

A new study looked at county level data and examined the relationship between several economic hardship indicators and deaths by overdose, alcohol-related causes, and suicide.

Mother Jones describes the findings this way:

Economic conditions explained only 8 percent of the change in overdose deaths from all drugs and 7 percent of the change in deaths from opioid painkillers—and even that small effect probably goes away if you control for additional unobservable factors. It explained none of the change in deaths from heroin, fentanyl, and other illegal opioids.

They quote the researcher as observing:

Such results probably should not be surprising since drug fatalities increased substantially – including a rapid acceleration of illicit opioid deaths – after the end of the Great Recession (i.e. subsequent to 2009), when economic performance considerably improved.

If it’s not economic hardship, what is it?

Vox describes the study’s conclusions this way [emphasis mine]:

. . . the bigger driver of overdose deaths was “the broader drug environment” — meaning the expanded supply of opioid painkillers, heroin, and illicit fentanyl over the past decade and a half, which has made these drugs much more available and, therefore, easier to misuse and overdose on.

Leonid Bershidsky from Bloomberg noted the following:

The absence of an opioid epidemic in Europe indirectly confirms Ruhm’s finding. European nations have experienced the same globalization-related transition as the U.S. In some of them — Greece, Portugal, Ireland, Spain, even France — economic problems were more severe in recent years than in the U.S. Yet no explosion of overdose deaths has occurred.

. . .

There’s also a notable difference in what substances are causing overdose deaths. In the U.S., heroin accounted for 24 percent of last year’s overdose deaths. In Europe in 2018, its share of the death toll was 81 percent. That should say something about how supply affects the outcomes.

Piling on

Then, as if to drive the point home, BMJ posted a study examining the relationship between opioid exposure and misuse. They looked at post-surgical pain treatment,

Each refill and week of opioid prescription is associated with a large increase in opioid misuse among opioid naive patients. The data from this study suggest that duration of the prescription rather than dosage is more strongly associated with ultimate misuse in the early postsurgical period. The analysis quantifies the association of prescribing choices on opioid misuse and identifies levers for possible impact.

The study “excluded patients with presurgical evidence of opioid or other non-specific forms of misuse in the six months before surgery.” (I would have liked more stringent exclusionary criteria, but it’s still instructive.)

Where does this leave us?

I’ll repeat (a modified version of) what I wrote in a post in response to Johann Hari’s TED talk that emphasized lack of purpose and connection as the cause of addiction and add economic factors to the mix.

  • Do economic/social/environmental factors cause addiction? No.
  • Are they important? Yes.
  • Could they influence the onset and course of addiction? Yes.
  • Is addressing those factors important in facilitating recovery for many addicts? Yes.
  • Do economic/social/environmental factors cause addiction? No.

Ok, but what about policy?

This leaves us with some uncomfortable (but obvious, to anyone paying attention to this crisis) findings to consider.

Much of the policy discussion over the last several years has been dismissive of supply as a factor in addiction. This poses very serious concerns about that stance.

I’ve never been dismissive of supply as an important consideration, but I am coming to believe that I’ve underestimated its importance.

A lot of that dismissiveness is in response to the drug war and the moral horror of mass incarceration.

The problem demands more of us than we are typically capable of. We need to figure out how to address illicit and licit supply without resorting to mass incarceration AND assure treatment of adequate quality, duration, and intensity.

Toward a “Conspiracy of Hope” (Bill White and Jason Schwartz)

This is being cross-posted from williamwhitepapers.com. Please visit and subscribe. (You won’t regret it!)


conspiracy-of-hopeSo it is not our job to pass judgment on who will and will not recover from mental illness and the spirit breaking effects of poverty, stigma, dehumanization, degradation and learned helplessness. Rather, our job is to participate in a conspiracy of hope. It is our job to form a community of hope which surrounds people with psychiatric disabilities. —Pat Deegan

With those words, Dr. Patricia Deegan, Adjunct Professor at Dartmouth College Geisel School of Medicine and indomitable recovery advocate, introduced two ideas with potentially profound implications for the future of addiction treatment and recovery. Below we offer a few reflections on these ideas.

A conspiracy of hope is an organized movement to inject the optimism of lived recovery experience into an arena historically fixated on addiction-related pathology and its progeny of injuries to individuals, families, and communities. But why is there need for such a conspiracy? Opposition to prevailing conditions often arises within the context of oppression. People suffering from addiction and those seeking recovery face innumerable sources of such oppression.

Addiction itself inflicts a rising cascade of consequences, crushing one’s sense of value and blinding one’s vision beyond the insatiable immediacy of drug hunger. Addiction-related social stigma—fueled by media fixation on the most lurid caricatures of addiction—further damages personal identity, fuels social isolation or entrenchment in subterranean drug cultures, and prevents or slows help-seeking. The resulting addiction-based social network behaves like crabs in a bucket—those trying to escape are repeatedly pulled back in. The paucity of helping resources and their lack of accessibility, affordability, and quality all reinforce the view that reaching out for help would be a waste of time and money. When help is sought, the therapeutic pessimism and paternalism of professional and nonprofessional “helpers” can also reinforce low recovery expectations.

As a result of such conditions, addiction-fueled despair whispers and then shouts that we are not deserving or capable of anything different—that recovery is a myth and that the ever-present threats of incarceration, disability, or death are rightful consequences of our unworthiness. Only an organized conspiracy of hope can challenge the oppressive conditions that stand as major barriers to long-term addiction recovery.

Character of the Conspiracy

But what would such a conspiracy of hope require? It would require the cultural and political mobilization of individuals and families in recovery and their allies. It would require a vanguard of such individuals and families willing to share their recovery stories at a public level. It would require those in recovery to move beyond their own personal stories and their particular recovery pathway to identify themselves as “a people” with a shared history, shared needs, and a shared destiny. In short, it would require a social movement aimed at shifting the governing image of addiction from that of the repeatedly relapsing celebrity to the millions of people living quiet lives of stable, long-term recovery. Shifting the dominant view of addiction from one of pessimism to hope will require the involvement of a broad spectrum of people and professions, but people in recovery will be central to this achievement through their individual and collective storytelling and their leadership within recovery advocacy efforts.

There are whole professions whose members share an extremely pessimistic view of recovery because they repeatedly see only those who fail to recover. The success stories are not visible in their daily professional lives. We need to re-introduce ourselves to the police who arrested us, the attorneys who prosecuted and defended us, the judges who sentenced us, the probation officers who monitored us, the physicians and nurses who cared for us, the teachers and social workers who cared for the problems of our children, the job supervisors who threatened to fire us. We need to find a way to express our gratitude at their efforts to help us, no matter how ill-timed, ill-informed, and inept such interventions may have been. We need to find a way to tell all of them that today we are sane and sober and that we have taken responsibility for our own lives. We need to tell them to be hopeful, that RECOVERY LIVES! Americans see the devastating consequences of addiction every day; it is time they witnessed close up the regenerative power of recovery. (White, A Day is Coming, 2001)

What makes this a conspiracy is the knowledge that through these simple acts of storytelling and advocacy we are part of a chorus of others taking similar strategic steps to achieve larger social gains. Built on the back of earlier recovery advocacy efforts, this conspiracy of hope was officially launched at the 2001 Recovery Summit in St. Paul, Minnesota. Christened the New Recovery Advocacy Movement, it has since spread throughout the U.S. and internationally. But the success of this movement hinges on more than our collective storytelling; in Deegan’s vision, it requires a new form of community-building.

Building Communities of Hope

Communities of hope involve creating the physical, psychological, and social space (recovery landscapes) in local communities and the culture at large in which recovery from addiction can flourish. Assuring such space requires building sustainable institutions through which recovery is supported within every area of community life, e.g., government, business and industry, housing, education, medicine, social services, religion, music, the arts, sports, and leisure. The idea of communities of hope means that people in recovery have opportunities to be supported by and in turn support other people in recovery and that those in recovery have opportunities individually and collectively to participate in the larger life of their communities. It also suggests the presence of safe sanctuaries that can serve as incubation chambers for those early in their recovery. We are now witnessing the spread of such new institutions (e.g., recovery community centers, recovery homes, recovery industries, high school and collegiate recovery programs, recovery cafes, recovery ministries, recovery-focused sports and entertainment venues, and recovery celebration events) that transcend the historical categories of addiction treatment or recovery mutual aid societies.

We are also witnessing the emergence of an ecumenical culture of recovery with language that links the distinctive cultures that have historically evolved within these professional and mutual aid settings. Within the addictions arena, the communities of hope that Deegan refers to are under construction across the U.S. and in other countries. That stands as a notable historical milestone within the history of addiction recovery. It is a trend that will benefit individuals seeking recovery and the service systems designed to serve them, but it will also mark a step in elevating the broader health and quality of communal life. We have followed closely the work of John McKnight, Peter Block, and Bruce Alexander on the value of deliberate welcoming, sharing gifts, and collaborative community building and commend their writings to recovery advocates and addiction professionals.

Implications for Addiction Treatment Programs

What does all this mean for addiction treatment programs? Addiction treatment programs could participate in this conspiracy of hope and recovery community building by taking actions such as the following:

*Elevating resilience and recovery as the central organizing constructs for the design and delivery of all services, e.g., strengths-based assessment protocol, recovery-focused training of all service personnel on the prevalence, processes, pathways, stages, and styles of long-term personal and family recovery. Identification and mobilization of client gifts are essential. Conspiracies of hope and communities of hope are built upon participant’s gifts, not their needs.

* Reconnecting what have become ever-briefer episodes of addiction treatment to the larger and more enduring process of addiction recovery via embracing  models of recovery management nested within larger recovery-oriented systems of care, e.g., precovery outreach services, assertive linkage to indigenous recovery support institutions, sustained post-treatment recovery checkups, and support services for families in long-term recovery.

*Assuring the presence, diversity, and visibility of people in long-term recovery within the treatment milieu.

* Actively supporting (without controlling or exploiting) local recovery advocacy and recovery community building activities.

* Using community standing to expand the conspiracy beyond people in recovery and beyond service providers, e.g., engaging employers and faith communities as well as other social institutions to make the community “recovery ready.”

Joining the Conspiracy

The journey from addiction to recovery is as possible and fulfilling as it is challenging. Few things are as spiritually energizing as being part of a “conspiracy of hope” to support those journeys. Such journeys are eased when nested within a community of fellow travelers. Few things are as fulfilling as being part of building such communities. Are you ready to join the conspiracy of hope and nurture the development of communities of hope? What steps could you take today to assert such a commitment?

The “rat park” guy

Bruce Alexander A Global Historical View Of Addiction And The Future Of Addiction Treatment FEADSeveral recent books have attempted to refute the disease model of addiction over the last few years. (See here, here, here and here for some examples.)

All of these books cite Bruce Alexander’s “rat park” experiments as important evidence that addiction is not a brain disease.

If you’ve ever been curious about Bruce Alexander, here’s your chance to watch a talk he gave earlier this year.

Is the disease model really in doubt?

I believe that there is no serious scientific disagreement about the matter.

Here are a couple of talks that explain the disease model.

First, NIDA Director Norak Volkow:

Second, Kevin McCauley in our own education series:

 

Most popular posts of 2015 – #2 – We all wish love was enough

fear_false_evidence_appearing_realThis article, claiming to have discovered the long suppressed cause of addiction, has been making the rounds and has been recommended by a lot of people.

Like a lot of things, it contains some truth but is not the Truth.

People generally bring up rat park and returning Vietnam vets to advance 2 arguments.

  1. That you can’t catch addiction by just being exposed to the drug.
  2. That environment is the real problem. If you put people in bad environments, they’ll look like addicts. If you enrich addicts’ environments, they’ll stop being addicted.

I whole-heartedly agree with argument #1. You can expose 100 people to drugs like cocaine and heroin and a relatively small minority will develop chronic problems–5 to 23, depending on the study you look at. So, even if the outlier studies were true, we’re still talking about 77% not becoming addicted.

Every field has its goofballs, but in my two decades in the field I have not heard any serious practitioners or researchers argue that simple exposure (even to large doses over an extended period) causes addiction.

Argument #2 is much weaker. It’s my understanding that follow-up studies with rats have failed to reproduce these findings and suggested genetic factors were important. The strongest statement you can make about environment is that it is a risk factor, but not anything approaching a cause.

As for returning Vietnam vets, this is from a post I wrote a few years ago:

These stories often ignore the fact that:

“. . . there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty.”

Hmmmm. That range….5 to 12 percent…why, that’s similar to estimates of the portion of the population that experiences addiction to alcohol or other drugs.

To me, the other important lesson is that opiate dependence and opiate addiction are not the same thing. Hospitals and doctors treating patients for pain recreate this experiment on a daily basis. They prescribe opiates to patients, often producing opiate dependence. However, all but a small minority will never develop drug seeking behavior once their pain is resolved and they are detoxed.

My problem with all the references to these vets and addiction, is that I suspect most of them were dependent and not addicted.

So…it certainly has something to offer us about how addictions develops (Or, more specifically, how it does not develop.), but not how it’s resolved.

Why is it so frequently cited and presented without any attempt to distinguish between dependence and addiction? Probably because it fits the preferred narrative of the writer.

So. . . rat park and returning Vietnam vets are not quite what he describes. Let’s continue.

I do appreciate the article’s call for compassion and I am a believer that purpose, meaning and connection are important elements of stable recovery. However, as I continue reading the article, I am reminded of Ralph Waldo Emerson:

Their every truth is not quite true. Their two is not the real two, their four not the real four; so that every word they say chagrins us, and we know not where to begin to set them right.

mencken-complex-problemHe says that addiction that begins with  prescribed pain medication “virtually never happens.” Well, it’s hard to pin down exactly how often it happens, due to chicken and egg questions related to how many pain patients have pre-existing substance use problems. However, reported estimates range from  “from 2.8% (Cowan et al., 2003) to 50% ( Saper et al., 2004).”

What about the Portugal miracle? We’ll a few things to keep in mind. First, the decriminalization approach is focused on getting addicts into treatment. Housing and treatment may be addressed, but it’s clear the focus is on treatment. Second, Portugal was starting from the position of a terrible heroin problem. They’ve gone from 1% addicted to 0.5% addicted. That’s great, but to provide a little context, the National Survey on Drug Use and Health pegs current heroin users at 0.1% of the U.S. population.

So . . . the article doesn’t tell the whole story, it oversimplifies some very complex issues and presents us with straw man arguments. (Who says that anyone who uses heroin is going to get hooked for life? [Note that he had to go back to a commercial from the 1980s and that a search for the reported text of the commercial only produces references to his article.] Or, that behavioral, environmental, social and other factors are unimportant in the development, course and recovery from addiction?)

I also worry about the implied message that we just love them enough, they’ll get well. I see countless families that provide housing, jobs, connection and love–only with watch their loved one slip further and further into addiction.

Addiction is a complex problem. Multiple factors influence it’s development, course and resolution. This is always the case with chronic disease. There’s a cultural narrative out there that addiction is not a disease, that it is rational, that it’s a product of environment, that it’s a learning disorder, that framing it as a disease is a foundation for violating individual liberties and that recovery needs to be redefined. Intended, or not, stories like this are part of that narrative.

I don’t engage in ad hominem arguments, but, while we’re on the topic of narratives, it would seem strange to not point out that this author has a history of playing fast and loose to advance a narrative.

Most popular posts of 2015 – #7 – “unintentionally comical” – Johann Hari’s Chasing the Scream

stop with the factsSeth Mnookin reviews Chasing the Scream and finds its review of the science troubling. (Previous post on Hari here.)

The first tip-off that Hari might be in over his head comes when he describes how “a small band of dissident scientists” had uncovered the answers he was looking for after working “almost unnoticed, for several decades.” Hari starts with Gabor Mate, a Hungarian-born Canadian physician whose theories about how the roots of addiction (and lots of other things to boot) can almost always be found in childhood trauma are, in fact, quite well known. To support his portrayal of Mate as a fringe renegade, Hari acts as if a rigid, deterministic model of addiction as a purely physical disease is almost universally accepted; if anything, the opposite is true. Even more problematic is Hari’s wholesale acceptance of Mate’s reductionistic approach when, in fact, there’s a significant body of work demonstrating its shortcomings.

The next researcher to benefit from Hari’s credulousness is Bruce Alexander, a Canadian psychologist who believes that drugs are not the cause of drug addiction. Alexander is best known for his “Rat Park” experiments in the 1970s, which were designed to demonstrate that rats in stimulating, social environments would not become addicted to morphine while rats in cramped, metal cages would. Hari explains why Alexander’s views have not been universally embraced by making the preposterous assertion that “when we think about recovery from addiction, we see it through only one lens — the individual.”

A few pages later, Hari is talking to a Welsh psychiatrist named John Marks, who is a proponent of providing prescription narcotics to addicts. Hari supports Marks’s claims by referring to “research published in the Proceedings of the Royal College of Physicians of Edinburgh” but then buries in the notes the fact that it was Marks himself who was the author of that research. Sometimes, Hari’s unquestioning acceptance of what these researchers say is unintentionally comical: At one point, he quotes Alexander explaining that drug addicts don’t get clean because they would rather spend their time doing “exciting things like rob stores and hang around with hookers.”

Read Mnookin’s entire review here.

“unintentionally comical” – Johann Hari’s Chasing the Scream

stop with the factsSeth Mnookin reviews Chasing the Scream and finds its review of the science troubling. (Previous post on Hari here.)

The first tip-off that Hari might be in over his head comes when he describes how “a small band of dissident scientists” had uncovered the answers he was looking for after working “almost unnoticed, for several decades.” Hari starts with Gabor Mate, a Hungarian-born Canadian physician whose theories about how the roots of addiction (and lots of other things to boot) can almost always be found in childhood trauma are, in fact, quite well known. To support his portrayal of Mate as a fringe renegade, Hari acts as if a rigid, deterministic model of addiction as a purely physical disease is almost universally accepted; if anything, the opposite is true. Even more problematic is Hari’s wholesale acceptance of Mate’s reductionistic approach when, in fact, there’s a significant body of work demonstrating its shortcomings.

The next researcher to benefit from Hari’s credulousness is Bruce Alexander, a Canadian psychologist who believes that drugs are not the cause of drug addiction. Alexander is best known for his “Rat Park” experiments in the 1970s, which were designed to demonstrate that rats in stimulating, social environments would not become addicted to morphine while rats in cramped, metal cages would. Hari explains why Alexander’s views have not been universally embraced by making the preposterous assertion that “when we think about recovery from addiction, we see it through only one lens — the individual.”

A few pages later, Hari is talking to a Welsh psychiatrist named John Marks, who is a proponent of providing prescription narcotics to addicts. Hari supports Marks’s claims by referring to “research published in the Proceedings of the Royal College of Physicians of Edinburgh” but then buries in the notes the fact that it was Marks himself who was the author of that research. Sometimes, Hari’s unquestioning acceptance of what these researchers say is unintentionally comical: At one point, he quotes Alexander explaining that drug addicts don’t get clean because they would rather spend their time doing “exciting things like rob stores and hang around with hookers.”

Read Mnookin’s entire review here.

We all wish love was enough

fear_false_evidence_appearing_realMore on Johann Hari, a post from earlier this year.

====================================

This article, claiming to have discovered the long suppressed cause of addiction, has been making the rounds and has been recommended by a lot of people.

Like a lot of things, it contains some truth but is not the Truth.

People generally bring up rat park and returning Vietnam vets to advance 2 arguments.

  1. That you can’t catch addiction by just being exposed to the drug.
  2. That environment is the real problem. If you put people in bad environments, they’ll look like addicts. If you enrich addicts’ environments, they’ll stop being addicted.

I whole-heartedly agree with argument #1. You can expose 100 people to drugs like cocaine and heroin and a relatively small minority will develop chronic problems–5 to 23, depending on the study you look at. So, even if the outlier studies were true, we’re still talking about 77% not becoming addicted.

Every field has its goofballs, but in my two decades in the field I have not heard any serious practitioners or researchers argue that simple exposure (even to large doses over an extended period) causes addiction.

Argument #2 is much weaker. It’s my understanding that follow-up studies with rats have failed to reproduce these findings and suggested genetic factors were important. The strongest statement you can make about environment is that it is a risk factor, but not anything approaching a cause.

As for returning Vietnam vets, this is from a post I wrote a few years ago:

These stories often ignore the fact that:

“. . . there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty.”

Hmmmm. That range….5 to 12 percent…why, that’s similar to estimates of the portion of the population that experiences addiction to alcohol or other drugs.

To me, the other important lesson is that opiate dependence and opiate addiction are not the same thing. Hospitals and doctors treating patients for pain recreate this experiment on a daily basis. They prescribe opiates to patients, often producing opiate dependence. However, all but a small minority will never develop drug seeking behavior once their pain is resolved and they are detoxed.

My problem with all the references to these vets and addiction, is that I suspect most of them were dependent and not addicted.

So…it certainly has something to offer us about how addictions develops (Or, more specifically, how it does not develop.), but not how it’s resolved.

Why is it so frequently cited and presented without any attempt to distinguish between dependence and addiction? Probably because it fits the preferred narrative of the writer.

So. . . rat park and returning Vietnam vets are not quite what he describes. Let’s continue.

I do appreciate the article’s call for compassion and I am a believer that purpose, meaning and connection are important elements of stable recovery. However, as I continue reading the article, I am reminded of Ralph Waldo Emerson:

Their every truth is not quite true. Their two is not the real two, their four not the real four; so that every word they say chagrins us, and we know not where to begin to set them right.

mencken-complex-problemHe says that addiction that begins with  prescribed pain medication “virtually never happens.” Well, it’s hard to pin down exactly how often it happens, due to chicken and egg questions related to how many pain patients have pre-existing substance use problems. However, reported estimates range from  “from 2.8% (Cowan et al., 2003) to 50% ( Saper et al., 2004).”

What about the Portugal miracle? We’ll a few things to keep in mind. First, the decriminalization approach is focused on getting addicts into treatment. Housing and treatment may be addressed, but it’s clear the focus is on treatment. Second, Portugal was starting from the position of a terrible heroin problem. They’ve gone from 1% addicted to 0.5% addicted. That’s great, but to provide a little context, the National Survey on Drug Use and Health pegs current heroin users at 0.1% of the U.S. population.

So . . . the article doesn’t tell the whole story, it oversimplifies some very complex issues and presents us with straw man arguments. (Who says that anyone who uses heroin is going to get hooked for life? [Note that he had to go back to a commercial from the 1980s and that a search for the reported text of the commercial only produces references to his article.] Or, that behavioral, environmental, social and other factors are unimportant in the development, course and recovery from addiction?)

I also worry about the implied message that we just love them enough, they’ll get well. I see countless families that provide housing, jobs, connection and love–only with watch their loved one slip further and further into addiction.

Addiction is a complex problem. Multiple factors influence it’s development, course and resolution. This is always the case with chronic disease. There’s a cultural narrative out there that addiction is not a disease, that it is rational, that it’s a product of environment, that it’s a learning disorder, that framing it as a disease is a foundation for violating individual liberties and that recovery needs to be redefined. Intended, or not, stories like this are part of that narrative.

I don’t engage in ad hominem arguments, but, while we’re on the topic of narratives, it would seem strange to not point out that this author has a history of playing fast and loose to advance a narrative.

“unintentionally comical” – Johann Hari’s Chasing the Scream

stop with the factsSeth Mnookin reviews Chasing the Scream and finds its review of the science troubling. (Previous post on Hari here.)

The first tip-off that Hari might be in over his head comes when he describes how “a small band of dissident scientists” had uncovered the answers he was looking for after working “almost unnoticed, for several decades.” Hari starts with Gabor Mate, a Hungarian-born Canadian physician whose theories about how the roots of addiction (and lots of other things to boot) can almost always be found in childhood trauma are, in fact, quite well known. To support his portrayal of Mate as a fringe renegade, Hari acts as if a rigid, deterministic model of addiction as a purely physical disease is almost universally accepted; if anything, the opposite is true. Even more problematic is Hari’s wholesale acceptance of Mate’s reductionistic approach when, in fact, there’s a significant body of work demonstrating its shortcomings.

The next researcher to benefit from Hari’s credulousness is Bruce Alexander, a Canadian psychologist who believes that drugs are not the cause of drug addiction. Alexander is best known for his “Rat Park” experiments in the 1970s, which were designed to demonstrate that rats in stimulating, social environments would not become addicted to morphine while rats in cramped, metal cages would. Hari explains why Alexander’s views have not been universally embraced by making the preposterous assertion that “when we think about recovery from addiction, we see it through only one lens — the individual.”

A few pages later, Hari is talking to a Welsh psychiatrist named John Marks, who is a proponent of providing prescription narcotics to addicts. Hari supports Marks’s claims by referring to “research published in the Proceedings of the Royal College of Physicians of Edinburgh” but then buries in the notes the fact that it was Marks himself who was the author of that research. Sometimes, Hari’s unquestioning acceptance of what these researchers say is unintentionally comical: At one point, he quotes Alexander explaining that drug addicts don’t get clean because they would rather spend their time doing “exciting things like rob stores and hang around with hookers.”

Read Mnookin’s entire review here.

We all wish love was enough

fear_false_evidence_appearing_realThis article, claiming to have discovered the long suppressed cause of addiction, has been making the rounds and has been recommended by a lot of people.

Like a lot of things, it contains some truth but is not the Truth.

People generally bring up rat park and returning Vietnam vets to advance 2 arguments.

  1. That you can’t catch addiction by just being exposed to the drug.
  2. That environment is the real problem. If you put people in bad environments, they’ll look like addicts. If you enrich addicts’ environments, they’ll stop being addicted.

I whole-heartedly agree with argument #1. You can expose 100 people to drugs like cocaine and heroin and a relatively small minority will develop chronic problems–5 to 23, depending on the study you look at. So, even if the outlier studies were true, we’re still talking about 77% not becoming addicted.

Every field has its goofballs, but in my two decades in the field I have not heard any serious practitioners or researchers argue that simple exposure (even to large doses over an extended period) causes addiction.

Argument #2 is much weaker. It’s my understanding that follow-up studies with rats have failed to reproduce these findings and suggested genetic factors were important. The strongest statement you can make about environment is that it is a risk factor, but not anything approaching a cause.

As for returning Vietnam vets, this is from a post I wrote a few years ago:

These stories often ignore the fact that:

“. . . there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty.”

Hmmmm. That range….5 to 12 percent…why, that’s similar to estimates of the portion of the population that experiences addiction to alcohol or other drugs.

To me, the other important lesson is that opiate dependence and opiate addiction are not the same thing. Hospitals and doctors treating patients for pain recreate this experiment on a daily basis. They prescribe opiates to patients, often producing opiate dependence. However, all but a small minority will never develop drug seeking behavior once their pain is resolved and they are detoxed.

My problem with all the references to these vets and addiction, is that I suspect most of them were dependent and not addicted.

So…it certainly has something to offer us about how addictions develops (Or, more specifically, how it does not develop.), but not how it’s resolved.

Why is it so frequently cited and presented without any attempt to distinguish between dependence and addiction? Probably because it fits the preferred narrative of the writer.

So. . . rat park and returning Vietnam vets are not quite what he describes. Let’s continue.

I do appreciate the article’s call for compassion and I am a believer that purpose, meaning and connection are important elements of stable recovery. However, as I continue reading the article, I am reminded of Ralph Waldo Emerson:

Their every truth is not quite true. Their two is not the real two, their four not the real four; so that every word they say chagrins us, and we know not where to begin to set them right.

mencken-complex-problemHe says that addiction that begins with  prescribed pain medication “virtually never happens.” Well, it’s hard to pin down exactly how often it happens, due to chicken and egg questions related to how many pain patients have pre-existing substance use problems. However, reported estimates range from  “from 2.8% (Cowan et al., 2003) to 50% ( Saper et al., 2004).”

What about the Portugal miracle? We’ll a few things to keep in mind. First, the decriminalization approach is focused on getting addicts into treatment. Housing and treatment may be addressed, but it’s clear the focus is on treatment. Second, Portugal was starting from the position of a terrible heroin problem. They’ve gone from 1% addicted to 0.5% addicted. That’s great, but to provide a little context, the National Survey on Drug Use and Health pegs current heroin users at 0.1% of the U.S. population.

So . . . the article doesn’t tell the whole story, it oversimplifies some very complex issues and presents us with straw man arguments. (Who says that anyone who uses heroin is going to get hooked for life? [Note that he had to go back to a commercial from the 1980s and that a search for the reported text of the commercial only produces references to his article.] Or, that behavioral, environmental, social and other factors are unimportant in the development, course and recovery from addiction?)

I also worry about the implied message that we just love them enough, they’ll get well. I see countless families that provide housing, jobs, connection and love–only with watch their loved one slip further and further into addiction.

Addiction is a complex problem. Multiple factors influence it’s development, course and resolution. This is always the case with chronic disease. There’s a cultural narrative out there that addiction is not a disease, that it is rational, that it’s a product of environment, that it’s a learning disorder, that framing it as a disease is a foundation for violating individual liberties and that recovery needs to be redefined. Intended, or not, stories like this are part of that narrative.

I don’t engage in ad hominem arguments, but, while we’re on the topic of narratives, it would seem strange to not point out that this author has a history of playing fast and loose to advance a narrative.