“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.