Addressing the Causes of Substance Abuse vs. Addiction

I saw Johann Hari interviewed on Real Time the other day, and what he essentially offered during the interview was a version of the essay published here, in which he argues that the real cause of addiction is the addict's environment, not the nature of the addictive substance itself:

This gives us an insight that goes much deeper than the need to understand addicts. Professor Peter Cohen argues that human beings have a deep need to bond and form connections. It's how we get our satisfaction. If we can't connect with each other, we will connect with anything we can find -- the whirr of a roulette wheel or the prick of a syringe. He says we should stop talking about 'addiction' altogether, and instead call it 'bonding.' A heroin addict has bonded with heroin because she couldn't bond as fully with anything else.

So the opposite of addiction is not sobriety. It is human connection.

Before I get into the obvious faults of Hari's theory, there is some merit to his position within the larger realm of substance abuse. Many people go through periods of their life in which they rely too heavily upon alcohol, or engage in the recreational use illicit substances or prescription medications, perhaps to the point that their lives seem to be coming apart at the seams, but are subsequently able to scale back or stop that behavior on their own. Their substance abuse may be largely situational, and when the situation changes so does the appeal of drugs or alcohol.

The problem that Hari's theory does not address is why certain individuals are not able to stop using drugs or alcohol without -- and sometimes even with -- significant intervention. Why, if it's the human connection that matters, some individuals will continue to use drugs even as their actions alienate every single person who is trying to connect with them or help them. Hari's theory might explain in part how dealing with addiction can seem like a game of whack-a-mole -- how the successful cessation of the use of one substance, such as alcohol, might be associated with the onset of the use of a different substance or a behavioral disorder. But his theory does not explain why addicts have different drugs of choice, or why rates of successful recovery can differ dramatically between substances.

Hari brings up behavioral addictions,

It was explained to me -- you can become addicted to gambling, and nobody thinks you inject a pack of cards into your veins. You can have all the addiction, and none of the chemical hooks. I went to a Gamblers' Anonymous meeting in Las Vegas (with the permission of everyone present, who knew I was there to observe) and they were as plainly addicted as the cocaine and heroin addicts I have known in my life. Yet there are no chemical hooks on a craps table.

Except, of course, there are. People do get a biochemical reward from gambling. Were that not the case, people would get nothing out of gambling -- there would be no thrill, just boredom associated with an overall loss of money -- and gambling would have no appeal. As it turns out, there is evidence "that the opioid systems in the brains of pathological gamblers may be different, affecting their control, motivation, emotion, and responses to pain and stress."

Problem gamblers appear to have an issue that is similar to that of some problem drinkers, "it seems that pathological gamblers just don't get the same feeling of euphoria as do healthy volunteers". As counter-intuitive as it may seem at first blush, a rapid response to intoxicants is an evolutionary defense against over-consumption. Broadly speaking, when you need to consume more of a substance to get the same thrill, you are at increased risk of addiction.

Hari engages in the dangerous practice of predicating his entire theory on a study of rats. Rats, he tells us, will deal with isolation and boredom by using drugs, but when given many exciting alternatives to drug use they largely choose life's other pleasures over drugs. While, yes, that does suggest that environment can affect rates of drug use, it tells us nothing about why two people who enjoy pretty much the same environment can have extremely different levels of interest in intoxication.

If you attend open AA meetings, those that welcome all members of the public, you will likely soon hear an addict describe his or her first experience with alcohol or drugs. You will very likely hear many speak of their extreme euphoria, their eagerness to repeat the experience, the steps they took to increase their access to their drug of choice and their frequency of use. While Hari would have us believe that in each case there was something -- some level of connection with others -- missing in their lives, and with some of those accounts suggesting such a lack of connection, Hari's argument nonetheless hits a stumbling block: Why do other people with similar or worse environments or levels of isolation try the same substance yet avoid a similar outcome? From another angle,

Time magazine reported using heroin was "as common as chewing gum" among U.S. soldiers [during the Vietnam War], and there is solid evidence to back this up: some 20 percent of U.S. soldiers had become addicted to heroin there, according to a study published in the Archives of General Psychiatry. Many people were understandably terrified; they believed a huge number of addicts were about to head home when the war ended.

But in fact some 95 percent of the addicted soldiers -- according to the same study -- simply stopped. Very few had rehab. They shifted from a terrifying cage back to a pleasant one, so didn't want the drug any more.

The thing is, every single veteran had a new, much more pleasant post-war "cage" -- so why did 5% remain heroin-addicted? Similarly,

If you get run over today and you break your hip, you will probably be given diamorphine, the medical name for heroin. In the hospital around you, there will be plenty of people also given heroin for long periods, for pain relief. The heroin you will get from the doctor will have a much higher purity and potency than the heroin being used by street-addicts, who have to buy from criminals who adulterate it. So if the old theory of addiction is right -- it's the drugs that cause it; they make your body need them -- then it's obvious what should happen. Loads of people should leave the hospital and try to score smack on the streets to meet their habit.

But here's the strange thing: It virtually never happens.

If by that Hari means that most people who are administered powerful opiates during hospitalization don't subsequently become heroin addicts, he's correct. But if he means to suggest that large numbers of addicts don't have their addictions start with their taking properly prescribed pain medications, he's wrong. Most patients will come out of surgery, deal with their inadequate post-hospitalization pain control, recover, and go on with their normal lives. Some will suffer a bit more during their recovery but again go on with their normal lives. Some will actively drug-seek, displaying behaviors consistent with substance abuse and addiction.

If Hari's theory were accurate, we should be able to easily define who is likely to become addicted and who is not. We could simply perform a survey of that person's life, their connections, their stressors and the like, and that should give us an excellent idea of who is likely to have a substance abuse problem and who is not. The problem is, you cannot predict substance abuse or addiction in that manner. You may find overall trends and risk factors, such as a family history of substance abuse, a childhood pain condition that was not properly managed, a history of being the victim of child abuse, and the like. Yes, some predictors do suggest a behavioral component to addiction -- which is what you would expect from something that is in large part a behavioral health problem. But other predictors are not behavioral. Why should it be a risk factor to you if relatives who you have never met, or who were never in a position to model addictive behavior to you, had substance abuse problems?

It's important to recall, also, that not everybody has the same reaction to the same substance. Alcohol triggers different physiological reactions in different people. Some people have little ability to metabolize alcohol, and within their communities rates of alcoholism are very high. Some people flush upon consumption of alcohol. Some become nauseous. Some quickly become tipsy, even with modest alcohol consumption. Others can consume large quantities of alcohol without displaying strong signs of intoxication. Similar things can be said of opiates -- if your reaction to opiates includes feeling itchy all over your body, feeling nauseous, experiencing severe constipation, or feeling confused and anxious, the odds are much lower that you're going to want to repeat the experience than if your principal memory is of euphoria.

These differences in reaction are biochemical, not behavioral. It reasonably follows that some of the differences in why people become addicted to drugs or alcohol, why people prefer one substance over another, and why some people have much greater difficulty establishing and maintaining sobriety, are biochemical. Yes, you may need to address psychological and environmental issues in order to help the addict achieve a stable recovery, but simply changing the addict's environment will not cure the addiction.

Hari suggests that the history of nicotine patches supports his theory,

Everyone agrees cigarette smoking is one of the most addictive processes around. The chemical hooks in tobacco come from a drug inside it called nicotine. So when nicotine patches were developed in the early 1990s, there was a huge surge of optimism -- cigarette smokers could get all of their chemical hooks, without the other filthy (and deadly) effects of cigarette smoking. They would be freed.

But the Office of the Surgeon General has found that just 17.7 percent of cigarette smokers are able to stop using nicotine patches. That's not nothing. If the chemicals drive 17.7 percent of addiction, as this shows, that's still millions of lives ruined globally. But what it reveals again is that the story we have been taught about The Cause of Addiction lying with chemical hooks is, in fact, real, but only a minor part of a much bigger picture.

Hari makes three fundamental mistakes in his comparison. First, he presupposes that the use of a nicotine patch is evidence that a smoker wants to quit. In fact, many smokers who attempt to quit are doing so not because they want to do so, but because they are under social pressure to stop smoking. Some people are afraid to quit smoking, for example because they fear weight gain. Second, he presupposes that establishing a baseline level of nicotine will remove any biochemical incentive for a smoker to smoke. The steady baseline certainly can help control cravings, but it is not going to provide the spike of nicotine exposure to which a smoker is accustomed. Hari is apparently referring to Treating Tobacco Use and Dependence, U.S. Department of Health and Human Services, June 2000, summarized here on page 491. Yes, Third, the abstinence rate for the study was premised upon six months of abstinence, so we're not merely talking about how well smokers abstained during their twelve weeks on nicotine patches, but during a period of months after they stopped using the patch. It's interesting to see that a nicotine nasal spray resulted in a 30.5% abstention rate over the same period, as did buprenorphine -- a medication that does not imitate nicotine, but instead blocks opiate receptors. If biochemistry weren't a big part of the story, the results should have been the same no matter whether the smoker received a placebo, a particular administration of nicotine, or buprenorphine.

Fundamentally, as with any addiction, no treatment program or assistive medication is going to work over the long-run unless the addict wants to stop using his drug of choice. Medications and treatment can provide a window of opportunity during which the addict can establish a period of abstinence and have an opportunity to consider a future both with and without his substance of choice, but unless the addict is sufficiently motivated to stop the addict will relapse. For that matter, many addicts who truly want to stop will still have problems with relapse, whether due to a momentary lapse in judgment, the strength of their cravings, or a combination of factors.

At the end of the day, yes, it makes sense for a recovering addict to improve his environment -- to address facors, internal and external, that contribute to addiction and could contribute to relapse. To ignore the biochemical side of addiction, the predispositions that some people have to the use and abuse of certain chemical substances, and the difficulty that addicts of all backgrounds experience when trying to establish and maintain sobriety, by suggesting... is it that this could all be fixed with warm feelings, love songs and group hugs... is to turn a blind eye to the leading factors in addiction.

Loving an addict is really hard. When I looked at the addicts I love, it was always tempting to follow the tough love advice doled out by reality shows like Intervention -- tell the addict to shape up, or cut them off. Their message is that an addict who won't stop should be shunned. It's the logic of the drug war, imported into our private lives. But in fact, I learned, that will only deepen their addiction -- and you may lose them altogether. I came home determined to tie the addicts in my life closer to me than ever -- to let them know I love them unconditionally, whether they stop, or whether they can't.

I'm not one to point to a show like Interventions and argue that it's a model for addiction treatment. The purpose of an intervention is to inspire an unwilling drug addicted person to go into residential treatment. Contrary to what Hari suggests, the message is not (or at least should not be) that "an addict who won't stop should be shunned" but is instead that the family has the right to draw boundaries and to state that, if the addict chooses to continue down the road to ruin, they will have to limit their role in the addict's life in order to protect themselves and their own mental health. Sometimes it takes a dose of that sort of reality to get the addict to go into treatment. Sure, others will reject the attempted intervention, but it's facile to suggest that it is a failed intervention that causes addicts to "deepen their addiction" -- addiction is a progressive disease and thus, absent some limiting factor, gets worse over time. Many addicts describe the fear of loss of family, the embarrassment of an arrest or jail sentence, and the like as the very thing that inspired them to finally work toward recovery.

What Hari describes as his ultimate take-away, "to let [the addicts in my life] know I love them unconditionally, whether they stop, or whether they can't", is a basic teaching of programs like Alanon, under the name of "detachment with love". Hari may not like some of the implications of that approach, the idea of telling an addict who calls you hysterically in the middle of the night that he was picked up by the police and needs to be bailed out, that he'll have to wait until morning -- or that he'll have to face the natural consequence of his decisions and find a way to bail himself out -- but allowing an addict to face those natural consequences is not an indication that you don't love them. It's a means of protecting yourself, of avoiding the anger and resentment that get in the way of love, and of allowing them to experience the negative consequences that they bring upon themselves such that they might decide that it's finally time to give sobriety a honest chance -- whether through inpatient treatment, an intensive outpatient program (IOP), counseling, peer support, and with or without assistive medication. When the addict reaches the point of wanting to recover, you can start implementing the structure and changes that Hari correctly associates with improving the chances of long-term sobriety. But no, when you're dealing with populations of addicts, you cannot simply work to improve their emotional environment and expect it to be a miracle cure.

Evangelical Christianity, Homosexuality and the Deeply Flawed "Tale of Two Bobs"

The other day I came across a blog post by Rod Dreher, in which he embraces a parable somebody wrote a couple of years ago about two neighbors, both named Bob, who get along even though the author assumes that they're not supposed to.

The opening of the parable could be this,

There once were two neighbors, both named Bob. One is a neo-Nazi, the other is Jewish. They've lived next to one another in a duplex for several years, and have been good neighbors: getting one another's mail when the other travels, hauling each other's garbage cans to and from the curb, and have occasionally had a cookout together. They are friends, but they've never really had a discussion about their differences.

Or this,

There once were two neighbors, both named Bob. One is a KKK member, the other is in an interracial marriage. They've lived next to one another in a duplex for several years, and have been good neighbors: getting one another's mail when the other travels, hauling each other's garbage cans to and from the curb, and have occasionally had a cookout together. They are friends, but they've never really had a discussion about their differences.

Or this,

There once were two neighbors, both named Bob. One is an evangelical Christian, the other is gay and agnostic. They've lived next to one another in a duplex for several years, and have been good neighbors: getting one another's mail when the other travels, hauling each other's garbage cans to and from the curb, and have occasionally had a cookout together. They are friends, but they've never really had a discussion about their differences.

The narrative continues,

One day, during March Madness, a stiff gust of wind knocked a tree limb into their power lines, and they found themselves without electricity, five minutes before the U of L game. They wandered out onto their respective porches and decided to go to a nearby pizzeria to watch the game.

Somewhere before the end of the game, this conversation began:

Bob 1: Isn’t it surprising that we've become friends?

Bob2: What do you mean?

1: Well, one of us has a [swastika / KKK emblem / rainbow sticker], and the other has a [Magen David / pro-diversity sticker / fish emblem]. According to most folks, we shouldn't get along.

2: Yeah, I'll admit it's crossed my mind once or twice. Does it bother you?

1: Does what bother me?

2: Well, that I am who I am?

1: Hmmm… I don't know how to answer that. Does it bother you that I am the way that I am?

The narrative continues,

Bob 2 scratches his chin, waits a moment.

2: I suppose there are two answers to that question. One is no, not at all. We've been good friends. You took my dog to the vet when it got into a fight with a possum. You share my hatred of the University of Kentucky. What's not to like? On the other hand, I think you've have committed your life to something that's toxic to our culture, and to yourself, and I wish for your sake, my sake, and the world's that you believed something different. So no. And also, I worry about you.

Bob 1 leans back a little, grinning.

2: Did I offend you?

1: No, not at all. In fact, I would probably give the same answer about you, though I'd phrase it a little differently.

2: How so?

1: Well first of all, I’d talk about your barbecue skills, and I’d admit that I like your smelly dog. Second, I’d say that I think who you are and who I am is more complex than beliefs and commitments… but I think that's true for myself too.

2: You don't think you chose to be that way?

1: Did you?

2: I guess I did and I didn't. Or maybe, I didn’t then I did. It was something I didn’t want, but eventually I had to admit it.

1: I guess I didn't and then I did.

2: That's a better way of putting it.

1: For both of us.

2: For both of us.

1: So all this simmers in the background while we see one another, day by day.

2: Yep.

1: But we just keep on being neighbors and sharing the occasional pizza.

2: Yep. Breathing the same air, trying to figure out how to get along.

The game got heated for a few moments and they drifted away from the conversation. Soon, it started up again.

1: Let me ask you something.

2: Shoot.

1: You're saying that you didn't choose to be the way you are, but then you did.

2: Yeah. It was a journey. I didn't want to believe it, but eventually, it became undeniable, and I had to accept it inwardly, and then I had to accept it outwardly.

1: How did your family react?

2: Well, they're more sympathetic to you than me… It wasn't easy. It still isn't. I get snarky comments occasionally, especially during election seasons.

1: Oh yeah… the worst.

2: The worst. Let me ask you something now.

1: Okay.

2: Has it caused trouble for you? Like, at work or anything?

1: Well, sometimes. Some folks just think it's awful, and you have to win them over by just being an ordinary person.

2: Because they think you're a monster?

1: Because they think you're a monster.

2: That's familiar.

1: Yep.

The game ends, the two walk back home, and their friendship resumes. Conversations return to this topic, and both try to convince the other of their errors… But thus far, not much has changed. They remain good friends and good neighbors.

The author argues,

This parable is meant to do two things. First, it’s sort of a Rorschach test. Which of the Bobs is a Christian, and which one is gay? In a culture that remains hostile to the LGBT community at one end of the spectrum, and at the other end, hostile to Christians who hold traditional beliefs, we will find folks like both Bobs: their social experiences are almost interchangeable.

Even within the context of "Which of the Bobs is a Christian, and which one is gay", the exchange is strange and contrived. When you recognize the fact that, perhaps with a slight adjustment for time and place, the exchange as easily "fits" contexts in which one person's views would be unacceptable by broadly held contemporary standards, the parable falls apart as a highly strained false equivalence. There is a difference between disliking somebody because of their beliefs, particularly when those beliefs cast you as somebody who is destined to Hell or inherently inferior, and disliking somebody over an aspect of their being that they cannot change -- such as their heritage, or their (or their spouse's, or their children's) skin color.

If you want to reduce it to a parable about mutual acceptance, to make it a song and dance number for a Rodgers & Hammerstein musical, you don't need to bring religion or status into the discussion. ">The farmer and the cowman can be friends. You say tomato, and I say to-mah-to. You say goodbye, and I say hello. The exchange actually works better if you treat the disagreement as being over a triviality. Consider Dr. Suess's story of the star-bellied sneetches, creatures identical in all respects save for the presence of stars on their bellies, who come to realize the absurdity of using that distinction as the basis of a claim of superiority. That form of the narrative can still serve as an analogy for much more serious, real world, bigotry and discrimination, but without the need for a false analogy.

Secondly, I think this conversation is very real and true to life. It’s a conversation that I’ve had in one form or another with many friends over the years. I’ve also had conversations that were much less friendly. But the context here is, I think, the key: being neighborly, being a friend, creates space for conversations that are hard. And while that probably won’t resolve the growing public tension over these issues, it might help us to live at peace with our neighbors, and that is, in some ways, far more important.

Except the conversation is not real and is not true to life. I'm not going to rule out the possibility, for example, that a member of the Westboro Baptist Church gets along with his gay neighbor, but this is not the conversation such a person would be at all likely to have with that neighbor. Also, the author starts from the preconception that gay people "shouldn't get along" with evangelical Christians, and vice versa. While some evangelical Christian churches and movements do preach intolerance, that's not prerequisite to being an evangelical Christian. And while a gay person might not like getting the stink eye from somebody who is intolerant of his relationships, there's absolutely no reason to presuppose that being gay predisposes you to not "get along" with an evangelical Christian. For goodness sake, you can both be an evangelical Christian and be gay.

The parable seems to recognize the inherent weakness of trying to analogize the condemnation of a group of people based on status -- something they cannot change -- and criticism of people based upon their beliefs, even sincerely held religious beliefs. The Bobs are posited as having this interchangeable view of their realizing that they were gay, or their embracing a form of evangelical Christianity that regards homosexuality as a mortal sin,

2: You don't think you chose to be that way?

1: Did you?

2: I guess I did and I didn't. Or maybe, I didn’t then I did. It was something I didn’t want, but eventually I had to admit it.

1: I guess I didn't and then I did.

2: That's a better way of putting it.

1: For both of us.

2: For both of us.

The problem here is that "gay Bob" would be describing a process by which he recognized and accepted his homosexuality despite strong social pressure not to be gay. Accepting the fact that you are gay is not a "choice" as posited by the narrative. In contrast, if a person in fact struggles with whether to join a particular religious or social movement, and struggles with those portions of its beliefs that teach intolerance of others, their ultimate decision to remain within the movement and to embrace those beliefs comes as the result of an actual choice. Under the interchangeable narrative, "Christian Bob" describes himself as coming from a family that holds different views than his own, and is accepting of gay people ("they're more sympathetic to you than me"). While "Christian Bob" may believe that his religion dictates his attitudes toward gay people, under the narrative he chose the path that led to those beliefs.

Some try to draw a fine line between homosexual thoughts and homosexual practices -- the conception being that if a gay person doesn't accept his homosexuality, or if he does accept it but represses any action on his desires, that he is somehow elevated above a homosexual person who involves himself in a gay relationship. Under that thesis as it plays out in the real world, you're asking homosexual people to either live a lie, usually at the expense of another person (their heterosexual spouse), or to openly state that they are homosexuality and then to live a life of chastity. Even if the latter path were realistic, many evangelical communities would not be welcoming to such an individual. We can debate the extent to which that's the result of the teachings of their church, the result of larger social views, or some combination thereof, but it's a reality. There's a vast difference between not excluding a gay parishioner and welcoming them into your church as a full and equal member.

To the extent that the narrative reminds evangelical Christians of the teaching that you can love the sinner while hating the sin, that you can be accepting of others without compromising your Christian values, that you can be neighborly even toward people whose lifestyles you find to be sinful, great. The preconception of the narrative, that evangelical Christians "shouldn't get along" with gay people is not necessary -- you can be a devout Christian without hating anybody. Why does a contrary impression exist? Not only because of the antics of groups like the Westboro Baptist Church ("God Hates Fags"), but because of attitudes like those acknowledged here,

I can't look my gay brother in the eye anymore and say "I love the sinner but hate the sin." I can't keep drawing circles in the sand.

I thought I just needed to try harder. Maybe I needed to focus more on loving the sinner, and less on protesting the sin. But even if I was able to fully live up to that "ideal," I'd still be wrong. I'd still be viewing him as something other, something different.

Not human. Not friend. Not Christian. Not brother.

Sinner.

And despite all my theological disclaimers about how I'm just as much a sinner too, it's not the same. We don't use that phrase for everybody else. Only them. Only "the gays." That's the only place where we make "sinner" the all-encompassing identity....

The author clearly felt immense pressure within his religious community to reject homosexuals. He also speaks of how, upon reflection, he can continue to hold his religious beliefs without joining in with that type of condemnation of his literal and figurative brothers. The author of the "Bobs" narrative asserts,

Christians make space for others all the time; neighbors who are adulterers or gluttons, alcoholics or tax cheats. We have family members who are liars and Christians – at their best – love these folks because they know that they are no different but for the grace of God. And so, Bob can make space for Bob even while he lovingly extends the offer of grace in Jesus Christ. That offer includes a call to repent of Bob’s sins, and that’s a tough pill to swallow.

Save for the contrived assertion that "Gay Bob" is agnostic, "Gay Bob" could have been Christian who attends a church that is accepting of his homosexuality. I doubt that the same sort of emphasis on "the offer of grace in Jesus Christ" or repentance of sins would be asserted if this were "Evangelical Bob and Presbyterian Bob", yet save for the author's contrivance "Gay Bob" could a devout Presbyterian, perhaps even a minister.

But the truth is that the other Bob wants to convert Christian Bob too – not to being gay, of course, but to his own worldview.

As the "Two Bobs" narrative unfolds, there's no reason to believe that to be the case. That is, with "Christian Bob" being able to be friends with his gay neighbor, there's little more that "Gay Bob" could hope to accomplish -- and no reason to believe that "Gay Bob" would be particularly interested in trying to push "Christian Bob" into making further concessions. After all, if most or all evangelicals were as neighborly, the author would have felt no need to write his parable.

Dreher's take-away from the parable was this:

Cosper’s point is that Bob 1 can be the gay agnostic, or the traditional Christian, and the same moral would apply. If you can’t see how either one could play either role in the conversation, perhaps you need to work on your empathy.

For reasons I've already outlined, and which should be readily apparent from the applicability of the parable to other contexts in which it becomes instantly uncomfortable, Dreher's first take-away fails due to narrative's reliance upon a false equivalence.

The argument for empathy -- for mutual empathy -- is more interesting. While the narrative flounders when it attempts to draw a parallel between immutable aspects of a person and their social or religious beliefs, there is no question but that people can be friends with evangelical Christians without sharing or endorsing their beliefs. Sure, just as political discussions are off the table at a lot of family Thanksgiving dinners, there may be discussions that don't occur in the interest of good neighborly relations, but that's part of how we get along with others who don't fully share our views.

The false analogy makes the argument for empathy a bit awkward -- I'm hard pressed to think of any gay person I've ever known who held the sort of blanket views of evangelical Christians that the author seems to believe are prevalent -- but certainly, there's room for neighbors with different social, political and religious views to find common ground. (Nonetheless, if "Christian Bob" is marching with the Westboro Baptist Church or is actively protesting gay marriage and lobbying politicians for a ban on employee benefits for same-sex partners, he needs to take responsibility for the fact that his actions make it much less likely that he will find common ground with his gay neighbor.)