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.

How About Taking Responsibility For the Medications You Take

Ruth Marcus seems oblivious to the fact that sedating medications, including Ambien, are frequently abused.

[Kerry] Kennedy may have taken the pill by mistake, they contended, but she ought to have known she was impaired and pulled over.

Excuse me, but maybe they should have tried taking this drug before filing criminal charges. Ambien and other sleeping pills are powerful. You take Ambien, and 15 to 30 minutes later, you begin to zonk out. A toxicologist who testified at Kennedy’s trial — for the prosecution, no less — said that someone under the influence of Ambien could fail to recognize that she was having a problem, or even to remember, later, what happened.

I think we can infer from Marcus's statement that she has taken Ambien, and thus knows how sedating it is. What Marcus probably has not seen is what happens when somebody takes Ambien and deliberately stays awake. The superficial affect is one of significant alcohol intoxication. Why do some people do that? Just as with abuse of common benzodiazepines, ecause they like the way it makes them feel, and some of them use other drugs or alcohol at the same time so that they can enjoy a magnifying effect.

Ambien may be something of an extreme case, given how quickly the sleepiness can come on, but how far would Marcus extend her "Let's assume it was an accident" rationale to other sleep aids? She draws a distinction between "medications with drowsiness as a side effect, [and] the ones whose sole purpose is sedation", but why? Many people take Benadryl to sleep, and sometimes pharmacists recommend it as a non-prescription sleep aid. Many people take opiate and opioid medications for pain, but they can be highly sedating and are commonly abused.

Marcus seems to feel that nobody who drives down a road after taking Ambien should ever face a criminal charge for driving while impaired by drugs, even if they injure or kill somebody. I have no problem working from the perspective that if you are too drugged to drive you shouldn't get behind the wheel, even if you took the wrong medication by accident. When somebody is intoxicated behind the wheel, I don't mind putting the impetus on that person to convince me both that it was a mistake and that they had no reasonable opportunity to recognize the mistake so as to get off the road. Kerry Kennedy was able to convince a jury that she took Ambien by accident, and didn't recognize its effect in time to safely stop her car. Marcus thinks that's too high a price for Kennedy and other Ambien users to pay, but it's not as if either of them are unaware of the dangers of that drug. They are both certainly aware of this case:

U.S. Rep. Patrick Kennedy said Friday that he will enter a rehabilitation program after crashing his car on Capitol Hill a day earlier....

He said in a statement Thursday evening that he was apparently disoriented at the time of the crash after taking the prescribed amounts of a sleep aid and an anti-nausea drug.

"I am deeply concerned about my reaction to the medication and my lack of knowledge of the accident that evening. But I do know enough to know that I need to seek expert help," he said Friday....

In his Thursday evening statement, Kennedy said he had returned home after final votes in the House of Representatives around midnight Wednesday and taken the sleep aid Ambien and an anti-nausea drug....

In his comments Friday, Kennedy said, "The recurrence of an addiction problem can be triggered by things that happen in every day life, such as taking a common treatment for a stomach flu.

Assuming she takes Ambien, Marcus, I expect, is very careful with Ambien due to the stories she recounts, including one that put one of her own children in danger. How many stories do we need, and how close to home do they have to hit, before we can reasonably expect people to look at their pills and read their pill bottles before swallowing a sleeping pill then getting behind the wheel of a car?

I won't argue with Marcus that manufacturers could create pill colors and shapes, or package sleep aids in a different manner, and thereby all-but-eliminate the "I was confused" defense. Perhaps at that point Marcus would accept that people intoxicated by Ambien should be subject to prosecution for driving in that condition. But for now, if people have multiple, similar-looking medications, they owe it to themselves and others not to confuse their pills. If people who have serious health conditions requiring them to juggle dozens of medications can keep their pills straight, I think it's reasonable to ask that people with minor medical conditions and two or three prescriptions to do the same, more so when incidents of carelessness will pose serious risk to themselves and others.

Don't Trust Addiction Treatment Claims About Success Rates or Not Being a 12-Step Program

When you're trying to find a drug or alcohol treatment center for somebody you care about, you'll likely find yourself at a disadvantage. First, the person who needs treatment may attempt to impose conditions on the treatment center you choose and, even when they sound reasonable, some of those objections may be more about "How do I stay out of treatment or find something more akin to a spa than a treatment center" than about trying to find a good fit. Second, when you call treatment centers for information about their programs, you are trusting somebody at the other end of the phone to tell you the truth. Sometimes that happens, but often it does not - you may in fact be talking to somebody who works in more of a sales capacity than an intake capacity. Also, sometimes they'll share information in good faith but the experience will turn out to be quite different. If at all possible, visit a facility and get a sense of its program and stability before writing a check. Please note, even if the center is suggested to you by a facility that has a strong reputation, you should not trust the recommendation - you need to investigate any recommended facility and, if at all possible, visit the facility and see it for yourself.

One claim that many addiction programs make, that they really shouldn't, is a claim of how many people who complete their program remain sober. First, even if accurate (and it won't be) the statistic is going to be highly misleading - if you focus on treating teenagers who smoke marijuana, you're going to have a much higher "success" rate than if you're treating IV drug users. The same is true if you're counseling people who are concerned that they might be using too much alcohol or using too many drugs, coming to you as self-referrals, as opposed to people coming out of a multi-day medical detox who are not even slightly interested in being sober. Second, the definition of sobriety used by the program may be designed to give a misleading picture of the client's sobriety - focused on the "right now". Third, as responses to patient surveys are voluntary many clients who have relapsed either won't be located or won't respond. Fourth, the questions almost never extend to subsequent treatment - the quack program doesn't care if you had four relapses, completed three IOP's and spent 90 days in Hazelden between your graduation and the present, if you're sober they'll count you as a success. Fifth, the definition of what it means to complete a program can render the statistic meaningless.

One program I saw touted an 80% success rate at five years for patients who completed its program, and while it was a good program what they didn't tell you unless you asked was that they defined their program as being five years in duration, with completion meaning that through those five years you attended weekly meetings (free, or should I say, included in the price of the program) at their facility. If you stopped attending, you didn't complete the program. If you lived in another part of the state or country and thus couldn't attend those meetings, you weren't included in the statistic.

But the claim that makes immediately skeptical of a program is when it presents as a front and center part of its marketing, "We're not a 12-step program". Let me be clear: I am not wedded to the twelve step model. Twelve step program have an interesting history, emerging out of a religious self-improvement program and being transformed into a somewhat secular model for addiction support and recovery. A lot of people have difficulty with the notion of turning their will and life over to a higher power, or with making prayer and meditation part of their daily lives, even if you can do both in a largely secular manner. But as one addiction counselor, who himself had struggled with his fit with the twelve-step model, explained to me, "I tell my clients who have difficulty with the steps that if I had something better, I would send them to it instead, but I don't." Part of that is the fact that AA groups are everywhere, while non-12-step support groups remain relatively obscure. Part of AA's success results from primacy but, whether or not its critics choose to admit it, its success depends on people voting with their feet - the addicts in long-term recovery who go back to AA year after year do so because it works for them.

Through experience, 12-step programs implemented some measures that correspond to certain aspects of addiction and recovery. For example, in active addiction the addict's impulse control diminishes - desire and action become unchecked by rational thought. Twelve step programs attempt to interpose an outside reality check on the addict - if you are craving drugs or alcohol, go to a meeting or call your sponsor. As a period of sobriety expands, the internal mechanism between impulse and action can start to rebuild itself. Similarly, the concept of "90 in 90" - doing ninety meetings in your first ninety days of recovery - is reasonably consistent with the amount of time it takes for the addict's impulse control to start to approach normal levels. The social aspect of the group can be reinforcing - you're dealing with people who have been through what you have, or worse, and they want you to succeed in your recovery. They'll also welcome you back if you relapse. The group's sayings and slogans can give you something to think about, even if you reject the larger program.

It's important to recall, however, that although treatment and therapy can incorporate aspects of the twelve-step model, twelve step programs are not therapy. They're structured peer support, coupled with a structured self-improvement program. Twelve step programs are an adjunct to treatment and, while some people achieve and maintain sobriety without any treatment or participation in 12-step or non-12-step support program, many people need the longer-term peer support and accountability. If you find a program that works for you, be it a 12-step program or one of the lesser-known non-12-step alternatives, it makes sense to take full advantage of the program. There's no reason you can't try more than one program, even at the same time, to see what works.

One of the reasons that long-term participants in 12-step programs can be dismissive of the argument, "I tried a twelve-step program and it didn't work for me," or "The twelve steps are nonsense", or "I don't see why I need to completely abstain from alcohol or substance use to be sober," is that they made those same arguments in their own early recovery. Sometimes they made those arguments for a period of years before they finally did what AA demands, surrendering themselves to the program, and that's when it worked. Again, I'm not arguing that 12-step programs can or will work for everybody, and if you're around addicts long enough you'll see unfortunate cases where a person who had achieved many years of recovery ends up relapsing despite seemingly doing everything right, but there is something to the argument that if you surrender to the program it can work for you.

The primary purpose of a marketing hook, "We're not a 12-step program", is to reach people who either are alienated by the very concept of the 12 steps, or people who find them difficult or intimidating. Were the argument intended to reach people interested in science-based recovery, it would put science front and center rather than a rejection of the twelve steps. To the extent that a recovery program can identify addicts who will or will not benefit from a particular treatment modality and channel them into programs and support groups that are likely to work for them, I'm all for it. But, as much as they may protest otherwise, when they flatly reject the 12-step model in toto they are rejecting approaches to treatment that have been documented to work for many people. If you're going to claim to offer science-based treatment of addiction the science should be front and center, not the rejection of a particular approach to treatment.

L.A. Weekly published an in-depth article about a treatment center that claims to reject the 12-step model,

I tell [a person who completed the program] that despite [the proprietor] Prentiss’ denouncements of 12-step programs, I saw residents’ schedules on the wall that indicated optional A.A. meetings.

“When I was there, we did six or seven [A.A.] meetings a week. Two or three in-house and the rest out,” he says. “And they were mandatory. When Chris wrote his book [The Alcoholism and Addiction Cure],that ended. That’s when he decided A.A. was the villain, because he decided he could make a fortune if he just claimed he had found the cure for alcoholism.”

The business executive continues in an upbeat, almost appreciative tone: “Chris has a brilliant scheme that they have cooked up there. He has the perfect sales pitch.” His voice suddenly drops. “I know. I fell into it. It’s a beautiful sales pitch when someone is at the end of their rope.”

When I tell Stuart I couldn’t find any of the success stories Prentiss brags about, he tells me, “People come in there, they fail and nobody can call him on it. He’s got clients with confidentiality agreements to hide behind.”

How did anybody at all get sober, I ask? The answer, says Stuart, is the ironic one: A.A. I remind Stuart just how adamant Prentiss was with me in mocking A.A.

“Chris was having trouble filling the beds, and the minute he changed the message, they filled to the brim. He created a cash machine,” Stuart [a person who spent $250,000 on the program] says. “After my stay in ’05, I was invited back as someone early in recovery, and I started talking of all the people I had been there with who had relapsed. And my message was, this is a great place, it’s just not gonna teach you anything about staying sober when you leave.”...

[Dr. Jason Giles, former medical director of the center] repeatedly hedges when asked to talk about Prentiss, but finally says, “The interesting part, I think, is how people are vulnerable to charlatans. I think these rehabs are modern-day quackery.”

Then he lowers his voice to a whisper and adds, “I’ve been in contact with a lot of my former patients from when I was there and the data, the data do not come anywhere near what he is quoting as his [84.4 percent] success rate.”

This came to mind when I saw an invitation to submit questions to the medical director of an addiction treatment center on the New York Times website. The center utilizes the 12-step model, so predicably the critics of the twelve-step approach appeared to denounce it. One in particular was pushing an "education program" as an alternative to treatment, sharing this link.

Outside independent professional research firms have certified a long-term success rate of at least 62% for the St. Jude’s Program. This compares to a success rate in the range of 0-20% for conventional programs.

Let's take a look at an example of that "research".

Clearwater consulted with BRI regarding the specific information needed for fielding. Baldwin [the parent company for the education program] and Clearwater mutually agreed to have Clearwater use Microsoft Access to randomly choose names from a list provided to Clearwater by BRI. After the names were selected, Clearwater accessed BRI’s in ‐ house database containing contact information for each participant in the Jude Thaddeus Program to gather specific information that was copied manully into a spreadsheet. The contact information was loaded into our CATI system and the interviewers began to contact designated individuals and complete interviews.

It catches my attention that no claim is made that BRI provided a complete list of people who have completed the program.

Out of a total of 956 records called, 232 resulted in completed interviews with both parties, giving an overall response rate of 26.17%. Clearwater interviewers “chased” members of the sample who were not reachable at the household or telephone number provided by BRI when someone we contacted could provide us with an updated telephone number.

The low response rate should catch anybody's attention, especially given this note:

Many Guests to whom we were never able to speak with were actually back in rehabilitation again. That information was tracked in the attempt messages, but may be something that should be tracked more quantitatively using a specific disposition or answer choice.

First, it's a misnomer to say "again", given that the program being investigated is an educational program, not a therapeutic program. Second, why exclude from the claimed success rate the percentage of people who could not be surveyed because they were in treatment?

Also, the survey appeared designed to maximize the number of respondents who could claim to be sober,

Have you been sober, not using any illicit drugs or alcohol, for at least the last 30 days?

Self-reporting is a relatively poor method of evaluating sobriety. Some of the people contacted had provided a "corroborator" who was independently asked if the alumnus was sober. When reached, the corroborators indicated a lower level of sobriety than the alumni. Yet the program's official website presents a conspicuous pie graph labeled "62.5% sober for the past 23 years", a claim that they know to be at best highly misleading. As I interpret the graph they are deliberately implying that 62.5% of people who complete their program are verifiably sober after completion, when they know that's anything but the truth.

Going back to the website linked from the New York Times, the statistical argument gets worse,

This compares to a success rate in the range of 0-20% for conventional programs. Data published by Alcoholics Anonymous (A.A.) indicates that its 12 step method has a success rate of no more than 5%. Research also finds that no treatment at all has a success rate of about 30%. This suggests that traditional 12 step programs are less effective than doing nothing.

The "success rate in the range of 0-20% for conventional programs" statistic seems to have been fabricated. No source or context is provided.

In terms of the claim that AA "has a success rate of no more than 5%", if you hear that from any person or entity claiming to be an expert in either addiction treatment or 12-step programs, my suggestion is to run away. The figure being described is a one-year retention rate - how many people who start AA within a particular 12-month period continue to attend meetings. In a survey of people who are attending AA, "35 percent were sober for more than five years; 34 percent were sober from between one and five years; and 31 percent were sober for less than one year. The average time sobriety of members is more than five years." As I indicated earlier, the people who keep going back to AA (and who do the work necessary to pay for meeting space, set up the space, provide coffee, make literature available, etc.) do so because it works for them. If you have to fabricate a 95% failure rate in order to promote your program, the reflection is on your program and not on AA.

According to somebody who reports having twice completed the St. Jude program,

For me, the greatest injustice of all is St. Jude/BRI's CONSTANT slandering of A.A. No, not because I support A.A. (it's a religious cult, with rigid dogma and rituals and little to zero efficacy), but because....well....the St. Jude Thaddeus program IS A.A. I know, weird right? Basically, the St. Jude program is identical to the 12-steps, and its crux (and a "guests" likelihood of success) rests on willingness to "serve others". In A.A. that means make coffee, give away cigs, and **** vulnerable women. At St. Jude it means do dishes, hide candy under your roommate's pillow, and **** vulnerable women. Essentially, instructors act as sponsors who aid in a "guest's" acceptance, surrender (formal surrender prayer said with a sponsor, shit, I mean instructor) a detailing of misdeeds and character flaws, a drafting of an ammends list, and on and on. The only difference? St. Jude insists meetings are unnecessary, it's all about choice, and that after completing the "workbook" you're cured for life!! I just can't believe how much effort they put into distancing themselves from A.A. whilst simultaneously being A.A.

So again we have a program that bashes AA but reportedly adopts or utilizes many of its precepts. The alumnus recognizes the marketing aspect, "St. Jude needs A.A. to exist so they can sell their services based around NOT being A.A.". It's also surprising how some of the most vocally anti-AA treatment centers and programs seem to be owned or operated by people who have no credentials in either behavioral health or addiction treatment.

Somebody who makes a statement along the lines of, "Conventional treatment and 12-step methods of recovery don't work", is being no more true to the facts than somebody who claims "Conventional treatment and 12-step methods of recovery always work". No treatment works for all addicts all of the time, and some treatments that won't work for an addict at one state of addiction or recovery may well be effective when they've reached a different stage in their recovery (or lack thereof).

Former Addict?

Ain't no such thing.

Comedian and former addict Russell Brand today gave evidence to the home affairs select committee on drugs.

The dragon may go to sleep, but it never dies.

Somebody Needs to "Twelve Step" The Man

You may have read something a while back that seemed a bit odd - even when Perry was riding high in the polls, his most significant historic financial supporter (and "Swift Boat Liars" financier) Bob Perry "(no relation)" was sitting on his wallet, along with a number of others who might have been expected to be writing checks. Perhaps they knew something that is now becoming obvious to the world.

I'm not saying it's the only possibility but, to me, a display like this:

screams "I took a benzodiazepine, probable Xanax and probably in too high a dose, before taking the stage." Somebody once described benzodiazepines as "alcohol in a pill". In the video, to me, Perry looks like somebody who is very intoxicated but is trying to act sober. What else do benzodiazepines do? They cause confusion. They can interfere with short-term memory.

As the video above confirms, I'm far from alone in wondering if Perry was "drunk or stoned". If I were inclined to give money to his campaign, despite the "high on life" reassurances of his campaign staff, I would want to see a blood screen. As Jon Stewart put it,

Best-case scenario, that dude's hammered. Worst-case scenario, that is Perry sober, and every time we've seen him previously, he's been hammered.

I don't want to dump on the man. It's easy to laugh. But by all appearances the man needs help and in my impressions are correct those who keep pushing him on stage aren't much different from this guy.

My campaign song suggestion ("Rehab") was pretty pointed, but one might infer that his staff prefers "Comfortably Numb".

Being a Sober Person at Charlie Sheen's Party

Beyond profits, there's a reason comedy clubs tend to ply the audience with alcohol. A performer is much more likely to be deemed funny if he's the most sober person in the room. Similarly, if you go to a party that is centered around drugs or alcohol and where everybody else is drunk, stoned or both, you're unlikely to have much fun as the only sober person in the room. I don't want to suggest that Charlie Sheen was intoxicated during his performance in Detroit - he seems to be able to pull himself together for work - but really, by all appearances he's an out-of-control addict. You want to see the consequent displays of grandiosity and belligerence? Fine, but as his Detroit audience found out you may instead find that you paid a good chunk of change to see his on-stage decompensation.

WRIF-FM (101.1) host Drew Lane said if the tour continues like this, Sheen's career will be in jeopardy.

No kidding? ("Will be"?)

Another review:

The energy picked up when the actor and his two "goddesses," miniskirt-clad, live-in girlfriends Natalie Kenly and Rachel Oberlin (aka Bree Olson) strolled out to a standing ovation.

This was the charming, elegantly wasted, fast-talking Charlie we wanted to see. He had the goddesses burn his "Two and a Half Men" shirt, and he donned a Tigers jersey (with "Warlock 99" imprinted on the back), to great cheers. Alas, the good time didn't last long.

Wow. Another huge surprise.

During the times Sheen had to speak and hold the audience's attention, things really fell apart. He was the reason the audience was there, they wanted to see their gruff, charming bad boy, the folk hero who never said "sorry," who told his boss to take his cushy job and shove it. Sure, over the years he never grew out of the Beverly Hills, rich brat persona but there was a self-deprecating charm underneath the caustic humor. Wasn't there?

Not that I am ordinarily inclined to answer rhetorical questions, but my guess is that a lot of the charm you see when Sheen is acting comes from his script. I have not followed Sheen's off-screen life at all, save for recent events that have led much of the mainstream media to deem his public self-immolation to be newsworthy, so I'm not the right person to ask. If you have followed him please tell me: in his decades of fame is there an off-screen statement or event I should look at that would indicate that any self-deprecating element to his narcissistic "charm" is anything but superficial, largely if not entirely scripted? Even one? (Public drunkenness, check; domestic violence, check; public displays of charm....)

With a team of writers and some time, Sheen could have pulled together something workable. But the "Violent Torpedo of Truth" show appeared to be thrown together and vetted by a close circle of friends who probably think Sheen is the funniest, most brilliant man alive. In that circle, he probably is.

Here's the thing. When you're a filthy-rich, self-indulgent, out-of-control drug addict, you don't have much room in your life for "Johnny Buzzkill". Sure, you need somebody to get you up in time for work and clean up after your messes, but they're background figures. Front and center, you have your enablers and hangers-on. Sheen didn't need more time to produce a decent show. He needed to involve somebody with the show who was willing to introduce him to some reality. Which wasn't going to happen. You can be pretty confident that, right now, he's being reassured that everything is okay with him and that it wasn't his fault that he had such a lousy audience.

There Are, After All, Sad Clowns?

Charlie Sheen is being lectured by "Dr. Drew" Pinsky - that's right, the guy who profits from a "celebrity rehab" show - that he needs to take rehab seriously. Would that mean going on Dr. Drew's show, so his private disclosures and embarrassing moments, as well as what seems to be a considerable amount of contrived drama, gets broadcast to the nation? ("We have Heidi Fleiss coming on the show... Hey, who's her ex-boyfriend who was convicted of domestic violence - Tom Sizemore. Let's get him, also. Oh, and he has a drug-using girlfriend - can we sign her up, mid-season?")

My initial reaction was, "That's like being lectured on seriousness by a clown," but then (as the subject indicates) I remembered that there are sad clowns.

It's not that I don't think Dr. Pinsky could run a decent drug rehab clinic. It's that I see him as instead choosing to create a public spectacle that puts him in the role of savior, involves stirring up drama for the benefit of the cameras in a context in which turbulence should be minimized and people should feel safe, and using what is ostensibly the medical treatment of patients in his clinic as an opportunity to build his own public image. It's great that Dr. Pinsky admits his own narcissistic tendencies, but not so great to see them play out like this.

Did You Miss The Word "Anonymous"

I realize that the words "ethics" and "paparazzi" have very little in common with each other, but for goodness sake - don't stalk people at 12-step meetings, even if they're celebrities.

When A Child Is A Parent's Meal Ticket

A couple of months ago my four-year-old became very interested in Michael Jackson. His "moves". She doesn't have much interest in his childhood work, but is absolutely fascinated by his dance sequences and choreography. She wanted to see him perform live. As I reflect on that, it didn't even cross my mind that Jackson was 50 years old. His changes of appearance were disturbing, saddening, but they had one of the effects he (owner of "Neverland") apparently intended. He did grow up but he became, in a sense, a man without age. Had he kept his original appearance, and become wrinkled and gray, I doubt that the public surprise at his early death would be quite the same.

The span of his career led to my daughter asking questions about his age in various videos, as well as his evolving appearance. The best explanation I had to offer for his surgeries was that I suspected that he didn't like himself. My daughter couldn't understand why somebody wouldn't like himself, and I'm grateful for that. But then, she didn't have Joseph Jackson raising her in an atmosphere of isolation and abuse. What a lovely guy.

Something that's apparent from Jackson's childhood is how readily people will ignore the abuse and mistreatment of children if it jeopardizes the gravy train. Tell me nobody saw Joseph make threats or administer beatings to his children, when they missed a step or a note during their childhood practices and performances.

He touchingly describes his humiliation at having severe acne as a child, and the relentless teasing by his brothers and father, who called him "Big Nose." "You didn't get that ugly nose from my side of the family," says father Joe Jackson, according to Michael. He also describes throwing up at the mere sight of his father who "threw him against a wall" and beat them with "anything that was handy."

Lisa Marie Presley comments on her relationship with Michael:

"I became very ill and emotionally/ spiritually exhausted in my quest to save him from certain self-destructive behavior and from the awful vampires and leeches he would always manage to magnetize around him," she wrote.

It's one of the strange thing people do... we develop coping skills to get us through our childhood, and have a hard time breaking out of those same patterns as adults, even when we have a "choice" and following the childhood pattern is self-destructive. It seems that Jackson was surrounding himself with versions of his father - people who would bleed him dry for their own devices. But as an adult, he could also choose people (or choose to end relationships with people) who wouldn't challenge him to break with the past and enabled his eccentric and self-destructive behaviors. I suspect that his pattern of conduct, relationships and surgeries was supposed to help him be happy, but instead provided at best brief moments of relief from the unhappiness they otherwise perpetuated. And I will not be surprise if, having expressed to Lisa Marie Presley the fear that he would "end up like" Elvis, his death involved a similar soup of pharmaceuticals - a maladaptive tool to escape from (and avoid) pain, physical and psychic, that probably ended up magnifying both.

A childhood only counts for so much. Jackson is responsible for the mistakes he made as an adult that led to his isolation in his final years. But if he's capable, I hope Joseph Jackson spends some time thinking about what he did to his children. That he's somehow able to feel shame, remorse, embarrassment for his role in the unhappiness of, dare I say, more than one of his children?
____________
Update: More on this theme from Eugene Robinson:

Jackson once said his father used to beat him, perhaps because he was the "golden child." Joe Jackson has always denied being physically abusive, but in a sense it doesn't matter. It seems to me that attaching oneself to one's young son like a leech and denying that boy any semblance of a childhood qualifies as abuse.

* * *

The worst choice, of course, was the way he frolicked with children at his Neverland ranch. Jackson was acquitted of child molestation charges, but he also paid a reported eight-figure settlement to the family of one alleged victim. Let me be clear that no childhood trauma would excuse molestation. My question, though, is where were the staff members and the agents and the hangers-on - and the loving family members - who had an inkling that all might not be right at Neverland? Did they choose to look the other way?

I believe Jackson's story that he suffered from the skin disease vitiligo -- though I don't believe that vitiligo or any other infirmity was the reason for the disfiguring plastic surgery that turned his face into a pale, taut mask. It had to be self-hatred - not necessarily an attempt to make himself "white" but to make himself hideous.

I don't think Jackson was trying to make himself hideous - that seems to be the inevitable result of having too many significant cosmetic surgeries. I'm more inclined toward thinking, body dysmorphic disorder.

Perhaps Not The Most Convincing Defense

I saw a video of Anna Nicole Smith in a store with her daughter, shortly before her death, in which she was clearly extremely intoxicated. It was the type of scene that would have been tragic even if she were still alive. So I don't have much sympathy going in, for the argument that those close to her couldn't have or shouldn't have recognized the nature or extent of her drug habit. That doesn't necessarily make them guilty of crimes, but it does make me question their motives and sincerity.

Steve Sadow, one of three attorneys representing [Smith's lawyer and boyfriend, Howard K.] Stern, told reporters outside of court that state Attorney General Jerry Brown's allegations Stern was Smith's "principal enabler" in acquiring the toxic prescription drugs that led to her death two years ago are a "blatant attempt to advance his own political career."

"He is innocent of the baseless allegations made against him in the criminal complaint," Sadow said. "Both Anna and Howard believed in their doctors and relied in good faith on their medical judgment."

So did Elvis¹.

__________

1. According to this article,

In the first eight months of 1977 Presley's physician, Dr. George C. Nichopoulos, wrote 199 prescriptions totaling more than 10,000 doses of sedatives, amphetamines and narcotics - all in Elvis' name.

Sound familiar?

Alternatives to the War on Drugs - The (Uncomfortable) Third Way

CrimProf blog tells us what anybody should already know - the "war on drugs" as presently fought is an extraordinarily costly failure, and the drug situation is not likely to improve unless we focus on demand instead of supply. But it's simplistic to suggest that treatment programs are the key to winning the drug war. Unless you're going to expand the meaning of "treatment" beyond the comfort zone of a lot of Americans.

Drug treatment is remarkably ineffective, not because we don't now have some pretty good programs and models for treating addicts, but because until an addict is ready for sobriety the odds of successful treatment are close to zero. If you're not an addict, this is really hard to grasp. I still can't quite fathom why somebody would spend time in a jail or prison, be completely broken from any physiological addiction to cigarettes, but then light up the moment they get out. It doesn't make sense, but that's addiction at work.

In a "war on drugs" parallel, a couple of years ago I met an addict who was in the process of detoxing from heroin, who described how he had previously spent a full year in a very expensive residential treatment center - about $30,000 per month. He had agreed to drug treatment as part of a one year drug diversion sentence for possession. His dad had picked up the tab to keep him out of jail. He indicated that although he was "clean" for the full year and passed all of his drug tests, he spent the entire year waiting for the moment his year was up. Within an hour of the court appearance at which he was discharged as having "successfully" completed the diversion program, he had a needle in his arm. He was back in treatment because he had been arrested again. My guess is that he's since again relapsed.

Meanwhile in Switzerland, they're experimenting with prescription heroin, administered in a clinical setting for a class of addicts for whom all else has failed. It's a bit jarring, but in fact if you want to reduce the demand for street drugs, sometimes you have to make their equivalent available in a clinical setting. This approach offers some benefits that may not be immediately apparent, including providing the addict with pharmaceutically pure drugs (the poisons and toxins in street drugs can carry serious health consequences), and opening the door to drug education, counseling, and the possibility of treatment. The U.S. has moved uncomfortably into the drug substitution and maintenance model, through methadone clinics, but an addict's participation in that type of program is often a result of desperation - they've reached a point in their addiction where their need for drugs exceeds their supply - and not about recovery.

Like it or not (and I don't), addiction is a part of human nature, and a consequence of human biology. There's not a country in this world that doesn't have a "drug problem", and there never will be. It makes sense to move into a model of a "war on drugs" that involves a sensible use of resources, and as much as possible removes the criminal element from the drug trade while treating addiction as a public health problem. But if the only tools we apply to the problem are "drug treatment" and "cutting off supply", we should not expect the situation to improve.

Tough Words To Say....

Our society makes it really hard to admit, but the excuses? Come on. A judge in disciplinary proceedings for being intoxicated on the bench explains,

during the alleged drunken appearances, he was taking the painkiller Vicodin for back and knee injuries from a car accident; an anti-inflammatory medicine; Ambien for sleep apnea; and medication for diabetes and high blood pressure.

Let's get one thing straight. You don't take Ambien (or any other sleep medication) for sleep apnea. You take it to help you sleep if you are having trouble with a CPAP or BiPAP machine, the actual treatment for sleep apnea. After you take it you go to sleep. You do not take Ambien and then go to work unless you are either intending to go to sleep on the bench or you are an addict.

He admitted that he went on the bench on two occasions after taking Vicodin and consuming alcohol.

On Dec. 6, 2006, he took three or four Vicodins before a 9 a.m. session in Bridgewater, and at lunch that day had two to three glasses of Chardonnay.

When you're gulping down a triple or quadruple dose of Vicodin, with a substantial alcohol chaser, you're either being extremely foolish and reckless in the treatment of your physical pain or you've moved well hinto the territory of addiction.

Sasso said he knew he should not take his daily Vicodin dosage all at once but added that he generally needs a large dose because he is 6'3" and weighs 290 pounds.

More likely, because if you take three or four times your prescribed dose you build up a tolerance. If you are taking prescribed pain relievers and they're not helping, here's what you do: You go back to your doctor and say, "These aren't helping at the dose you prescribed. What do you recommend?"

Similarly, if you find yourself taking Ambien and not falling asleep, you go back to your doctor and say "These aren't helping me sleep. Can we try something else?" If you take Abmien and intentionally stay awake, it's unlikely that you're taking it for any purpose other than its intoxicating effects (which, as Patrick Kennedy (and the officer who investigated his accident) can tell you, are a lot like alcohol intoxication).

Let's draw a line here between addiction and dependence. If you take certain medications for a long enough period of time, including opiates, you develop a physical dependence on those medications. You may also develop a tolerance that requires an adjustment of your dose or a change of medication, and may be dependent to the point that you will suffer withdrawal if you suddenly stop taking your medications. That's not addiction. Where you transition from dependence to addiction is when your medications stop improving your ability to lead a normal life, and your focus shifts to clock-watching or drug-seeking. There's also a syndrome called pseudoaddiction, where somebody who is receiving inadequate pain relief may demonstrate obsessive or drug-seeking behaviors that resemble those of an addict, but those symptoms resolve when their pain is adequately treated. But if you're buying shoeboxes of drugs from your maid (in addition to taking the drugs you get from your doctor), or gulping down huge doses of opiate medication with alcohol, it's safe to assume that you're an addict.

The AA/NA model for addiction dictates that the very first step in recovery is admitting your powerlessness over your drug of choice. I'm fortunate enough not to have a history of addiction, but I can say this: When the Rush Limbaughs, Patrick Kennedys, and even lesser known people like Judge Sasso avoid making that direct, honest concession - when they insist that their addictions are somehow more elevated because they claim to have physical pain, or are somehow more pure because they're abusing prescription pharmaceuticals - they're lying to themselves and to anybody who listens to them.

It would be really nice to hear one of these high profile addicts discard all of the excuses and finger pointing and simply admit, even if prefaced with an explanation of how they became addicted, "I did it because I am an addict." (e.g., "Although I didn't seek out this disease, and had no experience with addiction before I received opiate medication for a back injury, I stole drugs from my charity because I am an addict.")

Addendum: To be clear, I believe that if high profile addicts are honest about their addiction, they will help diminish the stigma of addiction. While we sometimes pretend otherwise, addiction strikes at all levels of our society and, while the rich and powerful are often better able to cover for their addiction or avoid street drugs, nobody is immune.

A Moment of Honesty

It's nice to see a politician speak with a bit of candor about his struggles with addiction. And given the number of addicts on Capitol Hill, all too rare.

Perhaps eventually, one will do the same about recovery.

Smoking II

News about nicotine addiction:

Researchers say they have identified brain cell receptors that appear to be responsible for nicotine addiction, a finding of clear importance for smokers who are desperately trying to kick the habit.

The receptors normally are activated by acetylcholine, a molecule that carries signals between nerve cells and has multiple functions in the body. A large number of acetylcholine receptors have been identified, each with subunits adapted for a specific function. Twelve of those receptors also are activated by nicotine.

Smoking

It has long been said that cigarettes are addictive in the same way as heroin (sometimes misunderstood as cigarettes being as addictive as heroin, which they aren't) - and now, following up on similar results from animal studies, UM researchers help explain why:

It's the first time smoking has been shown to affect the human brain's natural system of chemicals called endogenous opioids, which are known to play a role in quelling painful sensations, heightening positive emotions, and creating a sense of reward. It's the same system that is stimulated by heroin and morphine.

* * *

"It appears that smokers have an altered opioid flow all the time, when compared with non-smokers, and that smoking a cigarette further alters that flow by 20 to 30 percent in regions of the brain important to emotions and craving," says David J. Scott, a graduate student in the U-M Neuroscience Program who will present the results.

Addiction As A Public Health Problem

To one who has long argued that addiction should be viewed as a public health issue, and that we should remove the impediments to researching treatments and medications for addiction, this sounds like progress.