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.