This week begins a 3-week series of posts about addiction, the driver of which will be made relatively clear in the third week. The series starts this week with a brief discussion of addiction models, and how empirical evidence and recent scientific study suggests that those models have been misrepresented or misunderstood by the masses and experts alike. In short, I’m going to totally defend my heroin habit. Just kidding! That’s next week’s post.
Before we begin, we should discuss what characterizes “addiction.” The layperson would probably describe addiction in terms of physical dependence — if a user stops using something and experiences withdrawal symptoms, they are physically dependent. Alternatively, a compulsion — a total lack of control, indicating a psychological dependence — in relation to a substance or activity would indicate an addiction; the inability to not smoke for 24 hours, or even anxiety at such a possibility. (Interestingly, the time limit seems to matter — if I told most readers they’d be unable to drink for an entire year, they’d probably experience some anxiety, though this wouldn’t be construed as addictive behavior by most people, whereas anxiety at the thought of a day or maybe even a week alcohol-free would.) The standard definition goes a bit beyond this and mentions that it is the persistent nature of these behaviors despite adverse consequences that characterizes the addiction (you can be addicted to sniffing glue, but you can’t be addicted to breathing), but the idea is generally there: physical or psychological dependence on something despite negative consequences.
In any event, we’ll start with the model that was presented to my generation in grade school. It went something like this: “If you take any addictive substance even one time, you will be hooked for life, and you will die.” This model bred some of the absolute greatest anti-drug PSAs of all time, including my personal favorite:
Now, before you call me out on this (too late?), this PSA doesn’t really discuss addiction in any way, but it does give you the “just one hit can kill you” message in spectacular fashion, and you’ll notice the ad presents his friend in the addict role — someone who justifies his habit as harmless in the face of reasonable protest, who presumably started out with a very similar “just one hit.” Jesus people, do I have to walk you through everything? It’s called subtext — heard of it?
Also, if you look closely you can see that the kid who ultimately blows his head off was clearly already high as a kite at the beginning of the PSA. I don’t know what that’s supposed to signify other than “we only had enough budget to do his makeup once.” Also, who smokes weed in their dad’s office?
In any event, everyone knows this model is totally bogus — who amongst us hasn’t had, like, a single drink and then stopped drinking? Who doesn’t know someone who smokes cigarettes or cigars sometimes on the weekend? Who amongst us doesn’t know someone (living on Colorado, obviously) who used to smoke those jazz cigarettes from time to time in college? And for the most part, most of us don’t really know a bunch of alcoholics or chain smokers or reefer madmen. People continue to function even in the context of occasional use of highly addictive substances, but we simplify the message to children because it’s hard for them to understand the concept of a gradual slide into oblivion, so we say “just once is enough to get you hooked,” and we let them figure it out as they get older.
Of course, my statement above completely ignores the common knowledge that some drugs are more addictive or dangerous than others. Science has classified drugs as more or less addictive, and even put together this sweet chart about how likely you are to keep doing them for the rest of your life and how short you can expect that life to be (more addictive, more dangerous substances show up on the top right, less addictive, less dangerous on the bottom left; the X-axis describes how much it takes to have the intended effect (a “dose”) vs. the amount it would take to kill the average person — basically, how likely you are to accidentally overdose to death, hence danger):
Everyone knows heroin is basically the most addictive substance on earth, so one … dose? hit? smack? (I’m not down with the hard drug lingo) of that and you’re hooked for life. Then again, if you look at the chart you’ll notice that, while heroin is indeed the only drug listed at “very high” (hahahahahaha lolz) in its dependence potential, nicotine is one level down in “high,” along with morphine. So maybe cigarettes aren’t that safe?
Or maybe the idea that anything can get you hooked in one shot is totally bogus. I won’t go into too much detail about heroin in particular, but even in the case of the single most addictive drug on the addictive drug chart, it seems like the slide into addiction tends to be something more along the lines of a long, slow slide rather than a single instance ruining the rest of someone’s life. It goes beyond that, though; there’s also the feeling that long, slow slide is inevitable; maybe you can quit after your first time, and some users do, but maybe it’s your second, or your third, or your tenth that really gets you; maybe it’s when you’ve been using twice a month for a year. At some point, you’re well-and-truly hooked, right?
At this point, it’s relevant for us to bring up the (adult) models of addiction; in particular, the medical model and the psychodynamic model (although the moral model’s assertion that “Drugs are evil” certainly deserves some commentary).
The medical model is what most people think of when they think of addiction — it’s a disease; it’s not the user’s fault, their brains have been changed and they have a physical dependence on the drug to function normally. The psychodynamic model is probably what addicts subscribe to right when they start using: the drug is a form of self-medication in reaction to an outside stimulus; when that stimulus resolves, the drug use will be unnecessary, and the user will stop. The bio-psycho-social model (which basically says “Yeah, all of it’s true, more or less”) would argue that both of these are contributors to addiction, and I think most people would agree with that; after all, how many movies or TV shows show someone getting laid off or divorced (outside stimulus) and hitting the bottle (self-medication), only to do the long, slow slide into a physical and psychological dependence (disease)? Isn’t that how it works?
I think that in many people, it is — I absolutely do not mean to demean people for whom their addiction is a disease by what I’m about to say (although I’m sure I will anyway). But I think that the disease model is a convenient thing for users to hide behind; “It’s not my fault, it’s a disease! I can’t help it,” is an easy out for a lot of people, and anyone saying otherwise “just doesn’t understand the disease;” denying the medical model sometimes seems like it gets you the bad rep of denying the holocaust at times. I also don’t mean to say that the disease model doesn’t provide a framework — and perhaps even a good one — to address these issues; putting the blame entirely on the individual could be counterproductive in any number of ways, and this model provides cover and context for those who legitimately need help while allaying social stigmas that might cause vicious circles.
But let’s address a key tenet in our collective understanding here: that the actions of psychodynamic model necessarily lead to the case described by the medical model. This theory seems to be pervasive, but it doesn’t always seem to pan out in real life — and the model’s pervasiveness may be detrimental to the addicted population as a whole. It is unpopular, for instance, to espouse the idea that addicts can be rational actors (i.e., that it’s not a disease beyond their control), in the face of fairly significant evidence. That last article is actually a NYT article citing a Columbia University study (Columbia — heard of it?) that suggests that crack addicts (crack — heard of it?) display rational behavior.
(For those who did not read it, which I encourage you to do, the study went like this: every day a nurse would give a crack addict a varying amount of delicious crack, and said addict would be given the opportunity to have money added to a fund for their use at the end of the study or more of the same amount of crack. What the study found was that the more money offered, the less likely addicts were to choose the crack, and the smaller the dose, the more likely they were to choose the money. The addicts were valuing the crack — even if they were going to ultimately spend the money on crack, if they thought they could get more crack later from the money they were given, they would choose that option. This flies in the face of the definition above, which states an uncontrollable impulse; the addicts in the study were clearly in control of their impulses.)
The article is interesting to me for two reasons; first, the paper explicitly mentions that “Eighty to 90* percent of people who use crack and methamphetamine don’t get addicted” (Carl Hart, study author) — completely refuting that “one time is all it takes” model. Of course, we already established that that was bogus, so the second point is more interesting: even in the case of the 10-20% of people who are addicted, Dr. Hart basically espouses the psychodynamic model, that people are using the drugs as a form of self-medication, and that the medical model doesn’t seem to hold, given their rational decisions:
“If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure,” Dr. Hart said in an interview, arguing that the caricature of enslaved crack addicts comes from a misinterpretation of the famous rat experiments. [Referencing studies suggesting that rats will self-dose well beyond the point of detrimental effects when given the chance.]
“The key factor is the environment, whether you’re talking about humans or rats,” Dr. Hart said. “The rats that keep pressing the lever for cocaine are the ones who are stressed out because they’ve been raised in solitary conditions and have no other options. But when you enrich their environment, and give them access to sweets and let them play with other rats, they stop pressing the lever.” [Referencing this study, which itself is a refutal of previously-mentioned famous rat studies.]
This was particularly interesting to me because it struck a chord with another story I had heard on one of my favorite podcasts, about the fear that American soldiers in Vietnam were abusing heroin and would return home with crippling heroin addictions. And while heroin use among troops in Vietnam was high, what they found was that even habitual users quit using when they returned home — the elimination of the underlying stimulus for using the drug (in this case, the Vietnam War — heard of it?) eliminated the need for the drug, again lending empirical evidence in a large population to the psychodynamic model:
This just goes to say that there is still a lot of work to be done in understanding the underlying causes of, and treatments for, addiction. That NYT article quotes Dr. Hart as saying, “Eighty to 90* percent of people are not negatively affected by drugs, but in the scientific literature nearly 100 percent of the reports are negative,” a point which belies the closed-mindedness about drug use and the addiction model in general. Popular acceptance of the medical model may actually do more harm than good. Bringing someone out of a toxic environment, getting them clean, and teaching them about how their disease makes them an irrational crack-fiend, then releasing them back into their toxic environment probably isn’t a the best recipe for treatment; neither is excusing people’s behavior as beyond their control. Rather, treating addicts as rational actors and clarifying the costs and the benefits of their behaviors may be a more suitable path for treatment; by pointing out the negative internalities and externalities of their behavior, those 10-20% of users who are negatively affected may see the math shift out of favor of their behavior.
But the point here goes way beyond this strategy — rather than pointing out that the math is already against them, why not change the equation altogether? The primary benefit of drug use is an escape from some external stimulus: poor conditions, squalor, lack of education or opportunity, and social inequality. Eliminate those stimuli, and the benefit of the drug is similarly eliminated, just as it was for the soldiers returning from Vietnam. In short, the drug epidemic, and perhaps certain cases of all addictions, is a symptom, not a cause, of underlying problems. Treating the causes rather than the symptoms could go a long way to eliminating the addictions altogether.
* It’s super weird to me that they say “Eight to 90” rather than “Eighty to ninety” or “80 to 90.” Anyone else?
I’m very excited to see the rest of this addiction series, especially the much-hyped third installment: Motivation.
“Rather, treating addicts as rational actors and clarifying the costs and the benefits of their behaviors may be a more suitable path for treatment; by pointing out the negative internalities and externalities of their behavior, those 10-20% of users who are negatively affected may see the math shift out of favor of their behavior.”
I believe this is the idea behind interventions, where people the addict on paper “loves” is sat down and those people explain how their addiction has these costs.
For you concluding sentence, what if the underlying causes are as (or more so) poorly understood as “addiction”? What if depression as we know it becomes (is?) the leading cause of drug addiction. What are the proven treatments for depression? More drugs? I guess an enriched life, but that’s probably much harder to come by and expensive to maintain than a Vicodin dependency. Plus I imagine the chemical imbalances that cause depression would treat an enriched life the same way as a drug. Sure, it’s great now that I have a spouse, but now I need to “up the dosage” on an enriched life so I can get a new high, otherwise ennui as any stage of enrichment may pull one back into addiction.
One of the super fascinating things to me about addiction (which I may or may not touch on in my post this weekend) is that if you look at certain populations, you sort of expect to see certain things — in lower-income, predominantly minority neighborhoods, you might expect to see rampant crack problems, for example (or heroin use among soldiers in Vietnam, etc.), whereas you expect the adults in middle-class suburban neighborhoods to be squeaky clean. But there’s also these huge problems where you wouldn’t expect to find them — housewives abusing Valium and middle-to-upper class suburbanites using heroin (typically because they got hooked on painkillers after surgery, or similar circumstances). And from one standpoint you can look at that and say, “That’s crazy, these people are living full, meaningful lives and they’re not being held back by The Man” or whatever, so they’re probably not using it as a temporary escape, as per Dr. Hart’s suggestion above.
But I think you can maybe make the argument that they are — not in all cases (clinical depression is a Thing, I am told, and is caused by medical mumbo-jumbo), but to some extent I think most people aren’t happy, and in the case of the housewife-valium epidemic, you can kind of identify with how that might help the soul-crushing realization that your best years are behind you, your kids have just gotten old enough to hate you, your husband is boring / controlling / whatever you didn’t realize 20 years ago when you married him, and you’ve been doing the same damn thing day in and day out for more than half your life. It’s not systemic societal oppression… but it’s not exactly a sunny day in paradise.
Now, what I was trying to get at with the concluding sentence (I did a poor job of conflating drug use with addiction, when addiction has a bunch of other stuff going on…), which is what I think Dr. Hart is getting at, is that specifically in the case of the war on drugs (which disproportionately affects lower-income minorities), the resources spent there would be better spent addressing the underlying societal ills (which admittedly are poorly understood) than addressing the symptoms thereof. I don’t know that that really applies beyond that case — obviously it’d be better if people didn’t come to said soul-crushing realization — maybe you could argue that the rules we’ve established as a society (monogamy, gender roles, whatever) are an underlying cause that needs to be addressed. Or maybe people just won’t ever be happy.
Or maybe there’s more to addiction — maybe the 10-20% who are negatively affected actually fall into this category, and there’s something else going on. I think the psychodynamic model completely neglects the psychological dependency portion, which is very real, beyond the immediate situation. The case studies I cited above make it sound like, for examples, those soldiers just stop using heroin and maybe they go through withdrawal or whatever but then that’s it, they just stop using — and I actually don’t doubt that that happened in a number of cases. But I think in the 10-20% case, the psychological dependency is the key factor; the constant craving, etc. that dominates the true addict. This is the reason recovering alcoholics are always “recovering alcoholics” not “former alcoholics,” and it’s just completely left out of Dr. Hart’s argument. I think the best thing to take away from this is probably something along the lines of “the current model of addiction over-predicts the degree to which the addictive nature of drugs poses a threat to users, and we should examine the degree to which perceived addiction can be eliminated through resolving underlying issues driving the addiction rather than eliminating the addictive behavior itself.”
tl,dr: Your explosion of the thesis beyond the “obvious” case in the quoted study is an interesting one, which I think bears further study and raises a few additional questions.