To discover the right answer, one must first ask the right question.
I recently watched a Ted Talk where the infamous investigative journalist Johann Hari shared his research into drug and alcohol addiction, along with his own personal history of substance use and his journey to recovery. The Ted Talk, titled “Everything you think you know about addiction is wrong”, can be found here. Also found in his book Chasing the Scream, Mr. Hari makes the bold claim that “the opposite of addiction isn’t sobriety; the opposite of addiction is connection”. What an interesting statement! After watching the standing ovation in the Ted Talk, and then, after hearing one of my instructors in a recent recovery coach training class repeat this bold claim, I’ve spent quite a lot of time considering this through the filter of my own long-term recovery. Is it true? Can it really be this simple? Take an addict and immerse them in an expansive, loving community of supporters such that they can’t help but feel connected in deep and authentic ways, and their addiction will slowly but surely subside and they’ll decreasingly look to artificial mechanisms to fill whatever gap drove them to start using in the first place. Hmmm… there are myriad different ways you could rewrite that to establish ‘connection’ as the thing that was missing to begin with, and that re-establishing connection would trigger and sustain a full recovery. I think at a minimum this is worthy of further discussion and, most likely when seen through the filter of broader experience, may emerge as an incomplete thesis.
Volumes have already been written about addiction, sobriety, drugs, substance use disorders, recovery, relapse, recovery capital, etc., and it’s easy to argue we’re debating the semantics of words when we already agree materially with the facts. I don’t agree that we’re all on the same page when it comes to addiction and recovery, and how best to approach our failed war on drugs and against drug users – the statistics reveal we’re losing the war and failing our addicted loved ones.
Everything you think you know about addiction is wrong
Let’s start with the title of the Ted Talk; of course, this title was designed to grab attention and immediately call into question why, after decades of our best thinking, investments, and efforts, we’ve not been more successful at preventing addiction or helping addicts overcome their illness once entrenched. Despite what addiction researchers and academics portray as progress and success, the unfortunate truth is that we’ve not really changed much for the better – production is increasing, trafficking and distribution are increasing, the ebb-and-flow of supply/demand dynamics remain (from natural substances to semi-synthetics to pure synthetics), substance use and abuse is increasing, dependence and addiction is increasing, and drug-related death rates continue to rise. A 2018 study by Our World in Data supports the above statements[i], as does the 2020 World Drug Report from UNODC (the United Nations Office on Drugs and Crime)[ii]. The Drug Policy Alliance released research in 2017 concluding the following (data sourced from NIDA and the CDC)[iii]:
- Accidental drug overdose is currently the leading cause of death in the United States for those under 50.
- Drug overdose deaths now exceed those attributable to firearms, car accidents, homicides, or HIV/AIDS.
- More Americans died from a drug overdose in 2017 alone than died in the entire Vietnam War.
Most telling is the 2018 UNODC finding that “direct deaths from drug use, other than alcohol, have increased over 60 percent from 2000 to 2015.[iv]” That’s a less than encouraging result.
Despite spending hundreds of billions of dollars over the past decades since Richard Nixon started the modern drug war, we still treat addicts like criminals instead of like sick people with a treatable illness, we vilify the drugs themselves (i.e., eradicate heroin and we won’t have heroin addicts) and, when we do treat an addict like a sick person, we treat the illness like a broken arm instead of a chronic disease[v] [vi] [vii].
It’s not a stretch to say most people know someone struggling with addiction, whether a member of one’s immediate family, coworker, or friend; it’s because addiction remains such an intractable problem, with deadly consequences, that ordinary people listening to a Ted Talk respond so strongly to a new and hope-inspiring approach. Does all of this mean we don’t understand addiction, what causes it, and how to help a suffering addict get better? Definitely not, and contrary to Mr. Hari’s claim that everything we think we know about addiction is wrong, we’ve made great progress in understanding the psycho-social, environmental, and physiological influences which cause and perpetuate addiction. Let’s explore this more closely through the lens of “the opposite of addiction is connection”.
The Opposite of Addiction is Connection
The concern this triggers for me is that because the idea sounds good and is new(er) and different from myriad existing and better-known solutions, people will treat it like the latest miracle (fad) diet and push the addict down yet another road of disappointment and disillusionment. Worse, when “connection” fails to deliver the expected results, once again the addict will be blamed and shamed, well-meaning supporters will distance themselves in the name of tough love, and the already suffering addict will sink deeper into hopelessness and despair. Again, I’m remembering the response Mr. Hari received at the end of his Ted Talk; the audience’s enthusiastic vocal and standing ovations struck me as OMG FINALLY A SOLUTION THAT MAKES SENSE! My response was one of great caution and concern.
If connection isn’t the thing, then what is? As stated above, we’ve made great progress understanding the nature and subtleties of addiction, from primary and secondary risk factors, to changes in brain structure and function (neuroplasticity and biochemistry), to the 5-phase transtheoretical model currently used as a basic roadmap to recovery (precontemplation, contemplation, preparation, action, and maintenance) gauging the addict’s willingness and readiness to change. While deeper examination of these influences is beyond the scope of this post, the critical point is that “like other complex illnesses and disorders, addiction is multifactorial, resulting from a combination of genetic, social, psychological, and environmental forces” (Kelly, 2020[viii]). Not only are the risk factors multifactorial, so are the protection factors, and so too are the various aspects and dimensions of recovery. Thinking about my own recovery along with the privilege I’ve had helping and observing others achieve and enjoy recovery, I can honestly say that moving from the “pitiful and incomprehensible demoralization[ix]” of bottomed-out addiction is akin to untangling the veritable Gordian knot – there’s no shortcut, and “connection” is not a magic pair of scissors that easily cuts the knot. The opposite of addiction isn’t connection; the opposite of addiction is recovery, leading to full self-directed wellbeing.
Your Grandmother’s Not a Junkie
Another concern I have with the development of Mr. Hari’s thesis is his use of anecdotes presented as foundations for facts. Anecdotes are not facts and, one of the examples he uses to support his thesis is the number of people who take opioid-based pain medications for an extended amount of time and then stop suddenly without withdrawal, dependency, or concern with being addicted. He uses, specifically, the example of one’s grandmother falling and breaking her hip, being on opioid-based pain medications for pain management, then being able to stop abruptly without having become a junkie. While there may be people who fit this example, there are many more who disprove this finding as demonstrated by the two words “opioid epidemic”.
Hundreds of thousands of people have died from opioid misuse since Purdue Pharma first introduced OxyContin to the market in 1996. And many more died from opiate (e.g., morphine, heroin) and opioid (e.g., Fentanyl) overdose prior to and since this unfortunate new twist in availability and use. A highly effective pain medication, OxyContin is the timed-release brand name version of the semi-synthetic oxycodone, which has the unfortunate side effect of extreme high risk for dependence and addiction. Close to 450,000 people died from opioid overdose between 1999-2018[x], not because they lacked connection or because no one was singing them love songs as Mr. Hari postulates, but specifically because of the chemical hooks Mr. Hari attempts to disprove anecdotally or by citing Bruce Alexander’s Rat Park Experiment. Brain hijacking is a real thing; we understand the structural changes brought about by repeated substance use (neuroplastic habituation), and also the functional (biochemical) changes resulting from repeated abuse of the reward pathway.
You don’t have to die to fall victim to this public health crisis. An unfortunate number of people have legally used opioids for legitimate pain management, only later to find themselves battling a severe dependence coupled with horrific withdrawal symptoms. Dr. Travis Rieder, PhD, Assistant Director for Education Initiatives, Director of the Master of Bioethics degree program and Research Scholar at the Berman Institute of Bioethics at John Hopkins University, learned this the hard way. Dr. Rieder shares his story in a Psychology Today article titled “America’s Other Opioid Problem” (August 2019). In the story, Dr. Rieder shares his gruesome tale of using opioids to alleviate unbearable pain, only then to find himself with “the worst flu you can imagine, multiplied by about a thousand” as he tried to taper off the drugs. He then writes that this terrible experience was minor compared to what followed and describes a whole new level of unimaginable misery. Then, he says, it got worse! Dr. Rieder’s article is well worth the read just for the dependence/withdrawal information, but also for the clear and useful distinction he draws between dependence and addiction. More, he shares his experience navigating a health care system ill prepared to deal with people like him – dependent but not addicted – concluding “Medicine is failing to solve the problem of dependence.”
Our Trillion Dollar War on Drugs
An unfortunate and attendant harm caused by our lack of readiness to help a person who becomes dependent upon or addicted to opioid-based pain medicine, is the lateral move to other opioids (or other drugs) once their prescriptions are reduced or removed; get a person hooked, then take away their medicine without a solution for their dependence/addiction, and either they suffer horrendous miseries, or they turn to illicit solutions to maintain their new reality of being hooked. Hooked – what an interesting word – I remember hearing “don’t get hooked on drugs” all the way back in the 60s and 70s. Now that we better understand the neurobiology of addiction, the word actually makes sense as a descriptor for the hijacking of the brain through its biochemistry. There are many excellent articles describing this; one of the best is from a News in Health article in 2015 titled Biology of Addiction: Drugs and Alcohol Can Hijack Your Brain[xi].
I cite the above attendant harm specifically as an unintended consequence of the drug war to make two points: first, “normal” people can become dependent upon or addicted to drugs – addiction is not confined to weak-willed and morally bankrupt junkies with poor character as is sometimes portrayed, and second, not only is the war on drugs not delivering the expected and desired results, but it’s also making the problem worse. Statistics published by the Centers for Disease Control and Prevention in 2020 (Understanding the Epidemic[xii]) track trends in deaths from opioids in three distinct waves – 1) deaths from prescription drugs attributable to the OxyContin disaster between 1999-2009, 2) rapid increases in overdose deaths involving heroin starting in 2010, and 3) significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl starting in 2013. The absence of decriminalization as a component of our drug policy has maintained manufacture and distribution as an underground criminal enterprise, and the drug war has put pressure on traditional heroin manufacture, giving rise to synthetics as substitutes. As the synthetics are less expensive to manufacture but also orders of magnitude more potent than heroin, they’re increasingly finding their way into street drugs (e.g., heroin, cocaine, meth, and MDMA laced with fentanyl). This fact is largely responsible for the recent dramatic rise in overdose deaths; according to NIDA[xiii], 59.8 percent of opioid-related deaths in 2017 involved fentanyl compared to 14.3 percent in 2010. It’s nearly impossible for a person to know what they’re buying from a street dealer, and the potential harms (including death) can be tragic.
Betsy Pearl writing for the Center for American Progress provides statistics[xiv] indicating we’ve spent an estimated $1 Trillion on this problem since President Nixon declared war on drugs in 1971. There are few, if any, statistics demonstrating anything like real progress from this war, although there are bright spots. The benefits of decriminalization and harm reduction are increasingly being embraced and implemented, and addiction is finally being seen as a chronic, treatable illness. Treating addicts as sick people instead of like criminals is a huge step forward, and I’m OK wrapping them with connection and singing them love songs as Mr. Hari proposes, as long as the result is recovery.
[i] Hannah Ritchie (2018) – “Opioids, cocaine, cannabis and illicit drugs”. Published online at OurWorldInData.org. Retrieved from: ‘https://ourworldindata.org/illicit-drug-use’ [Online Resource]
[ii] World Drug Report 2020 (United Nations publication, Sales No. E.20.XI.6).
https://wdr.unodc.org/wdr2020/en/exsum.html
[iii] Drug Policy Alliance (2017) – Drug Overdose. https://drugpolicy.org/issues/drug-overdose
[iv] World Drug Report (2018). Prelaunch: https://www.unodc.org/wdr2018/prelaunch/
[v] Dennis, M., & Scott, C. K. (2007). Managing addiction as a chronic condition. Addiction science & clinical practice, 4(1), 45–55. https://doi.org/10.1151/ascp074145
[vi] Saitz, R., Larson, M. J., Labelle, C., Richardson, J., & Samet, J. H. (2008). The case for chronic disease management for addiction. Journal of addiction medicine, 2(2), 55–65. https://doi.org/10.1097/ADM.0b013e318166af74
[vii] NIDA. (2005, June 1). Drug Abuse and Addiction: One of America’s Most Challenging Public Health Problems. Retrieved from https://archives.drugabuse.gov/publications/drug-abuse-addiction-one-americas-most-challenging-public-health-problems on 2021, February 20
[viii] Kelly, John F. (2020) Psychology Today. Recovery from Addiction. https://www.psychologytoday.com/us/articles/201912/recovery-addiction
[ix] Big Book of Alcoholics Anonymous, Chapter 3, More About Alcoholism, Page 30.
[x] Centers for Disease Control and Prevention (2020). Understanding the Epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html
[xi] News in Health (2015). National Institutes of Health, part of the U.S. Department of Health and Human Services. Biology of Addiction: Drugs and Alcohol Can Hijack Your Brain. https://newsinhealth.nih.gov/2015/10/biology-addiction
[xii] Centers for Disease Control and Prevention (2020). Opioid Basics. Understanding the Epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html
[xiii] NIDA. 2019, February 28. Fentanyl Drug Facts. https://www.drugabuse.gov/publications/drugfacts/fentanyl
[xiv] Pearl, Betsy (2018). Center for American Progress. Ending the War on Drugs: By the Numbers. https://www.americanprogress.org/issues/criminal-justice/reports/2018/06/27/452819/ending-war-drugs-numbers/