Addiction as a Social Disease

We don’t deal readily with social factors and social class in America – it seems to violate our sense of democratic fairness to think about these things. But nowhere is social class more evident than in addiction and recovery – as it is in all areas of health.

Take our two most common legal drugs – cigarettes and alcohol. Given the steadily rising prices of tobacco, you’d think that only the rich could afford it, right? In fact, smoking is a downscale social activity.For example, 12 percent of college grads smoked in the last month, compared with 34 percent of those without a high school diploma and 29 percent who graduated HS but didn’t go to college.

Drinking is more complicated. We know that well-off people use recreational drugs as much as poorer ones. In the case of drinking, better-educated, well-off people drink more often than poorer, less well-educated Americans. Thus about 70 percent of college grads drink alcohol, while only 35 percent of those lacking a HS diploma do.

How do we explain these data? Before you say, “people at the lower end of the social scale don’t have enough money for alcohol,” keep in mind that they more often smoke cigarettes, which have become high-price items. Could it be that moderate drinking is a generally benign or healthy behavior, while smoking is not, that leads better-off people to drink but not to smoke?

Here is one more data point. Although higher socioeconomic status (SES) people drink more often, they binge drink on many fewer of the occasions when they do drink. Thus 23 percent of those without a HS diploma binge drink, compared with 22 percent of college grads. Seven percent of the former are heavy drinkers, while 6 percent of the latter are. These are percentages for the whole group. If we divide binge drinkers or heavy drinkers by the percentages of drinkers for each group, we find that 19 percent of drinkers without a HS diploma are heavy drinkers, compared with 9 percent of college grads.

These are significant differences in favor of better-off, higher SES people’s chemical health (to borrow Bob Muscala’s term). Now, what about drugs? Don’t we always hear that heroin is spreading to the middle class, that addiction to heroin, meth, etc. is an equal opportunity destroyer? Because illicit drug use is less common than drinking and smoking, we can’t find these answers directly in government surveys that incorporate demographic variables.

Instead, we have to go to the grass-roots level to understand the issue. Consider this description in the New York Times of the poorest county in West Virginia: “A half-century later, with the poverty rate again on the rise, hardship seems merely to have taken on a new face in McDowell County. . . .Towns are hollowed out as people flee, and communities are scarred by family dissolution, prescription drug abuse and a high rate of imprisonment.” The article describes family after family ravaged by abuse of painkillers (along with meth).

Do you think that there are similar rates of drug addiction in Appalachia and inner-city ghettos, on the one hand, and in the prosperous suburbs and well-off urban enclaves – think of the Upper East Side of New York or Park Slope, in Brooklyn (where I live)? Or what about in prosperous college communities?

We might like to think drug addiction is spread evenly among these areas. And we might be led to this belief by regular news stories of the ravaging heroin epidemic that supposedly strikes everyone equally. But it’s simply not true. There is nothing like the hopelessness in these prosperous places that so often leads to persistent, aggravated drug abuse in poor places. Thus, when we see news stories about the heroin epidemic in Maine, Vermont, and elsewhere, we most often end up with scenes in the poorest parts of these regions.

Of course, humans being human, there are some in the “best” neighborhoods who end up hooked on drugs. But, even when higher SES people do engage in high-risk, addicted drug use, the most important thing to consider is how likely they are to escape this addiction.

Consider data often thought to show that heroin addiction was irremediable that was based on heroin addicts treated at the Public Health Hospital in Lexington, KY. Research showed that 90 percent of those leaving the hospital relapsed to addiction back on New York and other inner-city streets in the 1950s and 1960s.

But famed addiction psychologist Charles Winick studied a smaller group of patients at Lexington – physician narcotics addicts who took advantage of their ready access to prescription meds and who were discovered by federal authorities and sent to Lexington. In an uncanny, almost exact mirror version of the inner-city addicts’ experiences, Winick found 90 percent of these well-heeled doctors stayed clear of drugs on their release.

Why might you imagine doctors were better at giving narcotics up? The answers Winick considered are obvious – doctors have more to lose if they don’t quit their drug addictions, and more resources (like therapy or alternative activities) to assist them in doing so.

Why would we doubt this common sense explanation? Because we are told that drugs strike and destroy all equally who fall within their paths. But they don’t. Like so many other areas of our lives and health, better-off people have more to prevent their becoming compulsively involved with drugs in the first place, and to get them away from drugs should they become addicted.

Even those we hear about in stories of the children of the privileged who develop serious drug problems – David Sheff’s beautiful boy, Bill Moyers’ son William Cope Moyers, Peter Lawford’s son Christopher Lawford, Bill de Blasio’s daughter Chiara – usually peer out at us from the other side of drug abuse/addiction, telling us how to achieve recovery like they did.

Consider an NBC Nightly News feature (April 7th) on Vermont’s heroin crisis. “Hooked, America’s Heroin Epidemic.” The NBC segment featured a young heroin addict who was the son of two doctors who themselves treat drug abusers! Isn’t this proof of the non-discriminating nature of drug addiction?

Of course, the young man featured on the NBC segment has been off of heroin for a year – the criterion for long-term remission in the psychiatric diagnostic manual, DSM-5. Most important, he is still very young. Young people are more likely – for a variety of reasons – to engage in risky behaviors and in particular to abuse substances, including alcohol. But the well-off pass this period by and don’t look back. Keep Chiara de Blasio in mind, daughter of mayor Bill, who proudly entered recovery at age 19.

Did her father’s and mother’s prosperity and education and her own bright future assist Chiara’s recovery? Dial back to the young man in the NBC segment, who appeared happy and well-adjusted. Would he have succeeded so readily in licking heroin (or Oxy or meth) if he were living in a trailer in Appalachia? Do the concern of his parents, his stable home, the potential he has to go on to be a successful professional – perhaps a doctor – himself impact his recovery?

Of course these are critical factors – THE critical factors – in remission. This conclusion is simple common sense, based on everyone’s experiences and observations of life. And realizing this truth – that people’s personal resources, support systems, and future opportunities, taken together, predict remission from drug addiction – leads to the best treatment, and the best policy.

Thus in my books – like Recover! Stop Thinking Like an Addict and Reclaim Your Life with The PERFECT Program and in treatment programs like my Life Process Program – the thrust is towards greater self-realization, coping skills, relationship formation, life success, and personal contentment. In terms of public policy, we’ll never eliminate drug addiction without addressing basic problems in people’s lives and social inequities in America.

Let’s return to the Times article on Appalachia. Its point is that poverty and social failure go hand in hand with addiction and have never been eliminated in the region:

When people visit with friends and neighbors in southern West Virginia, where paved roads give way to dirt before winding steeply up wooded hollows, the talk is often of lives that never got off the ground.

“How’s John boy?” Sabrina Shrader, 30, a former neighbor, asked Marie Bolden one cold winter day at what Ms. Bolden calls her “little shanty by the tracks.”

“He had another seizure the other night,” Ms. Bolden, 50, said of her son, John McCall, a former classmate of Ms. Shrader’s. John got caught up in the dark undertow of drugs that defines life for so many here in McDowell County, almost died of an overdose in 2007, and now lives on disability payments.

As the article notes, fifty years after Lyndon Johnson declared his War on Poverty, little has changed here. And if little changes in the social fabric of McDowell and other counties and urban neighborhoods, then little will change in the frequency of addiction, its irremediable nature, and the periodic scares that result when we become conscious of what is going on beneath our noses all the time.

By Stanton Peele for The Fix