The Surgeon Generals Addiction Report Repeats Old Bromides—Here’s What He Ought to Be Telling Us
Our policies and public proclamations around addiction resemble a slow-motion, inevitable car crash.
On November 17 a summit was convened in Los Angeles at which US Surgeon General Vivek Murthy sounded the latest alarm on addiction: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.
“Addressing the addiction crisis in America will require seeing addiction as a chronic illness, not as a moral failing,” said Murthy (pictured above). “Addiction has been a challenge for a long time, but we finally have the opportunity and the tools to address it.”
Finally! Alas, Murthy’s report largely recapitulates a long lineage of similar American efforts: Bill Moyers’ 1998 five-part PBS series “Moyers on Addiction”; Benoit Denizet-Lewis’s long 2006 New York Times Magazine article “An Anti-Addiction Pill?”; Nora Volkow’s 2007 HBO series “Addiction.” All combine chronic-brain-disease addiction theory with 12-step-disease-recovery mantras.
So we might well ask how Murthy’s “first-of-its-kind” report, heavily pushing treatment and prevention policies based on the conception of addiction as a brain disease and recovery groups (while giving a brief nod to some harm reduction measures to help “those who are not yet ready to participate in treatment”) improves the situation.
In fact, since Nora Volkow took over as director of the National Institute on Drug Abuse (NIDA) in 2003 and propelled the brain disease model to absolute dominance in the field, drug-related deaths (overwhelmingly multi-drug poisonings, but erroneously referred to as overdoses*) surged to record levels in 2014, increasing exponentially for heroin, tranquilizers and painkillers.
The surgeon general’s report is a tragic missed opportunity, one that will continue to hold us back. Here are five damaging themes on which Murthy and his allies are doubling down:
1. Scare people (even more!) about opioid “overdoses.”
If people were to consume pure doses of heroin or other opioids, their likelihood of accidental death is reduced to nearly naught. As Edward Brecher reviewed the research in Licit and Illicit Drugs in 1973, a lethal dose of narcotics is several orders of magnitude above a standard narcotics dose. In countries where heroin is legally medically administered (e.g., Switzerland, Portugal, Germany, Vancouver in Canada), there have been no heroin-related deaths under medically supervised conditions.
Yet the myth that people typically develop an inordinate, insatiable desire for a single drug—when in fact those most at risk are mixing a variety of substances, in what can be considered either a chaotic pattern or an abandoned, intentionally self-destructive one—still fatally misinforms our policies.
2. Convince people that drugs cause addiction.
The headline news from the surgeon general’s report: “1 in 7 in USA will face substance addiction.” “We underestimated how exposure to addictive substances can lead to full blown addiction,” Murthy told NPR. “Opioids are a good example.”
Note to the Surgeon General: The definitive US psychiatric guide, DSM-5, no longer applies the term “addiction” to anysubstances, but only to non-drug activity. How he rationalizes his perspective that drugs have an insufficiently recognized special quality of addiction with the DSM-approved possibility of becoming addicted to gambling, or the non-DSM-approved but still-real possibility of becoming addicted to sex, love, the internet or any other compelling involvement, is anyone’s guess.
And let’s look at opioids: Very few lifetime consumers of heroin currently use the drug (about 10 percent) and far fewer of even current users, as drug scientist and Influence columnist Carl Hart points out, can be said to be addicted (10-20 percent)—translating to between 1 percent and 5 percent of those who have ever used heroin being currently addicted. The percentage of prescribed opioid users who are addicted is even smaller.
Addiction is not in the thing. Addiction is in the life. And when addiction is understood as being steeped in people’s lives, we recognize that myriad drug or non-drug experiences are liable to become compulsively destructive. The thrust of Murthy’s thinking—an impetus to further restrict access to certain drugs—is as flawed conceptually as it is unachievable practically.
3. Emphasize “prevention”—meaning avoiding substance use altogether.
“The earlier people try alcohol or drugs,” says the surgeon general’s report, “the more likely they are to develop a substance use disorder. For instance, people who first use alcohol before age 15 are four times more likely to become addicted to alcohol … than are those who have their first drink at age 20 or older. Nearly 70 percent of those who try an illicit drug before the age of 13 develop a substance use disorder in the next 7 years…” Prevention, to Murthy et al., means prevention of drug use, as opposed to what it should mean: prevention of addiction or death.
I don’t deny the accuracy of these US statistics, but they are meaningless when considered outside of people’s life context, a context I provide in my book, Addiction-Proof Your Child.
Consider that in Southern Europe, where people begin drinking legally at much younger ages (typically 16), rates of problematic drinking are far lower than in the US and other temperance (Northern European and English-language) countries. Consider that in the US, given restrictions on the use of alcohol and other drugs, people’s first experiences with them are likely to be binge episodes with their peers, rather than moderate use with older, experienced family members. Consider that despite “Just Say No” being repeated to kids for decades, 40 percent have used marijuana by the time they leave high school, and 33 percent have drunk alcohol in the last 30 days—the majority of whom, critically, have engaged in binge-drinking. Both of the numbers rise rapidly following high school and into people’s early 20s, as shown in theNational Survey on Drug Use and Health.
Simply teaching people not to use drugs has gotten us where we are today.
4. Hype the supposed biological causes of addiction and minimize the social ones.
“We now know from solid data that substance abuse disorders don’t discriminate,” Murthy told NPR. “They affect the rich and the poor, all socioeconomic groups and ethnic groups. They affect people in urban areas and rural ones.”
This is quite wrong. Addiction does affect people from all backgrounds, but not at equal rates. It does discriminate.As discussed by Influence columnist Maia Szalavitz:
“Addiction rates are higher in poor people — not because they are less moral or have greater access to drugs, but because they are more likely to experience childhood trauma, chronic stress, high school dropout, mental illness and unemployment, all of which raise the odds of getting and staying hooked.”
This is a theme I have elaborated on:
“We are frightened to say that people in our country who are disadvantaged economically, socially, or, alas, racially, are more likely to become addicted … Instead, we satisfy our instinct for equality by emphasizing that people in upper-middle-class communities also take drugs — conveniently ignoring the very different rates of problematic drug use.”
Murthy instead pursues a line of thinking that has yet to produce a single meaningful diagnostic or treatment tool:
“Now we understand that these disorders actually change the circuitry in your brain. They affect your ability to make decisions, and change your reward system and your stress response. That tells us that addiction is a chronic disease of the brain.”
Murthy’s misdirection supports our heavily funded medical efforts to thwart addiction while we ignore the critical social levers for reversing our addiction epidemic—an approach which would instead require major social change to address the havoc in poor urban and rural communities which turns them into centers for addiction.
5. Expand our drug treatment industry and addiction support groups.
“We would never tolerate a situation where only one in 10 people with cancer or diabetes gets treatment, and yet we do that with substance-abuse disorders,” said Murthy, speaking of an estimated 20.8 million Americans with these disorders.
Contrary to this perceived shortfall, no other country in the world provides as much disease-oriented addiction treatment (i.e., 12-step and vaguely biomedical treatment—“vaguely” since no treatments actually directly address supposed brain centers of addiction) as does the US. Yet North America, as a global harm reduction report also released last week notes, has the “highest drug-related mortality rate in the world.”
Murthy’s report itself indicates that, “by some estimates, it can take as long as 8 or 9 years” as well as “multiple episodes of treatment” to achieve recovery in this way—and recovery, of course, is by no means guaranteed.
The report, despite its extended focus on 12-step and other support groups in the “recovery” section, notes that 25 million Americans have experienced some form of recovery from substance addictions—a figure that dwarfs the total membership of such groups (AA, the largest by a huge distance, has just over 2 million US members).
Government research repeatedly demonstrates that those addicted to drugs regularly solve their addictions given supportive life conditions. In fact, the large majority of dependent drug users reverse addiction on their own—most who ever qualify for a substance use disorder diagnosis move past it by their mid-30s. We note this all the time when considering the many ex-smokers we know (even though smokers, compared with those dependent on illicit drugs, require the greatest effort and longest time to overcome their addictions).
And so, Murthy is forced to implicitly acknowledge, while wishing to do no such thing, that most addiction treatment is no more effective than the ordinary course of the “disease,” and that recovery without treatment or a support group is the norm.
Don’t you think these might be important facts to include in a report on addiction?
Time for Something Different
What, then, are the messages that the US surgeon general should be spreading?
1. Loudly advertise the dangers of drug-mixing (in New York City, for instance, “nearly all (94%) of overdose deaths involved more than one substance”). Spread this message widely, including in schools, along with other critical information about drugs, while teaching drug-use and life skills.
2. Call for legal regulation of heroin and other currently illegal drugs to protect users from unwittingly consuming the haphazard, fraudulent and dangerous combinations often sold on the street. Call for painkillers to be available to people who want them under medical supervision, along with heroin maintenance sites, while making medical or other trained supervision of use available.
It is worth noting here that just as the Surgeon General’s addiction report came out, the British Medical Journal issued a clarion call: “The war on drugs has failed: doctors should lead calls for drug policy reform.” The BMJ’s report does not contain the words “brain,” “disease,” or “addiction.” Instead, it asserts:
“…a thorough review of the international evidence concluded that governments should decriminalise minor drug offences, strengthen health and social sector approaches, move cautiously towards regulated drug markets where possible, and scientifically evaluate the outcomes to build pragmatic and rational policy.”
3. Proclaim (as the SG’s report does to a degree) the usefulness of medication-assisted treatment, including broad use of drugs like methadone and burprenorphine to assist in quitting heroin with greatly reduced risk (but add that medications are not necessarily required, nor are they sufficient in themselves, to permanently quit a drug or alcoholaddiction).
4. Demand the full-scale deployment of other harm reduction services and supplies, from naloxone (Narcan) to syringe access to supervised drug consumption rooms—an expansion that will not only save many lives, but also do far more to reduce the stigmatization of people who use drugs than the empty words in the current report.
5. State that addiction is not a disease (and therefore, it is not escapable and not a lifelong identity!). Instead, point out, it is a phenomenon driven by psychological and social factors, and therefore inseparable from the realities of people’s daily lives. Publicly tell politicians that if they really care about reducing addiction, taking meaningful steps to address inequality and absence of opportunity would be the single best thing they could do.
6. Declare that we must abandon the futile goal of a drug-free society, which decades of efforts and billions of dollars have been unable to accomplish. Instead, recognize that we are all drug users—from caffeine and alcohol to prescribed medications to commonplace Adderall use by students. Affirm that drugs are a normal part of human experience, that they provide benefits, and that they are even enjoyed—despite their potential dangers. This is how we approach experiences and involvements—from driving to love and sex—that can have dangerous or overwhelming effects. It’s how alcohol is used throughout Southern Europe—indeed, how it is used by a majority of Americans.
Radical as this is to American ears, we must normalize and rationalize the reality of our drug use—as opposed to encouraging uncontrolled and chaotic use of drugs while simultaneously vilifying and demonizing them.
And we must do this soon. As Murthy’s report trumpets by way of perversely recommending more of what has long failed us: An American dies every 19 minutes from narcotics-related drug use.
*The overwhelming majority of such deaths are due to intentionally or inadvertently mixing heroin or opioid painkillers with one another, or with other drugs, including tranquilizers, alcohol, sedatives, and sometimes cocaine or amphetamines. One among many examples is the cause of death for Philip Seymour Hoffman. But first, the widely rumored cause of his death: “The autopsy and coroner’s report has yet to be released, but police are confident Hoffman died from a heroin overdose.”
Ah, when will those police ever learn? The actual autopsy? “Medical examiner finds heroin, cocaine, benzodiazepines and amphetamine in his system.” And, keep in mind, Hoffman had repeatedly participated in standard addiction treatment, and was actively attending a 12-step group at the time of his death, where he learned the mantra, “I am an addict.”