The War of the Addiction Worlds
Four incompatible views of addiction fight to capture America’s consciousness
his post is going to be unusually brilliant, even for me. In it, I review four factions warring against one another for our consciousness about addiction.
“Chronic Brain Disease” = the dominant view of addiction in American society, but one with which the other perspectives in this blog are in a life-and-death struggle. Predating Nora Volkow’s regime at the National Institute on Drug Abuse, the idea that addiction can be reduced to brain chemistry is actually a persistent and pervasive one in American history (see Nancy Campbell’s remarkable book,Discovering Addiction). But Volkow has legitimized and popularized (with, most notably, the New York Times as her PR department) this view to a degree never before seen in America. Her efforts were capped by Volkow’s gaining medical acceptance and recognition of brain-chemistry addictive medicine as a specialty (in re the American Board of Addiction Medicine), while really the brain-disease model is simply a highly stylized way of conceptualizing an idea that has almost no practical medical and clinical application. There will never be genuine, effective medical treatments for addiction and, really, everyone knows this.
Even within this “brain disease” movement, spurred by Charles O’Brien (one of the “brain disease’s” most prominent modern exponents), DSM-5, by deciding for the first time that non-drug activities (in DSM-5’s case, gambling) can be addictive, vitiates the entire dopamine, brain-chemistry model claimed to underlie the modern notion of addiction as a chronic brain disease. O’Brien makes the pro-forma argument that gambling has been shown to affect the same chemical brain-reward pathways as the host of drugs also mistakenly claimed to follow the same pathways. In doing so, O’Brien reverts to a centuries-old view that many activities are capable of provoking addictive responses, while he extends the brain disease model beyond even the realm of a remotely plausible fiction that it has heretofore occupied.
One last demonstration of the hopelessly confounded octupus chronic-brain-disease monster that is forming as we speak is the proposed (I am not the one to speak of how far advanced this event is) merger of the NIDA and the NIAAA (see below) into a new Substance Abuse/Addictions Institute to replace the two separate agencies. This merger might be presided over by Vice President Joe Biden who, as a senator, actually proposed such a merger as a part of his kooky “Recognizing Addiction as a Disease Act of 2007,” which would make it illegal NOT to think of addiction as a disease. It is no accident that Biden is the administration’s point man in maintaining America’s current drug policy; he was rushed to Latin America to fight the now irrepressible movement for drug legalization in that part of the world, since the current arrangement is killing Central and South America. (See Harm Reduction below)
Epidemiology. NESARC was the National Institute on Alcohol Abuse and Alcoholism’s (NIAAA) earth-shattering survey, the results of which were announced at the NIAAA website as “Alcoholism isn’t what it used to be.” Actually, this narrative too is a fiction, in that NESARC is simply the latest in a series of epidemiological studies (which included the NIAAA’s own NLAES study a decade earlier) showing that alcoholism — and also addiction — is a highly variable function of people’s lives that changes with changing conditions, in some cases quite rapidly. From the start of these representative population surveys conducted in the 1960s by the Berkeley Alcohol Research Group, it has been impossible (once you leave the confines of Hazelden and AA meetings) to find a condition known as addiction or alcoholism that stably defines a significant proportion of the population. NESARC (the National Epidemiological Survey on Alcohol and Related Conditions) found that people massively overcome a diagnosis of alcoholism, in most cases without abstaining. It is not remarkable that this finding has emerged — since this IS reality, has always been so, and will always be; no examination of Americans as a whole will ever show anything different. What IS remarkable was that the result was featured at the NIAAA’s website.
Recovery Redefined. At some point in my life I found myself at a national SAMHSA (Substance Abuse and Mental Health Services) conference in DC. I was obviously the fall guy — a outcast in the recovery, 12-step meeting the conference comprised. (This reminds me of the one time I appeared at a national NIAAA conference, where the local recovery nabob from New Jersey, where I lived, Riley Regan, preceded my debate there by announcing that he never thought he would witness the shame that I would be allowed to speak at such a confab.) That has changed, and SAMHSA became reality-oriented by tuning into the world beyond the recovery movement when it solicited national expert mental health professional opinion on the meaning of recovery. SAMHSA announced the result of this survey as a new definition of recovery. Again, the past is rediscovered — DSM-IV does not define remission as abstinence. It defines it as the absence of problems. SAMHSA goes beyond DSM-IV to make clear that — in both mental illness/health and addiction, recovery means improved functioning and gaining control of one’s life by formerly mentally ill and addicted individuals — the diametric opposite of the 12-step, abstinence-uber-alles, once-an-addict-always-an-addict definition.
Harm Reduction = the major drug policy reform movement in the United States and worldwide. Harm reduction — which implies drug decriminalization — defies the idea of chronic brain disease, which implies usage –> inexorable worsening usage patterns –> death. HR instead presents the societal policy of living with substance use that is, in fact, the reality of 21st American (and human) experience. Maia Szalavitz — Times Healthland writer (and occasional PT blogger) — is the epitome of the individual trying to square the circle of accepting “chronic brain disease”and adovcating drug policy reform. It can’t be done — the two tacks express fundamentally opposed world views.