Monday, December 17, 2018

Thoughts on the Disease of Addiction

I’ve mentioned a few times in previous posts that I have a friend who is struggling with addiction to illegal drugs, mainly heroin and meth. In attempting to be a supportive presence, I’ve found myself struggling to understand how I can be the best and truest friend I can be for him. Discerning such knowledge is not always easy.

I dare say my experience is familiar to many reading this. After all, substance abuse and addiction impact millions of individuals and families across the U.S. It’s a problem that is often referred to as the “opioid epidemic,” and a grim indication of just how serious it has become is that drug overdoses are now the leading cause of death of Americans under 50. I don’t want my friend to die; I don’t want him to be part of that frightening and tragic statistic. At the same time I know I can’t “fix” him or even really “help” him.

What I’m beginning to understand is that I can't really do anything. Rather, I can be there for him in ways that encourage and support his own efforts to do two things: 1) trust and get in touch with his whole and authentic self, a self that is deeper than his addiction yet obscured by this insidious disease; and 2) find, participate in, and persevere with what is known as “evidence-based treatment” for the disease of addiction.

I’m sharing all of this as I want to do my bit in somehow acknowledging and addressing the issue of addiction. Specifically, I’ve decided to launch a new series at The Wild Reed, one whereby I’ll be sharing some of the writings on addiction and its treatment that I’ve found to be helpful as I’ve accompanied my friend through his ongoing struggle.

I begin this new series tonight with an excerpt from David Sheff’s 2013 book, Clean: Overcoming Addiction and Ending America’s Greatest Tragedy. Sheff is also the author of Beautiful Boy, a memoir of his efforts to accompany his son through his addiction. Sheff’s memoir, along with the one penned by his son, form the basis of the recent film Beautiful Boy.

This first excerpt is a concise and insightful articulation of the foundations of Clean: Addiction is a preventable, treatable disease, not a moral failing. As with other illnesses, the approaches most likely to work are based on science – not on faith, tradition, contrition, or wishful thinking.


The main problems with America’s addiction-treatment system stem from its roots in the archaic notion that addiction is a choice, not a disease. One common symptom of the disease of addiction is relapse. Kicking an addict out of treatment for relapsing is like kicking a cancer patient out of treatment when a tumor metastasizes.

How are diseases treated? Many addicts describe programs in which “therapies” included group sessions during which patients were encouraged to denounce and rebuke one another – the goal was to break them. The philosophy behind such “treatments” is that addicts are undisciplined and morally bankrupt, so they have to be punished. In many treatment facilities, patients are lambasted, criticized, and berated. They’re told they aren’t going “with the program” and scolded for their bad attitude or arrogance. In the Congressional Quarterly, former congressman Patrick Kennedy, who’s been open about his addictions, summed up the problem with sad, hard-won eloquence: “I’ve made a very close personal analysis of treatment centers. I’ve gone to the best in the country myself . . . It’s all based upon . . . treating your weakness instead of your strengths.” I’ve never heard of any disease that responds to censure, blame, or denial of treatment.

Over the course of centuries, medicine has evolved from a disorganized and dangerous realm dominated by guesswork, received wisdom, faith, and fear into a comparatively reliable and effective means of dealing with a wide array of illnesses. It’s now grounded in evidence-based approaches – also known as evidence-based treatment (EBT) or evidence-based programs (EBP) – ones developed by doctors and researchers and proven effective in clinical trials. EBT is the paradigm that defines treatment in Clean. People choose proven treatments, not shots in the dark.

The current addiction-treatment system is based on shots in the dark., at least most of the time. There’s a standard model used for other illnesses. A patient sees a doctor and explains his complaint. A history is taken, and that’s followed by a physical examination. There are ancillary tests if needed, diagnosis, treatment, and then follow-up care. Bur patients with drug problems are rarely examined at all by a medical professional. If they are, the physical comes after they’ve been diagnosed, often by people without any credentials whatsoever, based solely on the addict’s behavior and their own descriptions of their drug use. Or they aren’t really diagnosed at all; everyone who walks in the door is presumed to be a drug addict, as if there’s only one form of the disease, and the addict is sent to generic rehab, as if there’s one form of treatment.

If you’re looking for treatments supported by evidence, the system is fraught with challenges, because, compared to other illnesses, there’s still not enough empirical evidence to offer a clear course forward. Many questions about addiction and treatment simply haven’t been answered categorically yet, and there’s active debate over the most basic assumptions about treatment – whether inpatient or outpatient programs are more effective, for example; what’s appropriate for adolescents and adults; whether (and when) medication should be part of treatment; how long treatment should last; which therapy models work and which don’t. It’s further complicated by the fact that most addiction treatments (indeed, most treatments for psychiatric problems in general) involve therapy, but there are limitless varieties of therapy. The evidence that supports or discredits each method is often inconsistent. Also, proven treatments may be poorly administered. Addiction medicine isn’t an exact science, and it’s still a relatively new one.

Related Off-site Links:
Amid the Opioid Epidemic, White Means Victim, Black Means Addict – Brian Broome (The Guardian, April 28, 2018).
If Addiction Is a Disease, Why Is Relapsing a Crime? – The Editorial Board (The New York Times, May 29, 2018).

See also the previous Wild Reed posts:
“Wholeness Is Never Lost, It Is Only Forgotten”
Interfaith Chaplaincy: Meeting People Where They're At
A Longing and a Prayer

Image: Richard Vyse.

1 comment:

Bose said...

Michael... so happy to see you exploring this topic, so sorry for your friend's struggle.

I spent a lot of time in related reading & study for a few years starting in 2000.

A key piece of my experience came in 2002 when I lost my best friend and former partner to his alcohol addiction. At 46, he had a nearly 2-decade pattern of 4-to-10-week sober periods full of peer support meetings punctuated by intense 3-7-day alcohol binges. There were many inpatient and outpatient treatment episodes and rich long-term connections to both layperson and professional treatment folks; he'd been trained and often served as a lay facilitator himself.

In early 2001, I started gently questioning/pressing him on taking a simple fairly small step: Since he'd crashed several vehicles over the years, and one of the consistent features of his binges was not just starting with buying a couple of big Scotch bottles, but getting back behind the wheel 24-36 hours later to replenish his supply, wouldn't it make sense to take responsibility for locking the car keys up somewhere beyond his control? It could be a lockbox with a drop slot, with only his sponsor able to re-open it.

After all, he had a many-year pattern of doing what he'd always done, and his professionals doing what they'd always done, with no change in results, including him driving impaired, putting pedestrians and other drivers at risk.

B shot back at me... yeah, I hear you and feel you, but I would lose all of my status as a decent, thoughtful guy in recovery if I admitted that I might need some relapse-mitigation or harm reduction care.