Category: Connect

…by Bill Abbott, M.D….

Bill has been a long-standing member of this blog community and he has contributed his leadership and knowledge to the SMART Recovery movement. Thanks, Bill, for taking the time to share your thoughts here.

……….

I’ve recently completed two books. The first is Marc Lewis’s recent one and it is a winner. In this book Marc describes a “model” to explain addiction that is counter to the prevailing “disease model” and he does so in a very credible and lucid way that is based on neuroscience integrated with personal experiences of people he interviewed. A very effective approach indeed.

The second book, republished recently, is entitled Love and Addiction by Stanton Peele, which was first published in 1975 – 40 years ago. In this book (and other books of about the same vintage, such as Diseasing of America) Peele described the problem of addiction in very similar ways – obviously without the neuroscience available today — and showed the similarities between addiction and some forms of love, as Marc does also.

This has left me both frustrated and somewhat sad – that is, so much was clear forty years ago and yet we seem to have learned so little, and I can only come to conclude the following:

1. The current way we approach the problem of addiction in the United States is abysmal; it isn’t working because it is wrong.
2. We have failed to learn from our mistakes.
3. Much of what we really need to know to understand addiction has been known for a long time, but we haven’t paid attention.
4. We know enough about the problem to effectively deal with it.
5. And finally, the disease model is not only wrong; it is harmful.

Marc suggests that the disease model is harmful to a certain extent, but my purpose here is to expand on that idea. I feel justified perhaps because I am a medical doctor — and in long term recovery from alcohol misuse.

As a disclaimer, what I describe pertains to the United States, where I live… but probably to some extent to other western countries as well.

The harm stems from two sources:

The first is a practical issue. If addiction is a disease, doctors will be expected to “treat” it. That may not be too bad in theory, but unfortunately the medical profession (in the United States at least) is ill-prepared by virtue of knowledge, training, and — most problematic — insufficient time.

What about psychiatrists, you say? They are doctors. This is true (although many seem to forget clinical medicine)… but because they are doctors they treat patients by managing their patient’s diseases by prescribing medication, hoping for cure.

The underscored words lead to the second and greater problem with the brain disease model; and that is that it shifts the focus away from people with a problem to an outside entity, thereby mitigating personal responsibility. This position in essence means looking for an outside solution for an inside problem…that only an inside solution can help.

Let me expand on that a little.

Marc brings up two very important concepts in his book: what he calls “now appeal” (officially delay discounting) and ego fatigue or depletion (the depletion of cognitive resources for applying self-control). A related idea is the concept of locus of control.

This concept has been around for a number of years and has been described a number of ways. In general terms what it refers to is whether an individual believes in or relies on self-management or tends to look to outside resources for problem solving. This is not a fixed or constant trait but rather a tendency that varies with the problems and stresses people face. It often tends to be more on the external side in those encountering hard times – not uncommon in the addicted person. Some incorrectly call it low self-esteem.

So if addiction is a formerly useful coping strategy, now gone amiss, then one needs to look for other coping strategies that work better and be motivated to put them to use. And these work better if they are self-empowered. They don’t work if you rely on someone or something else. They just can’t.

The neuroscience points to the same conclusion; it is the “desire” that Marc is talking about that makes recovery work.

What is needed is a shift toward an internal locus of control. Something which the disease model tends to undermine because it fosters dependence on another power.

Surely you can and ought to seek help, advice, support, or what have you, if that can help. But ultimately you have to do it—for yourself

This is why the disease model is so insidious and counterproductive to successful recovery in many people. Although your doctor will encourage your participation, basically he is telling you what to do. This is prescription — be it medication or behavior. “You must stop drinking or you will die,“ my doctor said to me. I went home and poured a drink to think about that.

The evidence supporting the self-management approach is all over the place.

Consider so-called natural or spontaneous recovery — statistics show that as many as 80% of those who meet criteria for substance use disorder in the DSM-5 recover with no intervention or support whatsoever.

This is the epitome of self-management and empowerment.

For those who do need some help, self-management can be learned or better relearned in any number of ways… but I am skeptical that it will ever be learned in a doctor’s office, where you wait next to people with medical illnesses like hypertension and hemorrhoids.

A disease like cancer needs the doctor to manage it; addiction does not.

What those of us who solved the problem of addiction share is self-empowerment and then learning the skills to manage life’s many stresses in a different and ultimately less destructive manner.

The whole disease model concept is based on some really bad science and that in itself is harmful. But the fallout is potentially more damaging.

I only hope people start paying attention, because the problem is getting worse and we gotta do better. The people who suffer deserve that much, and if we help them to see what they can do for themselves, they may in fact do it — and feel good about the fact that they did.

I had read about a third of Johann Hari’s powerful book, Chasing the Scream: The First and Last Days of the War on Drugs, in quick snatches during my weeks of travel. I’d seen his TED talk and read reviews in the press. He’s the guy who traveled the world uncovering the damage done by the War on Drugs. He’s the poster child of decriminalization – and perhaps legalization. I liked his book a lot, and I kept looking forward to spending more time with it.

Hari is a journalist by profession, and he writes in stirring detail about the victims of the draconian punishments handed down by court systems all over the world, intended to stamp out the scourge of addiction. He writes about the mayhem and murder that keep sprouting up in the footprints of drug prohibition – resulting not from drugs but from the clashes of criminal gangs. And he writes about the feelings and beliefs of those who’ve supported, enforced, and legitimized anti-drug policies for compelling personal reasons.

Now I was about to meet him: He was designated as the chair of my final talk in Australia, to be held in the magnificent Sydney Opera House. Who was this guy? What was he like?

I had a foretaste a couple of days before my talk. We were interviewed together on a popular Sydney radio station. He was rather manic, or so it seemed in the flat silence of the studio. His answers went on too long. Isn’t it my turn now? I thought, maybe success has gone to his head. We’d agreed to go out for a drink after my lecture, but maybe that wouldn’t be such fun after all.

Then I met him again onstage. He was a delight. He introduced me with real generosity and warmth. His clever, sometimes pyrotechnic wit and sparkly knowledge of the addiction field created the perfect backdrop for my talk, and we got into an easy banter in response to comments from the audience. I started to like him a lot.

We left the Opera House and found an outdoor café – one of dozens lining the harbor in a royal road of good cheer. And I noticed a couple of times without really noticing it that he had his voice recorder on the whole time and he kept asking me questions. The guy was interviewing me! I guess I was flattered – I really didn’t mind – but by the time we parted I realized I had done all the talking. I regret that now…

Before meeting Johann, I’d gotten into an email discussion with a guy name Percy Menzies, a thoughtful and passionate man who worked for a major pharmaceutical company, a division of DuPont, for many years, training doctors in the use of medications derived from opium. This company had produced a number of well-known medicines, most important among them being Naloxone and Naltrexone, opioid antagonists which suppress the effects of heroin, making it almost impossible to OD. Now he runs several clinics combining drug therapy with counseling to help addicts withdraw, stay clean, and reconnect with their community.

Well Menzies has what can only be called a simmering contempt for Hari. Like other “pro-choice” advocates, Hari reminds us that heroin-addicted American GIs mostly quit the habit once they got back from Vietnam. Just as in Rat Park, environment mattered hugely, so addiction could be seen as a response to trauma and disconnection rather than a characteristic of drugs themselves.

But Menzies makes the following counterargument:

Yes, they came home to a “park” mostly free from fatal threats and populated by loved ones. Environment mattered.

But what mattered most was supply. In their day-to-day lives, most returning soldiers were in no position to continue scoring dope, especially not at the potency they had enjoyed in Southeast Asia. The 1980s Soviet experience in Afghanistan is particularly revealing: many soldiers found themselves addicted to the region’s pure heroin. But unlike their American counterparts, demobilized Soviet troops continued using heroin back home as it was readily available. Today Russia has one of the worst heroin problems in the world.

Menzies goes on to another potent example of why access matters so much:

Hari ignores all historical evidence that identifies access and price as the two most significant factors contributing to the spread of addiction. We as a society have known this for the longest time, yet people like Hari ignore these facts.

In his intellectual arrogance, Hari fails to consider the larger consequences of drug legalization. Returning again to Afghanistan, before the early 1980s that country had virtually no heroin addicts. Local drugs of choice were hashish and smoking opium. This was because most of the opium grown in Afghanistan was smuggled into other countries for processing into heroin. But a combination of international trafficking disruption and supplier economic savvy relocated processing to the countries where opium originates. Cheap, potent heroin was now available to Afghans for the first time ever. As a result, today Afghanistan has more than 1.5 million heroin addicts.

Now what are we to make of this? I am very taken with Hari’s investigation of the War on Drugs. I’ve plunged back into his book, and I’m now savoring every chapter. I am taken with his intelligence, compassion, his courage, and his mesmerizing ability to write about suffering without muting the pain or descending into sentimentality. And his argument about the damage done by drug prohibition is indisputable.

In fact, Menzies agrees that criminalizing drug use and locking up addicts is inhumane, ineffective, and wrong-headed. He says:

If we…tackle the drug addiction [problem], we have to begin with decriminalization and start dismantling the ‘treatment industrial complex’. These entrenched silos of residential treatment programs, jails prisons, methadone clinics, buprenorphine clinics have to be inter-linked. Indeed, the present treatment sets the patient up for failure and sometimes overdose deaths.

This is someone whose views resonate with my own.

Where Menzies and Hari differ is on the issue of legalization. If we decriminalize drug use, then do we make drugs legal? That is essentially what happened in Portugal, and Hari sees that small revolution as a huge step forward. But will cocaine and heroin be sold in stores in my town? Do I want my kids to be able to meander down to the local smartshop (we have these here in the Netherlands — very progressive) and buy a gram of methamphetamine?

Let me know what you think. And I’ll think about it some more myself.

 

It’s good to be back. I took my kids to school this morning. The air was fresh and the bushes were sparkling with dew. The Rhine (which they call the Rijn) was placidly flowing by, the odd boat tootling along. And Isabel and I had a few hours to reconnect last night. Which was especially nice. It’s surreal to be in my own living room, but I like it here. A good place to live.

The flight from Australia was fairly hellish. Fifteen plus hours to Abu Dhabi (United Arab Emirates), then a transfer to the next flight. Sat on that plane for two hours before we were told that the technical difficulties were insurmountable. Shuffled back into the terminal, went through security a third time, and finally sent to a workable plane, then seven more hours to Amsterdam. And then I got on the wrong train. Could hardly see straight. A couple of “young people” offered to help me with my bags, which made me aware I was bumping into walls. Announcements in Dutch that I could almost understand. Then Amsterdam Centraal — what a scene. After being in North America, the UK, and Australia for six weeks, I became aware how different it is here. The public toilets aren’t the cleanest, the signs aren’t the easiest to follow…but these people are dynamic and cool, alive in some special way.

I don’t have a lot to say at the moment, I’ll just post a few pics. Then in another post, in a day or two, I’ll tell you about meeting Johann Hari — Chasing the Scream — and about an interesting and intense rebuttal of his views — e.g., the benefits of decriminalization — by someone who works for the drug company that invented Naloxone.

 

Isabel and the kids at the

Roman baths, Bath, UK

 

 

 

 

 The boys and me in  Cambridge

 

 

 

 

 

 

On the way to Australia

— can’t get enough of Abu Dhabi

 

 

The Festival of Dangerous Ideas               

Sydney Opera House

Sydney at night

Nobody’s right if everybody’s wrong.  Do you remember that song from the late sixties? By Buffalo Springfield? Anyone else that old? Here, have a listen.

I’ve been in Australia for about three days. I say “about” because I truly can’t keep track anymore, though I could look it up. I dreamed that I was in Arabia for a while on the way here, but there must be a logical explanation, like I was having an astral projection or something. And yet…look what I found on my camera:

I actually woke up the other day, looked around at the standard hotel-room features and had no idea where I was. The feeling lasted about 20 seconds and I just let it be, enjoying the novelty of it. Australia evokes that readily because it seems like such an arbitrary continent. Aussies, please forgive me, and I’m sure many people feel this way about Canada, but the sense is: What’s this place doing here? Who put it here?

The Aussies are good to me. After my talk at the Melbourne Writers Festival, I was told that my book was the best seller of the whole Festival — except for a children’s book that apparently didn’t count. That’s a beautiful thing. And there was a supportive Q&A just published in the Australian version of  The Guardian, and other positive reviews online and in the press. All in the Mind, a radio show on ABC (A is for Australian) just aired this nice podcast connecting my views with those of Gabor Mate, whom I respect, not to mention Tom Waits.

And I’m still getting some great publicity from other lands. Jane McGonigal (@avantgame) has 130,000 Twitter followers and here’s a recent tweet from her. She’s a trend setter when it comes to the impact of IT on people’s thinking and behaviour, including the influence of video games on…just about everything. And look what she says…

But all this praise is only half the story. The forces of darkness have been gathering. I’ve gotten some of the nastiest reviews I’ve ever seen, ever even imagined. I’ve been called quite a few names, the mildest of which was “zealot” in the Washington Post. That review was moving along nicely until the writer, Marianne Szegedy-Maszak, got in touch with her reserves of….I guess contempt:

But despite the legitimizing heft of brain science, romanticizing the addict and turning recovery into a heroic narrative seems one of the central and unsettling aspects of Lewis’s perspective. When he writes that addiction is a “vivid instance of the role of suffering in individual growth,” he seems to imply that addiction is not just not a disease but noble. Addicts become heroes and addiction their heroic vehicle. It is difficult not to see this as a way of inserting himself, as an addict, into the story, while playing down the staggering social costs of addiction.

At least that’s marginally rational. Do I really think addiction exemplifies nobility or heroism? Well, no, actually. But I do see people’s determination to quit, and their sometimes long drawn-out battles to do so successfully, as worthy of real admiration. I see those efforts as courageous and maybe even heroic. But that’s an entirely different point.

And this business about “inserting myself, as an addict” into my writing… Sure I do, but how is that wrong? A few have argued that Lewis just claims addiction is not a disease because he got over his. So, let’s see, that was sure easy. What’ll I do for excitement next weekend? Maybe that’s what Ms Szegedy-Maszak is implying.

But some of the nastiest criticisms come from the pages of Customer Reviews on Amazon.com. One had this to say:

I will not buy another piece of garbage from this author after having wasted time and money on his last self-aggrandizing, narcissistic, egotistical piece of trash… This guy is a snake-oil salesman, a charlatan, a quack, sham and fraud masquerading as a neuroscientist interested in advancing the field of Addiction Recovery. He may have conquered his addictions, though he admits he still drinks alcohol, but he hasn’t given up the behaviors that he learned as an addict…

At least he or she isn’t pulling any punches. Other negative reviews are just as silly or rude, or too dumb to be upsetting. But there are a couple that get to me. Like the guy (I assume it’s a guy) who said…

He reminds me of a nurse I worked with on a hospital inpatient detox unit. He felt that when he was addicted to drugs, he stopped on his own without treatment, so he spent his time abusing the patients on the unit for not helping themselves. He was ultimately fired for his involvement in a patient suicide on the unit. Lewis needs to read a good work on Phenomenology to learn to bracket his experience when studying another’s addiction.

The problem is that it almost sounds rational, and it’s just so damn ugly. Although I’ve been told repeatedly — especially by Isabel — never to respond to negative reviews, I just had to reply to this one. I was almost civil. Now that’s heroic.

So here’s the net result — so far. Quite a few people really like the book. And a pretty large proportion — at least of those moved to write customer reviews on Amazon — hate it with a passion. Yet it seems to me they hate it for different reasons. Some oppose it because they think it’s so obviously wrong and others because they think it’s so obviously right that anyone could have written it. Go figure.

I’m not deeply upset by the criticism — either the stupid attacks or the cleverly devised barbs. It’s part of the game, I know, and controversy — even animosity — helps publicize ideas and sell books. I just thought I’d let you know how it’s going out here.

And by the way, if any of you folks feel like writing a flattering customer review on Amazon, nobody’s stopping you. But if you say anything even slightly negative, I know where to find you.

“Mostly say hooray for our side”

 

The sign on the door of the Insite supervised injection site was gone again. Russ wasn’t surprised. He said it happened all the time, so we continued our tour outside. We walked down a couple of blocks inhabited by the most dessicated, fragile, and helpless humans I’d ever seen except maybe in India. They looked like they were hanging on by a thread.

Addicts come to Vancouver from all over Canada. Some from the U.S. as well. Why? Because the weather is more tolerant than anywhere else in the country, and so is the city. Everyone knows they’re here. They live here. They’re left alone by the police and other agents of society. And they have the Portland Hotel Society to look after them.

The PHS runs Insite, but that isn’t their main contribution. Their larger project is to provide decent housing — at least marginally clean and well-run rooming houses — for the population of addicts that live here. Russ (Russ Maynard — see last post) ushered me into the lobby of a beautifully refurbished historical building, past the bearded, wizened security guy in the little booth — “Hey Russ, How’s it going?” — into an elevator with walnut walls and gleaming brass metalwork. He beamed as he told me how they’d acquired the building by promising to renovate it at half the cost demanded by standard developers. Yet behind the stately doors, past the supervisor’s station on each floor, lived people who’ve been addicted to heavy drugs for most of their lives. People whose lives depended not only on getting the drugs they needed but on treating current infections, avoiding new infections, escaping the violence that surrounded this place like an encampment of stormtroopers.

Most of the buildings weren’t nearly that nice. They were all converted single-room-occupancy hotels, left to rot when the lumber and mining industries scaled back and their population of seasonal workers slackened as well. But even the most run-down residence had this glow to it. I stood in the supervisor’s station (not sure what else to call it) in a building that looked ready to cave in. The stairs creaked and the walls were riven with cracks. Yet the workers were bright, cheery, competent young people bustling about their little office, attending to the petty and portentous problems of straggling residents, one trying to carry his bike upstairs, barely strong enough to carry his own spindly body all that way — “We’ll take care of it for you, Hal” — another who’d lost his keys again, a third whose sores were weeping uncontrollably. “Come into the infirmary, Mary. We’ll fix you up.” I turned away. She was a mess.

They’re not addiction counselors, said Russ. They’re not mental health workers. They’re a different breed. Young, idealistic kids, studded with tattoos and rings, doing this job because they cared. They had big hearts and good brains. They could do it. They wanted to do it.

And they understood what the PHS was about and what this community needed. It’s a civil rights issue, Russ told me. Not an addiction issue. In a nutshell, abstinence doesn’t work for a lot of people. Sure, we encourage people to detox, and we’ve got special residences for that. But we don’t expect them to stay clean. Rather, we’re providing them with a respite, a break from the chaos of their lives, constantly needing to score, and sell themselves or do whatever they have to do to get dope. We don’t get mad or kick them out when they go back to it. We need to heal these people, not displace them.

You have to understand where they come from, Russ explained. They grew up in foster homes. They’re cut off from mainstream society. They don’t know how to talk with normal people. They don’t know any normal people. They’re so used to being threatened, shamed, hunted, reviled. But we don’t shame them. Shame is so counter-productive. We’re killing people with shame.

So would you say they fit the “self-medication” model of addiction? I asked him. Sure, you could say that, he replied, not much caring what model I chose. But there’s a connection to be made with mainstream thinking in addiction. Some of these folks are the ones Gabor Mate wrote about in Hungry Ghosts. I now saw how the label fit.

This was the one stop on my book tour that took me completely out of myself, out of my clever arguments, my pride of accomplishment, my illusion that I understood addiction. My head was spinning. I had never seen people living so close to death, kept alive and cared for by such unstinting kindness. I’d never seen an institution with such a human heart.

But the one scene at the core of all this, the experience I’ll never forget, was being inside Insite. It’s the first and most famous supervised injection site in the world. Active for 13 years now, according to Russ. People came in off the street, signed in with their usual nickname or pseudonym, sat in a waiting room if there were  no booths available, and were then invited into the injection room. There they gathered supplies at a counter, placing what they needed — sterile solution, a wrapped syringe, alcohol swabs, etc. — in a cardboard container, the way you would at a cut-rate cafeteria. Then one of the workers would place a hand on their shoulder and point them to a booth, a well-lit counter top, about a meter wide, with a single chair pulled up to it. The booths were arranged in a broad semicircle, with at least one staff member keeping an eye on things. Unobtrusively.

And then they’d do their thing.

I hadn’t seen anyone shoot up for decades. The sight of it fascinated and disgusted me. The spidery search for veins that still worked, the bruises and scars and sores they worked around, the needle penetrating flesh, the change you could see, feel, almost taste, in body and soul, as the drug took effect. And then they were allowed to just sit there for awhile, draped on their little chair, their eyes droopy or glassy, the tension drained out of their thin frames. They were allowed to indulge in this brief moment of peace or contentment, before it was time to move on, vacate the booth for the next customer. And they were ushered into another room, asked if they needed anything, if they needed any kind of medical care. Then they got a handshake or a pat on the back, and back outside they went, back into the street that was a jungle, an impoverished playground, and, to many, a home.