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“There, but for the grace of God, go I.”
If you, like me, have a family member or close friend who is in the early-recovery stage of addiction, whether it’s to drugs or alcohol, then you know how hard it is on everyone -- especially around the holidays. Given that a 2017 Pew Research Center survey found that “...nearly half of the public (46%) say they have a family member or close friend who is or has been addicted to drugs,” it’s highly likely that one of these thoughts have crossed your mind recently:
Can the rest of us still drink eggnog for Chritsmas, and champagne on New Years, or will that be too triggering for them? They said they were going to an AA meeting at 6:30 p.m., but it’s 9:00 p.m. now and they still aren’t back -- were they lying about where they were going? If they don’t want to go christmas tree shopping with us, should I just let them stay home alone, or is that enabling? I was going to gift him a new watch for Christmas, but I don’t want to give it to him if he’s just going to turn around and sell it for drug money...
It’s easy to drive yourself crazy with questions and stress, so this year give yourself, and your loved one, the gift of compassion. But don’t wait until midnight to resolve to understand their condition better, because it’s hard to be compassionate if you hold any number of common misconceptions about addiction. Instead, read on to learn more about what addiction is and is not, so that you can better understand and empower your friend(s) and family.
The most common misconception about addiction is that, even for people with addiction, substance abuse is a choice. The thinking goes that if addiction isn’t a choice, then if you offer an alcoholic a drink they shouldn't be able to resist drinking it, no matter the consequences. But if you hold a gun to their head... the majority won’t drink it; thereby proving that substance abuse is a choice, as opposed to a disease like cancer, which can’t be willed away under any circumstances.
The problem with the choice model of addiction is that it fails to recognize how highly constrained one’s choices become once your brain has been changed by drug exposure (Satel, 2019). Just because you can resist having one drink under extreme, but also obviously unsustainable circumstances, does not mean you are cured of a chronic disease. As soon as the person holding the gun walks away, the pay off changes, and you’ll no longer have the motivation to resist. (Motivation = Expectancy x Value / Impulsiveness x Delay) (Vermeer, 2012.)
The Choice Model of Addiction also fails to capture how differently the brain of a person struggling with addiction reacts to the circumstances compared to the brain of a healthy person.
The mid-brain of the person with addiction thinks to themselves, “I wonder if I could get away with it?” Whereas the frontal cortex of a healthy person evaluates the choice rationaly, because their body has no subconscious cravings for alcohol. Cravings are not a choice, and the same way you can’t will your body to stop craving oxygen, people struggling with addiction can’t simply will their bodies to stop craving substances (McCauley, 2012).
So while it is true that sometimes people struggling with addiction can respond favorably to consequences, the right response to addiction is treatment, not punishment. No one chooses to become an addict, even if they, at some point during their life, made a choice to take addictive substances. I mean, haven’t we all made that choice at some point in our lives? If you’ve ever tried alcohol, even if it was just a sip of red wine as communion, you made a choice to expose yourself to an addictive substance.
The first time I tried alcohol I was at my mother’s 15-generations-old family winery in Alsace, France. I took a huge gulp out of my father’s glass, probably thinking it was juice or something, and shocking everyone at the dinner table. I was probably only eight years old at the time, far too young to understand the potential consequences of my actions. All I understood was that my family made special grape juice, that the adults would all spend hours talking about and spend lots of money on it. There were no indicators in my world that wine was dangerous.
Thankfully, if there’s addiction in my family, I don’t have those combinations of genes because I don’t struggle with addiction. But if I had been predisposed towards addiction, would it really have been fair to hold me accountable for making that uninformed decision at the time? What if I had been 16 instead? Or 18? The legal drinking age in America is 21, but that number is totally arbitrary, and even relatively high compared to other countries. If the legal drinking age was determined by the average age when the human brain is considered fully developed, or the average age for the development of strong impulse control, the drinking age would be closer to 25 or 30. But most Americans are initially exposed to alcohol when they are between 11-13 years old!
For all of these reasons and more, there are obvious flaws with the Choice Model of Addiction. The next most common misconception about addiction is the Genetic Model of Addiction. The genetic model assumes that if you randomly sampled 300 people from a population, and gave each of them a fixed dosage of an addictive substance for a given period of time, only the people genetically predisposed towards addiction would end up forming a problematic dependency at the end of the experiment. Genetics does play a large role in how people respond to various substances, for example: “[a] vulnerable person may have a high preference for a particular substance. Or experience extreme withdrawal symptoms if they try to quit. On the other hand, a person is less vulnerable if they feel no pleasure from a drug that makes others euphoric...” (McCauley, 2012). But genetics aren’t everything.
Evidence from twin studies suggests that alcohol addiction is about 50% heritable -- though this number is higher for opiates, and cocaine (Ducci & Goldman, 2012). This means that 50% of the variation in addiction, in a given population, is explained by differences in their genes. (Behavioral geneticists draw this conclusion by studying identical twins who are raised apart. Any variation between them, given their identical genetic makeup, is attributable the shared or non-shared environment.) While this may seem like a strong genetic influence, what it really tells us is that vulnerability is not inevitability (McCauley, 2012). This is why we see, after major surgeries or injuries, when people are put on highly addictive pain medications only 10% of them will become addicted. You would expect this number to be higher, assuming it’s relatively random who ends up undergoing these surgeries and subsequently being prescribed addictive painkillers.
So What's the Answer?
So if addiction isn’t a choice, and it’s not a result (exclusively) of genetics and drug exposure, then what causes addiction? The answer is a combination of things: your genetics, plus your environment, plus your psychology (Hari, 2015). Addiction basically used to be bad luck, but now, as Johan Hari’s points out in his book Chasing the Scream (which if you don’t feel like reading the whole book, watch his TED talk on addiction here), it’s harder than ever to prevent in vulnerable populations.
Society spent so long thinking of addiction as a moral failure, and as a choice, that most of our resources invested into solving the problem of addiction have been invested into the criminal justice system instead of into the health care system.
The other, more modern problem, contributing to the recent Opioid Crisis, is that we live in a time where people want fast and easy solutions to all of our problems -- importantly, not because we are lazy, but because everything goes so fast now, that we fear being left behind if we are inefficient in any area of life. What this looks like in practice is people want a glass of wine, or a pill, or a new car, to solve all of their problems. When what people really need is: a sense of belonging and purpose. So while there are medications that are making it easier for people not to relapse, addiction is a chronic disease that is far more complicated than a headache. Palliatives don’t work for addiction, so while Methadone, etc. can help you get clean, behavioral interventions, such as Alcoholics Anonymous, are often what keep people sober.
In his book Hari discusses how a famous 1960s experiment in which 9 out of 10 rats pressed a lever which administered drugs (cocaine, heroin, morphine, etc.), instead of food, until the point of overdose or starvation, contributed to the common oversimplification of addiction. Further he debunks the original study by sharing how in 1978 Dr. Bruce Alexander reran the study, only he dramatically improved the living conditions of the rats being tested by providing them with social, sexual and aerobic opportunities etc., instead of enforcing the unnatural, cramped, and anxiety-inducing condition of isolation used in the original study (a now obvious confound). The effect was dramatic, the majority of these un-caged rats hardly self-administered any drugs whatsoever -- because they were happily busy with other things.
You’ll notice that in addition to experiencing an opioid epidemic, America is also seeing an epidemic of depression, anxiety, and suicide. These issues are not unrelated. In fact, there is now a term “disease of despair,” which is used to describe deaths by drug overdose, suicide, and alcholic liver disease all as one category.
Our societal-level misconception of addiction is costing not just those who struggle with addiction, but us too, their loved ones. These misconceptions made it hard to find compassion for people who are suffering, when that is often the thing they serve to benefit from the most. Because it’s not bad people that use drugs. It’s everyone. It’s the rich and the poor. It’s doctors, and it’s drop outs. It’s our grandmothers and our grandsons. You’ll notice that not once do I ever refer to a person struggling with addiction as an “addict,” this is because they are so much more than their disease. And however they came to be addicted to drugs, it’s our responsibility to recognize that while they didn’t have a choice in their addiction, they do have choices when it comes to their recovery.
So if your loved one excuses themselves from the dinner table to go to a meeting, let them go. Have compassion for yourself to know that their recovery is their choice and their responsibility. But take comfort in knowing that their sponsor, and their other sober friends are there for them in a way that you can’t be if you aren’t someone who also struggles with addiction.
Please note: if you or a loved one are struggling with addiction, for your sake as much as for theirs, seek group support either through free AL-Anon meetings (find your local meeting here: https://al-anon.org/al-anon-meetings/find-an-al-anon-meeting/) and/or one-on-one support with Smart Talk.
Pew Research Center. Political typology: Financial well-being, personal characteristics and lifestyles. (2018, September 18). Retrieved December, 2019, from https://www.people-press.org/2017/10/24/10-financial-well-being-personal-characteristics-and-lifestyles-of-the-political-typology/#drug-addiction-has-impacted-gop-and-democratic-groups-alike
The Problem Of Addiction - A Conversation with Sally Satel [Interview by S. Harris]. (March 04, 2019). Retrieved December, 2019, from https://samharris.org/podcasts/149-problem-addiction/.
Vermeer, A. (2012, February). How to Get Motivated: A Guide for Defeating Procrastination. Retrieved December, 2019, from https://alexvermeer.com/getmotivated/
McCauley, K. (Director). (n.d.). Pleasure Unwoven: An Explanation of the Brain Disease of Addiction [Video file]. United States: The Institute for Addiction Study. Retrieved December, 2019, from https://addictioneducationsociety.org/dr-kevin-mccauley-pleasure-unwoven/
Johnson, S. B., Blum, R. W., & Giedd, J. N. (2009, September). Adolescent maturity and the brain: The promise and pitfalls of neuroscience research in adolescent health policy. Retrieved December, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892678/
DeWit, D. J., Adlaf, E. M., Offord, D. R., & Ogborne, A. C. (2000, May). Age at First Alcohol Use: A Risk Factor for the Development of Alcohol Disorders. Retrieved December, 2019, from https://ajp.psychiatryonline.org/doi/pdfplus/10.1176/appi.ajp.157.5.745
Ducci, F., & Goldman, D. (2012). The genetic basis of addictive disorders. The Psychiatric clinics of North America, 35(2), 495–519. doi:10.1016/j.psc.2012.03.010
Szalavitz, M. (2016, May 10). Opioid Addiction Is a Huge Problem, but Pain Prescriptions Are Not the Cause. Retrieved December, 2019, from https://blogs.scientificamerican.com/mind-guest-blog/opioid-addiction-is-a-huge-problem-but-pain-prescriptions-are-not-the-cause/
Hari, J. (2018). Chasing the scream: The first and last days of the war on drugs. New York, NY: Bloomsbury Publishing. Retrieved December, 2019.
Center for Disease Control and Prevention. Suicide rising across the US. (2018, June 07). Retrieved December, 2019, from https://www.cdc.gov/vitalsigns/suicide/
United States Joint Economic Committee. (2019, September 05). Long-Term Trends in Deaths of Despair. Retrieved December, 2019, from https://www.jec.senate.gov/public/index.cfm/republicans/2019/9/long-term-trends-in-deaths-of-despair