What I Know and Don’t Know About Addiction

“we want ppl writing about their experience of adxn, but it’s important to know what you don’t know & really hard to achieve ;-)”
– Maia Szalavitz, Twitter, 8/23/17

I write about my experiences with addiction with these imperatives and caveats:

  • Do no harm.
  • Report what the data says.

Do no harm.To the best of my ability to do so, I do not express opinions, views or perspectives. If I am expressing an opinion, I say so. Instead, I express my personal experience as anecdotal evidence – from which no general conclusions can be drawn about other individuals or groups – then report the empirical evidence published in research literature, which, because of the rigors of the scientific method – has been found to hold true for most people, most of the time, better than other treatments, and better than no treatment at all.

To the best of my ability to do so, for everything I utter and write about addiction, I can cite an authoritative, empirical source. Neither my personal experiences, nor my logical deductions, are empirical sources.

I link to the most authoritative sources I can find, unless, I judge, based on my training and experience as a teacher, counselor and writer, a complex subject requires a simpler source. I link to reports Laurel Sindewald and I have written because I can know, first-hand, that they are based on exhaustive literature reviews and ruthless determination to excise bias. This report, for example, has been one of the most controversial we have issued, but we talked about its content for several years, and spent 3-4 months researching it and writing it. Laurel wrote the final draft and I reviewed and edited it. I trust its findings.

To meet author Maia Szalavitz’s criterion for writing about addiction, I want to summarize what I know and don’t know. In order to do no harm, I must achieve that.

First, a brief overview of the context:

  • In 2012, I found myself compelled to continue to drink alcohol despite harmful consequences – the definition of addiction.
  • I thought I was treating myself to gold standard treatment for alcoholism by abstaining and attending a 12-step support group. To my bafflement, horror and shame, I continued to suffer and failed to thrive.
  • My father, a retired professor, hired two researchers, and the four of us began to study the research literature on addiction. We began to find that twelve-step approaches are not evidence-based treatments for addiction.
  • I began to research, then compile, evidence-based guides to addiction treatment for myself and others. I learned to differentiate between treatment, support, and self-help. (I continue to update this guide to evidence-based self-care.)
  • Maia Szalavitz’s book came out in early 2016, and Dr. Vivek Murthy’s report came out in late 2016, and the secret world of belief-based practices was exposed. <– That’s my opinion. I no longer felt like the lonely Lorax, speaking on behalf of the “trees,” i.e. on behalf of the people with substance use disorders, like I am, who need and deserve evidence-based treatment.
  • I finished my memoir (the conclusion is scheduled to be published by The Fix on 8/29/17) and want to return to advocating for evidence-based treatment.
  • As of this writing, for 4 years and nearly 8 months, I have been abstinent from ethanol, an identified neurotoxin, a substance legally available for consumption in my country. <–These are facts, not opinions. But this is where things get interesting. Instead of “ethanol” – which is startling – I could have written “wine, beer and other alcoholic beverages” – which is commonplace. I am aware of my word choice. I know what I am doing. I am writing. Writing is a skill, an art, and a power.  I must do no harm with it.

A disclosure of my opinions:

  • Defining terms is critical. If we don’t have mandated definitions, or co-agree on what definitions we’re going to use, we will not communicate and not achieve intended ends.
  • Each individual is unique, or different enough from other individuals, to have a unique case and need individualized, customized care.
  • Given limited resources and the urgency of the condition, individualized, customized care is impossible. Therefore, algorithms must be derived that, based on the data, help most people most of the time. We’ll miss some people. This is a hard truth to bear.
  • When people take adamant positions, regardless of how crystalline their logic, underneath is probably fear. “What might I/you/we be afraid of?” is a useful question to ask when discussions shift from cognitions to emotions.
  • If addiction is a disorder of the organ of the brain, then let’s attribute addiction to that organ. Anything that attributes addiction to the person, and not to the organ of his or her brain – to the person’s morals, character or willpower, to the person’s mental, emotional, cognitive, behavioral, psychological and/or spiritual problems or deficits, to the person’s lack of motivation or “readiness for change,” even to the person having “learned” addiction – perpetuates malpractice and stigma.
  • Malpractice and stigma can, and do, kill.
  • Given that death rates due to opioid use disorder, alcohol use disorder, and tobacco use do not move lawmakers, insurance companies, medical boards, and society at large to institute evidence-based treatment for people with substance use disorders, I do wonder if the secret, unspoken belief is that people with addiction deserve to die. Is it “Good riddance to bad rubbish”? Edit: First, suffer as punishment for perceived sins. Then die.
  • Abstinence-based outcomes, as measured by negative urinary drug screens, are criminal malpractice. For no other medical conditions are people mandated to the criminal justice system, denied custody of their children, or denied employment because of fluctuations in a chronic health condition.

What I don’t know about addiction:

  • What it really is.
  • What really causes it.
  • What the definition of “treatment” is, what really “treats” addiction, and what would satisfy us as “good enough” results from the treatment, even if we did know what it was.
  • Why some people “spontaneously recover” and some don’t.
  • Why the people in my town with opioid use disorder do not have ready access to methadone and buprenorphine, the only known treatments to cut the death rates by half. Unless the secret intent is for them to suffer and die. Because that is happening.
  • If addiction is a medical condition, what a counselor without medical training is supposed to do for people with addiction.

Here’s what I think I know about addiction:

  • No one really knows what addiction is and what lessens it, reverses it or cures it. To some extent, we’re all f*ed.
  • What is known is readily available, even in an easy-to-read format.
  • Belief-based, theory-based, practitioner experience-based, and personal experience-based methods dominate addiction treatment.
  • Beliefs, theories, and experience with addiction by persons or observed in others, dominate public discourse and policy.
  • Medical science is full of uncertainties. Chemo or radiation for cancer? What else to do but IV fluids and oxygen for someone with ebola?
  • My case is one case, no more and no less. What worked for me cannot be generalized to others. What didn’t work for me cannot be dismissed as unworkable for others.
  • If addiction is defined as the compulsion to continue to drink, use or do despite harmful consequences, abstinence is not a treatment for addiction. Abstinence creates the conditions under which a compulsion becomes nearly involuntary, automatic, reflexive, instinctual.
  • If the end in mind of addiction treatment is to decrease the number of premature deaths and to decrease harmful consequences for individuals and society, then what supports handling abstinence or harm reduction – rather than achieves them – needs to be the focus of “treatment.”

Finally, I study epistemology and acknowledge the limits of my ability to know what I know.

My awareness of what I know and don’t know continues to evolve. I purposely and purposefully seek out the latest published research on addiction and review the clinical studies ahead.

If fault is found with anything I’ve written, I’d be glad to learn of it – if sources are cited. My opinion is that I don’t have time for opinions. The stretchers are lining up at the addictions treatment tent. What does the data say about how we shall care for our citizens and, all the while, do no harm?

Photo: Greg Kiebuzinski

The opinions expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends.  This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

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