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.

The Conversation about Addiction Has Changed Since Maia Szalavitz Came to Town

One year ago today, author Maia Szalavitz came to town to talk about addiction.

The conversation hasn’t been the same since.

Maia Szalavitz visits Blacksburg, Virginia

We speak differently about addiction than we did a year ago in our rural town in Southwest Virginia.

  • Our conversations about addiction are increasingly informed by knowledge, not based on belief or theory, particularly with regard to opioid use disorder.
  • We share our personal experience with addiction, either our own or what we’ve observed in loved ones or others, as our individual experience, not as “truth” that others should follow.
  • We’re increasingly aware when we’re speaking uncertainly and say so.
  • People can increasingly arrive at their primary care physician’s office and state they have a substance use problem and get help for it. As Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health recommends, we are finding that consulting primary care physicians for substance use disorders offers first-line, evidence-based care for addiction and optimizes use of the infrastructure we already have in place to take care of our people.
  • Local addiction treatment providers are increasingly embracing evidence-based treatment for addiction and jettisoning the moral model that has dominated addiction treatment for nearly a century. The belief that addiction is a personal problem, rather than a medical one, has inadvertently provided non-treatment and ill-treatment to its sufferers, untold anguish to those with addiction and their loved ones, and needless, tragic deaths. Real care for real problems is making a real difference.

To further deepen our conversations about addiction, let’s talk courageously about these questions:

We can continue to keep our conversations about addiction informed, and monitor hype vs. reality, by examining the data.

  • 14 in 100 Americans are expected to develop a substance use disorder in their lifetimes. (Source)
  • 1 in 100 Americans, 12 and older, met the diagnostic criteria for opioid use disorder in 2015 (0.2 percent for heroin use disorder, and 0.8 for pain reliever use disorder). (Source)
  • Fewer than 2 in 100 Americans met the diagnostic criteria for marijuana use disorder in 2015 (1.5% for 12 and older, 1.3% for 18 and older.  (Source)
  • 6 in 100 Americans, 12 and older, met the diagnostic criteria for alcohol use disorder in 2015. (Source)
  • 15 in 100 Americans, 18 and older, smoked cigarettes in 2015. (Source)
  • Nearly 35,000 opioid-related deaths in year 2015. (Source)
  • About 88,000 alcohol-related deaths every year. (Source)
  • Estimated 300,000 obesity-related deaths every year. (Source)
  • Over 480,000 tobacco-related deaths every year. (Source)
  • No overdose deaths from marijuana this year or ever. (Source)

Let’s keep defining terms to make sure we know what we’re saying. Let’s keep differentiating between correlation and causation.

One year later, what’s author Maia Szalavitz talking about?

How am I doing since, a year ago, I dejectedly typed my woebegone search terms about how to survive alcoholism into Amazon’s search box and Maia Szalavitz’s newly-published Unbroken Brain: A Revolutionary New Way of Understanding Addiction, appeared in the search results?

People throw around the phrase, “You saved my life.” I don’t want to go back in time and miss your visit to Blacksburg, Virginia to find out for sure, but I do believe you saved my life, Maia. I’m not sure what would have happened to me without you.

Thank you, beyond words, for visiting my town, Maia Szalavitz.

Laurel Sindewald contributed to the research for this post. Our reports on addiction treatment and addiction policy are here.

Updated 8/14/17

A Cohort of 300

I am one among a likely cohort of 300 who developed addiction in Blacksburg, Virginia after the Virginia Tech shootings. I developed an addiction to alcohol.

According to research on the relationship between community violence, trauma, and addiction, of the 40,000+ people living in Blacksburg, Virginia in 2007, research predicts 15% of them would develop post-traumatic stress disorder, PTSD. That would be 6000. Of that 6000, research predicts 5% would develop addiction. That’s 300.

Flag at half mast, Virginia Tech, April 2007

Addiction is defined as continuing to drink, use or do despite negative consequences. The person’s actions don’t make sense, yet he or she persists. It’s irrational. Brain studies now show us rational data to explain that irrationality: the very brain structures and networks needed to recognize cause-and-effect relationships, make decisions, and other executive functions – to stop what we’re doing – have become impaired.

For me, that meant drinking wine at 5:00 PM, falling down the stairs, cracking my bones and skull on the steps, banister, and walls, vowing never to drink again, and shifting my weight to ease my bruised body while I poured the first glass of wine at 5 o’clock, again, the next night.

What was not known in 2007 but is known 10 years later, thanks to the Surgeon General’s report, Facing Addiction in America, is that people with addiction just need to be taken early, at the first signs, to a doctor. No drama, just medical care for the medical condition of addiction. Then to be screened for mental illnesses that may accompany addiction. Like PTSD.

I have disclosed publicly that I developed alcoholism and have experienced first-hand, in the fish bowl of a small town, the stigma of addiction and its heartbreaking consequences. Comments like “All alcoholics should be shot at dawn – and that goes for drug users as well,” abound on the Internet and are unspoken in many minds and hearts. New Virginia laws mandating if and how people with opioid addiction can receive life-saving medication are based on the medieval premise that people with addiction got themselves into this in the first place. The belief is that if they suffer from it, even die from it, they deserve it.

I hope members of my likely cohort of 300 who developed addiction after the Virginia Tech shootings will reach out to me. I will ask them if I can do for them what should have been done for me. I will ask if I can take them to a doctor. And I will never disclose their identities. It’s not safe out there.

Photo: Steve Jacobs, Flag at half mast, Burruss Hall, Virginia Tech, May 5, 2007

Do No Harm to People with Substance Use Disorders

What can you do to help the over 16,000 people in the New River Valley of Virginia with substance use disorders? Here’s an executive brief.

Executive summary:

  1. Do no harm.
  2. Help people get health insurance and medical care.
  3. If they’re open to it, accompany people to their appointments.
  4. Start a SMART Recovery meeting.
  5. Lobby against federal and state restrictions on medications that treat addiction.
  6. Host substance-free gatherings and events, both at home and in the community.
  7. Help people help themselves.
  8. Inform yourself about addiction and addiction treatment in our locale.

An explanation of #1 – Do no harm – follows. The full brief is here.

I will try to help

 1) Do no harm.

What harms people with substance use disorders?

  • Telling them that your personal experience with addiction, or your knowledge of several people’s experiences, will work for them. Addiction treatment needs to be research-backed, evidence-based, recommended by health care professionals, and individualized for each person’s unique case.
  • Telling someone they have to “hit bottom” before they recover. “Hitting bottom” is a state of physical and mental emergency that can result in death.
  • Telling someone to “Just stop” and “Get over it.” That’s like telling someone with Parkinson’s to stop shaking or someone with dementia to “Just remember!” Addiction is a brain disorder. Like people with Parkinson’s, dementia and other chronic brain disorders, people with addiction need medical care.
  • Telling someone your belief or opinion about addiction. If you can’t cite the research on what you’re saying about addiction, don’t say it.

Most of the over 16,000 people with substance use disorders (SUDs) in our area struggle with alcohol, not opioids. Most people with opioid use disorders struggle with use of other substances as well – including alcohol. Most are not receiving care.

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
Alan Marlatt

What limits people with substance use disorders from receiving evidence-based care in our locale?

  • Continued belief – by lawmakers, health care professionals, treatment professionals, and society at large – despite the vast and extensive data that reports otherwise – that addiction is a moral problem, not a medical one. Addiction is believed to be the individual’s fault and the individual’s responsibility to cure. Lack of improvement is blamed on lack of character and effort.
  • Federal and state restrictions on access to addiction medications.
  • Lack of knowledge among health care providers and treatment professionals on research-backed, evidence-based treatment for addiction, including medications for addiction. Most people with substance use disorders get recommendations in the reverse order from the standard of care: support group attendance, then, if that doesn’t work – which the evidence says it won’t for most people – counseling. Rarely is the first-order, standard of care – medication – considered.
  • Lack of sufficient trickle-down knowledge to society at large about the latest research on addiction. People still believe they know best, even if the data says otherwise.
  • Lack of early treatment. Many people in our locale have acute, advanced cases of addiction from long-term, multi-year lack of evidence-based treatment or from mistreatment. The signature brain impairments of addiction result in behavioral symptoms that can make people with SUDs challenging patients. As with acute, chronic cases of other life-threatening illnesses, premature death may result. Harm reduction or palliative care – not incarceration or multiple rehab stays – may be the most humane and cost-effective option for our citizens with the direst cases.
  • Arguments about what prevents addiction. The only thing that prevents addiction is never having done the thing – no sip of beer snuck from a parent’s beer can, no first cigarette, no first toke, no sex, no porn, no Internet, no gambling, no exciting experimentation of any kind. The vast majority of Americans, about 86%, do not develop addiction. Through a complex set of known and unknown factors, 14% do. Attempting to prevent addiction through limiting supply is attempting to prevent people from being human. It has, and will, fail.

An explanation of #1 – Do no harm – is above. The full brief is here.

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.

What You Can Do to Help People in the NRV with Addiction

An executive brief on what you can do to help the over 16,000 people in the New River Valley of Virginia with substance use disorders.

Executive summary:

  1. Do no harm. 
  2. Help people get health insurance and medical care.
  3. If they’re open to it, accompany people to their appointments.
  4. Start a SMART Recovery meeting.
  5. Lobby against federal and state restrictions on medications that treat addiction.
  6. Host substance-free gatherings and events, both at home and in the community.
  7. Help people help themselves.
  8. Inform yourself about addiction and addiction treatment in our locale.

I will try to help1) Do no harm.

A full explanation is here.

2) Help people get health insurance and medical care.

Use the Surgeon General’s report on addiction as a guide.

The Surgeon General’s report recommends substance use disorder treatment in this priority order: medications, counseling, and support.


Help people get health insurance. In the New River Valley of Virginia, help people with severe mental illnesses and low incomes call New River Valley Community Services at 540-961-8300 to make an appointment for help with enrolling in GAP. If they’ve previously paid federal taxes, sit down with someone at a computer and help them navigate healthcare.gov, or call Laura Goorskey at Muneris for help with signing up for insurance through the Affordable Care Act.

Help people make appointments with their primary care physicians (PCPs). While an appointment with a psychiatrist might be optimal, wait lists for appointments in our area are 6 months or more and require a referral from one’s PCP anyway.

Some medications that treat addiction, illogically, are not available in all areas of our locale, are available only through a wait list, or are available for cash only. If your person has an opioid use disorder, you will discover the horror of the double bind in which we place our citizens.

Join with community stakeholders to create attractive packages of positions, salaries, caseloads, housing and Virginia Tech football tickets – whatever it takes – to attract more psychiatrists and medical professionals to our area who have the expertise and credentials to treat addiction.


Help create and update a list of counselors in our locale who are currently accepting new clients, who are open to taking clients with substance use disorders (many are not or don’t feel qualified to do so), who offer cognitive behavior therapy (CBT), the top recommended therapy for SUD, and who may give discounts to low-income individuals. Dialectical behavior therapy (DBT), is an increasingly evidence-based counseling approach as well.

Counseling does not directly treat addiction, but can assist people with abstinence, drinking or using less problematically, and with co-occurring mental and emotional issues. According to the Surgeon General’s report, individual counseling is the recommended modality, group therapy less so.


The more local support group meetings we have on different days of the week, at different times, in various locations, the more people who need support for the 24-7 condition of addiction can get it.

3) If they’re open to it, accompany people to their appointments.

Study the Treatment section of the Surgeon General’s report, print out several copies, and highlight sections that pertain to your person’s condition. Be ready to point to those relevant section, others as they come up, and to hand over your highlighted copy. (Printouts of very recent research reports can be helpful. For alcohol, try pages 4-24 and 4-25 from the Surgeon General’s report from 2016, and this one from 2107. Although medications for methamphetamine use disorder are still unknown, this report from 2017 is promising. For opioids, this piece of journalism from 2016 is stellar.)

Demand for health care exceeds supply in our locale and many of our health care professionals are saving lives and relieving suffering, not studying the latest research on addiction. Some, unfortunately, offer belief-based treatment, not evidence-based treatment. Help inform them. Advocate if you need to. Keep what happens in the appointment rigidly, absolutely confidential.

4) Start a SMART Recovery meeting.

SMART Recovery does not require meeting facilitators to be in recovery from addiction themselves.That means that any citizen can volunteer to train quickly as a host, and more extensively as a facilitator, and we can, as a community of trained “citizen counselors,” offer therapeutically-based recovery support services to our own community members.

The more citizen volunteers we have hosting local SMART Recovery meetings, the more support we offer and the more stigma-busting we do. I share with permission that to support the launch of our locale’s first open community meeting of SMART Recovery, our town’s mayor, Ron Rordam, attended. If you can go to business, community, educational and religious buildings and see the butcher, the baker, the candlestick maker – and the mayor himself – at a SMART Recovery meeting, well, maybe addiction is just an unfortunate condition for which the whole community backs recovery and wellness.

Mob SMART Recovery Facebook pages like our local one with “Likes.” That explodes the stigma of  “Is she or he ‘one of them’?”and transforms “Us vs. Them” into “We.”

5) Lobby against federal and state restrictions on medications that treat addiction.

Contact your representatives and urge them to work to repeal federal and state laws, and Virginia Board of Medicine policies, that limit access to medications that treat or ameliorate addiction. The logic of the laws is that if people have trouble getting substances, or are punished for using them, they won’t use them. Given human nature – we’re wired for pleasure, excitement and experimentation – and the nature of addiction – addiction’s brain impairments result in persistence no matter what the cost, no matter what happens, and no matter what punishments are levied – this is a position of tragic illogic.

6) Host substance-free gatherings and events, both at home and in the community.

Brew Do, Fork and Cork, Cocktails and Collaborations…where can an adult go locally to be with other adults not using substances? And how about gatherings of family and friends accompanied by wine, beer, marijuana, or other substances? Research on addiction reports that environmental cues can illicit automatic use or near-use. Many people with substance use disorders simply cannot risk being around substances. Consider declaring or hosting one gathering per quarter as a substance-free event to protect and enhance the lives of citizens and loved ones with addiction.

To help coordinate gatherings and events, consider volunteering to launch a New River Valley recovery community organization (RCO). A .pdf of the recovery community organization toolkit from the Association of Recovery Community Organizations and Faces and Voices of Recovery is here.

(Recovery advocacy and activism is too lonely to be tolerated long-term by one person and, ultimately will be ineffectual. Faces and Voices of Recovery has found, “[R]ecovery voices are marginalized and ineffective when the work is shouldered primarily by lone individuals.” Groups of individuals can make things happen.)

7) Help people help themselves.

Given the scarcity of treatment and medications for addiction in our locale, and given that addiction is a 24-7 condition, most people with addiction will have to provide much of their own care much of the time. Innovative programs like this exist in other areas. Here, we DIY (do-it-yourself). Help people discover what’s helpful to them and to practice evidence-based self-care.

8) Inform yourself about addiction and about addiction treatment in our locale.

To become quickly informed about the science of addiction, I recommend the NIDA site. For further study, consider the Surgeon General’s report (minus the section on TSF, included for legacy reasons, but which is not an evidence-based treatment), and Maia Szalavitz’s comprehensive report on addictions research, the New York Times bestseller Unbroken Brain: A Revolutionary New Way of Understanding Addiction. Maia continues to report on addictions research and a list of her recent articles is here. Laurel Sindewald and I have written a series of brief reports listed here. This is an excellent academic article by Nora Volkow, M.D., and on pages 16-19 in this publication, she offers a more mainstream explanation of the science of addiction.

To inform yourself about addictions treatment in our locale, the next time you go to a health care appointment, ask your providers what they would do for you if you told them you had a problem with alcohol, opioids or another substance. You’ll learn why it takes 3,000 words to describe how to get addictions treatment in the New River Valley of Virginia.

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.

Last updated 4/27/17