Thursday, February 06, 2014

On Addiction

A friend on Facebook posted a link to this blog post from

Posted in the wake of the relapse and death of actor and addict Phillip Seymour Hoffman, the article makes some points, both good and bad. Now keep in mind that this is a complicated subject, and a complicated case as well, but early on Bayer's post reads like an over-long exercise in excuse-making and victim mentality. So much so that it's tempting to just say tl;dnr (which you may wind up doing here, too). But her better points are at the end.

 "Wally" (a friend of my friend), insightfully responded, "His free Will was in place the FIRST time he stuck the needle in his arm."

EXACTLY. And his Free Will was in place in those moments when he had actually taken the drug and the "fight or flight mechanism" was no longer in place.

It does the addict no favors whatsoever to tell him that he has "no choice" in the matter... that it's just the way his brain is wired, when that is "factually incorrect", to use Bayer's own mis-applied term. He has the choice to seek help, always. And it does no good to imply that a doctor can cure your addiction.

My wife couldn't quit cigarettes though she tried for 17 years. This was not merely an addiction to nicotine. Addiction is not just about the substance. I bought her nicotine patches and she still smoked, and got sick from the excess nicotine. I got her nicotine gum; same result. I got her e-cigarettes... the kind that look like cigarettes. They never got shorter, so she'd suck on them and suck on them until she'd exhaust a two-pack equivalent in 20 minutes, getting sick and inflaming her mouth. And she'd still want the "real" cigarette.

Finally she decided that she could not do it on her own. With a cigarette in her hand, cravings satisfied, she agreed that I should buy her no more. And that, when she begged for one, I should not supply her. And I haven't. Nor will the kids, nor any of her friends. Note that it was her decision... simply telling an addict isn't enough. She will go around you. Education alone is useless. There is no amount of "help" or "treatment" that you can offer that will work unless that choice is made. Ever.

Debbie Bayer's title is factually wrong.

I use the phrase "addictive personality", understanding that our personality is shaped by our physiology. Your brain and mine are not identical machines running different software. It doesn't have to be cigarettes. An addict may become addicted to anything that brings them comfort. There is a physiological component of addiction, but that's not all there is. This is why we can become "addicted" to things that have no physiological component. The amount of endorphin released by a blog post is minuscule. Nevertheless people can be addicted to the Internet (and it's a real addiction). We can even become addicted to imaginary stimuli. But though our personality is shaped by our physiology, that is not absolute. We can make choices when we are sober that will keep us sober. We can make those choices when we are convinced that we are empowered to do so, and never when we are beaten into believing that the choice doesn't exist. But the effective choice is to seek help, not to overcome the addiction, because that will never happen.

Bayer is also factually incorrect when she states that addicts don't know their "brains are broken". My father was a morphine addict. He knew that wasn't "normal". Addicts often know about their problem long before the people around them do. Being "in denial" doesn't mean you don't see the truth... it means that you see the truth and reject it. The point of an intervention isn't to reveal his addiction to an addict, it's to reveal the fact that you know about it. That his denial isn't working. The addict has to acknowledge the problem, yes. But then he must come to the realization that it affects other people, and that an addict is never cured. An alcoholic who hasn't taken a drink in 20 years is still an alcoholic; and the solution isn't to pretend to "cure" it so that alcohol is OK... it's to stay away from alcohol. And that is something that no doctor anywhere can do for you, no matter how many sheep died to line his wall. There isn't an "anti-addiction pill" or potion or regimen that works other than staying away from the substance.

When Bayer says that a person can "...stay in treatment long enough to allow his brain to rewire itself around those sensitivities and render him clean and sober again." that's not neuroscience. That's just wishful thinking. Likewise, Bayer's whole invocation of the "fight or flight response" is suspect. A "hijacking" of the frontal lobe floated in the mid 1990s by Daniel Goldman in reference to "emotional intelligence". This very quick, almost reflexive reaction is very different from what happens in the case of addiction. Unlike in a "fight or flight response", an addict has the opportunity to weigh his options. This is decision-making, not reflex.

Before we move on, let's look at the twelve steps of a typical "12-step program":

Twelve Steps
  1. We admitted we were powerless over our addiction—that our lives had become unmanageable.
  2. Came to believe that a power greater than ourselves could restore us to sanity.
  3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
  4. Made a searching and fearless moral inventory of ourselves.
  5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
  6. Were entirely ready to have God remove all these defects of character.
  7. Humbly asked Him to remove our shortcomings.
  8. Made a list of all persons we had harmed, and became willing to make amends to them all.
  9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
  10. Continued to take personal inventory, and when we were wrong, promptly admitted it.
  11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
  12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

Bayer refers to 12-step programs dismissively, despite the fact that Step 1 is acknowledging that the problem is bigger than you... exactly the same thing that she's saying. Seriously, she wants you to understand that you can't control the problem, and that is literally the first step of a 12-step program. So that portion of the message is really old news.

But rather than focus on the helplessness of it all, the 12-step program goes on to principles like recognizing how your addiction has wronged others; bridge-building and making amends... which removes the emotional distress that  often drives people to substance abuse. This solves the root causes so as to deal with the purely physiological stress. It's a hell of a lot easier to battle physical pain alone than it is to battle pain, guilt, and depression. And it requires you to help others, building a network of support where addicts don't have to deal with the social stigma of their addiction. Humility is stressed; it works better than resolve. When you say "I'm going to beat this thing" and rely on yourself, then any failure simply adds to the sense of defeat and depression.

But 12-step programs rely on God. Where they are effective, the members have done that. Where they fail, they haven't. So 12-step programs aren't appealing to atheists because they introduce an entirely new stress. Not only do you have to overcome pain and shame and guilt, but you have to look at religion in a new way. Not everybody is prepared to do that, so this most obviously will not work for everybody.And this is despite the fact that the AA 12-step program is extremely flexible on spirituality. You are encouraged to rely on God "as you understand Him". It is not a church..

That's not a failing of the program. When I buy wood paint and it doesn't stick to my metal door, it's not a fault of the paint, but rather in my choice of paint. If the very idea of spirituality is offensive to me, then I have to deal with my addiction in some other way. Fortunately, there are other programs, but you will find that they are no more universally effective than a 12-step program... it's just that different people find them ineffective.

For instance, the New York Times reveals an anti-religious bias with their headline, "Review Sees No Advantage in 12-Step Programs", but when you read the article you find this (emphasis added):
The researchers, led by Marica Ferri of the Italian Agency for Public Health in Rome, found little to suggest that 12-step programs reduced the severity of addiction any more than any other intervention. And no data showed that 12-step interventions were any more — or any less — successful in increasing the number of people who stayed in treatment or reducing the number who relapsed after being sober.
(I'd like to point out the fact that "interventions" are rarely effective at all, no matter who does them. That's because an "intervention" is forced upon someone rather than a matter of their choice. That's entirely different from entering a program voluntarily... which of course, Bayer erroneously claims you're incapable of doing.)

A good treatment on the subject is found at Hazelden is an organization staffed by physicians, psychiatrists and therapists that specializes in the treatment of substance abuse.

Note that the problem with "treatment" is that it is of limited duration. Relapses after rehab are common because there is no cure. The big problem isn't getting clean, it's staying that way. Staying sober requires follow through and commitment. A 12-step program encourages participation for life, not only for your personal benefit; but for the benefit of others with similar problems.

Organizations like Hazelden suggest a combination of approaches that include medical treatment as well as lifelong participation in 12-step programs to prevent relapse. This rejection of "either/or" mentality in favor of a "both" offers the best chance of continued success. It does no service to anyone to misquote and mis-characterize 12-step programs (which are supportive and non-judgmental) as being accusatory and liken them to a prison sentence, as Bayer does. Bayer says "Hang in there, recovered and recovering 12 steppers. I’m on your side.", but that is an astonishing lie.

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