Addiction & Judgement

cat with cigarette

This is a reposting of the first of a series previously written on alcoholism and addiction.

I was listening to Bill O’Reilly on the radio recently, discussing a sports figure whose career was ended by drug use. He was using it as a segue into his philosophy about drug laws, enforcement, legalization and addiction. Now, I generally like O’Reilly, and agree with him maybe 60-70% of the time, but he–and almost all conservatives I’ve listened to on this topic–are way off base about this issue. His conclusion, in essence, was that all this discussion about “diseases” such as addiction was an excuse to avoid personal responsibility and create victims–addiction was, pure and simple, a personal choice made by individuals, who could just as easily choose to give it up and live responsible, upright lives.

It’s a sentiment I understand fully. And it’s fully wrong.

First of all, why talk about addiction here? As a physician, I’ve been interested in the problem of addiction and alcoholism for many years, even though it’s not my main area of specialty. Like most physicians, I have had to sort out patients with legitimate need for potentially addictive medications, such as opiates, from those seeking the same drugs for different, abusive reasons. This might seem easy at first glance, but those with drug addiction are masters at deception – it’s a survival skill, learned through repeated practice. Why does one patient get a prescription for pain pills, take a few, hate the way they it makes them feel, and flush them down the toilet, while the next fellow gets the same prescription, triples the dose, tells you he “lost the prescription”, and demand more in a few days? It’s easy to blame this on irresponsible hedonism, but it’s nowhere near that simple.

Secondly, I have many friends who are in recovery from drug and alcohol addiction, and have spent quite a few hours discussing and understanding their histories, behavior, and the recovery process. There is no better way to shatter misconceptions about alcoholism and addiction than to go to the source–those who’ve walked through hell and survived to reclaim their lives and tell their stories.

Lastly, the solution to the problem of addiction is, somewhat surprisingly, far more spiritual than medical or sociological in nature. Hence, it is a natural for a blog on medicine, religion, and politics (not so sure about the pet connection, although the photo above is not a Photoshop edit, so maybe I’m on to something…)

I anticipate blogging a series of articles on aspects of this topic, since there is a lot of ground to cover. Libertarians and liberals should not feel too smug just yet – they’ve pretty much got it wrong as well. More on that later.

First let’s address the issue of the “disease” of alcoholism and addiction. I use scare quotes because that is the way most conservatives view this problem–a pseudo-disease fabricated from thin air by psychologists and social workers, to create another class of victims in need of a big-government fix. Conservatives, who pride themselves on their reliance on logic, reason and tough love over emotion, feelings, and faux compassion, have abandoned science and objective truth on this subject, however.

The simple fact is that medical science is rock-solid in conclusion that alcoholism and addiction are well-established disease processes, comprised of genetic, physiologic, and mental illness components. As a quick MEDLINE search will demonstrate, there is a vast amount of medical literature addressing this disease in its many medical, psychological, behavioral and social aspects. One of the better recent summaries of this body of research appeared last year in the New England Journal of Medicine ( NEJM 2003;349:975-986 [subscription required]) entitled Mechanisms of Disease: Drug Addiction. To summarize some of the evidence:

  • Family History: Children of alcoholics are much more likely to become alcoholics. This is true even when adopted at birth by non-alcoholic parents.
  • Genetics:Specific genes have been identified which influence the metabolism and psychological effects of drugs and alcohol. Alcoholics and non-alcoholics metabolize the drug differently because of differences in the enzyme aldehyde dehydrogenase; a neuropeptide Y gene mutation is associated with higher incidence of alcoholism; a gene expressing the gamma opiate receptor, when mutated, is associated with a higher risk of heroin addiction. Many other such genes have been identified related to cannabis, codeine, nicotine, and other addictive substances
  • Animal Research: Specific genetic modifications in mice can reproduce or block addictive behavior.
  • Neurophysiology: Addictive drugs have profound effects on critical neurotransmitters, such as dopamine and GABA, which are long-lasting and have profound impact on affect, behavior, and thought processes.

The point here is not to bore with excessive medical details, but to emphasize that the addict is different: physically, genetically, biochemically, mentally. They are not simply wanton hedonists who wake up one day and decide to live a life of pleasure-seeking and irresponsibility, and can just as easily wake up and decide to stop. No doubt some–perhaps even many–enter the world of alcoholism and addiction by means of such ignoble motives. But once ensnared, their journey back to sanity and wholeness without drugs, even if pursued with passionate willfulness and desperation due to a destroyed life, faces enormous challenges inherent in their genetic, biochemical, and mental liabilities. And many enter the slavery of addiction through otherwise legitimate portals, such as social drinking or legitimate prescription use. The addict is in many ways a hidden time bomb waiting to detonate.

Yet conservatives, and society in general, are entirely justified in seeking and demanding solutions to the problem of addiction. Addiction plays a major role in virtually every social disruption we face: divorce, homelessness, inner city crime and gangs, child and spousal abuse and neglect, unemployment, poverty. It has engendered an enormous illegal industry which corrupts entire countries and funnels vast amounts of money to crime and terrorism.

But to find a solution to such daunting challenges it is imperative that our understanding of the problem be one of clarity and truth, not prejudice and false premises. Solving the addiction crisis by demanding personal responsibility may feel good, but does not begin to solve the problem. Personal responsibility is a result of recovery from addiction and alcoholism, but an ineffective means to accomplish it. Surprisingly, the real answer comes from the spiritual rather than the will.

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6 thoughts on “Addiction & Judgement

  1. Thank you for this. There was a time in my life (long, long ago) when I naively imagined that alcoholism was a “symptom” of some “deeper” issue. Due to experience with a family member I got over that thinking. There may very well be another trigger or underlying issues contributing to the behavior, but it is clear that alcoholism in most cases becomes THE problem, not a symptom.

    And as you say, deception is vital to the experience. I can understand why someone who has been drinking continues to drink, even to the toxic stage. I have never beren able to understand what allows (or causes) that “first” drink after a long period of sobriety, often measured in months or even years when the chemical influence of drinking is long gone. Deception is so powerful that it apparnetly tricks the victim as well as the enabler.

    You are on the right track with a spiritual approach. There may not be science to validate the results, but spiritual healing is not as easily measured as clinical remedies. Some recoveries cannot be accounted for by other exoplanations.

  2. Thanks for reposting some of your older material.

    Being relatively new, this is new material for me…

  3. Good choice for reposting. I have, in the past, spent a lot of time with mostly recovering alcoholics/addicts; I even spent a week in a family workshop at a rehab’ facility and got a lot of information along the way. I still am inclined to think that personal responsibility enters in before recovery, that even an active addict or alcoholic can choose to make the effort to get clean and sober, but I’m not sure that’s a hill worth dying on.

    Commenting on the first comment, above: I understand that the chemical factor never really goes away. Other issues may be worked through in periods of sobriety, but for at least some recovering addicts, the desire to use never fully disappears. I have known one or two who seemed to have fully lost the desire, which makes me wonder how *chemical* their addiction was. But I also remember hearing that, because the chemical factor never disappears–that, in fact, it takes at least three generations of non-users in a family line to clear it–the effect of alcohol or other drugs is much greater, after years of sobriety, than it had been before. I.e., a person who had exhibited no outward signs of impairment until he’d downed a six-pack of beer and a couple of other drinks might, after several years of abstinence, find one or two drinks having much greater effect.

    I heard all of that 20 years ago and don’t know whether it is backed by more current science, however.

  4. If I may? I am going on 2 years sober. Before that I had 4 years. I hated drugs and alcohol, but I couldnt stop. If I picked up either, I couldnt stop, my brain just kept telling me I needed more. I was ashamed at my own weakness but could not seem to stop. I hated myself, at the end I couldnt even look in a mirror. I thought the only way to stop was to kill myself. You can see I didnt succeed. However I was put into a place that weened me off of what I was on and then gave me the tools I needed to advance farther in recovery. I can never take another drink or drug. That first inbibe will kill me. maybe not that day…but it will.

    Thank you for your post Dr.

  5. It was so refreshing to read a very well balanced article on addiction. I’m pretty new to recovery and become somewhat frustrated with viewpoints of persons non-addicted who don’t get it. I never did either until I found myself there. Sure, there is willpower and wanting to be sober, but there are also other factors which we all know about. The more education and awareness that is available the better. Don’t get me wrong, I was exposed to enormous amounts of education and awareness and still drank until it became the choice for me of death or life. All I know at this time in my life I have a long road ahead of me not only for sobriety but for trying to repair the destruction I have created. I now find myself devouring every article, story, movie, etc. on addiction. Bottom line is it’s easy to die, but hard to recover and the power of alcohol and drugs is undescribable and of all who seek treatment a very few survive. Christina R.

  6. I am glad that you are reposting this series. I thought they were great the first time I read them…and will send my readers your way.

    God bless!

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