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.

Legends of the Call

hunting knifeThis is my call weekend.

Call weekends–where you cover for a host of other physicians, so that the fortunate many may enjoy some time off at the expense of the unfortunate SOB on call–are akin to ritual self-flagellation: long days, longer nights, countless phone calls from emergency rooms and ailing patients, most of whom you know nothing about beyond what they tell you over the phone. If your Karma is good, you may be spared the worst, perhaps even get some sleep. If not, the punishment is severe, and survival until Monday becomes your sole goal in life.

On occasion, however, there are a few lessons to be learned. Such was the case this weekend, my instructor being a most unfortunate gentleman who, alas, had plans far different from being my teacher. This weekend I learned:

  1. Don’t drink to excess.
  2. If you do, don’t try to sober up using crack cocaine.
  3. Don’t visit prostitutes, whether or not you adhere to lessons 1 and 2.
  4. If you do visit prostitutes (and I’m not suggesting that you do–see lesson 3), pay them for their services.
  5. If you refuse to pay them (and I’m not suggesting that you do–see 3 and 4), don’t inform them of this fact while standing around in your birthday suit.
  6. If you decline payment for the services of a lady of the evening, while still in your birthday suit, be sure she doesn’t have rapid access to sharp knives.

I encountered a man, at 2 AM Saturday morning, who embodied the Proverbial addage: “Better to meet a bear robbed of her cubs, than a fool in his folly”–and who managed to make all of the above mistakes, in perfect sequence. The fair maiden, her purity despoiled and robbed of her just desserts, did repayeth said gentleman with the “unkindest cut of all”–a deadly underhand stroke designed to rob him of his manhood. It was, sadly, not a Burma Shave moment, although a close shave nevertheless: while sparing the rod, she spoiled the child–or the children, more accurately–laying them quite naked to the world, neatly bivalving the scrotum while miraculously sparing the jewels.

For those of you with very strong stomachs–or the steely detachment borne of depersonalizing professional training in medicine–here are the operative photographs, before and after the repair.

I warned you not to look unless you had a strong stomach … couldn’t resist, could you?

When asked how such a sequence of events might have taken place, our unfortunate teacher responded: “I don’t know–all I did was start down the stairs…”

I, for one, am going to be staying on the first floor for a while, avoiding the stairs at all costs

The Engine of Shame – Pt II

DRGWIn my previous post on guilt and shame, I discussed their nature and differences, their impact on personal and social life, and their instrumentality in much of our individual unhappiness and communal dysfunction. If indeed shame is the common thread of the human condition–fraught as it is with pain, suffering, and evil–it must be mastered and overcome if we are to bring a measure of joy to life and peace to our spirits and our social interactions.

Shame is the most private of personal emotions, thriving in the dark, secluded lairs of our souls. It is the secret never told, the fears never revealed, the dread of exposure and abandonment, our harshest judge and most merciless prosecutor. Yet like the Wizard of Oz, the man behind the curtain is far less intimidating than his booming voice in our subconscious mind.

The power of shame is the secret; its antidotes, transparency and grace. Shame thrives in the dark recesses of the mind, where its accusations are amplified by repetition without external reference. Shame becomes self-verifying, as each new negative thought or emotion reinforces the theme that we are rejected and without worth. It is only by allowing the light of openness, trust, and honesty that this vicious cycle may be broken.

The barriers to this liberating openness are fear and mistrust: fear that revelation of our darkest selves will lead to rejection, pain and humiliation; and lack of trust that the sharing of such darkness will be used against us to our detriment. This fear and mistrust lock us into a self-imposed prison from which there is seemingly no escape. Our only recourse becomes the adaptive but destructive defenses of withdrawal, self-attack, avoidance, or aggression.

The most dangerous type of infections in medicine are those occurring in a closed space. As the bacteria grow, they generate increasing pressure which drive deadly toxins into the bloodstream. Only by uncovering and draining the abscess can the infection be treated and health restored. And so it is with shame: we must take that which is most painful, most toxic, and release it, lest we become even more emotionally and spiritually sick.

So just how do we go about such a process? It is not something to be done lightly, as the world remains a dangerous place, and there are many who cannot bear such disclosure–and who may indeed use it against us. It is for this reason–this reasonable fear (amplified many times over in the echoes of our inner chambers of shame)–that many will not take this step until life circumstances become so difficult or painful that they have no other choice. Hence you will find this process first in the alcoholic at his bottom, at the therapist for intractable depression, at the counselor after divorce, in the prodigal son re-seeking fellowship in a grace-based church or small group.

But we need not wait for such disasters before beginning the process of addressing shame. There are a number of principles to begin the journey from shame to sanity and peace. Here are a few which come to mind:

  • Sharing of shortcomings with trusted friends: First and foremost, we must be willing to open the door, to begin sharing something of our inner selves with others. This involves finding someone trusted, someone who is a good listener and not quick to judgment. It means taking some risks, as many people may be unwilling–or unable–to be safe harbors for our vulnerabilities, failures, and shortcomings. Test the waters by sharing some small issues with others who seem trustworthy–or perhaps even better, by being open to others who may be willing to share their pain in some small way with you. Nothing builds the trust of others quite like your own vulnerability: it signals a willingness to establish a relationship based on true intimacy. We all put our best foot forward, expending great energy at maintaining our masks. But at the same time, we all hunger for the intimacy of being truly open with another.
  • Learn to listen: Our isolation begins to lessen when we hear our story repeated by others. As we begin to hear the bits and pieces of our own experiences, failures, and struggles in the lives of others, the uniqueness–and the shame–of our own experiences begins to lessen. We develop compassion for the struggles of others–and thereby become willing to accept our own shortcomings. Becoming mutually vulnerable is the essence of true, intimate relationships–and to achieve this we must be willing both to share our own weaknesses and to accept those of others.
  • Honesty: Deceit and shame go hand-in-hand–dishonesty with self and others is a requisite for the maintenance of the autocracy of shame. Dishonesty becomes habitual, making life far more complicated and difficult than one based on openness and truth. The main driving force for deceit is fear: fear of discovery, of condemnation, of judgment, of rejection. In reality, the consequences of honesty about our failures and shortcomings–particularly with those we trust and with whom we reciprocate acceptance–is far less onerous that of sustaining the fragile edifice of a life of lies.
  • The importance of forgiveness: When you begin to make yourself open to others, trusting them, you will sooner or later get hurt–perhaps intentionally, more likely inadvertently. Count on it, it’s a sure bet. Once it happens, you then have some choices: you can withdraw, no longer exposing yourself to the pain, or strike back, or carry a resentment. These approaches are proven shame-builders: they do little or nothing to visit revenge on our offenders, but rather replay the injury over and over (re-SENT-ment: to experience–to feel–again), reinforcing our loneliness and worthlessness. Forgiveness allows you to move on. It may mean taking the risk of confronting the one who has hurt you–a terrifying thought for a shame-based person–but such courage pays off in restored relationships at best, or maintaining your dignity at worst. Courage is not acting without fear, it is acting in spite of fear–and is the best antidote to fear, as reality is virtually never as bad as the scenarios our fearful minds fabricate. Bear the pain, reconcile where possible, and move on from there.
  • Other-orientation: We are designed to give, but have been programmed to receive. We try to fill our inner emptiness by getting: material stuff, the attention and admiration of others, pleasure, the oblivion of drugs or alcohol, food, sex, success, achievements in work or society. None of it works–the emptiness remains, as we are not worth something because we have something. We become worth something when we give–when our actions and efforts are helping others, improving their lives, giving them joy, help, comfort, support. This is why someone like Mother Theresa experienced a richness in life unmatched by endless hosts of wealthy, famous celebrities or business billionaires. We nod, agreeing that this is so–but no one wants to walk her path: we lack her faith, and her calling. But we don’t need to move to Calcutta to start down the same path: we can begin in small ways, one little act at a time. Make an effort to help someone out each day, somebody who doesn’t deserve it, perhaps someone you don’t like or would rather avoid. Do it when you’re too busy, or self-absorbed, or too tired. Do it willfully, not grudgingly. Don’t do it with any expectation of return. Try it–and watch miracles begin to happen, in your life and those around you.
  • Grace and mercy: Grace is receiving what we do not deserve; mercy is not receiving what we do deserve. Shame tells us we deserve nothing good, that we are tried, convicted, and condemned both by ourselves and by others. Grace trumps shame by not waiting until we are worthy, or worthwhile, or “fixed”, but by accepting us right where we are, just as we are. It must be experienced–it cannot be appropriated by logic, reason, will or effort. It is, indeed, anti-logical. It starts when you tell a friend a painful, dark secret–and hear that he has done far worse. It begins with terror at relating humiliating events, and ends with laughter and perspective about those same events. It arrives when you tell of hurting another, and receive not condemnation but understanding and guidance on repairing the damage and restoring relationships. And it shatters the gloom like shafts of light through broken clouds when the God whom you have driven away and abandoned–a God in whom you have lost all hope and confidence–instead wraps His arms around you in tears of joy at your return. When you have experienced such grace, your life will never be the same again.
  • The role of faith: People struggling with guilt and shame often turn to religion for answers and relief. This is not invariably a wise decision: religion can be of enormous benefit in overcoming these liabilities–but can also greatly exacerbate them. Guilt and shame are the golden hooks of toxic religion and religious cults, and even mainstream religious denominations which have a highly legalistic emphasis can cause far more harm than good. Cults and toxic religion lure the wounded by offering “unconditional love”–which later proves very conditional indeed. You are accepted only when you rigorously follow the rules–which may be arbitrary, capricious, or even unspoken–and interaction with “unbelievers” outside the sect is severely restricted, leading to isolation, ritualism, and depersonalization–and severe rejection should you choose to leave. Becoming enmeshed with such groups, driven by shame, is highly detrimental and a recipe for personal and emotional disaster. But true grace-based faith and spirituality can transform shame into service, guilt into gratitude. It finds the balance between a God who is just and One who is merciful. It is a place where love accepts us with all our imperfections and shortcomings–yet desires their removal that we may live with more joy and purpose, not hiding our flaws but using our own brokenness to restore, heal, and lift up others.

There was–the story goes–a holy man, who sat by the side of the road praying and meditating. As he watched and prayed, the broken of the world passed by–the crippled, the lame, the ragged poor, the sick, the blind. In his prayer, with broken heart, he asked God, “How could such a good and loving Creator see such things and do nothing about them?”

There was a long period of silence with no answer. Then, in a soft voice, God replied: “I did do something about them: I made you.”

Our shame, our brokenness, brings us great pain and wreaks much destruction in our lives. Yet it is by this very means that God equips us to be His hands, His heart, His voice, His compassion. In such can be found a purpose in life unmatched by anything else we might wish for or desire. Such are the ways of the God of endless surprise and limitless grace.

The Engine of Shame – Pt I

Steam locomotiveA wise friend–a man who helped me emerge from a period of considerable difficulty in my life–once taught me a simple lesson. In less than a minute, he handed me a gift which I have spent years only beginning to understand, integrating it into my life with agonizing slowness. It is a lesson which intellect cannot grasp or resolve, which faith only begins to illuminate–a simple principle which I believe lies close to the root of the human condition.

My friend taught me a simple distinction: the difference between guilt and shame.

While you no doubt think I am devolving into the linguistic morass of terminal psychobabble, I ask you to stick with me for a few moments. What you may discover is a key to understanding religion, terrorism, social ills such as crime and violence–and why the jerk in the next cubicle pushes your buttons so often. On the other hand, if you’re among those who believe guilt and shame are simply the tools of religion and society to restrict your freedom–that as a perfectly liberated postmodern person you are beyond all that–well, you are probably wasting your time reading this. But most of us recognize the influence of guilt and shame in our lives–even while trying not to focus on them, as they are uncomfortable emotional topics, best avoided if possible.

There is a tendency to conflate guilt and shame, merging them into a single human response to bad behavior or personal shortcomings. Yet they are quite different. Guilt is about behavior, shame about being. Allow me to expand on this a bit.

Guilt is an emotional–or some would say spiritual– human response to behavior or actions which violate a respected set of rules. The rules violated may be internal or external, and may be based either in reality and truth or distortion and error. The rules which may engender guilt must be respected: that is, they must originate from a valid source of authority–parents, elders, religion, law–or have been internalized into one’s personal mores or conscience from one or more such sources. Rules which are not respected pose no difficulty: I feel no guilt at not becoming a suicide martyr for Allah, since I do not respect (i.e. recognize as valid) the rules which promote such behavior. The response to violating respected rules is at its heart based on fear: fear of punishment by God or man, fear of rejection, or fear of ostracization from friends, family, or society.

Since guilt is an uncomfortable emotional state, we generally make efforts to avoid or mitigate it if possible. There are a number of means by which this can be accomplished, with greater or lesser efficacy. We may of course, practice avoidance of the behavior which induces the guilt. If the rules are legitimate and based on worthwhile principles, this is obviously a beneficial approach: if you don’t steal things, you won’t go to jail for burglary. But avoidance may prove destructive if the rules are based on error. For example, if your parents or religion have taught you that all sexual activity is wrong or evil, this can prove a huge impediment to physical intimacy and relationships in marriage.

Guilt may also be mitigated–especially when it is chronic and recurring–by changing the rules. You may leave a religion which is highly legalistic for another less so–or for none at all; you may change your situation or environment to one where the rules can be ignored and not enforced; you may seek counseling to correct perceptions about sexuality or other destructive interpersonal biases or beliefs. Or you may simple practice denial–justifying your behavior through the creation of new internal or social rules, while avoiding or rationalizing the inevitable consequences of your still-errant behavior.

So guilt may be addressed by modifying behavior or changing belief systems, through choice or denial. What then about shame?

Shame–the very word makes us uneasy, striking deeply into the core of our being. For shame is not about what we do, but about who we are. It speaks to a deep sense of unworthiness, rejection, inadequacy, and isolation. It says we are not OK, that what we truly are must be hidden. And this we do with all the energy at our disposal, throwing up an impenetrable wall to keep others out at all costs. For the essence of shame is relational–it says that if you really knew what I was like, you would be repulsed and thus reject me. The resulting isolation–real or perceived–is a devastating threat, engendering a pain so profound it approaches unbearable.

The origins of shame are varied, and not fully understood. We seem to be programmed to interpret certain words and behavior by others–especially parents and siblings in childhood–as not simply critical of our behavior, but a statement of our worth. This is an especially powerful force coming from parents, under whose authority and supervision we are molded into social beings. While this may be especially pronounced in dysfunctional or abusive homes–alcoholism, sexual abuse, and mental illness come to mind–it occurs even in well-functioning family units, and with speech and actions which are not intended as critical or demeaning, but which are interpreted as such. The soil of the soul seems fertile ground to bring forth a tainted crop of shame, even from the seemingly benign bruises of normal human interactions and relationships.

From the Judeo-Christian perspective, this propensity toward shame is understood as rooted in the spiritually-inherited rupture of our relationship with God, manifesting itself in an extreme self-centeredness and self-focus, which acts as a toxic filter letting in the destructive while keeping out the good. Having been born into a state of remoteness from God–perceived at a spiritual level as rejection by Him, though in fact just the opposite–we are acutely sensitized to rejection by others: it fits the mold perfectly. Thus every real or perceived hurt, criticism, or rejection simply confirms that we are rejected, worthless, and of no value. Our self-centered mindset insures that even events not focused on our self-value are interpreted in ways that affirm our sense of shame–hence the child that blames herself for her father’s drinking and abusiveness.

While shame lives deep below the surface–a monstrous child kept hidden from public view–its manifestations are legion, and its ability to percolate to the surface and alter our lives and behavior is formidable. The pain of shame requires response, no less than a hand on a hot stove, and it may be triggered by many means: by concerns about physical size, strength, skill, or ability; by issues of dependency or independence; by competition with others; by worries about personal attractiveness and sexuality; or when dealing with matters of personal closeness and intimacy. Thus triggered, an outward manifestation is inevitable, and will generally fall into one of four general responses:

  • Withdrawal — perhaps the most natural response to pain, we retreat from its source to avoid the risk of exposing our vulnerability. Hence we steer clear of people or circumstances which may trigger shame, withdrawing into a nominally safer–but profoundly lonely–world. This response may range in manifestation from shyness up to deep, pathologic depression or psychosis.
  • Attack Self — The loneliness of withdrawal and isolation is itself a deeply uncomfortable state, and often raises the profound terror of abandonment. To avoid such painful estrangement, many will resort to demeaning and depreciating themselves, thereby becoming subservient to others more powerful, resulting in a condition of dependency. While this may lessen the pain of isolation and abandonment, it further exacerbates the underlying shame by reinforcing one’s worthlessness and inferiority. The relationships so formed are not those of equals, and therefore satisfy the need for true intimacy poorly. Such responses range from obsequiousness and self-demeaning deference to others, to depression, and all the way to masochism, self-mutilation, and suicide.
  • Avoidance — If the shame cannot be eliminated, the feelings most surely can: shame is soluble in alcohol, can be freebased, and its pain assuaged as well by a host of other self-destructive behaviors. One’s choice of drug–chemical or behavioral–is influenced by genetics, neurochemistry, and environment, but all have the common goal of emotional oblivion. Eating disorders, obsessive-compulsive behavior, behavioral addictions to work, computers, gambling, or sex can divert the mind and stimulate sufficient endorphins to make the pain go away–at least for the moment. But the drugs and behaviors only worsen the underlying sense of failure and inadequacy, and lead to fractured and destroyed relationships, loneliness, and sometimes physical illness and death.
  • Attack Others — Rage and anger are common responses to shame, as we seek to defend our threatened worth by destroying the antagonist–or at least diminishing their worth, through sarcasm, criticism, gossip, physical, verbal or sexual abuse, or violence. But as with other coping mechanisms for shame, the outcome is invariably destroyed relationships, and adverse consequences, both legal and personal.

Thus the engine of shame drives a host of behaviors which are both personally destructive and socially disruptive. If you scratch the surface of nearly any dysfunctional personal or social problem–alcoholism and drug abuse, obesity, school violence, inner city crime and teen pregnancy–even international terrorism–you will find at its dark heart the issue of shame. It is, at the very least, a common thread among such societal and personal liabilities, if not a central driving force.

So it behooves us to get a handle on this matter of shame, uncomfortable though it may be. Our responses to its provocations are major causes of personal agony and social crisis. But like a schoolyard bully, once confronted face-to-face, the tyranny of shame can be broken through courage and openness, and the strength of numbers. On these thoughts I will be reflecting in a subsequent essay.

The Revenge of the Fifth

MercuryIt seemed like such a great idea at the time…

His name is Darin. Of course, that’s not his real name, but he is a casual friend of mine. A bright young man, possessed of good looks, a warm smile, and a soft-spoken demeanor. Darin is brilliant with computers–not merely competent, as many are, but a true geek, tear-’em-down-and-rebuild-’em smart, fearless in the depths of sockets and motherboards, Windows registries and Unix terminals. A true success story, you might say, bright future, make some girl very happy. But Darin was toolin’ down the freeway of goin’ nowhere fast.

You see, Darin had a little problem: a fondness for the grape and the snort which always seemed to get the best of him. Not that he didn’t try: he was in and out of AA rooms more often than a pastor’s wife at church socials, always returning beaten and remorseful, determined to do better this time. “This time” rarely lasted more than a few weeks or months.

Darin was quiet, but a man of passion. He was always in love. Intoxicated with the flush of a new romance, that rush of euphoria so real yet so maddeningly transient. Each new girl was “the one”, but nights of passionate, drug-enhanced sex soon proved impotent to overcome the waning charm of Miss Demeanor, the rumpled sheets, and the rumblings of his restless soul. Before long he was again cruising for some other codependent wench, herself seeking a sodden soul to save. Like an ugly tie wrapped up pretty under the Christmas tree, Darin’s package looked good at first glance, but he quickly proved to be a daddy’s nightmare: “no phone, no food, no rent”, as the song goes. Soon he was once again welcome only in his mother’s house, with whom he could do no wrong.

Unfortunately, the same could not be said of Darin: someone did him dirty, stiffing him out of a good deal of cash, and forgiveness was not one of his many charms. The details are murky: a computer built or repaired, promises made but unkept. There was much lighthearted chatter at the coffee houses–was it Darin’s fault, or his nemesis? No matter–like a quiet bubbling cauldron in a witch’s lair, Darin was cooking up his favorite dish: a rip-roaring resentment. Not visible on the outside, of course, but raging like a Jerry Springer slug-fest in the conference rooms of his mind. It was the perfect mixed drink: a perceived injustice blended with that unique obsessiveness which addicts possess seemingly in endless measure.

It is not clear when the brainstorm struck–an idea so brilliant, so flawless, that it would right all injustices and settle all disputes: Darin would break into his detractor’s home and steal back the computer which tortured him so. No mere larceny, mind you, but the picture-perfect crime, a liberation to rival Paris in ’45. Carefully timed when the enemy was not at home, staged so not even Sherlock Holmes would presume that Darin might be the perpetrator. Sweet revenge, sweetly executed.

Like tightly-written computer code, Darin’s nimble mind set the parameters, checked the variables, and executed commands in a tight loop whose efficiency and speed wasted no cycles. The Day of Vengeance arrived, with only one small ingredient missing: courage. But Darin had that algorithm factored as well: a fifth of Vodka erased all fears, drowning all doubts. By stealth of night, with watches synchronized and bottle drained, the window glass parted to usher him to glory. The mission was underway.

No one knows whether anyone heard the shattering of glass, but despite his stealth the disruption somehow caught the notice of neighbors. When the police arrived, the cause of the disturbance became evident: there was Darin, passed out on the floor, beside the untouched computer he coveted. Fate had struck a cruel blow–his celebratory blackout had arrived on the wings of Mercury rather than with the spoils of Mars. He awakened to handcuffs and an open-ended reservation at the Gray Bar Hotel.

All good stories–even true ones–should have a moral, but Darin’s story eludes easy lessons. He was taken by that peculiar insanity which alcoholics possess in abundance, even while sober. When Darin hatched his master plan, he was not drinking, but engaged in one of his countless attempts to clean up. For the alcoholic, the danger lies not in the bottle, but in the brain. The sane among us make mistakes, to be sure: wisdom comes from experience, and experience often comes from lack of wisdom. But facing the inevitable consequences of bad choices, we generally rearrange our lives and priorities to ensure that such a travesty does not happen again. Not so the alcoholic. Obsessively repeating behavior long ago proven destructive, he nevertheless pursues the optimism of denial which says the next time will be different. This baffling disconnect from reality cascades from farce to tragedy, as the alcoholic perceives no problems other than those bastards who are out to get him.

There is much resistance to the idea that alcoholism and addiction are a disease. Much of this comes from conservatives, and those of religious conviction, whose proper emphasis on personal responsibility and moral rectitude sees in the alcoholic only reckless hedonism and wanton irresponsibility. These qualities the addict has in spades, but less obvious is the driving obsessive compulsion, the thought disorder which is their engine. The medical evidence for the disease model of alcoholism and addiction is deep and wide, as I have detailed in part elsewhere (see also this and this for more on the topic). The liberals have this one right: the alcoholic is a victim of his or her genetics, and the addition of a mind-altering drug–which one is probably moot–starts a swirling whirlpool whose vortex holds only misery, destruction and death. Not many survive its power.

Yet defining deviance from normal as disease also has its risks: the proliferation of social disorders redefined as diseases seems endless, and points to the abrogation of all responsibility for one’s actions. It can become laughable at times. Several years ago, I saw a patient, a healthy, athletic women in her 40’s, who was covered under Medicare. Medicare covers the elderly, but also those with chronic renal failure and the disabled, so I inquired as to the nature of her disability. I was informed she had “hyperactivity disorder.” Attention deficit hyperactivity disorder (ADHD)? No, just hyperactivity disorder–she was restless. A black belt in Karate, she traveled around the country constantly, competing in tournaments and teaching seminars. She was disabled, in short, because she couldn’t sit still. No “cripple” jokes around her, no siree, unless you wanted your skull crushed by a foot you’ll never see coming.

The concern about labeling alcoholism, or any other behavioral disorder, as a disease is the tendency to tolerate and rationalize the resulting behavior, to use the “disease” label as an excuse for selfish, self-centered behavior destructive to one’s self, society, and those around you. The issue is not disease or no disease, but rather what drives the behavior and what can be done to change it.

The paradox about 12-step programs–which have the only reliable track record for successful recovery from addiction–is that they emphasize the disease as the problem, and honesty, integrity, and personal responsibility as the solution. They do not excuse the behavior while admitting the disease, and this blend of honesty and humility, acceptance and tough love, works like nothing else. It is, as recovering alcoholics are quick to point out, a spiritual program: the Catch-22 of a body which craves alcohol without limit and a mind which denies the resulting problems cannot be solved any other means.

But as any recovering alcoholic will tell you, the problem is not the booze; it is not even the obsessive, irrational mindset which drives the drinking. Both these problems are symptoms of an underlying decay, one of spiritual dimensions, characterized at its core by extreme self-centeredness. The pursuit of happiness by feeding this monster creates not the promised joy but rather pain and emptiness. Alcohol hides that pain for a while, until the monster, growing ever stronger by its constant feeding, kills its host spiritually, emotionally, and often physically.

But addiction is hardly alone as a symptom of this dark core. The list of destructive behaviors arising from its belly is endless: obesity, sexual promiscuity, compulsive overwork, materialism, computer obsession, gambling, the pursuit of beauty over character, the lust for money and power. Some may be biologically-driven; some learned behaviors or dysfunctional coping. All seek to fill a hole with no bottom, providing the wrong salve for the pain, and more of the same when the salve makes the wound fester.

And what of Darin? In many ways he is fortunate: his life is on hold, and forced reflection and change are his for the taking–should he choose to grasp them. The price is high; it might have been much higher. Yet his choice–and ours–is the same: feed the monster, or turn life over to One whose burden is light, who alone can fill that deep inner void.

There Is a Solution

rose“There is a solution.” So starts a chapter of the
Big Book of Alcoholics Anonymous – the virtual Bible of recovery from alcoholism and the basis of all 12-step recovery programs. And it works – according to the testimony of millions of recovering alcoholics and addicts in the nearly 70 years since the inception of AA by its two founders, Bill Wilson and Dr. Robert Smith.

In our age of science, secularism, and skepticism, such simplistic answers seem almost mythical, perhaps purely psychological in origin. And the basis of the success of 12 step recovery programs remains incompletely studied and poorly understood. To those in recovery, this comes as no surprise, for they attribute their success to a fundamentally spiritual process of transformation, one therefore not likely to reveal its secrets through the rigors of scientific study. But the overwhelming power of addiction in the lives of those affected – seemingly immune to force of will, ravages of disastrous consequences, or the intervention of psychology, counseling, or pharmacotherapy – succumbs only to the apparent impotence of humility, honesty, and submission to others.

Despite our culture’s formidable expertise in psychology, neurophysiology, pharmacology, and social science, despite billions spent on the war on drugs, we have failed miserably at solving the addiction problem. Yet the very fact that anyone can recover from the hopelessness and destructiveness of this disease is remarkable. That millions have done so – unaided by medical science, psychiatry, or neuropharmacology – is truly a phenomenon.

In some regards, recovery programs like AA are rather simple: if you don’t drink, or take the drugs, you don’t start the physiological process which creates an intense craving for more of the same. Furthermore, the adverse consequences of substance use also disappear: if you don’t drink, you don’t get a DUI, or end up in jail for vehicular homicide. If you stop shooting up, your chances of acquiring hepatitis, AIDS, or endocarditis go away. Most alcoholics and addicts who stop drinking or using find their lives get better relatively quickly: their health improves, many social conflicts resolve, they keep their jobs and become more stable financially. Reason would dictate that this is the only sane way to live. But reason evades the addict even when dry, and such logical and will-based attempts at sobriety are surprisingly short-lived as a rule.

It is not clear whether the thought disorder of addiction – the obsessive desire to pursue a substance despite diminishing euphoric returns and increasingly dire consequences – is acquired as a result of the intake of the large quantities of drugs over time, or is rather inherent in the underlying physiology and genetics of addictive disease. It is likely, however, that the secondary psychological compensation mechanisms – denial, rationalization, minimalization, etc. – are a result of the need to accommodate the cognitive dissonance resulting from obsessive-compulsive drug pursuit and the spiraling negatives resulting from such abuse. Herein lies the trap for willpower-driven abstinence: it does not remove the obsessive component and is therefore undermined by the mind’s incredible capability to use denial to achieve what it so desperately desires. And here is where the true wonder of recovery lives: successful recovery provides the tools to overcome the obsession and the profound denial which enables it.

So how do 12-step programs like AA accomplish this feat? Recovering addicts and alcoholics are quick to reply that they don’t understand it, it just works. But it is not hard to postulate some mechanisms by which it succeeds.

Cessation of drinking or drug use, after a period of physical withdrawal (a high-risk period both physically and for relapse), ultimately removes the physiological craving induced by the drugs themselves. But the psychological obsession remains and is typically intense, often for many days or months. It is during this period that the continual support of peers who have endured and survived this extraordinarily difficult passage is critical. Group meetings, frequent phone contact, and close association with recovering individuals is critical at this juncture.

This is the main value of treatment programs, especially those with inpatient confinement. The addict is separated from their drug, isolated from high-risk environments and associations which can trigger the potent denial mechanisms to their detriment. The alcoholic or addict is also thrown into forced association with others in the same dire straits, as well as those in recovery who understand the problem clearly and objectively. This provides an excellent opportunity to begin breaking down the self-deception and dense denial which propagates the problem. It is easier to see a problem in others than in ourselves – particularly when their experience parallels your own, and others’ weaknesses and shortcomings are openly shared. The alcoholic or addict may not believe in the principles or program of recovery, but it is hard to deny the proof of its effectiveness in the lives of those who have traveled the same journey, successfully overcoming their liability.

There is a certain amount of magical thinking among public policy makers and pundits about the value of drug and alcohol treatment, however. Treatment facilities do not have some magic mojo they can whip out to convince the addict of the errors of his ways, forever setting him on the path to a sober life. What must occur is that the alcoholic must be willing to change, and trust the guidance of others to succeed at something far too difficult to master by oneself. Trust of others also runs counter to the endemic paranoia of addicts. These are no small hurdles for those who enter treatment, even willingly – and for those involuntarily confined without sufficient desire to change, they can be insurmountable.

This is what alcoholics call “hitting bottom”: pain intense enough, and willingness sufficient enough, to become determined to change and follow the direction of others to overcome the hopelessness of addiction, no matter how foolish or implausible the process seems. Self-denial not self-confidence or self-control – is the key ingredient. Some, through impenetrable denial and determination to resist change no matter what the cost, never reach this point. “Their chances” – as the Big Book says with classic understatement – “are less than average”, with relapse, disaster, and often death the ultimate fruit of their recalcitrance.

The surprising benefit of pursuing recovery successfully lies not only in deliverance from the obsessive destructiveness of alcohol and drug abuse, but in the almost inevitable acquisition of life skills and peace of mind which are enormously positive and enriching. Those successfully recovering from addiction – particularly those who maintain relationships with others in recovery, pursuing honesty, self-sacrifice, and regular efforts to enhance their spiritual lives – are often far better adjusted than even emotionally healthy individuals who have never abused drugs or alcohol. What is evident here are the fruits of brokenness: a deep humilty from reaching the end of our own resources, the gift of grace manifest in selfless giving by others so humbled, and the power of God to transform lives, overcoming evil with good.

The Downward Spiral

Japanese woodblock printIf you take the opportunity to speak with those who have survived the ordeal of addiction and alcoholism and who are in recovery, you will find a wide range of stories and experiences. When we think about those who are alcoholics and addicts, they are typically viewed through the lens of late-stage affliction: homeless, disheveled, living on the street or under bridges, hanging out in seedy bars or shooting galleries, exhibiting anti-social and criminal behavior. What is less apparent until we take a closer look is that addiction is an equal-opportunity destroyer. I have spoken with men and women in recovery from many walks of life, from high-rolling investment bankers to common laborers; physicians, attorneys and accountants; contractors and convicts, housewives and hookers. Each person has his or her own story, but there is an eerie commonality shared among them.

Early patterns and progression of drug or alcohol use in addicts vary widely among individuals and their preferred drugs. Some drink to blackout from the first; others pursue what appears to be normal consumption for years before accelerated use. At times, surprisingly, early experience with alcohol or drugs is decidedly adverse, yet repeated use still follows. The substance used can also have a large impact on abuse and behavior: drugs which cause large and rapid swings in neurotransmitters, such as crack cocaine, tend to produce more rapid behavioral change and addiction. At some point, early or late in the user’s history, the most significant change occurs: the addict begins to crave the drug in an obsessive manner, regardless of negative consequences or experiences. The drug is no longer merely wanted for its effects; it must be used, no matter what its effects. The fatal attraction has begun.

Repeated use of drugs or alcohol produces certain physical and physiological changes. The substances stimulate enzymes and metabolic pathways which enhance their metabolism by the body. This phenomenon is known as tolerance. Tolerance occurs not only for the euphoric or mood-altering effects, but for other effects as well. For example, opiates in high doses in non-tolerant individuals produce sedation, severe constipation and impaired respiratory drive, and can result in cessation of breathing altogether. Yet opiate-tolerant individuals (addicts and those taking such medications for medical purposes, such as cancer patients) can tolerate doses which would be lethal in others, with little adverse effects.

The other major physical effect of prolonged drug use is dependence, wherein sudden cessation of the drug results in a withdrawal syndrome which is highly unpleasant or even fatal. Exact symptoms vary by drug, but often include irritability, mood changes, agitation, abdominal pain, sweating, hallucinations, and seizures.

A common misunderstanding – even among medical professionals – is that addiction and physical tolerance and dependence are one and the same. They are not. Place the addict and the non-addict side-by-side, and administer potent narcotics such as morphine on a regular basis over time, and both will develop tolerance and physical dependence, requiring more drug to achieve the same effects. Both will exhibit physical withdrawal symptoms if the drug is suddenly stopped. The difference is seen in what happens next: the non-addict will be glad to be off the drugs with their unpleasant side effects; the addict will obsessively seek them again, even if their euphoric effects are no longer experienced – a dilemma which is increasingly likely as length of use and dose increases.

It is this obsessiveness, and the resulting compensatory mental responses to its demands, which lies at the heart of addiction and alcoholism. The drugs themselves in susceptible individuals produce intense physical craving for more – far exceeding such instinctual demands as hunger and sex – but it is the mental obsession which is ultimately so destructive. Were the adverse physical and social effects of addictive drugs – and their rapidly diminishing euphoric benefits – the only problems addicts and alcoholics faced, most would endure the suffering of withdrawal to restore their physical, emotional, and social well-being. But the obsession persists even when sober, ultimately laying the trap for recurrent use, progressive physical, personal, and social adversity, even to the point of insanity, incarceration, illness or death. And this process occurs while the addict or alcoholic remains blissfully and stunningly unaware of profound negative consequences.

As drug or alcohol use accelerate, and physical and social problems multiply, the obsession does not relent, but rather intensifies, resulting in a host of
psychological defense mechanisms, including denial, minimalization, and rationalization. Deceitfulness is a cardinal manifestation as well, lying both to oneself and to others until the line between truth and untruth is no longer discernible. Indeed, the ability to use free will at all becomes severely impaired, as pursuit of the obsession becomes equated with survival itself. As Dr. Jeffrey Smith states in his discussion of alcoholism and free will:

Alcoholics and addicts not yet in recovery behave as if they were fighting to preserve life itself. They act as if they are citizens in a malevolent society where operatives are using every technique including authoritarian force, manipulation and seduction to attack their existence. They valiantly resist all efforts to effect change. They may not like to lie, but they will if necessary. They use specialized psychological defenses including denial, minimization, rationalization, blaming, intimidation and proclaiming the right to make their own decisions in life. Like victims of oppression, they go underground in their attempts to protect their freedom. Their defenses become habitual and function smoothly even when cognitive faculties begin to fail.

Such a perversion of thought and action is extraordinarily destructive, not only to the individual, but to immediate acquaintances, family, co-workers, and society as a whole. It is unsettling and mystifying to see an end-stage alcoholic, days from death, denying his problem and demanding a drink, but this is the end result of a process of compulsive self-deception driven by forces far larger than the ability of mere human will – no matter how determined – to resist.

It is the failure to understand the physical power and mental distortions of addiction which results in so many simplistic societal solutions, doomed to failure however coercive or well-intentioned. By understanding these forces, however, although simple solutions to this pervasive problem do not immediately spring forth, nevertheless the journey to freedom can begin. This is the testimony of many who have recovered and repurchased their lives from its destructive slavery.

Addiction & Judgement

cat with cigaretteI 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 like O’Reilly, and agree with him maybe 60-70% of the time, but he — and almost all conservatives I’ve heard — 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 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 montage, 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.