July 5

Of Guns and Butter: The Economics of Prohibition

Since the Harrison Act in 1914, the national policy for managing substance abuse in the United States has been prohibition. In 1970, the Controlled Substances Act began the War on Drugs, although under President Richard Nixon most of the funding went to treatment rather than enforcement. There have been many other legislative attempts to reduce drug and alcohol use in our nation. Yet despite these increasingly harsh laws, drug overdoses– an indicator of overall drug usage– have continued to skyrocket. In 1970, there were 7,101 drug overdoses. In 2020 there were over 90,000. The mortality rate from overdose has jumped from about 1 per 100,000 people in 1979 to 21.6 in 2019.

Clearly prohibition isn’t working.

Is there a better way? Consider the experience of Portugal, which has seen drug use (as measured by usage in the previous 12 months), overdose deaths, HIV, Hepatitis C, and drug-related social costs drop since decriminalizing drugs in 2001.

And yet these two very different national experiences were predictable– and should have been predicted by anyone who has studied economics.

If you’ve taken an economics class, you probably remember the “guns and butter” charts. These demonstrate that because production capacity is limited, producing more of one thing requires producing less of something else. But they also tell us something about price: If more guns are produced, the supply of butter drops and the price goes up. This makes it more profitable to produce butter– an economic opportunity. It’s also an opportunity to invent new substitutes for butter in order to fill the demand.

Now imagine we replace these two products with two others: milk and heroin. As the supply of heroin drops, the price goes up, making it more profitable to supply. And there’s incentive to find and supply substitutes, like oxycodone and fentanyl. Consider that an oxycodone bought by prescription costs about 33 cents, but on the street it sells for $20– a gross profit of 6,000%! That’s quite an incentive. As you can see, prohibition on heroin actually encourages increased supply because it becomes so much more profitable to sell.

But there are other economic behaviors that tell us prohibition should fail. For example, when something is scarce, people want it more. It becomes a status symbol. Which is more attractive to wear: a rare shirt you bought at the concert of your favorite band or a common t-shirt purchased at Walmart? Many people would choose the one that no one else has. Rarity adds value.

And prohibition removes any possibility of regulating content or safety. So long as the substance is outside governmental control, its quality relies solely on the ethics of the provider. And if the substance is illegal, the provider is by definition a criminal whose ethics are open to question. With so much money involved– and a desperate market for the product– customer satisfaction isn’t much of a concern. This is why so many overdoses are linked to adulteration. A poster in a New Hampshire hospital, above, warns that much of the heroin has been contaminated with carfentanil, an animal tranquillizer that is 10,000 times more potent than morphine. People are dying because the drug they are addicted to is illegal.

From the standpoint of economics, so long as there is a demand– for drugs or for any product– there will be a supply. The more we try to stamp out that supply, the more the price goes up and the more incentive there is to provide the product. We cannot reduce demand by reducing supply. That’s not how economics works.

On the other hand, when something is readily available, in the absence of other factors like billion-dollar marketing campaigns, it becomes less appealing.

There are, of course, many other factors driving the addiction crisis in this country. But so long as the substances are illegal, we have virtually no way to control the social cost of this epidemic, nor to limit the tragic loss of life.

June 18

Who We Think We Are (And Why It Matters)

How we think about ourselves determines how we behave in the world. And how we think about ourselves stems from who we believe we are– our self-identity. We identify ourselves in many ways. These include where we live, our ethnic background, our hobbies, our religion, our political party, and what sports teams we root for. But most often, when you ask someone who they are, they will respond by telling you what they do. We identify ourselves most closely with our actions. “I’m an accountant.” “I’m a lawyer.” “I’m a chef.” “I’m a full-time mother (or father).” What we do with most of our time tends to be how we see ourselves.

It shouldn’t be a surprise, then, that someone who struggles with addiction identifies themselves as an addict. That’s how society identifies us. Our behavior is illegal and unacceptable, so we’re forced to hide it. This is true even for alcoholics– even though alcohol is legal, we have to hide how much and how often we drink. And when we get arrested, the judge doesn’t look at us as a parent or employee, he sees an addict or alcoholic who violated the law.

And our lives support this self-identity. We may have a job, but the purpose of that job is to provide money to get drugs or alcohol. We wake up thinking about our drug. We plan for how we’re going to get it and when. Our biggest concern is that we might run out. Our addiction is the central feature of our lives.

Of course, we won’t admit that to anyone else. Often we won’t admit it to ourselves, either. We tell ourselves that we’re good employees, good parents, and good children. But when faced with a choice between our job or our family and our addiction, we most often choose our addiction. I recall several times when I didn’t show up for family Christmas because I was “sick.” I wasn’t sick at all– I was too loaded to drive. My wife says that she insisted she loved her son above all else, but she would often put him in the car after she’d been drinking. The truth is, our addiction came before our family.

The only people who can understand the hold addiction has over us are other addicts. This creates a social bond between those who are addicted, and separates us from those who are not. We may even believe that people who don’t use drugs are the abnormal ones, because everyone in our social circle uses like we do. (If they don’t, we don’t hang out with them, so they don’t stay in our social circle long!)

But of course we lie to our using buddies, too. We claim we don’t have any drugs even when we do, hoping that they’ll take pity on us and share what they have. We steal each other’s drugs and drink each other’s booze–and then deny we did it. We lie about where the money came from and how much dope we have. Because if we tell the truth, we risk getting taken advantage of by someone who is just as desperate as we are to feed their addiction. Despite our social circle, we usually feel pretty isolated because there aren’t many people we can trust. We certainly can’t trust those who don’t understand addiction. And we can’t trust our fellow addicts, either.

So this is most often how we see ourselves: as addicts, alone in the world, struggling to survive, and no one understands us. The world is unjust. We are outcasts, unaccepted and unwanted by society. I remember thinking not that what I did to feed my addiction was illegal, but that I was illegal, because I didn’t believe I had a choice about drinking and using. (And if they really didn’t want me to drink and drive, the city buses would run at closing time!) My identity had become entirely focused on my drug and alcohol use.

When we try to stop drinking and using, this identity needs to change. But change doesn’t come easily. In the beginning, we see ourselves as addicts trying not to use. We still identify as addicts. We’re trying not to use, but we know that the definition of an addict is someone who uses. So we don’t really believe we can stop. We tell ourselves (and anyone else who asks) that we can. But deep down, we don’t believe it because we are addicts and that’s what addicts do. It doesn’t help if we’ve been through the justice system a few times and had cops, judges, and probation officers reinforce that belief, or if our families have given up on us in frustration.

How do we change who we believe we are? It’s a paradox. We change our identity by living differently, and by associating with other people who have changed their identity. But that means we have to live differently and associate with different people, which we don’t believe we can do.

This is where the Twelve Step programs really excel. They take a two-pronged approach. In the short term, you show up at meetings and don’t drink or use no matter what. Anyone can do that for one day, right? So you do it today. And tomorrow you do it again. In the beginning, this simply takes stubbornness and the support of encouraging people.

But there’s only so long we can do this if nothing changes. Eventually, something in our lives becomes overwhelming, and we only have one tool for dealing with it. We may last a week or a year. But eventually, we go back to drinking and using because it’s the only solution we have.

So while we’re stubbornly not using today, we begin doing the program of recovery. We learn tools for dealing with conflict and uncomfortable emotions. We learn new habits like connecting with other people in recovery, talking on the phone between meetings, and taking small steps toward risking trust in them. As we do this, we discover that not using becomes easier each day. We gain more tools in our toolbox. We find other ways to cope with the challenges of life.

As we’re doing this, we also begin to realize that we’re not just addicts trying not to use today. We have become addicts in recovery. And addicts in recovery don’t use.

There are practical ways we can support this change in identity. Perhaps most importantly, we take note of our clean date (our our sobriety date), and we hang on to it. Mine is May 12, 1985. There have been several times over the years that just knowing I would have to give up that date has motivated me to ask for help when I was in danger of relapsing.

We connect with people who are also in recovery, and we build relationships with them. We get to know them, and we let them get to know us. They will see our attitude changing for the worse before we do, and they can warn us that we’re not doing the things we should in order to stay in recovery.

And we become members of a group of recovering people. This is important. When we feel connected to a group, that group membership influences who we think we are, just as belonging to a political party or a church do for “normal” people.

And we begin to share our experience with others. This reminds us of where we come from and how we’re different today. My first sponsor told me that if I have 30 days clean, I have something to share with the person who only has one day clean. (It’s so easy to forget that when I had one day clean, 30 days seemed impossible!)

These are the basics of living a life free of active addiction. There are more tools, and we gain more experience, but these basics will take us well into recovery. And as we do, we probably won’t even notice that our self-identity is changing. But it is. We are ceasing to be addicts trying not to use, and becoming addicts in recovery. We are giving up a hopeless state of mind and beginning to live in hope.

But we don’t just live in hope, we become symbols of hope for those who still struggle. When we realize that, our new identity has fully taken hold.

March 15

Why I Write About Politics I

I work with people struggling with addiction. I am a person who struggled with addiction. Helping others is my passion, and my debt to those who helped me.

So why do I write about politics? Because politics and addiction are related. Decisions made in the political arena directly affect not only those who now struggle, but whether or not people who have not become addicted will do so in the future.

The Criminal Justice System

The criminal justice system is one of the biggest influences. It’s a system that not only fails to promote recovery, but often makes recovery more difficult. First, we should know that the rate of recovery among prisoners released after serving time for drug offenses is approximately zero. A 1974 study noted, “[w]ith few and isolated exceptions, the rehabilitative efforts that have been reported so far have no appreciable effect on recidivism.” Based on that observation, decades of inattention to rehabilitation followed.

Not only that, but even for those who desire to get clean it’s often difficult to recover with the realities placed on them by the system. For example, it’s hard to get a decent paying job or even rent an apartment with a felony on your record. Here in Harrisonburg, where James Madison University’s huge enrollment strains the availability of rentals, often the only option for those coming out of prison is a room in one of the “drug den” hotels downtown. When I took one man down to look at a place, in the 20 minutes we spent there he saw five people he knew from his substance abuse years. That’s hardly an environment conducive to recovery!

In rural Utah, released prisoners are not allowed to get their drivers licenses back until they’ve paid their fines. Yet they may live 20-30 miles from where work is available. If they don’t work, they can’t pay their fines and they go back to jail. If they drive to work without a license and get caught, they go back to jail. It’s a Catch 22. Many of them do go back to jail because they can’t find a solution to the conundrum.

The Fallacy of Prohibition

Our drug policies not only fail to prevent and treat addiction, they actually promote addiction. A 1992 study showed that despite increasing negative consequences, illicit drug use actually rose in some communities, while the use of legal substances like alcohol dropped.

How is it possible that prohibition promotes addiction? The Cato Institute cites Richard Cowan’s “Iron Law of Prohibition”:

[T]he more intense the law enforcement, the more potent the prohibited substance becomes. When drugs or alcoholic beverages are prohibited, they will become more potent, will have greater variability in potency, will be adulterated with unknown or dangerous substances, and will not be produced and consumed under normal market constraints.

The 1972 book, Licit and Illicit Drugs by Edward M. Brecher found a similar link. The stronger the prohibition, the more potent the form of the drug and the more rapid the ingestion method (i.e. smoking or injecting as opposed to swallowing or snorting).

This is not only economics. It’s common sense. As Creedence Clearwater Revival noted in their 1969 song, “Bootleg,”

Take you a glass of water
Make it against the law.
See how good the water tastes
When you can’t have any at all.

The basic laws of economics say that something becomes more valuable as it becomes scarce. Prohibition makes the prohibited substance not only more expensive, but also more desired. We can try to blame that on immorality, but the truth is, it’s basic capitalism. Prohibition is an anti-capitalist approach.

We lament the rise of addiction and overdoses in this country, but our legal system isn’t designed to reduce the problem. Instead, it makes it worse for those who are already in addiction. Whether it prevents people from becoming addicts should also be obvious– if our legal system worked as a preventive measure, the problem wouldn’t be increasing.

There are some basic changes we could make to move us in the direction of positive change. Decriminalization is one. And I say this as a recovering addict who knows first-hand the danger and damage of the substances involved. But the fact is, criminalization is a failure. It has made the drug problem worse. And, as we say in recovery, “If you kleep doing what you’re doing, you’ll keep getting what you’re getting.” If we want something different, we have to do something different. And that is a political problem, not a moral one.

March 10

Broken Minds in a Broken System

Cory grew up in a violent home. He turned to alcohol at an early age. He also suffers from schizophrenia. When he drinks, he sees the world as a threat and responds in kind. He was released from prison a few months ago after a decade for making a threat he did not have the ability to carry out.

Cory needs psychiatric help. He’s been on a waiting list for months. Now he’s back in jail, awaiting trial for getting drunk and making a threat he had neither the means nor the knowledge to act on.

Jack, too, grew up in a violent household. He turned to drugs at age 12 and lived on the streets for a time. He recently graduated from a recovery house and is trying to live clean and sober. But Jack suffers from bipolar disorder. When he gets manic, which is about every other week, he gets paranoid and believes the world is out to get him. The only way he knows how to manage this is through self-medication. Needless to say, he hasn’t stayed clean for more than a few days at a time.

Jack, too, has been on the waiting list to see a psychiatrist. In his desire for help, he went to the emergency room and was hospitalized, but the medications they put him on didn’t help. He wound up back there again last week, in a suicidal depression after a week of manic behavior and drug use. The doctors changed his medications and sent him home.

These two men, both of whom want to change their lives, may be just statistics for most people, sad stories that we want to believe are the exception rather than the rule.

I don’t have that luxury. Like them, I have struggled with addiction. Like them, I suffer from mental illness– in my case, PTSD (Post-Traumatic Stress Disorder). And like them, I struggle to get help in a broken mental health system.

When Trauma Comes Home

My recent troubles began, like so many things, with Covid. The isolation caused by the pandemic not only led to depression, but eliminated a lot of my regular coping mechanisms. Visiting friends and working at the library became impractical if not not impossible. My world shrank to our home, and my family became my social circle. Between Covid and the weather, my 6-year-old, special-needs son has only been to school about one day a week this year, causing his problem behaviors to multiply and adding to my emotional challenges.

Meanwhile, our political situation deteriorated, frighteningly resembling a traumatic situation I experienced almost 30 years ago. I’ve done a lot of work on my trauma over the past two decades, but now the nightmares returned. So did the irritability, depression, and sensitivity– all classic symptoms of PTSD.

I’d been seeking help. It took over two years to find a practitioner who dealt with trauma (and accepted my insurance), and I’ve only been working with her for a couple of months.

About two weeks ago, unbeknownst to me, my 16-year-old intentionally startled my wife. She let out a blood-curdling scream. And something inside me snapped. I left the house and drove around for two hours, unable to deal with my feelings and the world around me. I scratched myself because the pain felt good.

After much internal consideration of less desirable alternatives, I went to the hospital. They shipped me to a facility two hours away, where I received medication and watched TV for a week. (I hate TV, so this was not a relaxing vacation.) Then they released me, advising that it would take weeks to know if the  medication was really helping. The side effects are arguably worse than the PTSD symptoms they are intended to treat, and the psychiatrist I saw after leaving the hospital immediately discontinued the medication.

Our Broken System

Our mental health system is broken. It doesn’t do prevention or healing, it manages crises. Getting an appointment if you’re not in crisis can be difficult or impossible, even with health insurance. Waiting lists are long for those who are not bad enough to be hospitalized.

For those requiring hospitalization, our system uses a “catch and release” approach, diagnosing and medicating patients, then sending them home before the effects of the medication on that specific person become evident. How often have we heard a psychiatrist, following up on a hospital visit, say, “I don’t know why they selected that medication!” When side effects crop up, refer to the previous paragraph. Your options are to suffer, or go back into crisis management. Six years ago, I was hospitalized three times– once for the condition, and twice to deal with the life-threatening side effects of the supposed treatment of the condition.

And our system doesn’t do healing. Instead, it manages crises of symptoms with medication. It works for some, but many do not find relief. This approach pays little attention to addressing the underlying condition– much like using pain pills without treating the broken bone.

There are exceptions. Dialectical Behavioral Therapy, for example, has been shown to reduce both the frequency of crises and, for some conditions, the need for medication. Eye Movement Desensitization and Reprocessing (EMDR) is incredibly effective in treating trauma. Long term inpatient substance abuse treatment, when paired with mental health care for underlying conditions, can be very effective not only in treating addiction, but in preventing future mental health crises. But there isn’t enough of it. In fact, in many communities, there isn’t enough mental health care available, period.

A system is defined as “a set of things working together as parts of a mechanism or an interconnecting network.” By that standard, our mental health “system” isn’t a system at all. The parts don’t work together. Some parts are missing.

Does ignoring our mental health make the problem go away? Hardly.

An estimated 56 percent of state prisoners, 45 percent of federal prisoners, and 64 percent of jail inmates have a mental health problem. –“The Processing and Treatment of Mentally Ill Persons in the Criminal Justice System
Few of these prisoners get treatment. Most will return to incarceration after being released.

Counting the Cost

We pay for our nation’s mental health problems, whether or not the treatment is effective. But instead of recognizing the problem, we ignore it or criminalize it. By official estimate, we pay $80 billion per year to incarcerate 2.3 million people, But that doesn’t include the out-of-pocket costs to the families of the incarcerated. One wonders, what kind of a nation would rather pay for jails and prisons than treatment facilities for its sick citizens?
Suicide is the 10th leading cause of death in the nation, and the 2nd leading cause (behind accidents) for Americans aged 10-34. Yes, you read that right: Suicide is the 2nd leading cause of death for children 10-14 years old, and continuing well into their 30s. Yet we’d rather argue about gun control than address the cause, which is mental illness.
With nearly 1 in 5 Americans living with a mental illness, you’d think we’d pay more attention to it. That’s almost one person in every American family. But we seem to be too ashamed of mental illness to admit this medical affliction– as if having diabetes, for example, was a moral failing.
Mental illness is NOT a moral failing. And that’s why I post about it. Go a few rounds with our mental health care “system,” and you may begin to see our national denial the way I do: Mental illness is not a crime, but ignoring it is.
January 4

Midwest Book Review on The Soul of an Addict

The Soul of an Addict’s ability to delve into the heart of the addictive personality and mindset leads readers onto a path of discovery and insights on the path away from addictive traits and habits… [The book] is an eye-opening, relevant, insightful guide that’s highly recommended for any individual interested in addiction…

Read the entire review here.

Then buy the book here!

December 1

“A Most Practical Book”

My eyes have been opened to dimensions of addiction I never knew about. One of the most practical books I have read in a long while, I expect to use it in my relationships with persons who have addictions. I recommend it to anyone wanting to better understand and relate to people in their lives who suffer addiction.

–Suzy Kanode, Pastor and Spiritual Director

Check out The Soul of an Addict today!

September 26

Why We’re Losing the War on Drugs

Singapore’s arrival card. The big red letters leave no doubt as to their policy.

In the past 40 years, we’ve spent trillions of dollars on the War on Drugs in an effort to eliminate supply. Yet drug overdoses are up over 1,200%. We’re losing the war. And not for lack of trying.

We’re losing the war because the very premise of it is flawed.

Trying to solve the drug problem by eliminating the supply presumes, as many conservatives believe, that drug addiction is a choice. Eliminate the supply and people will make better choices.

It’s like those candy displays at the cash register of your local store: you want it because it’s there. It’s tempting. That’s called an impulse buy. And if it didn’t work, they wouldn’t keep doing it.

But drugs are not an impulse buy. Yes, the first time a person uses is clearly a choice, unless it’s given by a medical professional. And that does happen.

But once a person becomes addicted, the drug fills a need that nothing else does. It’s no longer an impulse buy. It’s a requirement.

As I argue in my book, The Soul of an Addict, for an addict the drug provides more than just relief from withdrawals and from past traumas and pains. It provides certain basic human needs which the user has not found anywhere else. These include identity, purpose, meaning for life, structure, and a moral code consistent with these.

Without the drug, in the absence of a suitable alternative, the person is miserable. They’re not waiting for an impulse buy. They are actively looking for relief, and they will do anything and pay anything to get it.

This is a ready-made market, a demand for the substance. And, as anyone who has taken an economics class knows, where there is a demand there will be a supply. Scarcity and risk cause the price to go up. But the person who needs drugs will find a way to pay that price, because they quite literally believe they can’t live without the drug. And that means the methods they use to obtain money may cross the line of legality, from theft to prostitution– and worse.

Is it even possible to stamp out the availability of drugs?

I say no, and here’s why.

Singapore is a small, island nation off the southern tip of Malaysia. It is ideally suited to control what crosses its borders because there are very few ways in or out. And Singapore has one of the toughest drug smuggling laws ion the world. Their arrival card makes it clear: the penalty for smuggling drugs is death. And they’re not kidding: smugglers are executed.

If anyone could eliminate the supply if drugs, it would be Singapore. Yet they had 14 drug overdoses in 2017. Their rate of overdose has more than doubled over the past 30 years. Yes, that’s far better than the U.S. rate of overdoses. Singapore’s is 0.25 per 100,000 people; ours is 18.75. They also have better health care and social services and less wealth inequality than we do, which would tend to drive down the rate of drug abuse and overdose.

But, even with supposedly absolute control and strict penalties, drugs are still available in Singapore. And if they can’t stamp them out with limited access points and draconian penalties, how do we expect to?

The War on Drugs is doomed to fail because it’s impossible to address the problem on the supply side. So long as there is a demand, someone will take the risk to make money by providing a supply. (Singapore’s penalty is death, yet people still risk it!)

And we can’t address it by locking up those who use drugs. We’ve spent trillions of dollars trying. Our prisons are full. Yet the problem keeps getting worse.

There’s got to be a better way.

And there is, but we’re not going to like it.

We’re not going to like it because it calls into question our post-modern ethos of consumerism, the whole premise that life can be fulfilling because of what we buy. That ethos is false, yet that’s what it takes to keep our economy afloat. People have to keep buying. When people start saving money instead, the Federal Reserve gets nervous. They need us to be happy consumers, floating in a sea of debt buying stuff we don’t need (but think we do).

Some of us may be satisfied with this purpose for life some of the time. But the fallacy is revealed in the rise of drug overdoses, alcohol deaths, and suicides. Consumerism doesn’t answer the big questions in life. Like, “What is it all for?”

That’s the realm of religion, not social policy. And religion is something society doesn’t prescribe for us. In fact, it has increasingly fallen out of favor. Over the past 40 years, the number of Americans who identify their religious affiliation as “None” has risen from 7% to 21%.

But even that number may be optimistic. I’ve been to many churches where the point of going to church is to go to church. It’s what we do. Yes, there’s a vague message that we should live good lives, but no specific guidance for doing so.

I’ve been to other churches which focus on what happens after we die. For someone like me, a recovering addict, this fails to answer the burning question of my life: how do I live now? (And if the afterlife is so much better, isn’t that an argument for a sooner death?)

Sociologist Emile Durkheim suggests that a religion provides identity, meaning, structure for life, and a moral code. If that is so, then much of what we experience in church fails to meet the requirements of a religion. It doesn’t provide these basic human needs. No wonder the fastest growing religion in America is “None”! And no wonder deaths of despair are rising.

Doing Something Different

There is an answer to the drug problem. The Twelve Step programs recognize it. Every aspect of those programs is designed to give people identity, purpose, structure, and a sense of belonging. Although most of these programs aren’t religious, they do a better job of practicing a religion, in the sociological sense, than some churches.

Why can’t churches do what the Twelve Step programs do? They could. So could non-religious groups. But that would mean bucking the national religion of consumerism– and potentially being branded un-American, or worse. It would mean pushing back against the long-embraced idea that religion belongs in the private sphere. If your purpose and structure for life comes from your religion, it’s going to show.

Do we really believe that it’s better to spend trillions of dollars on trying to stamp out supply and incarcerate users, no matter the price tag? Is that a necessary “overhead expense” to maintain our consumer economy? Or is that just what we’ve always done?

In either case, it isn’t working. The problem is getting worse.

It’s time to do something  different.

September 9

Praise for Soul of an Addict

“The book elucidates the agony of addiction in a fresh, new way. It emphasizes the role of trauma in setting the stage for debilitating behaviors, and explains the importance of community support in the healing process. With anecdotes of many people who grapple with addiction and have survived, as well as sad stories of addicts who died, this book provides healthy doses of grit and inspiration.” –Christopher Key Chapple, Loyola Marymount University

September 7

The Medical View of Addiction

Medicine has struggled to understand addiction. This may be because it’s not entirely a medical problem. But science doesn’t consider spiritual aspects, and for the purposes of this discussion I’m willing to leave those aside.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the “bible” for diagnosis by professionals. The current version is DSM-V. Not surprisingly, the previous version was DSM-IV. The newer version introduced some major changes to the way substance abuse disorders are diagnosed.

DSM-IV, issued in 1994, generally offered two categories of substance abuse disorders: substance use disorder, and dependence. These corresponded to chronic abuse of a substance, and physical dependency on the substance. There were codes for various substances, distinguishing for example between opioid dependency and alcohol dependency. The DSM-V (2013) combines there and streamlines the diagnosis. As this summary explains, DSM-V

does away with separate “dependence” and “abuse” diagnoses and combines them into “substance use disorder.”

The current version sees substance abuse as a spectrum rather than two separate conditions.

While this does make diagnosis easier, it appears to me to move substance abuse treatment backward by failing to recognize the complexity of factors at play.

For example, let’s consider physical dependence. Anyone who takes opioids (or other physically-addictive medication) over a long period will become physically dependent. It doesn’t matter whether they began using for pleasure, or if they were prescribed the drug by a doctor because of a medical need. They will need the drug to avoid going into withdrawals, which are typically both painful and disorienting. And in the case of alcohol (and certain other drugs), withdrawal can be life-threatening. Someone dependent on alcohol, for example, will crave it. And the cause of this craving is biological: they’ll go into withdrawals if they don’t get it. This is what DSM-IV described as “dependence.”

Yet dependency alone does not indicate whether that person will return to the drug once separated from it. When the physical dependency is relieved through a withdrawal process, medically supervised or not, there is no further need for the drug. Many people, once relieved of their dependence, take what might be described as the sane response: they never touch it again.

On the other hand, let’s consider what is sometimes described as “risky use.” A person who is not dependent on a substance nevertheless seeks it out and abuses it. The cause of this is not physical but psychological. Whether they seek pleasure or to kill the pain of some past trauma, the drug serves a purpose in their lives. They choose to pursue it of their own free will. This is what DSM-IV described as “substance use disorder.”

Interestingly, substance use disorder does seem to be a spectrum. Some people are able to choose to quit of their own volition. Others need help to quit. And some pursue their obsession with the substance, as Alcoholics Anonymous observes, “into the gates of insanity or death.”

These two, very different, facets of substance abuse are combined in DSM-V into a single spectrum. Yet the opioid crisis should show us the fallacy of this “improvement.”

One of the popular news items in the opioid epidemic is the number of people who began using because an opioid was prescribed by their doctor for a medical condition. (Here’s an example.) This theory presumes that chronic physical pain is the cause of opioid use that results in dependence. And this may well be for some people.

Yet many, perhaps most, opioid addicts struggle with a condition I can only describe as “addiction.” Yes, they are physically dependent. Yet once separated from the drug, whether through rehab or incarceration, they return to it despite its adverse effects on their lives. Not because of physical pain, but because of a psychological obsession with what the drug does for them.

At the very least, in these people we can see an overlapping of two distinct conditions: dependency and an obsession to use. These are not the same. One is physical, the other is psychological. Both need to be treated for successful recovery. Yet without recognizing the difference between the two conditions, how can they be treated?

This is true for any drug user. For a successful result, a person who is dependent because of chronic pain must be treated differently from one who is not dependent but seeks the drug by choice. Yet in the case of the addict, who has both conditions, treating one or the other is simply pointless. Not only is it ineffective, but the failure of this approach erodes confidence that recovery is possible.

And recovery is possible! While success with opioid addiction recovery from a medical perspective remains dismally low, tens of thousands have recovered through other, non-medical methods. These include Twelve Step groups like Narcotics Anonymous, religious based programs like The Bridge Ministry, and many others.

Because when withdrawals end, that’s when the real healing begins. Now that we don’t have a physical need, how do we live without the psychological need? Medicine doesn’t do that. Even psychology tends to fall short in offering resources.

Perhaps this is because they don’t really understand what an addict needs, because the vast majority of medical professionals have never experienced it.

But those who have been there and recovered do know. It is to them we should look for answers. Oddly, that seems to be the one place science hasn’t looked. Which may be why their understanding of addiction and recovery sometimes seems to be moving backward.

 

For more on addiction, read my book, The Soul of an Addict, available in Paperback and Kindle editions.

September 3

Getting Out

Whether it’s jail or rehab, how does an addict stay clean when they get out?

I met William in his last week at a program that helped former inmates deal with addiction and prepare for the real world. We talked for almost an hour. I told him my history, and about how I stayed clean. He seemed excited to know someone in recovery. He took my number, and promised to call as soon as he got settled in his new apartment.

I never heard from him.

The are literally hundreds of thousands of men and women incarcerated for drug related offenses, many of them nonviolent. What happens when they get released? Some of these go to halfway houses or rehabilitation programs. Do these improve their chances? Thousands are voluntarily in rehabs. Are their chances any better?

There’s one aspect of addiction that few programs, and few theories of addiction, take into account: Addiction is a way of life. It defines what we do with our time. Conversely, it tells us what to do when we don’t know what to do.

This means the first day or two after getting out, whether from incarceration or from a program, are critical. Structure has been removed. Even if there’s a job to go to, which there often isn’t at that stage, there are still 16 hours in the day to navigate. In an unfamiliar world. With complete freedom of choice. After months or years of complete structure, the person is suddenly expected to know what to do with their time.

That’s not a reasonable expectation. Anyone who has become unemployed, or who has faced a quarantine that disrupts their normal routine (and that’s most of us now), knows that it isn’t easy to find a new routine. And we generally start with what we know, whether that’s exercise or prayer.

What an addict knows is not exercise or prayer. I say this as one who struggled with addiction for many years. The drug becomes the center of our lives, defining our identity and our purpose. And it tells us what to do with our time.

How long will a person wait for something new to happen before returning to their old ways? My experience indicates that it may be as little as 24 hours, and certainly not more than a few weeks.

This is the window of opportunity for the person to develop not only a new routine, but a new circle of friends and support. In the absence of those, he or she is alone and without tools for navigating their new reality.

If you think about how long it takes to find and adopt a new routine, find support, and make friends, this is a nearly impossible task.

So what is the answer?

Those who have relationships with supporters and friends before their release are more likely to succeed. They already have some of the most important pieces in place. If we want to support addicts in staying clean, this should begin while they’re still inside, whether it’s a rehab or a jail.

But secondly, when they get out we shouldn’t expect them to reach out to us. They have been conditioned not to trust, and to believe that those who need help are weak. It takes time for those beliefs to change– time they may not have. There’s also the shame factor. They may be ashamed of their social status, and of their need for help. They also may be afraid of rejection, betrayal, or abandonment– all common occurrences in the world of addiction.

We need to reach out to them! And we need to do so with persistence, but not harassment. They may or may not respond. They may or may not stay clean. Working with addicts always risks heartbreak, including the ultimate heartbreak of funerals. But we do it because there would otherwise be even more funerals.

William, my new friend who disappeared, taught me one thing: not to just give out my number, but to take his. I didn’t do that for him, and he is likely back in the trap of old behaviors. But I have done it for others since then.

For more on addiction, read The Soul of an Addict: Unlocking the Complex Nature of Addiction.