In it I dispel the myths that:
- Addiction is caused by drugs,
- once an addict always an addict,
- addiction is progressive
- abstinence is required to initiate treatment or for remission.
I feel strongly that if we allow these myths to continue, we will not develop practical and helpful treatment modalities or public policies. At the end of the talk I made some suggestions regarding treatment. Comments and criticisms are welcome!
All around us, on a daily basis, we find news about addiction. We are exposed to a variety of messages, but most of them seem to carry a common theme. Many treatment programs and websites define addiction as a primary, chronic, relapsing, progressive disease of the brain usually caused by the uncontrolled consumption of alcohol or other drugs. What this means, among other things, is that addiction is:
- a separate entity on its own – it is a disease in and of itself, not a symptom;
- a lifelong disorder from which recovery is unlikely;
- that stable remission is unlikely;
- the longer you have it the less likely you are to remit;
- that the alcohol and drugs are the cause of addiction.
No matter what you have heard or been told, there is no unitary proven model that explains addiction to any degree of satisfaction.
This is a logical fallacy called Berkson’s bias. Can you imagine looking at only the very sickest of people who contract flu – we would assume that flu was a deadly disease and would hospitalise everyone who developed even a slight cold! This would have disastrous effects. Examples could include –making people even sicker (by exposing them to pathogens in the hospital), it would lead to massive costs in treatment, it would create a huge market in snake-oil “cures”, create fear and stigmatisation….. you get the idea. If you define the problem incorrectly, you will define the treatment incorrectly. We need to see the disorder for what it is in order to develop interventions and treatment approaches that actually work.
So one of the ways to get more accurate data is to gather data from a wider representative population, regardless of their treatment history.
I would like to dismantle a couple of myths that are commonly repeated in the field of addiction. I hope that you will begin to see things differently, and perhaps will do your own research to find out what the data really says. The myths I will talk about are:
- Drugs cause addiction
- Once an addict always an addict
- Addiction is a progressive disorder
- Abstinence is needed to initiate treatment or achieve remission.
For the sake of clarity let's first define some terms of reference:
How will we define “addiction”?
How do we define “remission”?
The main studies I will be quoting:
- Epidemiological Catchment Area Survey (ECA) [n=20 000],
- the National Comorbidity Study (NCS)[n=8 100],
- the National Comorbidity Study Replication (NCS-R)[n=9 200],
- and the National Epidemiological Study of Alcohol and other Related Conditions (NESARC)[n=43 000].
- I will also refer to data from various annual National Survey on Drug Use and Health reports commissioned by the Substance Abuse and Mental Health Services Administration (SAMHSA).
Looking at the data, there are two important questions one has to ask here, and
the first is:
Why do some drugs appear to be more “addictive” than others?
Why do some people become addicted and others not?
So, I’ve just shown that given the right environment, rats can recover from their heroin addiction. Is the same true for humans?
We could also look at the myriad of other behaviours that could conceivably constitute an addiction. Although only gambling is currently listed in the DSM5, there are a number of potential addictive disorders listed in section 3, that are undergoing further investigation
But what does the data say?
Maturing out is a good phrase. We can see that drug use peaks during the early to mid 20s. These are the results of the National Survey on Drug Use and Health (2011) showing past month usage of illicit drugs:
I say this because we also know that people over the age of 30 are more likely to suffer from addictive disorders if they are single, divorced or widowed.
In fact, Gene Heyman calls marriage the antidrug relationship. This data is extracted from the ECA study and reported in Robins and Reiger, 1991, reflects marriage across a range of psychiatric disorders and abuse/dependence:
In the words of NIDA: ‘drugs change the brain to foster compulsive drug abuse….[which]if left untreated can last a lifetime”.
There are many people who recover from a heroin use disorder but occasionally indulge in marijuana, or drink socially.
If all of what I’m saying is true, if the popular beliefs about addiction are wrong, then perhaps we have not gotten our treatment modalities right. I would certainly agree with this. We know that treatment can actually predict worse outcomes than no treatment at all.
“Rather than convincing people that they have a lifelong disease and that recovery is all about abstinence, treatment needs to encourage and train people toward belief in themselves and the ability for independent living.”
- · Drugs do not cause addiction: It is a confluence of confounding factors in which drugs may or may not play a role.
- · In most cases addiction is not a life-long disorder: The majority of people recover, with or without treatment.
- · Addiction is not progressive: The chance of remission remains constant over the drug using career.
- · Abstinence is not always the best approach for treatment: Harm reduction and focusing on underlying conditions is helpful.
- More outpatient treatment that helps people learn how to function within their current environment
- A less punitive approach to treatment and changes to legal policies
- Lower barriers to entry into treatment and not insist on abstinence
- Introduce more harm reduction initiatives so as to ensure that people survive and mitigate the harms during their using days
- Make treatment more about problem solving, life-skills and developing healthy relationships than about stopping drugs
- Greater emphasis on treating comorbidity
- The Development of a cumulative continuum based model of treatment that addresses the current treatment needs and can be built on as the goals change.
Original Sources and References
The following are the articles and books from which I have drawn my body of information. Since this was not prepared as an academic article, I have not put specific citations except for the graphs, which are cited on the image. This list is not exhaustive.