Treatment & Recovery
Presentation to Leeds and York Partnership, NHS Foundation Trust, March 23 2018
Bruce K. Alexander, Professor Emeritus, Simon Fraser University
Latest revision May 28 2018
We are meeting today amidst a crisis of opioid overdose deaths in the US and Canada. We are all doing our best to end this crisis, but the death toll keeps rising. Historically, the current opioid crisis is not an isolated event, but only the latest tsunami to blow in across a rising global tide of addiction to many drugs and other habits. We are not doing well with the larger problem either.
I believe that I know why we are not doing better. Almost all of our interventions are based, at least partially, on a very old narrative about drugs that has outlived its usefulness, but stubbornly refuses to release its hold on our thinking. I will propose a paradigm shift from this played-out “old story” to a “new story.” I will show at the end of this presentation how the new story can help us to respond better to the current crisis and to the rising tide of addiction to which it belongs. Along the way, I will show why the old story is so very hard to leave behind.
The Old Story
The old story is about a drug that is so addictive that once people use it a few times, they lose their self-control, and spend the rest of their lives craving and pursuing it. They become not only addicted, but also reckless and violent in their pursuit of it.
The essence of the old story is that the free will of people who are addicted to this drug has been usurped by something that dwells within them. This usurper is sometimes conceptualized as a “physical addiction” that manifests in unbearable withdrawal symptoms when the drug supply is cut off; sometimes as a portion of the brain that has been altered by exposure to the addictive drug; sometimes as a deeply learned, maladaptive habit of drug consumption; sometimes as ineradicable psychological scars of youthful trauma that render the addicted person dangerously vulnerable to the pleasures of drugs; and sometimes, in religious contexts, simply as a demon that has possessed the addicted person’s soul. Only expert help can possibly restore control to the drug addicted person. Depending on how the usurper has been conceptualized, the expert could be a physician, a psychologist, a psychiatrist, or an exorcist.
I assume that every one in this room has heard some version of the old story, because it is deeply rooted in western culture. It is promulgated, in its current form, by eminent authorities (Volkow, Koob, & McLellan, 2016; U.S. Department of Health and Human Services, Office of the Surgeon General, 2016) or simply assumed in the popular media (e.g., Quinones, 2016;Time Magazine, 2018). It influences much of what we do in the field of addiction, however much we may personally accept it or reject it.
The old story has been told about a great variety of drugs. Today it is mostly being told in Canada and the US about prescription opioids (especially oxycodone and fentanyl) and heroin. Overdose deaths caused by these drugs have become is the third addiction crisis of the twenty-first century for us. The first two were the crack cocaine crisis that began in the late twentieth century and extended into the twenty-first, and the methamphetamine crisis. In accord with the old story, experts held that crack was “instantly addictive” and methamphetamine was “the most addictive drug on earth”.
However, many other drugs have played the addictive drug role in the story at various times and places, including gin in 18th century England (the London “gin craze”) and distilled spirits in 19th century Canada and the United States (“demon rum”), followed by morphine, chloral hydrate, and cocaine late in the 19th century, heroin in the early 20th century, marijuana in the 1930s (“Assassin of Youth,” “Reefer Madness”). In the second half of the twentieth century, our addiction crises involved heroin and barbiturates, cocaine, benzodiazepines and metrobamate. The twentieth century ended, as the twenty-first began, with the crack cocaine crisis. And briefly, in the US in the 1970s, the addictive drug in the old story was model airplane glue! (Brecher, 1972, pp. 321-334).
I spoken both in the Czech Republic and in Brazil in the past year. These countries are also currently involved in moral panics, but not to opioid drugs. In the Czech Republic it is methamphetamine, in Brazil it is cocaine, primarily crack.
If you read the historical coverage of the crises over these different drugs and in different countries over the last two centuries, you will see that the rhetoric is surprisingly similar and that it becomes similarly apocalyptic at its peak (Warner, 2002; Murphy, 1922/1973; Time Magazine, 2018). An entire generation is at risk! The most drastic measures must be taken! Donald Trump (2018) recently announced that the US would be placing more reliance on draconian punishments, including the death penalty, to bring the current menace under control. President Duterte of the Phillipines has made a similar announcement and carried out the executions with dispatch.
There are literally hundreds of variations that make the old story seem more scientific than it is. I remember initially learning the old story as a child from a “Batman” comic book and having it confirmed by my father. But, when I went to university to become a psychologist, I relearned it as it in terms of the behaviourist learning theory of the 1950s and 1960s, which made it sound more scientific, although it was basically the same old story. I later learned to tell the old story in the languages of Alcoholics Anonymous, of Christian doctrine, and of the neuroscience of endorphins that was discovered in the 1970s. More recently, I learned to tell the old story in the languages of today’s chronic brain disease model of addiction (“BDMA” or the “NIDA model”), today’s more advanced genetics and epigenetics, some meditation disciplines, modern cognitive learning theory, and the psychology of trauma.
The origins of the old story lie deep in the history of western culture. Contemporary scholars have meticulously traced it back to Aristotle’s concept of “akrasia” in his Nichomachean Ethics, i.e., a state in which people carry out actions while being fully aware that they will be harmful (Aristotle, 330BC/1925, Book 7; Heather, 2017). Eight centuries later, St. Augustine spelled out the old story in religious terms in his Confessions (St. Augustine, 397AD/1963, Book 2, chap. 2). The old story is the foundation of some of the explanations of harmful addiction to alcohol in the writings of early modern England (Lemon, 2018, pp. 83-85), although the word “addiction” was then used in a variety of different ways as well (Lemon, 2018).
Sometimes I call the old story “the myth of demon drugs” because it is so similar to tales of people who lose their souls because they yield to the temptations of demons of all sorts. Such tales were told long before drugs became a widespread issue. Demon possession stories became culturally important in Early Modern England (Raiswell & Dendell, 2004).
Here are the four basic elements of the old story as it has been applied to drugs in its twenty-first century form:
1. Addictive Drugs are the most important cause of society’s addiction problem.
2. Addiction occurs because individuals – foolishly or wickedly – use addictive drugs, disregarding the council of older and wiser people.
3. Using addictive drugs takes away the will power of some or all users, transforming them into addicts who have lost control over their drug consumption and will act recklessly to satisfy their drug cravings.
4. To be even partly successful, recovery from addiction must be organized by expert professionals or by organized self-help groups.
Two Sets of Variations
Some variations of the old story emphasize the power of the drugs, by putting the stress on elements 1 and 2. In these variations, the problem must be solved by removing the demon drugs from the face of the earth or by making people so afraid that they would never try one. These variations have served to justify cruel – and futile – Wars on Drugs and terrifying anti-drug propaganda in many countries. They are implied in today’s calls for a new surge in the War on Drugs (Trump, 2018)
Other variations stress elements 3 and 4 of the old story, putting the emphasis on the putatively out-of-control addicts who must be helped to manage their cravings. Help can come from medicines, vaccines, psychological counselling, cognitive-behavioural therapy, motivational interviewing, existential therapy, 12-step groups, other self-help groups, various religious traditions, contemporary methods of literally exorcizing demons, meditation, harm reduction, hallucinogenic drugs, shamanistic rituals, acupuncture, dietary treatments, recovery groups, special housing projects, or many other sources.
The good news is that the last fifty years has seen a movement from the War-on-Drugs variations of the old story to the help-oriented variations in many places, including places where the War on Drugs has been waged most fiercely in the past (e.g., Volkow, 2018). Along with the conceptual movement, we have seen much of the world moving from a War on Drugs towards a more compassionate regime based on many forms of compassionate care and harm reduction, all of which have proven helpful to some addicted people. This has been a genuine triumph of humanism over violence! I am proud to have played a small role in advancing this movement in my own city and country -- even though, despite this shift, the same “old story” (with the emphasis on elements 3 and 4) is still the foundation of most of our thinking.
The bad news is that, despite the movement towards the help-oriented version of the old story, the problem of drug addiction has not decreased and in many places seems to be increasing alarmingly. Even Portugal, Switzerland, and the Scandanavian countries, with their wonderful life-saving advances in treatment and harm reduction provide little solid evidence of an overall reduction of drug addiction or of other kinds of addiction.
My own city of Vancouver provides one of the most discouraging examples of the failure of the second variation of the old story to reduce the addiction problem. Even though our movement away from the war on drugs now has deep and widespread support, we are currently suffering from an all time high number of overdose deaths due to opioid drugs, especially fentanyl. Many people fear for their children as they grow up. Fortunately, our authorities are responding to the apparent crisis primarily by increasing harm reduction and treatment services, rather than regressing to the War on Drugs. But the question persists: Why do our enlightened new methods not have better results?
Vancouver also appears to be suffering from a rapid growth in behavioural or process addictions (that do not involve drugs) as well: on-line gambling, social media, pornography, video games, methamphetamine, alcohol, cocaine, wealth, consumerism, religious fanaticism, overeating, and anorexia. We have many other kinds of serious addiction as well and the trend appears to be upwards.
How could this be? Why have we not seen a better outcome from a more humane interpretation of the old story, based on genuine advances in neuroscience, psychological theory, drug law, and compassionate spirituality?
Today, I want to propose that the old story of the demon drugs is fundamentally wrong in both of its variations. I propose that we will need an entirely new story if we are to understand where addiction comes from and what to do about it. In essence, I am proposing that the first, and most important, step in controlling addiction to demon drugs is unmasking them, i.e., showing that there are no demons of any sort involved!
More and more researchers are challenging one or more of the elements of the old story. In fact, some are beginning to argue – correctly I think – that all four of them are wrong. The evidence is overwhelming, and I have summarized much of it in my earlier writings. It comes from a great variety of sources, particularly clinical case studies, biography, history, anthropology, and critical analyses of neuroscience data. For a review of this literature, which goes back several decades, please read my books (Alexander, 1990; Alexander, 2008/2010, chap. 8), visit my website (especially Alexander, 2014), or look at the writing of other critical researchers, neuroscientists, and therapists who have disputed part, or all, of the old story (e.g., Chein, Gerard, Lee, and Rosenfeld, 1964; Peele & Brodsky, 1975; Heyman, 2009; Hart, 2013; Satel & Lilienfeld, 2013; Lewis, 2015, 2017; Heim et al., 2014; Vintiadis, 2017; Heather et al., 2017)
But I will not lay out evidence against the old story in detail today. Instead, I will leave it out of this presentation on the basis of the simple historical fact that the old story has gotten us nowhere after more than a century of being taken very seriously, in its many variations, by drug addiction professionals, governments, and the public (White, 1998). Not only has the old story been unproductive, but there is also overwhelming evidence that the first variation is still used by unscrupulous politicians as a way to persecute large numbers of people in the racial and economic underclasses of many countries (Hart, 2013; Hari, 2015; Baum, 2016; Rodriques and Labate, 2016).
We need a better story. So I will offer one today that is gaining ground everywhere, and is supported, in general terms, by some of today’s most honoured thinkers outside of the field of addiction. This story is well known in various corners of the field of drug addiction, although it only beginning to find a place in the centre, where policy is set.
A Paradigm Shift in the Field of Addiction
The paradigm shift from the old to the new story will be a major event in cultural history. It will radically the focus of attention of people concerned with addiction from a narrowly defined problem to a much broader problem that is now usually overlooked. This kind of re-focussing can be illustrated with a shocking but amusing picture of some golfers in one of the western regions of Canada and the US that have been engulfed with forest fires for the last few summers. The fires are destroying huge amounts of forest that are vital animal habitats, carbon dioxide sinks, and workplaces for thousands of forest workers.
Fig. 1. When it is time to re-focus our attention.
The gentlemen golfers in this picture are concentrating intensely on their game. They know that a good game of golf is an excellent way to improve quality of life for affluent people like themselves after a certain age, and that golf also helps the economy, because important business connections are made while golfing. Because playing golf well is extremely difficult, they must concentrate hard. But, if these people really want to improve the quality of their lives and their society, they are concentrating on the wrong problem.
No matter how much these gentlemen sharpen their golf skills, their quality of life is endangered. They could dominate their league or even develop a brilliant new variation on the game of golf, without improving their quality of life or the economy. If they really want a better quality of life, they need to change their attention from a less important problem to the more important, flamingly obvious one. Not only is the fire alarmingly close, but the forest fires that are burning all over Western North America are doing huge environmental and economic damage, and many experts say that they are a manifestation of a much larger problem of global climate change. We could say these golfers need a “new story” about how to improve their lives or we could say that they need to join a “paradigm shift” that is already under way, or we could see that they need to see the world in a very different way.
This golf picture is popular among people that I know right now. I believe that it is a powerful metaphor at a time when reformulations of many basic problems – paradigm shifts – are so urgently needed.
Roots of the New Story
Like the “old story”, the “new story” or “new paradigm” for dealing with the drug problem that I will propose is not historically new. It too springs for deep roots in the history of western culture. However, it has been marginalized in the field of addiction for most of the past century and is now re-emerging. Neither the old story nor the new story can be proven. They come from culture, which is the source of the deep structure of paradigms in general (Kuhn, 1970).
Old and New Sources of the New Story:
Plato, Book 8 of the Republic (ca. 360 BC; Stephanus numbers 544a-575a; see summary in Alexander and Shelton, 2014, pp. 78-80)
Folk Myths: Canadian Indian, Scottish (see Alexander, 2015).
Sigmund Freud’s Civilization and Its Discontents (1929/1952, 771-776, 801)
Secular Critique of the Modern Era (e.g., Franz Kafka, 1937; Karl Polanyi, 1944; Vaclav Havel, 1978, Naomi Klein, 2007, 2014, 2017; George Monbiot, 2016a,b; Byung-Chul Han, 2015, 2017)
Theological Critique of the Modern Era (Ignacio Martín-Baró, 1994; Pope Francis, 2013, 2015; Kent Dunnington, 2017)
Rat Park (Alexander, 2010)
Contemporary History, Sociology, Anthropology. For example, the history of the worldwide spread of alcoholism among aboriginal people in the wake of global colonization by the European powers (Bayly, 2004; Alexander, 2008/2010, chaps. 5, 6). Another example: the linguistic history of the word “addiction” in the English language during the 500 years of the modern era (Warner, 2002; Lemon, 2018).
“Social Determinants of Health Perspective” emerging in the World Health Organization (see also Laing, 1967; Davis & Gonzales 2016; Arnold, Coote, Harrison, Scurrah and Stephens, 2018).
Rat Park. For the sake of time, I must confine today’s remarks about sources of the new story to the single source I personally know best: Rat Park. I have written more about the other sources elsewhere (e.g., Alexander, 2008/2010; 2017). Rat Park is important to me, because it started me on the path to the New Story almost a half century ago. But I wouldn’t have got there without a lot of help from very wise people.
I began studying addiction as a professional psychologist in 1971. I volunteered as a therapist at a local treatment agency in the heart of Vancouver’s heroin-using area, was given an office, and instructed to persuade heroin users who were receiving methadone maintenance to stop taking drugs altogether, including methadone. It was a fascinating – if impossible – challenge for a young psychologist. Most of the addicted men and women who sat across that desk from me were only a little younger than me, but they were weary, battered, and miserable from living as “junkies” in the full fury of the War on Drugs.
As they told their very different stories, a theme emerged that contradicted the old story. Most of the time, they did not think of themselves as “out of control”! Rather they saw themselves as having access to a useful drug – heroin – that reduced their pain and misery. The lifestyle they explained to me had a comprehensible purpose and a high content of adventure. They spent most of their time desperately seeking enough money to pay for this drug, most often by trafficking, theft, or prostitution. They were brutally handled by the local police in the drug war of the day (Alexander, 1990) and had the scars and missing teeth to prove it. However, along with the suffering and the pharmacological pain relief, they gained an important identity and feeling of solidarity in the community of people who were also chasing heroin and being chased by the police. Contradicting the old story, they showed me in a hundred ways that they were not “out of control” but living the most meaningful lives they could construct, given their anxieties, their lack of education, and/or their origins in dysfunctional families.
Since I was a new university professor of psychology as well as a new therapist, I was eager to share these observations with my students, and to raise possibility with them that perhaps these addicted people were at least partly right, and that the old story that was the dogma of the day was at least partly wrong.
Some of my students were very interested in exploring these possibilities, but others threw the old story back in my face. One student actually shouted his disagreement from the back row of a classroom: “Don’t you know about the rats?”
By “the rats” he meant the research on rats in “Skinner Boxes” that was headline news in the 1970s. He knew – everybody knew – that rats housed in Skinner Boxes consumed huge amounts of heroin and other addictive drugs, and were sometimes so absorbed in dosing themselves that they forgot to eat and died of starvation! This was interpreted in those days as scientific proof that drugs like heroin were so irresistible that a person – or any mammal, down to the lowly rat – which experimented with them would become lost forever. This seemed, in those days, like an irrefutable, scientific argument for what I am calling the “old story.”
Fig. 2. Rats in the Skinner Box experiments of the 1960s received an injection of heroin through the tube when they pressed the lever on the wall.
As the debate continued, a small group of student and faculty researchers, myself included, became interested in exploring the possibility that the rat research in the Skinner Boxes was wrong. We knew that rats are highly social creatures and guessed that keeping them isolated in the Skinner Boxes as well as their solitary home cages amounted to a kind of torture. Perhaps giving them access to drugs like heroin, when nothing else was available, was like offering a soothing painkiller to a human being in prolonged solitary confinement!
So eventually we built Rat Park…
Fig. 3. Rat Park provided plenty of room for both socializing and meditation.
Fig. 4. Female rats in Rat Park spent much of their time taking care of their pups.
…and offered unlimited access morphine hydrochloride both in rats in Rat Park, and to rats isolated individual cages that were no larger than Skinner Boxes. (Morhine has virtually identical effects to heroin and the rest of the opioid or opiate family of drugs.) We recorded much more drug consumption in the isolated cages, suggesting that the earlier Skinner Box research provided no real evidence for the old story at all. The extraordinary consumption of drugs in the Skinner boxed rats now appeared to be an artefact of an impoverished environment (Alexander, 2010). Now that the Rat Park research has become known around the world, it has helped to open the door for the new story that will eventually replace the worn out old story that is confusing the understanding of addiction today (See Alexander & Peele, in preparation, for the most recent update).
However, there is a limit to what can be learned about human addiction from tis kind of laboratory research. In the end, rats are rats. Only a limited amount about human addiction that can be learned from them. Therefore, I will tell the new story in the plain language of history, rather than the esoteric language of the rat laboratory, or of any of the other predecessors of the new story that I mentioned earlier. Then I will discuss the implications of the new story for the treatment of drug addiction.
The “New Story”
The new story contradicts all four elements of the old story and negates the narrow conception addiction that is implicit in them. The essence of the new story is that the “drug addiction problem” is only one corner of a much larger problem of harmful forms of addiction, dependence, and self-destructive lifestyles that are built into the five century span that historians call the modern era. The new story asserts that the really harmful addiction problem is not merely “drug addiction”, but a great many severe, harmful forms of addiction and related problems – of course including drug and alcohol addiction. The new story asserts that although many people get through life without becoming casualties to harmful forms of addiction, most people know addiction, because they use beneficial forms of addiction in coping with life and because, at one time or another, they feel the attraction of harmful forms of addiction. The new story ultimately points to the daunting conclusion that harmful forms of addiction can only be solved by epochal changes in the emerging modern world society. The new story is as different from the old story as a forest fire is from a game of golf.
I have centered my representation of the new story on a portrait of Christopher Columbus, looking worried. I hope you will quickly see why Columbus should be the central image, and why he was right to worry.
Fig. 5. Modernity-Addiction Feedback Loop.
Of course, the modern age has spawned dangers that are even more terrifying than the rising tide of addiction, for example, nuclear annihilation, environmental cataclysm, obscene income inequality, and increasingly violent, mass resentment. This presentation focuses on addiction, because that is the topic that brings us here today. However, I also hope to show, that part of the reason that addiction is such a serious problem today is that it is inextricably interwoven with other dangers of the modern age (See also Alexander, 2015).
“The modern age”, taken as the five centuries of western history since Columbus’ voyages, has long been a topic of intense study among historians, literary scholars, and social scientists. The first couple of centuries of the modern age are conventionally known as the “early modern” period, and the last couple of centuries as “late modernity.” For a serviceable, compact description of how social scientists conceptualize the modern age, see Berman (1988, pp. 15-21). For more recent, but less compact, descriptions, see Mishra (2017), Monbiot (2017), or Han (2017). In this presentation I focus on three major aspects of modernity:
1. Massive, interlinked, global markets and institutions like multinational corporations, the Internet, free trade agreements, and the World Bank with powers over ordinary people of a magnitude once only associated with Kings, Emperors, and God.
2. Spectacular, all encompassing advances in science and technology, including the technology of controlling and surveilling people.
3. (Paradoxically)…Relentless celebration of individualism, freedom, and privacy.
Many great thinkers have described the psychological problems of modernity eloquently: Today, I am thinking especially of Fyodor Dostoyevsky, Charles Dickens, Franz Kafka, Aldous Huxley, George Orwell, Eduardo Galeano, and Byung-Chul Han for powerful nightmare critiques, and Karl Polanyi, Vaclav Havel, Naomi Klein, George Monbiot, and Pope Francis for critical analyses that point towards a way out.
As you contemplate the new story of addiction that I am discussing today, please keep in mind that showing that addiction is built into the modern age is not the same as calling for a return to the Stone Age. Every human civilization of the past has its characteristic achievements and successes as well as unwanted side effects that have eventually led to its collapse (Toynbee, 1948). The achievement and successes of the modern age are real, and they have been celebrated effusively (Pinker, 2018). Although the dire side effects of early modernity were obscured by its dazzling accomplishments and the wealth that it brought to many people, today’s late modern society must face and rectify these side effects if it is to avoid disaster.
Please also keep in mind that saying that addiction is built into modernity, is not the same as denying that well-documented risk factors increase the likelihood of addiction. These include degrading poverty, early-life traumas, family dysfunction, depression, loneliness, racial prejudice, insidious advertising, perfectionism, predisposing genes, and deliberately-addicting social media, games, and insidiously designed gambling machines. Rather, the new story shows how the structure of modern society tilts the playing field in favour of addiction by increasing the likelihood that people will be exposed to most of these risk factors, and many others, as the consequence of social and economic forces beyond their control. Modern society also tilts the playing field by making it difficult for people who have acquired harmfully addictive lifestyles to find deeply satisfying alternative ways to live.
From the time of Christopher Columbus onward, Western European powers crushed pre-modern societies and aboriginal tribes around the globe by conquest, disease, enslavement, enticement, economic exploitation, forced religious conversion, and ecological devastation of their territories. This social fragmentation was made possible by modern advances in science and technology, like the ship’s compass, steam engines, heavy gunnery, mass production of cheap trade goods, and by powerful modern ideologies that brilliantly justified subduing the entire planet to increase the wealth and power of the civilized nations and the great corporations of the world.
As the colonizing European nations fragmented societies overseas to magnify their national wealth and power, they also crushed and impoverished the rural subcultures of their own homelands, although with somewhat more restraint. Agricultural and industrial revolutions, which accompanied and enabled global colonization, devastated stable peasant farms and commons throughout Europe. Refugees from this domestic fragmentation were cruelly stigmatized and economically exploited in European slums or shipped abroad to populate the colonies.
Although it is sometimes overlooked now, European nations also fragmented their own upper crusts of the wealthy and powerful. Rich adventurers, manufacturers, and bankers competed relentlessly to maximize their individual wealth and glory and many wound up in ruins (Galeano, 1973, 22-28, 55-56). As Viennese scholar Karl Polanyi (1944, p. 128) described early modern England, “... the most obvious effect of the new institutional system was the destruction of the traditional character of settled populations and their transmutation into a new type of people, migratory, nomadic, lacking in self-respect and discipline—crude, callous beings of whom both labourer and capitalist were an example.”
In late modernity, countless works of philosophy, fiction, poetry, and song lament the fragmented lives of the affluent and well educated as well as the poor and exploited. Think, for example, of the fiction of Dostoyevsky or Kafka, or the poetry of T.S. Elliot and Allen Ginsberg.
The fragmentation of society that began in the early modern era still escalates in both rich and poor nations in the 21st century. This fragmentation has been shaped by different economic and political regimes in different times and places over the centuries of the modern era, but it is currently shaped primarily by the dominance of free-market capitalism; neoliberal politics; ecological devastation; consumerism; gross inequality; mining of personal information from social media to enable targeted advertising, news, and propaganda; third world “development;” financialization with its periodic fiscal crises; corporate culture; “enterprise culture;” “metacolonialism;” high-tech surveillance; high speed technical change; real estate bubbles and crashes; relentlessly advancing efficiency in manufacturing and agribusiness; robotization; “smart cities;” “ludocapitalism;” and continuing plunder of the remaining aboriginal territories. Today’s continuing global fragmentation is not only propagated by original European colonial nations, but also by the United States, and by other major powers, as they modernize along the lines that originated in Western Europe five centuries ago.
In my earlier writing, I focussed on free-market capitalism as the cause of modern fragmentation. I still see free-market capitalism as centrally important, especially in my own country, but broader historical thinkers have shown that the cause runs deeper, to the very roots of modernity itself. Christopher Columbus was not a capitalist, nor were Vladimir Lenin, Joseph Stalin, Fidel Castro, Deng Xiaoping, and Xi Jinping. But they have been vigorously and sometimes mercilessly modern. Christianity, Marxism, and free-market capitalism have all provided justifications for the fragmenting advance of modernity in different times and places.
Modernity creates obvious economic and environmental fragmentation, but my focus today is on its devastating social destruction. Beneath the steamroller of modernity, extended families and communities are scattered; nuclear families become dysfunctional; local cultures are pulverized; legitimate authority is toppled, religious certainties disappear; and cultural arts are reduced to mass production of trinkets for tourist shops. People and social groups that do not contribute to the advance of modernity are marginalized or exterminated.
Societal fragmentation has come to seem an inescapable consequence of the modern miracles that have enabled the earth to support seven billion people. But this miraculously modern, emerging world society is in deep – possibly terminal – trouble. Part of this trouble comes from the diverse side effects of fragmentation, most obviously environmental destruction, obscene inequalities of wealth and power, and the possibility of nuclear war. The most important of these threatening side effects for this presentation, however, are mass dislocation and, in its trail, mass addiction.
Mass Dislocation of Individuals
I use the word “dislocation” to designate the individual psychological consequences that follow from societal fragmentation, as they manifest themselves in people’s everyday lives throughout the modern world.
Dislocation has many other names. For example, psychologists speak of rapidly growing deficits of attachment, belonging, identity, meaning, and purpose leading to disorders such as anxiety and depression in the people they study. Sociologists speak of the alienation and resentment of individuals in large bureaucratized societies that crush both community and economic structure. Christians speak of the poor in spirit or of declining faith within the secular world. Existentialists describe feelings of anxiety, dread, absurdity, despair, loneliness, and nothingness in people who inhabit a pointless bourgeois society. Evolutionary biologists speak of failure to satisfy the innate social needs of the human species in modern times. Dislocation has not yet been adequately described in the language of neuroscience – but it surely will be as the old story gradually loses its paralyizing grip on neuroscientists (see Heilig, Epstein, Nader, & Shaham, 2016).
Dislocation is brutally obvious in the poor and homeless of today’s world, but it not confined to them. It afflicts every level of society. In richer societies, dislocation is devastating the affluent as well as the poor (e.g., Luthar, Barkin, & Crossman, 2013; Powell, 2016; Curran and Hill, 2017; Han, 2010; 2017; Solnit, 2018).
One touching story about mass dislocation describes affluent Japanese people sometimes hire actors to stand-in for long lost spouses, friends, and relatives in everyday family events and in important rituals like weddings, funerals, and welcoming new babies into the world. These practices are documented in a recently published article (Morin, 2017).
Fig. 6. “Renting Friends and Family in Japan” (Morin, 2017)
Mass dislocation has come to seem inevitable. The modern market system requires that individuals must perform competitively and efficiently, unimpeded by sentimental ties to families, friends, religious values, or norms of compassion. Children must be prepared for a life of cut-throat competition. Since they are too young to comprehend this, they must be pushed relentlessly by their parents, for their own good (Stewart, 2018). After all, “business is business” and we expect our politicians to produce “economic growth” and to “create jobs” at all costs. Stringent economic rationality is said to make the law of supply and demand function efficiently, and thus to “clear the markets” each day. China, India, Brazil and other nations that have joined the economic superpowers are paying the price in surging dislocation – and addiction.
Seen in a positive light, individual dislocation can provide a space for initiative and creative freedom for people who have felt stifled by their societies (Han, 2017, chap 13; Bruder, 2017). However, prolonged, radical dislocation exacts a high price, because it ultimately generates misery in the form of anxiety, suicide, depression, disorientation, hopelessness, and resentful violence. In fact, prolonged dislocation is so unbearable that it has been imposed as an extreme punishment from ancient times to the present. Punishments like exile, ostracism, banishment, shunning, excommunication, and solitary confinement are, essentially, imposed dislocation. Extreme social isolation, which is essentially imposed dislocation, is an indispensable part of today’s terrifyingly scientific technology of torture (Klein, 2007, chap. 1).
As a human experience, “dislocation” resists quantitative measurement. For example, psychologists like myself may speak of dislocation as the lack of attachment, belonging, identity, meaning, and purpose. But can a strong identity make up for a weak sense of purpose? Can a strong sense of attachment and belonging make up for other lacks? How are dislocation, attachment, belonging, identity, meaning, and purpose measured? Such questions cannot be answered precisely at this time. Nonetheless, dislocation – under its various names – has long been recognized by critical observers of the modern era. It is easy to overlook the importance of dislocation in an academic milieu that is dominated by empirical epistemology and reductionist ontology. Unfortunately however, empiricism and reductionism cannot legislate dislocation out of existence. They can only obscure it.
Flood of Addictions: Severe Addiction as an Adaptation to Dislocation
Just as dislocation historically follows fragmentation of a society, a flood of addiction problems historically follows dislocation. Extensive historical, anthropological, and clinical evidence documents this predictable sequence.
I have spent decades studying the deadly outbreak in harmful addictions in the indigenous people in Western Canada that followed the fragmentation and consequent mass dislocation of their cultures imposed by British colonization (Alexander, 2008/2010, chaps. 5, 6). Unfortunately, the tragedy of modern colonial fragmentation and dislocation of aboriginal people, followed by mass addiction, is not restricted to Canada, but has been repeated on every continent (Bayly, 2004; Mann, 2011).
Methamphetamine provides a more contemporary American example of the effects of fragmentation and dislocation on addiction. An American methamphetamine panic broke out at the end of the 20th century in the US. The surge in methamphetamine use and addiction was explained as the work of an irresistibly addictive drug. Some champions of the old story announced at the time that methamphetamine was the “most addictive drug on earth.” Then, investigative journalism showed why methamphetamine was spreading so fast and why the spread was concentrated in the farming states. Mass dislocation had emerged in the American farming states following legislation and immigration practices that destroyed what had remained of the traditional American family farm culture. Large numbers of dislocated former farmers and dislocated workers from meatpacking and other agricultural industries appeared in a region with abundant farm chemicals that could be converted into methamphetamine. The result was a devastating increase in methamphetamine use and addiction in the American farm belt, which was later renamed “Methland” by one author (Reding, 2009).
Abundant clinical and biographical evidence reveals the reason why severe addictions track dislocation so closely. Addictions can provide dislocated people of all races and social classes with some relief and compensation for bleak, empty lives, when nothing else works for them. Addictions can be adaptive in a fragmented, modern world because – in psychological terms – severely dislocated people can use addictions to obtain some morsels of attachment, belonging, identity, meaning, and purpose, at least in the short term (Alexander 2008/2010: chaps. 6-8; Hart 2013: 74-95; Fetting 2016; Dunnington, 2017). Without their addictive identities and their connections in the addict subculture, many dislocated people would have terrifyingly little reason to live, and would risk incapacitating anxiety, depression, or suicide.
For example, opioid drugs, including heroin as well as prescription drugs, provide real relief for the physical and psychological pain of dislocated people. It is not hard to understand why opioid drug use is more and more common in the modern, dislocated, stressed-out world. The great majority of users do not become severely addicted (Alexander, 2008/2010, chap. 8; Satel, 2018) and if they do, they do not remain addicted for very long (Heyman, 2009). However, the most dislocated opioid users must endure intractable, crushing absence of attachment, belonging, identity, meaning, and purpose in their lives. For them, opioid addiction – not just opioid use – can provide a desperately needed, irreplaceable, substitute for what is missing.
When opioid addicts wake up in the morning, at least they know who they are and what they must accomplish that day. Rather than being overwhelmed by unbearable emptiness, they keep frantically busy chasing drugs, and interacting with other drug chasers, within a loose community of other addicted people. At the same time, addiction can enhance their identity and self-esteem by symbolically linking their miserable existences with the fascinating lives and deaths of opioid-addicted celebrities like William S. Burroughs, Sid Vicious, Curt Cobain, Phillip Seymour Hoffman, Amy Winehouse, Michael Jackson, Robin Williams, Prince, or Carrie Fisher (Pryor, 2003; O’Donnell, 2018).
Other well studied examples of the adaptive value of severe addiction: Many dislocated people use horserace gambling addictively to colourize their otherwise bleak lives. They exchange information and hunches at the track with a subculture of track habitués, and share a mythology of famous gamblers and legendary horses (Ryan, 2014a, b). Some people who gamble addictively on slot machines or the Internet do not seek human social interaction, but rather a “zone” of intense engagement with dazzling gambling machines that have been ingeniously designed to be engaging and interactive, without having the threatening or annoying qualities of actual human beings (Schüll, 2012).
People who are not addicted to drugs or gambling, or who are addicted in a minor or temporary way, can use drugs or gamble without getting into serious difficulties. However, there are millions of people whose dislocation is so desperate that they build their lives around drugs or gambling or other potentially addictive pursuits. When severely dislocated people find that an addictive lifestyle provides their best hope for enduring their existence, they seize it with the same iron grip that they would apply to a piece of floating junk in a stormy sea. Quite often, they seize more than one piece of junk and have multiple addictions.
Speaking of harmful addictions as adaptations is utterly incompatible with the old story, because the essence of the old story is that addicted people have lost their will power and are acting maladaptively under the control of a drug. Adaptation does not imply loss of control. But neither does it imply free will. Adaptation by-passes the ancient, unresolvable dichotomy of free-will and determinism completely. It comes from a different, evolutionary way of thinking (see Alexander and Shelton, 2014, chap. 7).
All of our human ancestors successfully adapted to their environments behaviourally, as well as anatomically and physiologically. We all survive by using the adaptive capacities that we inherited from them. The possibility of becoming intensely devoted or dedicated to a habit is one of these capacities. Addiction is an adaptive capacity we can use for various purposes, including responding to chronic dislocation (Alexander, 2008/2010, chaps. 6-8). When addictions are short-lived, as they most often are (Heyman, 2009, chap. 4), they can function to help people to endure bouts of dislocation and then move on to more socially integrated lives. Unfortunately, addiction like many other forms of adaptation can become harmful or fatal if worked to exhaustion when the individual has no more feasible way of adapting to a long-term stressor (Selye, 1950; Angeli, Minetto, Dovio, and Paccotti, 2004).
Evolutionary biology provides the key insights here, but, as is so often the case, Shakespeare said it first. The roguish knight, Falstaff, in Shakespeare’s two plays about King Henry IV was boisterously and charmingly addicted not only to drinking, but also to companionship – usually in taverns – with Hal, the son of Henry IV, who eventually became King Henry V. In a famous soliloquy Falstaff celebrated the benefits of his addiction to strong Spanish wine (sack).
Centuries of Shakespeare’s audiences have seen how adaptive this duplex addiction was for Falstaff … until it wasn’t. As Hal matured and eventually assumed the throne of England, he rejected his old drinking buddy. Falstaff was left alone with his liquor, and, having no other alternative, drank himself into oblivion and death (Lemon, 2018, chap. 3).
Using the word “addiction” in this broad, adaptive sense further affronts the old story, because the old story essentially, or at least primarily, reserves the word “addiction” for drug and alcohol use. However, the new story fits the fact that addictions to a very large number of habits, like gambling, overeating, sex, extreme sports, cult practices, religious fanaticism, social media, Internet usage, narcissism – and countless more – can become as destructive as drug addiction when they are used to adapt to chronic dislocation.
The new story fits with the very broad meaning of the word “addiction” that has prevailed in the English language from the earliest days of the modern era (Lemon, 2018). The current online edition of the most authoritative dictionary of the English language (the Oxford English Dictionary) defines addiction in this traditional way as a state of: “…being dedicated or devoted to a thing, esp. an activity or occupation; adherence or attachment, esp. of an immoderate or compulsive kind...” Note that there is no mention either of loss of control or of drugs in this definition.
Of course the word “addiction” is often defined within today’s version of the old story as a disease caused by drug use, but this relatively recent, alternative definition did not appear in the Oxford English Dictionary until 1933 (definition 1b in the current edition), while the traditional definition, which is much older, remains as definition 1a. Unfortunately, the word “addiction” has been exported to the non-English-speaking world only in the sense of the drug-disease definition, rather than in the traditional definition. This has helped to make the old story seem irrefutable in those places that have been heavily influenced by English-language culture.
I will be using the traditional definition of the word “addiction” for the remainder of this talk. Using the traditional definition allows us to recognize that addiction is a kind of concentrated focus of energy, attention, or commitment that can be highly adaptive. In fact, “addiction,” in traditional English usage, was most often used to describe habits that are adaptive and admirable, such as addiction to scholarship, religious devotion, or love (e.g., King James Edition of the Bible, 1 Corinthians, 16:15; Lemon, 2018, intro, chap. 1, 2).
The new story explains why a perfectly good adaptive capacity like addiction so often goes wrong among individuals in a modern era or relentlessly increasing fragmentation and dislocation, and, in extreme instances becomes harmful or fatal. The new story also suggests that although many people get through life without becoming casualties to harmful forms of addiction, most people know addiction, because they use beneficial forms of addiction in coping with life (Lemon, 2018, chap. 6) and because, in the fragmented world of the modern era, they feel the attraction of harmful kinds of addiction when more beneficial kinds of addiction cannot work for them.
The individual and social functions of addiction in the modern era go a long way towards explaining why addictions of every imaginable sort are as intrinsic to late modernity as competitiveness, loneliness, and anxiety. The individual utility of addiction in adapting to dislocation partially explains its dangerously high prevalence in a world of dislocated people. But addiction also has adaptive functions for modern society itself. The insatiable economy of the modern world requires overwork and overconsumption to keep the wheels of industry turning, the GDP growing, and the share prices rising. Therefore the addictions that favour economic growth and corporate profit, e.g., addictions to wealth, consuming, shopping, casino gambling, creative narcissism, and overworking, are encouraged by modern society and deliberately cultivated by commercial advertising. Because addictive involvements with products can be a huge competitive advantage, product addictions are deliberately cultivated by product designers who pay close attention to scientific studies of drug addiction (Eyal and Hoover, 2014).
In an extensive literature review and meta-analysis, Sussman, Lisha, and Griffiths (2011) tried to use all the research on addiction in the United States in the last few decades to estimate the prevalence of 11 different kinds of severe addictions. The study was provocatively entitled, “Addiction: A problem of the majority or the minority?” Addiction was not defined as a drug problem as in the old story. It was defined in more accordance with the inclusive traditional definition, but limited to only those addictions that were actually harmful to addicted persons and/or their society.
Here are Sussman, Lisha, and Griffith’s estimated frequencies of harmful addictions in the United States in any twelve-month period:
“Based on the above review, we estimated the overall last 12-month prevalence of the 11 addictive behaviours among U.S. adults as follows: cigarettes—15%, alcohol—10%, illicit drug use—5%, eating—2%, gambling—2%, Internet—2%, love—3%, sex—3%, exercise—3%, work—10%, and shopping—6%”
These percentages add up to 61%. But, as Sussman, Lisha, and Griffiths point out, it would be wrong to conclude that 61% of Americans are harmfully addicted to something in any 12 month period, because many people are addicted to more than one habit. Their final conclusion, based on a set of simplifying assumptions, is that probably 47% of Americans are harmfully addicted to one or more habits in any 12-month period. Nearly half the population of the United States!
The adaptive functions of severe addiction in the modern world are often denied. Many severely addicted people deny that they live in a state of dislocation, because they feel embarrassed to think that they do not “have a life”. They may not know that most people in the modern world experience painful dislocation, at least some of the time. They may be unaware or ashamed of the adaptive functions of their own addiction. In moments of insight, however, severely addicted people can explain the functions of their addiction with surprising candour (Alexander, 2008/2010, pp. 158-160; Schüll, 2012; Pond & Palmer, 2016, pp. 21-22).
Mass media endlessly proclaim that addiction is a chronic brain disease caused by the effects of addictive drugs on the brains of people with a genetic predisposition to addiction, rather than an adaptation to dislocation in a fragmented world. Scientific authority and media dramatization bolster this contemporary version of the old story. It is lavishly funded and sponsored by the National Institute of Drug Abuse in the United States, despite its evident deficiencies.
Another complication that obscures the adaptive functions of severe addiction is that people may be addicted, especially for a short time and in a relatively mild way, for reasons that have nothing to do with dislocation. People may fit the traditional dictionary definition of addiction when they undertake a binge of work to finish an important project before a deadline and thereafter return to normal work habits. They may also fit the definition when they devote themselves to compassionate service and asceticism out of concern for suffering humanity, when they drink their way through a period of grief, when they fall head-over-heels in love, or when they devote themselves to caring for a baby. The dislocation theory of addiction explains the high prevalence of harmful, long-lasting kinds of addiction in fragmented society, but less extreme, shorter-lived forms of addiction can serve quite different adaptive functions and often occur in situations where dislocation is minimal. For example, you don’t have to be dislocated to fall in love, but you do have to be dislocated to sacrifice your life addictively to a dysfunctional love relationship (Peele & Brodsky, 1975).
The words “dedicated” or “devoted” – the key words in the traditional definition of addiction – describe two of the most important and admirable characteristics of our species. Not only are dedication and devotion frequently adaptive, they are also virtuous to most of us. We human beings are able to solve the most difficult problems by marshalling our energy and concentration in a sustained way, i.e., by dedicating or devoting ourselves to finding the best solutions or to a way of thinking that will help us find the best and must humane solution. Civilization itself requires a radical division of labour; Genetically similar people must concentrate their energies in a way that fills out the spectrum of hugely different vocations and roles. Could human civilization exist without the capacity for addiction?
I believe that addiction must be understood at a deep psychological or existential level, and perhaps spiritually as well. Rebecca Lemon argues in her recent book that addiction, understood broadly in the way it was used in early modern England, experientially illuminates one of the quintessential human mysteries: The mystery of simultaneously pursuing the gratifications of individualism and autonomy on one hand and selfless service to a revered idea or person on the other. Understanding addiction deeply, Lemon argues, puts us in a position to “open space and light into an otherwise divided sense of being” (Lemon, 2018, p. 167).
Of course our addictive virtues can go terribly wrong when the dedication or devotion are misplaced or when dislocated people with no other options continue their addictions beyond the limits of their effectiveness, even to their deaths. It is these harmful forms of addiction that are our concern today, but I believe they can only be understood in the context of a broader understanding of addiction in human social life. Is it possible that even the most damaging and despised form of addiction entail a component of dedication or devotion? What implications would that have for treatment?
Consequences of Severe Addiction: The Cycle Continues.
Many people cling to severe, harmful addictions because they are indispensable adaptations to dislocation in an increasingly fragmented modern world. And some kinds of intense, prolonged addiction, such as addictions to work, achievement, and shopping are encouraged and promoted by society because they help to maintain high levels of production and consumption and can create a competitive advantage. But there is yet another important reason why severe addiction is intrinsic to the modern world. Long-term harmful consequences of severe addictions, not only harm the addicted person, but also exacerbate the fragmentation of modern society, thereby increasing the dislocation that society causes. increased mass dislocation leads to more addiction. The Modernity-Addiction Feedback Loop takes another turn. (See Fig. 5).
Consequences of addiction that exacerbate social fragmentation include: Environmental and social destruction mandated by wealth and power addicts pursuing profits in the executive suites of their multinational corporations, investment banks, and hedge funds; environmental and social destruction caused by wasteful addictive consumption of millions of more-and-less severely addicted customers; the fragmentation produced by all the talented people who are lost from healthy family functioning and productive work because of severe addiction, protracted recoveries, or overdose deaths; social insecurity produced in local communities by the overtly criminal street addicts supporting their drug habits and gangs supplying the drugs; and elders who cannot contribute stabilizing wisdom to succeeding generations because they are addicted to television, bingo, Sudoku, prescription drugs, or whatever.
Because of its long-term socially fragmenting consequences, severe addiction is not only a downstream adaptation to societal fragmentation but also an upstream cause of it. Addiction is built into modern, global society structurally.
The vicious cycle that is built into modernity cannot continue indefinitely. Eventually the strain on the earth’s ecosystems and on human culture would become unsustainable, and modern civilization, like every civilization that has preceded it, would collapse (Toynbee, 1948).
How does the New Story Help Us Respond Better to the Opioid Overdose Crisis?
1. The best responses to overdose deaths are supervised injection sites, naloxone access, and provision of relatively safe opioid drugs to addicted people. These harm reduction methods are especially important lifesavers when dangerously strong drugs like fentanyl are circulating in illicit markets. That these measures save lives has been thoroughly documented in the Scandanavian countries, Switzerland, the UK, Portugal, and Canada. These responses to the overdose death crisis can fit comfortably into the narratives of both the old story and the new story, and harm reduction methods are therefore spreading to many parts of the world, even those where it has been stoutly resisted in the past (D’Souza, 2018).
2. Medical and psychological treatment of addiction can only have a relatively minor effect on the crisis of overdose deaths. This is because the people who are most likely to overdose are generally so dislocated and desperate to use opioid drugs that they are poor candidates for treatment and partly because providing enough treatment for the number of people now dealing with opioid addiction problems would require a long time and a huge amount of public funding. Treatment has, of course, a more important role in dealing with the long term addiction problem and I will discuss it again, under that heading.
3. The worst response to the crisis of overdose death is imposing stringent limitations on drugs supplied to medical patients by doctors. Doctors should provide opioids cautiously, as most do, but they should refuse to hold a monopoly on access to opioids. Opioids should continue to be used in surgery and post-surgical care, without a prescription. Doctors should prescribe, or not, to addicted people and to people suffering from pain, according to their best judgement. But full-strength opioids should be also sold over the counter in drug stores – in the safest possible, dilute solutions of course – because doctors cannot tell whether a person really needs them for physical or psychological pain and also, particularly in the United States, because many suffering people can afford the services of a doctor.
Denying opioids to people suffering from severe pain is cruel, and sometimes has fatal consequences. If you don’t believe this, please read case studies of chronic pain patients who must desperately seek alternative drug sources in the hope of controlling their agonizing pain when their prescriptions are cut off (Cates-Carney, 2016; McCoy, 2018). Please also read studies of suicides of chronic pain patients who have had their opioid supplies restricted or eliminated (Langreth, 2017; Satel, 2018), or ask me after the presentation and I will tell you about my own experience, when I was a chronic pain patient, decades ago.
I know that, in room as big as this, some people understand severe chronic pain, because they have experienced it or are experiencing it. Others do not. I know that you cannot understand it without having it because I did not understand it until I lived through it myself! I will never again underestimate the importance of having access to opioids when pain becomes unbearable.
The consequences of allowing the sale of full strength opioid solutions in stores on demand are easy to predict. Some buyers of opioids will use them unwisely of course, but in countries where opioids have been sold on demand in dilute solution, the rates of opioid addiction and overdose death have been far lower than they currently are in those same countries. Crises of overdose deaths were unheard of. These countries include the US, Canada, and the UK. These facts are, of course, inconceivable under the old story in the middle of an opioid panic, but the historical record is clear and available to all who are willing to read it (Brecher, 1972, chaps. 1-6; Berridge & Edwards, 1987; Courtwright, 1982).
4. The best interventions will probably succeed in lowering the death toll back to the previous “normal” rates, but there will be another addiction crisis down the road and another after that. To deal with this addiction crisis and the next and the next, we have to go beyond the current crisis of overdose deaths and solve the deeper problem of the inexorable rise of addiction. Treatment for addiction has a more important role to play in this process but, even there, it is only a part of the solution.
How does the New Story Enable Us to Respond Better to the Rising Tide of Addiction?
I have summarized my seven-part answer to this question here. Taken together, I believe that this answer can help us deal more effectively with the present opioid crisis, future drug and addiction crises, and also stem the steadily rising tide of addictions of all sorts in the modern world.
1. Treatment of many sorts can help people recover from addiction.
'Severely addicted people often overlook alternative ways of coping with their dislocation. Many can benefit from wise counsel and support. Compassionate, intelligent psychotherapy can help many people.
Professional authority can help too. It is often helpful for professionals to use the status and expert knowledge to talk authoritatively with addicted patients and for physicians to give their patients the benefit of their professional prerogatives by dispensing and monitoring maintenance drugs like methadone and suboxone.
But addiction professionals should refuse to claim that they can cure addiction better than anyone else. Helpful treatment can come from doctors, psychologists, and specialized addiction counsellors, but it can also come from social workers, members of the clergy, members of self-help groups, friends, and relatives. This is especially true when an addicted person has been through the professional system, but emerged feeling just as addicted as before, but also misunderstood and alienated.
Dare I say, that even grandparents can be as helpful as professional therapists? I speak from direct personal experience as a person who has worked with addicted people, at different stages of my life, both as a professional psychologist and as an unpaid neighbourhood “grandpa.” Addicted people often find it comfortable to confide in elders about their addictive problems and their frustrations with the professional services, or lack of services. And a neighbourhood “grandpa” can express empathy, as well as realistic advice about alternatives to a destructive way of living, without worrying too much about whether a person completely abstains from drugs down the road.
There is no reason to suppose that only interventions that explicitly reject the old story can help people. Any narrative that stimulates people to reconceptualise their lives and change their path can help some addicted people to sort out their dislocated lives. There is no reason to disparage any kind of intervention that sometimes helps.
However, the often-heard, dogmatic pronouncements that “treatment works” (e.g., National Council for Behavioral Health, undated) claim too much. In fact, it is people (not treatments) who do the work of sorting out their lives when they are recovering from addiction, often with great intelligence and bravery, and often without treatment. Treatment can sometimes help, but all treatments have far more individual failures than successes.
Another excessive claim is an assertion that any particular treatment is the “Best Practice” or that only it can help addicted people, because it alone is “evidence-based.” The historical fact is that many treatments have been shown to help some (although not all) people, and they survive because of their observed utility. All of these can rightly be called “evidence based.” Many others have been tried and disappeared because they scarcely help anybody.
2. Even if treatment does not undo addictions, it can be an act of kindness for suffering people. Often I have heard addicted people express gratitude for treatment even when they are still dangerously addicted. Kind attention and caring from an interested doctor, therapist, support group member, friend, or grandparent can be an important, sustaining experience, especially for people who have been regarded as less than human. Attention and caring is a profoundly humane gift that should never be devalued. Once again, this value of treatment does not require explicit rejection of the old story.
Harm reduction is usually understood as a way of saving lives, rather than a form of treatment. However, harm reduction workers of offer addicted people kind attention and caring as well. Therefore, harm reduction can provide one of the main gifts of treatment, even when it does not help people overcome their addictions.
3. Many addicted people find themselves in the “new story.” Although the new story is not indispensable to treatment, it can sometimes play an inspirational role, by providing a stimulating, new narrative for addicted people. Many addicted people recognize themselves in the new story and are deeply grateful to know that their addictions are understandable in the ordinary language of human deprivation and striving that applies to virtually everyone in a fragmented society, so that their problems do not make them aliens.
When therapists and agencies previously attributed addictive problems to a brain that had been damaged by drugs, a maladaptive habit that has been overlearned, unbearable withdrawal symptoms, an ineradicable childhood trauma, or a demon drug, it created an expectation that only doctors or other professionals can effect a cure and that addicted people, as patients, can only follow the treatment regimen and hope that the treatment will “work.”
When it is seen that a large proportion of the population suffers from dislocation that is mass produced by society, and many people struggle with and eventually overcome addictive ways of adapting to that dislocation, then an actively addicted person can hope to figure out better ways to adapt to the social fragmentation that surrounds them in terms of their own understandings of the world. Treatment can help in this process and continuing social support of a welcoming, supportive community can help even more.
The new story also changes the narrative of what can happen after recovery from addiction, because it is built on a critique of fragmentation of modern society which leads to mass dislocation and then to addiction for many people. Because the old story contains no social critique whatever, it implies that recovery means a return to the conventions and dictates of the existing society of late modernity. Within the new story however, recovery means a return to an existing society that is deeply flawed and in need of structural revision. The new story liberates recovering people from rigid conventionality and points them towards membership in the various subcultures who are experimenting with forms of wholesome unconventionality and social activism. Perhaps this points people towards the kinds of liberated thinking that was promoted by the radical psychiatrists of the late twentieth century, like Stanislov Grof and R.D. Laing (Capra, 1988, chap. 4).
The new story also leads to an expanded appreciation of the importance of understanding each person’s unique embodiment of a widespread social problem. Why is a particular person vulnerable to heroin addiction and alcoholism, but not to gambling addiction? Why is another person able to use all drugs recreationally and harmlessly, if at all, but on the verge of suicide because of gambling debts? Why are some people addicted to sex and pornography, but not to shopping or religious fanaticism? I believe the answer lies in the meaning that the particular habit-of-choice has in the unique, lived experience of the particular addicted person. Only some people are attracted by the junkie mystique or to the identity of a daring gambler or a sexual superachiever or a religious zealot, and hence to those particular addictions.
To help people find an alternative to a harmful addiction, it is important to have a clear idea of the function that their addictions serves for them. Beyond function, it is important to understand the meanings of that people’s addictions have for them. Perhaps it is also important to appreciate and celebrate the elements of devotion or dedication that are built into some, and possibly all, addictions (Lemon, 2018).
4. Many effective treatment interventions are deprofessionalized community activities, wellness activities, or social movements. Community activities provide alternatives to dislocation and to isolated addictive solutions to dislocation. This has recently been demonstrated in Iceland, where a major investment in well organized community sports and other activities targeted at teenagers, together with efforts to promote family involvement with teenagers and schools has dramatically reduced the level of drunkenness and other indications of forthcoming drug addiction problems. This oft-copied form of intervention has recently been publicized as the “Icelandic model” in Europe (Young, 2017). There is no necessity that addiction professionals organize these kinds of community activities, nor does their need to be any explicit mention of the addiction issue in running them.
The Icelandic Model is only the cutting edge of an rapidly expanding movement towards providing organized, wholesome community life as an alternative to help people climb out of dangerous addiction. This movement is often called the “recovery movement”. It is can be based in a secular understanding of the new story (White, 2011; Best, DeAlwis, & Burdett, 2017) as well as many spiritual traditions and religions.
The new story does not lead to the conclusion that the solution of addiction problems lies in greatly increasing addiction treatment per se. It points more towards improving the opportunities for all people, including those who are dangerously addicted to engage in community life and to learn what it is to both belong to a group and maintain a sense of freedom. It is within community and of family that the eternally divided human soul can flourish and that healthful and socially beneficial human commitments can flourish, with no real need for harmful addictions.
5. However, no existing individual treatment, or harm reduction measure, or community activity, nor all of these together can make a dent in the spreading problem of addiction. This is because dislocation is built into, and mass-produced by, the increasingly fragmented society of the modern age. This means that, ultimately, the addiction problem can only be solved by re-structuring modern society on a global as well as a local level before it destroys itself either in the heat of global warming, the cold of nuclear winter, or, perhaps just as likely, an ever-rising flood of addiction. This is a task of generations and the new story points us directly to it.
Perhaps the resilience of the old story, long after its putative facts have been disproved and its lack of utility for controlling addiction has been demonstrated, is understandable in this stark context. The old story protects us from the daunting, indeed terrifying realization that the problem of addiction is even more serious than it seems at the height of an opioid crisis, that the solution will be require a huge commitment of human energy from all of us, that there are powerful vested interests that will oppose it, and that there is no guarantee of success.
6. There is no Miracle Treatment for Addiction in the Pipeline. The kind of serious addictions that we are concerned with in this presentation are ways of adapting to dislocation. There can never be a miracle cure for addiction because, quite simply, there is no disease! Adapation is not a disease, although it can cause diseases when it is worked to exhaustion. This logical deduction from the new story has been borne out historically.
We have a very long history of distracting ourselves with exciting, new miracle cures that appear infallible for a while. This history was manifested in the 19th century with a string of dramatic miracle cures for alcohol addiction. Most of these disappeared long ago. (White, 1998). In the last few decades a new series of miracle cures for drug addiction has emerged and none of these have gotten us very far either. The most effective treatments, which do help some addicted people, were all developed decades ago (Helig, Epstein, Nader, & Shaham, 2016). But the dream lives on. A 2018 New York Times headline proclaims, “A drug to end addiction? Scientists are working on it.” (Haberman, 2018).
For example, one recent hope for a miracle cure is a vaccine that prevents addicted people from feeling and enjoying the effect of heroin (Jacobs and Ramsey, 2017; Rosenbaum and Dury, 2018). But, this hope is based squarely on the old story. Suppose a heroin (or fentanyl, methamphetamine, cocaine, or THC…) vaccine actually worked, and drug addicts could no longer feel the effects of their primary drug of choice. Would the vaccine cure these dislocated people of their addiction or just of their use of one particular drug as focus for their addiction?
Most severely drug addicted people are multiply addicted to a number of drugs and other habits. The reasonable expectation is that one of their other addictions would grow to replace the overwhelming involvement previously provided by the heroin addiction in vaccinated persons. Antibodies to heroin and other drugs have been known since the early 1970s and research on vaccines has been heavily funded since the 1990s, but here have been no significant clinical applications yet (Kinsey, 2014).
Nothing less than overcoming the dislocation that is intrinsic to the modern age, at least so far, can be expected to provide a stable recovery from addiction. Nothing that can be injected into the blood stream or into the mind of an addicted person, or snipped from his or her genome can overcome dislocation. Achieving a reasonable level of psychosocial integration requires a long period of continuous interaction between a person and a welcoming, integrated society (Erikson, 1963). The world must be well enough organized that the great majority of human beings can achieve a secure place within it.
7. We Who Work in the Field of Addiction Need to be as Brave as the Policemen Who Blew the Whistle on the War on Drugs. If the new story is correct, treatment professionals can never be more than minor players in the essential project of controlling addiction in the fragmented world of the late modern age. Even the very best and most compassionate treatments, harm reduction services, and recovery centers can never solve the problem. We need to be brave enough to say so.
The fact that our methods of helping drug addicted people have improved dramatically in the past half-century but our addiction problem continues to expand cannot be explained from behind the blinders of the old story. The old story logically leads to the conclusion that both the War on Drugs and the more compassionate treatment-oriented regime should have substantially reduced the addiction problem.
However, the fact that addiction continues to expand makes perfect sense within the new story. The fragmentation and dislocation of modern society cannot be substantially reduced either by declaring war on drugs or by introducing more compassionate or more effective therapies for drug addicted people. Nor can fragmentation and dislocation be reduced by better drug laws and regulations, or by harm reduction or recovery movement measures, no matter how enlightened they may become. Because fragmentation and dislocation cannot be reduced in these ways, neither can the rate of creation of new addictions, nor the rate of relapse to existing addictions.
Moreover, drug addictions comprise less than half of serious drug addiction problems (Sussman, Lisha, & Griffiths, 2011). Nothing we do about drugs will have any substantial effect on the majority of serious addiction problems! In fact, dislocated people who do not become drug addicted are very likely to become addicted in other ways. For example Singapore, which has been able to control drug importation through draconian measures including capital punishment in a unique geographical situation, is experiencing exceptionally high levels of gambling and gambling addiction among the population (Chin, 2014).
The causes of fragmentation and dislocation built into the economic and social structure of the modern age and they are not decreasing. They can only be overcome by epochal changes in society on a global level.
It is vitally important for world society to get serious about addiction. This means finding a way to reconcile the modern age with satisfaction of people’s deep social, psychological, and spiritual needs. We know that this can be done, because it is being done with some degree of success in some very modern smallish countries (Buettner, 2017). I can only guess at how long this may take to be actualized on a global level, or what the eventual alternative to current form of modernity will look like.
However, I think that addiction professionals have a uniquely important role to play in getting rid of the old story and, thus, focussing attention on the defragmentation of world society that will be necessary to bring addiction and other crucial problems under control. For addiction professionals, I believe that this means going beyond providing compassionate support, treatment, and harm reduction, and recovery communities to addicted people, even though we must continue to provide these services, as long as they help some people.
Politicians and the popular media today are pinning the public’s hope on a treatment breakthrough – a new vaccine, a new more spiritual approach to therapy, a new form of cognitive behavioural therapy, a new drug that somehow reduces cravings, a “non-addictive pain-killer”, deletion of a gene for addiction, new restrictions on prescribing, a newly rediscovered eastern spiritual practice, vast increases in the budget for existing treatments, a regime rational drug regulations, etc. (Obama, 2016; Pond & Palmer, 2016). Often these are touted as if there was not a long history of innovative medical treatments, spiritual discoveries and re-discoveries, and new regimes of drug control extending back well into the 19th century (White, 1998). This simplistic rhetoric, based on the fourth element of the old story, needs to be challenged. I think we addiction professionals can best interrupt it by emulating the brave policemen who I have mentioned.
In the past, many policemen who had been burned out by the war on drugs spoke out to inform the world that it cannot punish our way out of the addiction problem no matter how much money is poured into enforcement. Similarly, today’s treatment professionals need to say that we cannot treat our way out of the addiction problem no matter how much money you give us. We also need to say that no matter how many research grants you give us, we are not going to discover a single, controllable gene for addiction or a widely effective medication or form of psychotherapy that will bring it under control. Of course our treatments do help some people and provide comfort to many others, but they can never be the basis for a full solution to the addiction problem or other human problems built into modernity. Modernity itself must be changed, and it can be.
When I was younger, people used to accuse me of youthful naiveté when I said things like this. Obviously that accusation is no longer applicable! In my old age, I find myself more and more convinced, as are many highly reputable public intellectuals (Harvey, 2011; Klein, 2014; 2017; Hedges, 2015), that nothing less than a revolutionary project carried out on a global scale will save the world for our descendants. I think it is important to understand the place of addiction in that world-saving project. A few brave addiction treatment professionals are speaking at this level of generality already (Pipher, 2013).
Addiction is a different sort of a problem than the one described by the old story, and we addiction professionals are the best qualified to say so with authority, both as individuals and as part of professional societies. To not speak out is to foster the comforting illusion that there is a quick fix to the problem of addiction and that we can eventually provide it … even if we haven’t quite got there yet. I think many more addiction professionals and professional groups will be publicly rejecting this illusion in the future and that we will then be justifiably proud of responding to the full gravity of the addiction problem in the modern world.
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