Saturday, August 07, 2004

Addiction & Judgement

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

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

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

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

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

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

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

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

  • Family History: Children of alcoholics are much more likely to become alcoholics. This is true even when adopted at birth by non-alcoholic parents.


  • Genetics:Specific genes have been identified which influence the metabolism and psychological effects of drugs and alcohol. Alcoholics and non-alcoholics metabolize the drug differently because of differences in the enzyme aldehyde dehydrogenase; a neuropeptide Y gene mutation is associated with higher incidence of alcoholism; a gene expressing the gamma opiate receptor, when mutated, is associated with a higher risk of heroin addiction. Many other such genes have been identified related to cannabis, codeine, nicotine, and other addictive substances


  • Animal Research: Specific genetic modifications in mice can reproduce or block addictive behavior.


  • Neurophysiology: Addictive drugs have profound effects on critical neurotransmitters, such as dopamine and GABA, which are long-lasting and have profound impact on affect, behavior, and thought processes.



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

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

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