Sunday column: Addiction edition

Today’s column is online here. The first question is about neighbors who smoke outdoors, and I’m sure to get angry letters about this bit of advice:

If you’re lucky, your neighbors will ask if their cigarette smoke bothers you, too, and then you can allow as to how it does. If they don’t bring it up themselves, however, tread lightly. I’ve yet to meet a smoker who is happy about his or her habit and the financial, health, and social costs that it entails. If your neighbors aren’t capable of quitting in order to improve their own quality of life, they’re certainly not going to do so to improve yours.

Tobacco is one of the most addictive substances out there and no neighborly requests, no matter how polite or eloquent, is going to change that. People like to think that their snarky comment or heartfelt plea or terrifying statistic will be the one that will Make The Difference, but it won’t. Think about how very, very many straws have told themselves that they, they would be the one to break the camel’s back. Think how many got chomped by that camel in return.

I try to give advice that will work, that isn’t overly based on “shoulds.” If the shoulds were working then nobody would have had to write to me in the first place.

What “works” with addicts is up for debate. One of the persistent themes of this blog is that stories are crucial to humans, and to our ability to understand an issue, but that stories are always a gloss on reality, not reality itself. And sometimes, a way of telling a story can be so compelling that it prevents us from seeing what is in fact happening.

This may be the case with addiction. The image of the trauma-created, spiritually bereft addict who must hit bottom, have a moral re-awakening, and struggle to achieve sobriety through lifelong abstinence and the creation of a “recovering addict” self-image … may not be the correct one. It’s a powerful, powerful cultural narrative, but the science simply doesn’t back it up, as Pacific Standard magazine reports:

The average cocaine addiction lasts four years, the average marijuana addiction lasts six years, and the average alcohol addiction is resolved within 15 years. Heroin addictions tend to last as long as alcoholism, but prescription opioid problems, on average, last five years. In these large samples, which are drawn from the general population, only a quarter of people who recover have ever sought assistance in doing so (including via 12-step programs). This actually makes addictions the psychiatric disorder with the highest odds of recovery.

Pacific Standard has more on addiction, here and here for starters. Aeon takes on the AA of addiction, which has been untouched by science since the 1930s:

The one-size-fits-all therapy of AA can’t possibly address every facet of the disease: addiction is a habit rooted in brain circuitry, but also frequently a consequence of a traumatic experience or exposure from childhood onwards. Most of us just flirt with addiction, stopping our habit without any formal treatment or intervention from self-help groups such as AA. Others struggle mightily over a lifetime, their addiction a spectre – an ever-present haunting.

Addiction, moreover, often exists in tandem with other neuropsychiatric disease – a find that the Big Book has not been revised to include. Nearly a third of adults who experience mental illness have an addiction. This number skyrockets for jail and prison inmates. Three quarters of those with mental health problems also have a substance use disorder.

AA can obviously be useful for individuals, of course–there’s no point denying those numbers–but it’s folk medicine with no empirical evidence, and that shouldn’t be forgotten, especially when judges are mandating treatment. (The program really does only work if you work it.)

Eve Tushnet of The American Conservative had a brilliant piece about what these competing views of addiction mean, in terms of storytelling and moral structures:

The two narratives have differing views of authority: The 12-Steppy model comes across as authoritarian, and can definitely be used as an excuse for cruelty, but it also has an anarchic respect for the wisdom of ordinary people. It attempts to turn followers into leaders through personal guidance. What I’m (again, super-reductively) calling the harm reduction model is simultaneously much more individualistic, and much more reliant on medical expertise. The expert-layperson hierarchy is in many ways more rigid than the sponsor/sponsee relationship. The harm reduction worldview tries to avoid the problems of class- and education-hierarchies by soliciting as much participation as possible from people on the ground, current drug users. “Nothing about us without us” is a slogan of the harm reduction movement, and one with which I agree… but it’s not a slogan AA ever needed, because AA’s whole genesis and development was by “us,” the alcoholics.

The harm reduction model is typically much more comfortable with the idea that different approaches to recovery are valid for different people. There’s much less pressure to force everybody into one method, goal, spirituality, and language.

Check out her entire piece. It’s an excellent meditation on the complex relationship between storytelling, science, morality, and public policy.