Meditations on what I consider to be the three primary models of addiction: The spiritual, the moral, and the medical.
My friend Shady atop Da Nanshan Mountain (大南山) in Shenzhen, looking cool in that effortless way that only Egyptians can look cool (cigarette not pictured, surprisingly). I miss my poodle, China, and my friends / fiancé deeply and roughly in that order; also, it appears that I've caught a serious case of whatever the opposite of pagoda fatigue is (pagoda craving? pagoda fever?).
"The more I see, the less I know, the more I like to let it go / Hey-oh..."
- "Snow" by the Red Hot Chili Peppers
Note: It just occurred to me that I'm probably the only person on Earth who is interested in reading my stream-of-consciousness intro on mythmaking, forcing the model, and implicit biases. Feel free to search "In science in particular" and start reading from that line if you're strictly interested in, you know, the topic that you clicked on this article hoping to read about. Jerks.
In "I Was Simon Song," I wrote about my experiences in the highly profitable, brutally competitive private education industry in China.
Recently, a former colleague sent me an entrepreneurial profile on an educational consulting firm in Beijing, which specializes in matching underprivileged Chinese high school students with research opportunities under American scientists and engineers.
I've met the founder of this company twice and am acquainted with his reputation. I'll be nice and put it this way: The article served up a Genius Founder myth on par with anything that Silicon Valley has to offer.
What intrigued my colleague and I, however, was the fact that the story of the company's vision and early days was entirely different from the one spun when we listened to the founder's pitch for seed money five years ago, at which point the company intended to serve the children of China's socioeconomic elite.
Based on the language of the write-up, I don't think that this is necessarily a case of deliberate distortion; it strikes me as more of a living narrative that evolved to highlight the company's strengths as they became apparent -- while conveniently forgetting goals that weren't attained and customer demographics that failed to take the bait.
As human beings, we have terrible trouble coming to terms with our own biases, our lack of objectivity. By our very nature, we are mythmakers, reality-deniers.
We cling to the notion of a shared, objective reality despite the fact that every iota of input into our systems is filtered through our hopes, judgments, and expectations. Even when we attempt to adjust for our biases in a deliberate, rational way, we fall far short of anything approaching objectivity.
Much of our tendency to warp reality to fit our needs and desires originates within our linguistic programming. Prime us with adjectives suggesting arboreal verdure, and we'll rate the air freshener brand Glade more highly than competitors; ditto with adjectives subtly connected to stunning sunrises and the dishwashing soap Dawn.
Many of our most powerful unconscious biases originate in the deepest, oldest parts of our brain, which control autonomic functions like breathing and temperature regulation. Ask people to rate the friendliness of new acquaintances in a chilly room or while holding an icy drink and they will score their new contacts significantly lower than people who they meet in a well-heated room while holding hot chocolate or coffee - even though the people in both groups are trained actors who appear, speak, and behave identically.
Part of our unconscious bias is due to coopted neural circuitry that sometimes conflates the literal with the symbolic (cold personalities and cold drinks), which came about as our species evolved its uniquely advanced linguistic capabilities.
Another less unconscious component, no doubt, is down to simple magical / motivated reasoning.
Memory, on its part, is so fundamentally unreliable that the highest court in the state of New Jersey has recently opined that eyewitness testimony should probably be excluded from court proceedings altogether (an astounding finding, given that a good portion of all criminal and civil trials up to the present day have hinged on such testimony).
Even when we do consciously apply a little creative license to reality - more specifically, in the case of the educational consulting company that I mentioned, to capitalist enterprise - can you blame us? After all, one of the ways that we deal with the vast pain and chaos of life is by endowing ourselves with potent powers and narrating ourselves into noble quests.
Seeing the world as we want or need to see it is a venerable coping mechanism. Self-delusion saves lives.
(Bear with me today, please. I'm going somewhere with this.)
It's not just law and business that are affected by cognitive and emotional biases, either. My stepdad, Lou, who passed away nine days ago, suffered for years from mycosis fungoides, a rare, Cutaneous T-Cell Lymphoma (CTCL) in which cancerous immune cells in the skin cause extensive, painful lesions.
Despite the fact that this cancer "should" be containable within the skin - something that the leading expert on the disease, an oncologist at Memorial Sloan Kettering Cancer Center in NYC, affirmed - Lou is dead partly because the disease spread to other organs.
At one point, Lou's brain was biopsied after a CT scan revealed evidence of infection in his temporal lobe. However, instead of finding signs of the infection that we were told was attacking Lou's brain, the neurosurgeon emerged from the biopsy confident that he had removed part of a second, primary cancer.
This finding, in turn, was reversed by the pathology report that arrived a week later, which concluded that the neurons of the biopsied area had demyelination that could have been caused by a stroke, an autoimmune disease such as Multiple Sclerosis, or numerous other conditions. In other words, there was neither infection nor cancer - at least, not as far as the pathologist could discern.
At several points, Lou suffered from un- or underexplained symptoms as well as unusual / unexpected side effects of his chemo and radiation treatments. In fact, at one juncture far too long into the treatment process, even the initial diagnosis of mycosis fungoides was called into question.
In science in particular, we tend to regard disease entities as having discrete, objective reality. However, cases such as Lou's show just how poorly delineated and lacking in explanatory horsepower our medical models can be (even for a disease such as cancer, which is relatively clearcut and well understood).
Everything that we perceive, every thought and emotion that we have is influenced by what we are programmed to expect. We are continuously remodeling reality to fit the schemata that we begin learning as soon as we enter the world.
Our understanding of that world begins within ourselves and is projected outward from there; we can no more perceive and understand things that conflict with our schemata than we can view light outside of the visible spectrum or hear sounds outside of the audible range.
This subjectivity is further enhanced when we're dealing with psychological illnesses as opposed to physical ones.
*Although all diseases are ultimately rooted in biology, of course, meaning that this distinction is an arbitrary and sometimes misleading one.
Recently, I've been reflecting on the extent to which the modern, disease model of addiction, which I discuss in more detail below, doesn't fit my own experience.
Because I had read about this theory of addiction fairly extensively by the time that I realized that I was an addict and entered treatment, I never really had the chance to observe and analyze my addiction without interference from preformed expectations deriving from the disease model.
One of the tenets of this disease model is that addiction is perpetuated in a cycle that begins with use of the drug of choice, which leads to guilt / shame* that motivate further use of the substance, which triggers an additional layer of guilt and shame - and on and on and on.
*The guilt and shame can come from embarrassing actions while under the influence or simply from failing to honor one's promise to oneself and others to stop using. The drug use, in turn, provides euphoria and numbness / insulation to help the addict ignore his destruction of his own life.
It's a shiny concept. And, for a while, I accepted it as fact rather than filter.
After all, it sounded nice and neat; it made a basic sort of sense. (In reality, this probably should have been my first warning sign, for addiction is messy and extraordinarily difficult to corner and examine; it resists all attempts to render it linear, predictable, sane).
When this guilt / shame cycle was discussed during treatment groups, I would share that - although after relapsing, I didn't feel these emotions viscerally, in the sense that people usually refer to their emotions - I experienced them cognitively, in the sense that I knew that I should have had and ordinarily would have had these emotional responses to my failure to stay clean.
What I really felt during active addiction was an emotional void - nothing at all. Sometimes during withdrawal (or, more rarely, apropos of nothing), my emotions would punch their rotting hands through the dirt above their graves, and I would succumb to horrifying, taboo nightmares and to waking panic attacks accompanied by whole-body shakes and thoughts that galloped toward psychosis.
Mostly, though, what I felt when I relapsed - whether after a few days or six months - was a profound easing of internal tension that persisted even after the drug wore off. The ending of the exhausting, day-and-night struggle against myself was an unspeakable relief.
To be fair, there was a part of me that was disappointed in myself when I continued to use despite my vows to stop. I felt guilty for dragging select loved ones through hell with me. It's true, too, that I felt humiliated by incidents that occurred during benzo binges.
Again, however, I'm not sure that this guilt and shame played a significant role in driving my continued use. It just wasn't strong or consistent enough.
What was actually motivating me to use was, by and large, a desire to avoid the agony of withdrawal. That was the first thought on my mind as my sweaty friggin' skeleton jerked awake each morning, and as far as level of motivation went, it was a 10 /10.
That my drugs of choice would also numb me to the pain, destruction, and squandered opportunities caused by my addiction was a fringe benefit.
The guilt / shame cycle is just one of several components of the disease model of addiction whose validity I justified by filtering my experiences through the provided lens.
In this case, I actually created a new, intellectualized form of emotion for myself* rather than admitting the truth - again, that for the vast majority of the time that I spent in active addiction, I felt nothing.
*What does "intellectualized emotion" even mean? Feelings are felt; that's kind of the point. Looking back now, my mental gymnastics seem ridiculous. I'm a little surprised that my therapists / counselors and peers didn't question this crock. Deciding that I ought to be experiencing an emotion and terming that recognition an "intellectualized emotion" is goofy.
This isn't a frivolous or philosophical point; without understanding what motivates a maladaptive behavior, it is often difficult or impossible to change it.
There are several other concepts and predictions of the modern, disease model of addiction that I have realized were either borne out through my confirmation bias or functioned as self-fulfilling prophecies. I touch on another one below.
***
It isn't just that I'm fallible in applying these theories of addiction, either. The models themselves are flawed. And even our best, most current model for addiction don't come close to passing scientific muster.
In medieval times and likely for centuries prior to that, addiction was viewed as the result of demonic possession.
As archaic as that theory might sound to us now, I believe that this spiritual model originated because it captures important truths about severe addiction, including the utter ruination of the soul and the self, from one's personality / essence to one's innocence / goodness.
As I've expressed before, the most accurate metaphor that I can think of for the worst stretches of my addiction is that of being coerced by a dark stranger who puts a gun to my head and dictates my every action. The nightmarish level of dread associated with disobeying this malevolent being's commands cannot be conveyed in words; it is spiritual, and it is Hellacious.*
*Interestingly. Eating Disorder sufferers also personify or demonize their affliction - Mia and Ana, for the initiates. I once watched a YouTube video about a young woman with Binge Eating Disorder who described being taken over by a ravenous spirit during her binges, in the course of which she would eat a month's worth of groceries in a few hours. She described not being able to control her hands, of chewing despite not willing herself to chew, of wolfing down regurgitated food despite her revulsion at this act, of "waking up" at the end of the binge and not remembering clearly what had occurred (as though she were recalling a dream or a period of intoxication).
Ideas about the demonic essence of addiction are by no means relegated to the ancient past.
William Burroughs, the infamous junkie-gentleman who wrote Naked Lunch and other experimental, brilliantly unreadable works in the 1950s -1980s, spoke of an entity responsible for his most addictive and outlandish behavior, including shooting his wife during either a gun-cleaning accident or a drunken game of William Tell (depending on when you asked him).
When pressed on the nature of this malignant entity, he clarified that it was no mere literary device - his Ugly Spirit was much closer to an Old Testament demon than a metaphor for human depravity.
A close friend of mine was given an exorcism during rehab in Brazil in the 2010s.
For the record, Natalie's exorcism didn't work, obviously because the demon was too powerful. You'd believe it if you knew her, trust me.*
*The women at this PTSD factory of a treatment facility were forced to drag a decomposing horse from a river in the middle of the night, presumably to impress upon them the horrors of death and decay, and to hit a wasps' nest until the insects went on the attack, probably as a metaphor for the senseless self-torture of addiction.
Me being me, I ribbed Nat mercilessly about her "special sacrament," of course. We lived together for a few months, and I'd answer the phone with: "Are you calling for Nat or the thing inside her?" Because it was a studio apartment, we slept in the same bed, and I'd often refer to how lucky I was to have threesomes every night.
Of course, the spiritual model isn't all about the dark side of the force.
The basic idea is just that the spiritual degradation of advanced addiction precludes a healthy relationship with God; I don't think that many people would argue with that.
Not surprisingly, I've known people who credit a renewed relationship with God as the thing that saved them from certain death™.
So, long story short, the spiritual formulation of addiction began in the mists of time and persists into the present day.
When German philosopher Friedrich Nietzsche, whose concept of eternal recurrence I have written about elsewhere, declared God dead in 1882, he presaged a massive shift away from spirituality and religion, including spiritual explanations for medical phenomena like seizures and addiction.
Humanity needed new theories for explaining its vices.
As the spiritual understanding of addiction fell out of vogue, a moral theory of drug abuse and addiction was advanced. Under this model, addiction was seen as the selfish prioritization of short-term pleasure over delayed gratification and fulfillment of one's responsibilities toward others.
From this perspective, addiction was the result of selfishness, dishonesty, laziness, weakness, hedonism, and inability to tolerate discomfort.*
*I'll have to save this list for the next time that I do one of those "Describe yourself in X adjectives" icebreakers.
This model, too, exists because it expresses profound truths about addiction.
The moral model is still quite popular, particularly in Southeast Asia and much of the developing world.
The level of stigmatization of addiction in China is almost unimaginable to the Western sensibility. In fact, the only comparably vehement Western stigma is that attached to pedophilia.
Although this Chinese societal reaction might seem harsh, at first, it's the reality that severe addicts cause more societal harm than almost any other demographic.
In advanced addiction, not only is the individual's productivity - his good to society - largely negated, but it is replaced by a set of harmful attitudes / behaviors that tend to infect others.
Addicts steal; we lie; we neglect our responsibilities, as well as ourselves, our children, and our elders; we're impulsive, sometimes even violent. Nothing comes before our drug.
This is the moral model of addiction. It holds that addiction is no disease, but rather a set of bad decisions that are rooted in character defects such as selfishness, dishonesty, emotional volatility, and a tendency toward unhealthy self-isolation.
From this perspective, it might quite reasonably be considered a moral condition with a moral solution - often a solution that involves character change through judicial punishment or some other social sanction.
Although it recognizes addiction as a disease in its verbiage, the reality is that the 12-Step program for addiction treatment - as used in Alcoholics Anonymous and Narcotics Anonymous - is essentially A) spiritual in that it proposes a turning over of one's will to a Higher Power as the first half of the cure for addiction, and B) moral in that it proposes the correction of character defects as the second component of the treatment strategy.
Unfortunately, the spiritual-moral fusion model of the 12-Step programs falls short in the ultimate test of any theory, which is its ability to solve the problems that it proposes to explain.
Compared to evidence-based techniques such as Cognitive Behavioral Therapy, 12-Step programs have significantly lower efficacy*.
*Although the Tradition of Anonymity and other facets of the Program that are designed to protect privacy have made it difficult to collect robust data, the most extensive dataset that I am aware of suggests that 12-Step programs are barely more effective than at-home, do-it-yourself abstinence.
To be clear, I attend 12-Step groups (although I don't consider myself a 12-Stepper; if you're not involved in the community, it's a difficult-to-understand distinction, I know).
I recommend that anyone with the remotest interest in the Program give meetings a shot.
The Rooms are filled with wise, wonderful people. Moreover, even if you don't achieve lasting sobriety, you are likely to connect with a valuable community and to learn skills that will improve your life and help to rein in your addiction*.
*For those who hold that some 12-Step groups have cult-like characteristics, my reply is that - so long as I'm not hurting other people - I would join any cult, don any tinfoil hat, if it meant release from the hell of active addiction. Shape me, guide me, Dear Leader.
There is, however, a cruel edge to the Program. One of its most famous slogans is "It works if you work it."
Unfortunately, I have seen many people who were making earnest, fully committed efforts fail to get clean or relapse afterward (a couple of them after years of clean / sober time, during which they were leaders in the Program).
To me, it seems nasty and unwarranted to say that anyone who the Program doesn't work for has failed through their own fault, and this is the clear attitude / implication of the Program when it comes to those cases in which it doesn't work.
The Program uses almost legalistic language to cover its lack of explanatory power and its failure to distinguish between subsets of addicted people.
For example, it asserts that "addiction is a chronic, progressive disease that over any significant period of time gets worse."
This sort of statement doesn't measure up to my lived experience.
Spontaneous recovery from any disease, including addiction, is a recognized phenomenon.
I have known fully, desperately addicted individuals who put hard drugs down, ostensibly on a whim, and never touched them again.
During my own life, I have had periods when - for reasons that I cannot explain - my own addiction has become less severe or even gone into a sort of remission.
As I have gotten older, my addiction has waned rather than intensified. It's become more amenable to management and more emotionally weatherable.
Part of this shift is down to skills that I have learned and practiced, no doubt, but some of these changes are nothing more than a sort of internal seasonality that has nothing to do with any constructive action on my part.
A hardline 12-Stepper would probably say that the years during which these positive shifts occurred did not constitute "significant periods of time" and would predict that my addiction will worsen and perhaps even kill me in the future. Once again, however, when we're talking about entire months and years spent clean and sober, this is legalistic nonsense.
In these and other ways, the moral model of addiction comes up short, one of its fundamental failings tied to a fact that is readily apparent to anyone who knows a severely addicted person - namely, that at a certain point, the addicted individual loses control over his or her decision-making (as evidenced by shifts in neurophysiology as well as the fact that addicts consistently undertake blatantly, horrendously, life-threateningly self-damaging actions, which no individual with the ability to choose to do otherwise would undertake regardless of the fleeting pleasure produced or the fleeting pain avoided by substance use).
When addicted individuals lack the ability to choose to stop using, the level of judgment and sanction prescribed by the moral model seems exceedingly cruel.
The modern, medical model of addiction as a disease of abnormal neurophysiology - akin to bipolar disorder, eating disorders, and other mental illnesses - is probably the kindest and at the same time the most disempowering of these three models.
It explains the strong genetic basis of the disease, as well as the aforementioned inability of affected individuals to make decisions in their own best interests even when their lives are at stake.*
*I've written elsewhere about the deterioration in executive function of the Prefrontal Cortex [PFC] and the other structural and functional changes that are observed in the brains of advanced addicts, which erode the ability to make different decisions.
Advanced addicts are programmed to use almost to the point of being robots / automatons. At one meeting, I listened to an alcoholic describe how he used to walk down the street to his favorite liquor store, buy a bottle of whiskey, and sort of wake up when he was halfway home - not recalling having made the decision to go purchase alcohol and not quite sure of why or how his feet took him there.
Unfortunately, however, this medical model fails to deliver a reliable cure.
Using the example of opioid addiction, at best we can currently use maintenance therapies like buprenorphine and methadone - or even treatment with antagonists like naltrexone - to modulate receptor dynamics and stabilize the addicted brain, sometimes enabling cessation of drug use.
However, as compared with comparably life-threatening illnesses, our failure rates are still woefully high. For alcoholism, it's estimated that current, evidence-based treatment techniques help perhaps one in 10 of those who enter treatment to achieve long-term sobriety.
For severe opioid addiction, on the other hand, even with opioid maintenance treatment, perhaps only two to four percent of patients achieve sustained abstinence time; without maintenance, it's possible that the figure is as low as one percent or even a fraction of a percent.
Granted, understanding a disease is different from being able to apply that understanding to treat it, but until we have achieved this latter aim, we lack the most important confirmation that our theory is on point.
One of the other problems with the disease model is that it doesn't work to tell people that they suffer from a mental illness over which they have absolutely no control. Despair and fatalism set in, and negative prognoses become self-fulfilling prophecies.
Unfortunately, the medical model of addiction - when reconciled with the practical need for empowerment of addicted people - leads to nonsensical catchphrases like "You aren't responsible for your addiction, but you are responsible for your recovery."
Exactly who is in control during the transition from active addiction to recovery is, conveniently, left unaddressed, as is the question of how addicts end relapses if they have once again forfeited their agency.
This is just one of several logical contradictions and unexplained areas that result from accepting the disease model of addiction.
The fact is that such a model is predicated on biological determinism, which holds that our thoughts and emotions - and, by extension, our actions - are caused by changes in our neurochemistry, just as the operation of all of our other organs can be reduced to fluctuating physiologic processes; as we have no evidence of a transcendent faculty of choice that somehow overrides our brain's biochemistry, biological determinism entails a rejection of free will.
This, in turn, means that people cannot choose to recover.
Environmental influences, including therapy and medications, can shift neurophysiology so that an individual stops using, but this is not the result of personal decisions as we commonly understand them.
To be clear, I believe that the disease model of addiction is the most scientifically valid model and that it also has the most explanatory power.
I've written about innovative therapies, including drug vaccines and agonist / antagonist pairs, which promise to utilize our knowledge of the biochemistry of addiction to prevent, treat, and perhaps even to reverse it.
But the point stands: When it comes to reconciling apparent contradictions and developing reliable cures, we aren't there yet - not even with our shiny, modern, disease model of addiction.
***
In sum, we have three sometimes complementary, often contradictory models of addiction: The spiritual, the moral, and the medical.
They arose because they explained and predicted important facets of addictive reality, but all three models have so far fallen short in delivering anything close to a foolproof solution to our addictive problems.
Combining them often yields better results than confining treatment to any one model, but - as I've pointed out above - this also leads to contradictions that highlight our confused understanding of the addicted state.
I'm interested to hear everyone's reactions. How do you think about addiction? Is it moral, medical, metaphysical? All three? None of the above?
How about the role of personal responsibility in addiction? Do addicts choose to become addicts? Is there a point at which addicts can no longer choose to stop using? Do addicts deserve more lenient punishments, such as drug treatment programs instead of incarceration, for crimes committed as a result of addiction - in acknowledgment of diminished agency from brain changes wrought by long-term drug use?
Again, I apologize that both I and my writing have been somewhat off this past week. Losing Lou really did a number on me.
I'm getting back to my usual, hopefully more polished and less ramble-y style with upcoming articles on:
(1) Dangerous shifts in the positions of LGBT community leaders with respect to a) medical transition of transgender kids, and b) associating our community with radical, leftist political views
(2) Signs that you're becoming dependent on and perhaps even addicted to your benzo or opioid prescription
(3) Rapid transition protocols for methadone to buprenorphine switches
(4) An at-home benzo withdrawal guide
Thank you all for reading. Really.
I wish that I could summon more moving words for how grateful I am that you find my thoughts worthy of your time (and even, sometimes, of your praise).
I've restarted my life many times, always with energy and the determination to do better.
Then, the pandemic imploded my family, my social circle, my career - every aspect of my life in China. For the first time in my life, I worried that I might have been permanently vanquished rather than temporarily set back.
I let myself fall into a terrible, defeatist mindset about my own life and character, and for months I was in an uncharacteristically deflated state (amazingly, I don't get depressed, in general).
Having a purpose in answering your questions about withdrawal, relapse, and treatment / recovery has helped to bring me out of that morale slump.
It means an incredible amount to me.