The Fix

How can we explain the difference in the fates of the two friends? The 12-step explanation would be that Robin was never a real alcoholic or addict, since he cured himself without following the principles of the programme. He did attend AA and NA meetings, both in and out of clinics, but found them useless. ‘AA members kept regaling me with these over-polished anecdotes about their miraculous recoveries, while the NA meetings seemed to be full of people who’d been clean for a couple of days and were obviously hoping to score.’

James, in contrast, met the sort of grisly fate that, according to the Big Book, awaits most untreated addicts. In the eyes of the fellowship, his leap from the balcony proved that he was the genuine article. One of the least attractive characteristics of 12-step ‘old-timers’ is the relish with which they describe disasters that befall those who stray from the true path.

But suppose that Robin and James had died at the same time, at the height of their drinking and drug-taking. (Robin did nearly kill himself with an accidental overdose, so it’s not an unlikely scenario.) Would a post-mortem on their brains have been able to establish which of them had the ‘progressive disease’ of addiction and which was just going through a phase? The answer is no.

Moreover, if Robin and James had been subjected to a battery of tests when they were still alive, it’s extremely unlikely that any of those tests would have distinguished between the ‘real’ alcoholic, doomed without 12-step treatment, from the ‘fake’ or temporary one, capable of curing himself. My guess is that the doctors would have said, correctly: both these young men are addicted to alcohol and drugs. But if the doctors were 12-step believers, as so many are, they might have added that neither of them could cure himself. Robin would have proved them wrong.

If you doubt that addiction medicine is heavily flavoured by 12-step dogma, let me point you in the direction of one of the most recent, supposedly authoritative, definitions of addiction by doctors specialising in the subject. It was published in 2011 by the American Society of Addiction Medicine (ASAM), which represents physicians who work with chemically dependent patients.

‘Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry,’ it declares. ‘Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviours.

‘Addiction is characterised by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviours and interpersonal relationships, and a dysfunctional emotional response.

‘Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.’3 (#litres_trial_promo)

This is what a definition looks like when it has been drafted by a committee. The 80 doctors who worked on it seem to have thrown everything at it but the kitchen sink. But what their definition cannot conceal – indeed, what it inadvertently reveals – is that addiction is far too complex a phenomenon for doctors to classify as a disease in the sense that cancer and tuberculosis are diseases. Hence the waffle.

Addiction specialists wouldn’t tie themselves in such knots if they had a diagnostic test for the ‘disease’ of addiction. But there is no such test.

Not only is addiction unlike cancer and diabetes, which show up in lab results. It’s also unlike brain diseases such as Alzheimer’s. That, too, lacks a simple diagnostic test: in its early stages its symptoms can be mistaken for stress or other forms of dementia. But eventually the involuntary behaviour of the patient should allow the doctor to make an accurate diagnosis, after which its progress is truly inevitable. There is no 12-step programme for Alzheimer’s to keep its symptoms under control. The end point is death, after which an autopsy will probably reveal shrinking of the brain that provides final confirmation of the diagnosis.

I’m not saying that medicine can’t identify addiction in the ordinary sense of the word: of course it can. Scientists can test for chemical dependence on a drug. They can measure a patient’s tolerance for it and predict the withdrawal symptoms. They can identify the precise damage caused by substance abuse and hazard a guess as to life expectancy. They can look at a patient and say: this person is an addict.

But what they can’t tell, even with brain-scanning technology, is whether a neurochemical ‘switch’ has been thrown which induces irreversible addiction, which is what disease-model advocates are now suggesting. We don’t even know whether such a switch exists. It’s a fashionable theory, but that’s all it is.

Post-mortems can’t identify a disease of addiction, either. A dead body may reveal organ damage caused by taking a particular drug, but it won’t necessarily tell doctors much about the behaviour that accompanied it. You can’t know from looking at the liver of someone who drank themselves to death whether their drinking followed classic addictive patterns. People develop fatal cirrhosis of the liver – a proper disease by any definition – from regular wine consumption that isn’t compulsive in character. Non-alcoholics in France die from this sort of drinking all the time. Likewise, the body of an obese person won’t tell you whether they ate addictively. Their obesity may have been caused by an illness that stopped them exercising, for example.

Why, then, is the ASAM definition of addiction so confident in its claim that addiction is a ‘primary, chronic disease’ – an assertion that it proceeds to justify with woolly and overlapping generalisations?

At the risk of sounding like a conspiracy theorist, I think the answer lies in the role of 12-step groups in devising the treatment programmes run by the doctors in ASAM.

There’s a bit of a giveaway in the definition. This says that dysfunction in the brain’s rewards circuits leads to characteristic ‘spiritual manifestations’. I’ve heard that phrase before. During my AA years, as I sat drinking powdered coffee in draughty basements, it was drummed into me that alcoholism was a spiritual disease. That is Big Book teaching; you hear it in virtually every meeting. But if you’re trying to define addiction, you run up against a problem: there is no agreed methodology for measuring ‘spiritual manifestations’. How could there be? In all my years spent studying the sociology of religion, I never came across an agreed definition of ‘spirituality’. It’s just the sort of concept that scholars fight over.

Many addiction specialists have a habit of throwing around words as if everyone agreed on their meaning. They’ll use a term like ‘compulsion’ without exploring the philosophical questions it raises about free will. They wander into other disciplines – philosophy, sociology and theology – without seeming to realise they’re doing so. Nothing must be allowed to challenge the one-size-fits-all model of the 12 steps.4 (#litres_trial_promo)

According to the psychologist Dr Stanton Peele, a long-standing critic of disease-centred definitions of addiction, ‘the American Society of Addiction Medicine was created – and is dominated – by true-believer 12-step types’.5 (#litres_trial_promo) Peele argues that AA preserved the temperance movement’s message of total abstinence – deeply rooted in American Protestant society – while relieving guilt by naming illness rather than sin as the cause of addiction. Also, 12-step advocates have proved to be expert lobbyists, persuading health institutes that theirs is the only recovery programme that works, and influencing judges and magistrates to send criminals on compulsory 12-step courses. Most substance abuse treatment in the US is based on 12-step models.6 (#litres_trial_promo)

Unfortunately, the media rarely bother to question the assumptions and allegiances that lie behind the pronouncements of addiction specialists. ‘Addiction is a brain disease, experts declare,’ said the LA Times when ASAM published its definition. ‘Addiction a brain disorder, not just bad behaviour,’ said USA Today.

But the most enthusiastic coverage came from The Fix (no relation to this book), an upmarket website aimed at recovering addicts with disposable incomes. It declared: ‘If you think addiction is all about booze, drugs, sex, gambling, food and other irresistible vices, think again. And if you believe that a person has a choice whether or not to indulge in an addictive behaviour, get over it.’ ASAM had blown the whistle on these notions, said The Fix, by revealing addiction to be a fundamental impairment in the experience of pleasure that ‘literally compels’ the addict to chase the chemical highs produced by drugs, sex, food and gambling.7 (#litres_trial_promo)

Note the finger-wagging tone of the article. If you think choice is involved in addictive behaviour, ‘get over it’. I can imagine Pippa nodding her head vigorously at that. When I showed the article to Robin, the former alcohol and heroin addict, he smiled and said: ‘That’s exactly the sort of take-it-or-leave-it message I heard every day when I was in treatment.’

Robin was in a rehab unit run by the Priory, a fashionable and expensive healthcare provider which specialises in alcohol and drug treatment and is best known for its celebrity alumni, who include Kate Moss, Robbie Williams, Courtney Love, Pete Doherty and the late Amy Winehouse. (As that list suggests, its track record is patchy at best.) Robin told me about his experience of the treatment there.

When I was in the Priory, all the doctors and counsellors emphasised the disease concept. We had lectures in the afternoons. One was from the medical director, a psychiatrist, on the disease concept. You have a disease, the disease of addiction, ‘dis-ease’, etc. When I asked him for the evidence, he said things like ‘we can see that the metabolic pathways are different in alcoholics’. Well of course they are, because the booze, not the ‘disease’, has changed them. I didn’t think he was being very intellectually honest, but he was the expert and if we had different ideas that was just evidence of the alcoholic’s arrogance.

As for the counsellors, they kept talking about ‘the illness’. Your illness, my illness. ‘My illness tells me I’m a bad person.’ The reason for this emphasis was that ‘it’s a shame-based illness’, and the whole point is to get away from the idea that you’ve been a wicked person and you should be ashamed – such ‘stinking thinking’ might cause you to fall into a ‘shame spiral’, and shame leads you to ‘pick up’ the next drink or drug.

You’d absorb the illness chat pretty quickly, but I could never bring myself to talk in terms of ‘my illness’ – it just seemed too pat and convenient to take away responsibility and turn your addiction into something outside yourself.

Addiction specialists would reply that of course they’re not saying the disease is ‘outside’ people. But the way they talk about addicts sometimes implies that sufferers are under the control of a malign puppetmaster.

There are recognised brain diseases which, like addiction, manifest themselves as behaviour – the jerking limbs of Huntingdon’s, for example. But it’s a funny sort of primary, chronic, brain disorder that makes you drive yourself to the pub, sink seven pints of beer with whisky chasers, and then drive yourself back, turning your car into a weapon of mass destruction.

In fact, there’s a world of difference between involuntary, chaotic spasms and long sequences of actions that look perfectly voluntary, if misguided, to anyone observing them. Professor John Booth Davies, director of the Centre for Applied Social Psychology at the University of Strathclyde – and one of Britain’s most prominent opponents of the disease model – makes the point that if a disease can force people to steal, to lift up glasses, or to stick needles in their arms when they’re actually trying not to, then any goal-directed behaviour could be a symptom of disease.8 (#litres_trial_promo)

The behaviour of addicts looks voluntary because it is. However intense the temptations offered by substances and experiences, there will always be people who, having given in to them, change their mind and pull themselves out of addiction.

As we’ve seen, AA brushes aside this phenomenon with unbreakable circular logic: if you cure yourself, you were never an addict. Medically qualified addiction specialists basically agree, though they usually espouse a more nuanced version of the disease theory. They don’t deny that some addicts appear to cure themselves – but they treat such cases as outliers or questionable diagnoses. The official line remains that, to quote the Sourcebook on Substance Abuse, ‘the majority of individuals who receive treatment for substance abuse relapse’.9 (#litres_trial_promo) Clinical reports that between 50 and 60 per cent of patients relapse within six months of ending treatment are accepted as evidence of the power of the disease.

There’s something wrong with this methodology, however, as Gene M. Heyman, a hospital research psychologist and lecturer at Harvard University, points out.

‘Most research is based on addicts who come to clinics,’ he says. ‘But these are a distinct minority, and they are much more likely to keep using drugs past the age of 30 – probably because they have many more health problems than non-clinic addicts. They are about twice as likely to suffer from depression, and are many times more likely to have HIV/AIDS. These problems interfere with activities that can successfully compete with drug use. Thus, experts have based their view of addiction on an unrepresentative sample of addicts.’10 (#litres_trial_promo)

Heyman went looking for large-scale studies of addiction in the US based on more representative samples of addicts in the general population, not just in clinics. He found four of them, carried out by leading researchers and funded by national health institutes.11 (#litres_trial_promo) Yet, mysteriously, the clinical texts and journal articles spreading the message of a ‘primary, chronic, relapsing disease’ fail to mention these epidemiological studies. Why?

Could it have been because none of the surveys found that most addicts eventually relapse? What they suggested, inconveniently, was that between 60 and 80 per cent of individuals who met the criteria for lifetime addiction stopped using drugs in their late twenties or early thirties. In short, high remission rates would seem to be a stable feature of addiction.12 (#litres_trial_promo)

In 1970 there was a shockingly sudden burst of heroin addiction among GIs in Vietnam. As Alfred McCoy describes in his book The Politics of Heroin, until 1969 the ‘Golden Triangle’ of south-east Asia was harvesting nearly a thousand tons of raw opium annually – but there were no laboratories capable of turning it into high-grade heroin. That changed when Chinese master chemists from Hong Kong arrived in the region. Suddenly South Vietnam was full of fine-grained No. 4 heroin instead of the impure, chunky No. 3 grade.

‘Heroin addiction spread like the plague,’ writes McCoy. ‘Fourteen-year-old girls were selling heroin at roadside stands on the main highway from Saigon to the US army base at Long Binh; Saigon street peddlers stuffed plastic vials of 95 percent pure heroin into the pockets of GIs as they strolled through downtown Saigon; and “mama-sans”, or Vietnamese barracks’ maids, started carrying a few vials to work for sale to on-duty GIs.’13 (#litres_trial_promo)

By the summer of 1970, virtually every enlisted man in Vietnam was being offered high-quality heroin. Almost half of them took it at least once; between 15 and 20 per cent of GIs in the Mekong delta were snorting heroin or smoking cigarettes laced with it. Ironically, heroin use soared after the Army cracked down on the much more easily detectable habit of smoking pungent marijuana. But the key factor, argues McCoy, is that drug manufacturers could make $88 million a year from selling heroin to soldiers; no wonder that ‘base after base was overrun by these ant-armies of heroin pushers with their identical plastic vials’. Rumours spread that the North Vietnamese were behind this intense marketing campaign – what better way to immobilise the enemy? But the truth was that South Vietnamese government officials were protecting the pushers.

In any case, combat troops avoided heroin use in the field: being stoned, especially on a drug as soporific as heroin, was more likely to get them killed. But they made up for it when they returned to base. One soldier came back from a long patrol of 13 days; his first action was to tip a vial of heroin into a shot of vodka and knock it back.14 (#litres_trial_promo)

Panicky headlines about the ‘GI epidemic’ started appearing in American newspapers. The Nixon administration was terrified of a crime wave caused by the return of thousands of desperate junkies to American cities. But it never materialised. Instead, the addicted soldiers cleaned up their act – fast.

We know this because the US government, anticipating disaster, commissioned a medical study that recruited more than 400 returning soldiers who snorted, smoked or injected heroin and described themselves as addicted (making it possibly the largest ever study of heroin users). To researchers’ surprise, back in the United States only 12 per cent of these addicts carried on using heroin at a level that met the study’s criteria for addiction.15 (#litres_trial_promo)

This is really powerful evidence that changes in social environment can dramatically affect people’s drug-taking habits. As Professor Michael Gossop, a leading researcher at the National Addiction Centre, King’s College, London, explains: ‘The young men who served in Vietnam were removed from their normal social environment and from many of its usual social and moral constraints. For many of them it was a confusing, chaotic and often extremely frightening experience and the chances of physical escape were remote except through the hazardous possibilities of self-inflicted injury.’16 (#litres_trial_promo) Gossop uses the phrase ‘inward desertion’ to describe what heroin offered the soldiers: a cheap trip to another world.

The scared, disorientated soldiers in Vietnam were being offered a chemical fix to relieve their fear. The social and psychological pressure to do something they would never dream of doing in America – take heroin – was intense: one in five slid all the way into addiction. But, once home again, they weren’t scared any more. They weren’t mixing with other users. The drug was expensive, hard to find, low-grade and highly illegal. The pressure went into reverse. In other words, the same combination of social and psychological factors that turned these men into addicts explains why they were able to stop.

True, these were remarkable circumstances. So we might expect other addicts, whose initiation into drug use was less dramatic and more gradual, to recover at a slower rate. And that’s precisely what those four big epidemiological studies show: they paint a picture of users slowly changing their behaviour when their circumstances changed. They don’t support the progressive disease model. The Vietnam statistics, meanwhile, directly undermine it. The US government went to a lot of trouble to make sure that the soldiers it was testing were addicts. Are we supposed to believe that the 88 per cent who later kicked the habit were misdiagnosed? Or that being drafted to fight in heroin-saturated Vietnam ‘doesn’t count’ because it was such an unusual situation?

The Vietnam survey identifies a key factor in addiction: availability. To quote Michael Gossop: ‘Availability is such an obvious determinant of drug taking that it is often overlooked. In its simplest form the availability hypothesis states that the greater the availability of a drug in a society, the more people are likely to use it and the more they are likely to run into problems with it [my italics].’17 (#litres_trial_promo)

This hypothesis might seem like a statement of the obvious. Actually, as Gossop says, the question of availability is often treated as a secondary factor, less important than any predisposition to a so-called ‘disease’.

Gossop identifies different dimensions of availability. There’s physical availability, obviously, but also psychological availability (whether someone’s personality, background and beliefs increases their interest in using particular drugs), economic availability (whether the drugs are affordable) and social availability (whether the social context encourages use of the drugs). In the case of Vietnam, he points out, many soldiers found that all the boxes were ticked. Troops in Thailand, by contrast, could easily get hold of heroin – but their lives were not in danger, they were free to move among a friendly population and their peers were not using it. Less than one per cent of military personnel took the drug.18 (#litres_trial_promo)

Availability doesn’t offer a comprehensive explanation for addiction, but it reminds us that we cannot hope to understand why people engage in addictive activities – be it shooting up heroin in the jungle or gorging on muffins in Starbucks – unless we take account of what that activity means in its social setting.

No one who has watched The Wire, the magnificent television epic of life in drug-saturated districts of Baltimore, can seriously propose that it depicts a black population afflicted by chronic disease. The characters in the show who smoke heroin do so, basically, because they live in districts where everyone does. If I lived there, I’d be a smack addict. Since I’m an addict, perhaps that goes without saying. But I have a sneaking feeling that even my local vicar would be hooked on the stuff.

Gossop, who has advised the British government on drug policy, is unusual among addiction experts for the bluntness with which he dismisses the disease theory. He describes addiction as a ‘habit’. That may sound less scary than an irreversible disease, but it isn’t. In a society overflowing with abundance, the implications of a habit of addiction driven by availability are every bit as alarming as those of a disease that strikes only individuals with malfunctioning brains.