Ad­dic­tions fought by fac­ing demons

The Weekend Australian - Travel - - Health - MATT GAUGH­WIN

IN the great game of foot­ball, Gary Ablett was more of­ten on the mark than off it. In the game of life it was of­ten the other way around. In the Week­endAus­tralian (De­cem­ber 8/9, 2007), Noel Pear­son wrote that Ablett is wrong’’ and in de­nial’’ when Ablett said that his ad­dic­tion to drugs was self-med­i­ca­tion’’ for de­pres­sion and hurt’’. Pear­son is wrong and off the mark. His crit­i­cism and anal­y­sis of Gary Ablett’s ac­count of ad­dic­tion to drugs are in­sen­si­tive, ill-in­formed and un­fair. He has played the man more than the ball.

Some peo­ple are fat. They eat too much. They are ad­dicted to food. Like the al­co­holic or drug ad­dict, they strug­gle to over­come their ad­dic­tion to food. Eat­ing food is plea­sur­able, just as tak­ing al­co­hol and co­caine are plea­sur­able. The so­lace that comes from eat­ing can tem­po­rar­ily ame­lio­rate emo­tional pain and suf­fer­ing. Some peo­ple are thin. They starve them­selves. Not eat­ing gives them a sense of con­trol and sat­is­fac­tion not avail­able else­where in their lives. They can’t eas­ily stop de­spite the harm they do to them­selves.

Ad­dic­tion to eat­ing or not eat­ing, or to gam­bling, shows even the scep­ti­cal ma­te­ri­al­ist that the brain it­self mat­ters when it comes to ad­dic­tion and not just the chem­i­cals we put in it. It stands to rea­son that the de­pressed or hy­per­ac­tive brain may try to get some re­lief.

Fun­da­men­tally, ad­dic­tion is an in­abil­ity to con­trol a repet­i­tive be­hav­iour that is re­ward­ing in some way. To re­duce and sim­plify it to any dom­i­nant con­struct, as Ablett has done (that ad­dic­tion is treat­ing psy­chic pain), and Pear­son has done (that sus­cep­ti­bil­ity fac­tors and pri­mary con­tribut­ing fac­tors should be clearly dis­tin­guished), de­flects and dis­tract us from ra­tio­nal and rea­son­able ap­proaches to help­ing in­di­vid­u­als and com­mu­ni­ties af­flicted by ad­dic­tions.

Pear­son’s un­der­stand­ing of causal­ity is New­to­nian when it should be prob­a­bilis­tic. If the tower of Pisa is lean­ing pre­car­i­ously, then it is at risk of fall­ing over. If some­one un­der­mines its foun­da­tion or some­one gives it a good push and it falls over, then we say those ac­tions caused it to fall. But if it was not lean­ing over quite so much in the first place it would not have fallen. Th­ese things in­ter­act to cause the tower to fall.

Some­times one cause is more in­flu­en­tial than oth­ers. If we do not want the tower of Pisa to fall then we should pre­vent its foun­da­tions from be­ing un­der­mined and we should prop it up when we need to. If Pear­son had looked at some re­cent sci­en­tific lit­er­a­ture on the ques­tion of sub­stance de­pen­dence and men­tal ill­ness he would have read con­clu­sions such as:

Risk for de­vel­op­ing al­co­hol de­pen­dence was sub­stan­tially in­creased by a prior episode of ma­jor de­pres­sion. The as­so­ci­a­tion was only par­tially ac­counted for by fa­mil­ial fac­tors, pro­vid­ing sup­port for a di­rect causal ef­fect such as self-med­i­ca­tion’’. An­other pa­per con­cludes: Sub­stance use varies with past year un­met need for men­tal health care and men­tal health care use in ways con­sis­tent with the self-med­i­ca­tion hy­poth­e­sis’’. And it can go both ways: panic dis­or­der and al­co­hol use disor­ders can both serve to ini­ti­ate the other via in­de­pen­dent mech­a­nisms’’.

Given Pear­son’s re­mark­able em­pa­thy for the suf­fer­ing of his peo­ple I am sure he un­der­stands that the foun­da­tions of ad­dic­tion within in­di­vid­u­als are es­tab­lished in the early years of life. His ar­gu­ment that not ev­ery de­pressed per­son be­comes an ad­dict is about as help­ful as say­ing not ev­ery­one who smokes to­bacco gets lung can­cer. If chil­dren are raised well and not abused, then they are un­likely to need in­tox­i­cants to cope with life. But even ap­par­ently ideal child­hoods do not pre­vent ad­dic­tion ab­so­lutely.

Sons of al­co­holic fa­thers at age 18 or so can drink their peers un­der the ta­ble be­fore they feel in­tox­i­cated, and are many times more likely to go on to be­come al­co­holics them­selves. Ad­dic­tion can be deeply bi­o­log­i­cal. The best ad­vice we can give the son of an al­co­holic is to be very, very care­ful around al­co­hol.

Pear­son is cor­rect when he says that ad­dicts and their com­mu­ni­ties won’t get bet­ter un­til peo­ple stop drink­ing and us­ing drugs. The best thing to do is to stop tak­ing sub­stances by get­ting ap­pro­pri­ate help. Short of liv­ing in a dry com­mu­nity, utopian or dystopian, the only way to stop ad­dic­tive be­hav­iours is for in­di­vid­u­als to learn how to refuse al­co­hol (or a sub­stance) when faced with the op­por­tu­nity of tak­ing it.

Most ad­dicts re­lapse within three months of stop­ping for a week or so if they don’t get spe­cific help. Many ad­dicts need the sup­port of Al­co­holics Anony­mous to main­tain the mo­ti­va­tion to keep on go­ing with­out re­laps­ing. Many ad­dicts need treat­ment for anx­i­ety and de­pres­sion. Some ad­dicts need highly aver­sive treat­ments, and some need sub­sti­tute ad­dic­tions that are safe. Ad­dicts need to ap­pre­ci­ate that they should say no’’ and then prac­tise say­ing no’’. Many ad­dicts need just the things that Ablett calls for: tol­er­ance, un­der­stand­ing and em­pa­thy. And they need a form of firm love’’ that says you are re­spon­si­ble for what you do’’.

If there is a root cause of ad­dic­tion, it is eth­i­cal. It is the ideas and val­ues we hold about free­dom and free will. We cher­ish the free­dom to make, ad­ver­tise, ped­dle, and use al­co­hol and drugs. The free­dom we have is un­bri­dled and un­hinged from ideas about re­spon­si­bil­ity and prin­ci­ples; in my com­mu­nity about 60 per cent of al­co­holics hold a li­cence to drive a car, and sadly treat­ing in­tox­i­ca­tion and its con­se­quences are grist to the mill in our hos­pi­tals. Why? Be­cause we tol­er­ate in­tox­i­ca­tion and ad­dic­tion too much. Our so­ci­ety does not say enough is enough’’. We are hyp­o­crit­i­cal; we de­monise to­bacco and drugs, while we al­low al­co­hol to be pro­moted when it kills and maims hun­dreds of our young peo­ple. Th­ese dis­cor­dances af­fect gov­ern­ments, in­sti­tu­tions, com­mu­ni­ties and in­di­vid­u­als. The best and hon­est way to deal with th­ese dis­cor­dances is to en­cour­age a prin­ci­pled au­ton­omy that en­ables in­di­vid­u­als and com­mu­ni­ties to face and then ex­punge their demons, whether they are in­ter­nal demons or the cryp­tic in­flu­ences of the ser­pen­tine pro­mot­ers of al­co­hol and drugs. The in­ter­ven­tions to cur­tail al­co­hol use in the NT may seem dra­co­nian, but they are an ex­am­ple of a prin­ci­pled au­ton­omy. When will we see al­co­hol la­bels that in­clude mes­sages such as Al­co­hol causes de­pres­sion’’ and Al­co­hol can kill you’’? The river of grog and drugs runs wide and deep in Aus­tralia and has bro­ken its banks. We are drown­ing in it. Its course and depth should be changed. The NT in­ter­ven­tions should spur a pol­icy re­think on what con­sti­tutes fair and rea­son­able co­er­cion to stem the flow of al­co­hol and drug-re­lated harm. But when they are tempted to have a free kick at the ex­pense of Ablett and co, Pear­son and oth­ers should keep in mind John Brad­ford’s words as he watched oth­ers go to the gal­lows: There but for the grace of God goes John Brad­ford’’. Matt Gaugh­win is a pub­lic health and ad­dic­tion medicine physi­cian in Ade­laide.

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