Addictions fought by facing demons
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.