Social Factors Are an Essential—And Changeable—Element of Addiction

    Resisting efforts to exaggerate the dangers of drugs does not mean we should ignore them. People suffer, and sometimes lose their lives, around excessive, compulsive and chaotic drug and alcohol use. But people’s likelihood of harmful and fatal substance use is linked, like so much else, to their societal circumstances. Addressing social concerns remains the key element to improving our alarming addiction profile and the proliferation of drug deaths in America. It is also the key to dealing with individual addictions.

    Although drug and alcohol harms are far more typical in marginalized areas of society, they also appear in privileged America, frightening those of us who usually feel immune. Terry McGovern, the daughter of former presidential candidate George McGovern, was a 45-year-old mother of two who died of exposure on the street due to extreme intoxication in 1994. In explaining his daughter’s long-standing alcohol problem, McGovern said: “She knew what it meant to love other people. But she fell short of loving herself.”

    Any theory of addiction—and any form of treatment or prevention—has to address people who “fall short of loving” themselves or who have other mental disorders. But that task is always easier when people have support and resources and communities. And those things, which are more available to the well-off, need to be found, or created, in order to help people who are marginalized.

    The state with by far the highest rate of drug deaths is West Virginia, which had 49.6 opioid-involved deaths per 100,000 population in 2017—more than three times the national average. West Virginia’s health commissioner, Dr. Rahul Gupta, set his department on the task of identifying every one of these opioid deaths.

    “We wanted to know who each person was and what we could have done to help them,” he said. The findings ultimately would show a depressing pattern: “If you’re a male between the ages of 35 to 54, with less than a high school education, you’re single and you’ve worked in a blue-collar industry, you pretty much are at a very, very high risk of overdosing.”

    The identical process takes place in many American inner-cities, where, like rural Appalachian addiction centers, opioid and other drug addictions are most typical among middle-aged male users. Per NPR:  “According to the Office of the Medical Examiner in Washington, DC, overall [opioid-involved] deaths among black men between the ages of 40 and 69 increased 245 percent from 2014-2017.”

    Experts and leaders typically ignore the reality of addicted people’s lives by describing addiction as an “equal opportunity destroyer.”

    This awareness of the link between social context and drug deaths is absent in American public health and drug policies. Addiction experts and political leaders typically ignore the reality of addicted people’s lives by describing addiction as an “equal opportunity destroyer.” Of course, this lays the entire addictive process at the feet of drug use per se, as in the “Truth Initiative” message, broadcast on media and billboards nationwide, despite general unawareness of the difference between dependence and addiction: “Opioid dependence can happen after just five days because the drugs are some of the strongest on the planet.”

    Do they really believe that the Obama daughters, for instance, with their solid two-parent family, private schools, year abroad and elite university attendance have the same chance of becoming addicted and dying as unemployed blue-collar workers in West Virginia, or as children growing up amidst violence and chaotic drug use in Baltimore?

    One of America’s foremost and most insightful medical critics, Marcia Angell, the former editor-in-chief of the New England Journal of Medicine, in reviewing many books on the opioid crisis, rejects the idea that our drug-death epidemic is due to overproduction and over prescription of narcotics. (It should be noted that Angell is a long-time critic of pharmaceutical companies.)

    In her December 2018 piece in the New York Review of Books, “Opioid Nation,” Angell notes, “We also need to remember an essential and crucial fact: opioids do have a legitimate purpose, and it’s an enormously important one. They treat severe pain.” Rather, for Angell, “As long as this country tolerates the chasm between the rich and the poor, and fails even to pretend to provide for the most basic needs of our citizens, such as health care, education, and child care, some people will want to use drugs to escape.”


    The Definition and Natural History of Addiction

     Although addiction is an identifiable, negative pattern of behavior, no person is by definition an “addict” whose fate is sealed by some accident of birth or traumatic event—or even a persistently traumatic upbringing.

    Hart’s experiment speaks to all of us: We respond positively when we see better options open for us. 

    Most of us seek out powerful experiences at some point in our lives, especially when younger, often with some greater or lesser negative consequences. We may persist for a longer or shorter time before reducing the behavior or ceasing it entirely. These experiences are capable of dominating our consciousness and emotions, with the potential for creating an addictive process for varying lengths of time. Although drugs produce direct, intense experiences, they are not alone in their ability to do this. And there is nothing chemical about drugs that make them inevitably—or singularly among all that we experience—the sources of addiction.

    Addictive involvements do the following:


       1. Diminish awareness of surroundings and feelings.

       2. Provide immediate, predictable and encompassing sensations.

       3. Offer a false sense of control and personal value.

       4. Reduce healthy options (impairing the person).

       5. Worsen negative feelings about self (causing distress).


    Along with these defining criteria, addictive involvements are notable because they:

      6. Occur along a continuum of severity.

       7. Reverse as people engage in positive life experiences (“recovery”).


    Despite their negative consequences, addictions do not entail losing all control of behavior. People with addictions recognize boundaries and are capable of changing with their circumstances. When smoking was banned from workplaces, daily smokers learned to wait for a break to smoke; people who drink problematically are usually not inclined to get drunk in front of their parents; frequent users of illegal drugs have places where they prefer to take drugs and can defer their use in exchange for small rewards—as Dr. Carl Hart showed in the case of regular crack users in his work, described in his 2014 book, High Price.

    Hart’s experiment speaks to all of us: We respond positively and delay and eliminate addictions when we see better options open for us. 


    Seattle’s Wet Housing Residents

     Seattle, like other cities, has a famous skid row populated by long-term street drinkers. These men and women often ended up in hospitals and prisons, at great public expense. In order to get these homeless drinkers off the street, Seattle offered them “wet housing”—safe residences where they could drink as they wished. Here is the result, as described in Time by Maia Szalavitz:

    The homeless residents in the study cut the number of drinks they consumed daily by 40% over the course of two years in a home that did not require abstinence. Moreover, for every three months of their stay, participants consumed 8% fewer drinks on average on their heaviest drinking days. The occurrence of delirium tremens, or DTs—potentially life-threatening withdrawal symptoms—also declined by more than half, with 65% of residents reporting suffering DTs in the month before being housed, compared with just 23% in the month afterward.

    Curtailing people’s worst addictive excesses (e.g., how much they drank at their highest-consumption moments) is harm reduction. We might choose to pray that people would cure their addictions and cease drinking altogether. But for a large, and possibly growing, number of people, often at the bottom of society’s ladder, that doesn’t happen. And these are human beings who are fully capable of living better and feeling better about themselves, as described in interviews with the residents and staff.

     From a staff member, many of whom originally opposed the program:

    “I would like to see our residents never drink again. I would like to see abstinence. But . . . that’s an unrealistic hope for our population. . . that’s an option that will only do more harm than good. . .so you want them to have the liberty to drink, but not hurt themselves or anyone else.”

    One resident said:

    “You’ve got to maintain a certain amount of intelligence to be able to stay here and get drunk at the same time. You don’t have to get drunk, just enough to go down, lay down, take a good, nice sleep. . . . Maintain. That’s it.”

     One of the few women in the housing said:

    “I’m not a bad person. You know, I feel like I’m not a bad person. I wanna help, you know? I wanna be. . .I don’t feel like a bad person. . . . I’ll get out of hand, but I stop myself, you know. . . . I’m trying to turn from . . .this person [to] that person. This person was a bad person, and that person is a good person.”

    Evidence like this from people who are among the clearest examples of addiction underlines that addicted people are human beings operating under value systems that they struggle to realize. Their problems may kill them or doom them to continued marginalization. But like all of us, they are seeking satisfaction, comfort and self-respect.

     With addiction seemingly all around usincluding areas of life where we never previously considered it, like gaming and electronic devices, eating, sex and lovefinding a balance between being exposed to powerful experiences and maintaining a stable life is a task we universally face. A negative bias against drugs does nothing to help achieve this balance—quite the opposite.


    This article is an adapted excerpt from Chapter 2 of Stanton Peele and Zach Rhoads’ book, Outgrowing Addiction: With Common Sense Instead of “Disease” Therapy, published by Upper Access Press in May 2019.

    Photo by Dan McCoy via Wikimedia Commons

    • Dr. Stanton Peele is a psychologist who has pioneered, among other things, the idea that addiction occurs with a range of experiences and recognition of natural recovery from addiction. He developed the Life Process Program for addiction and has authored many books since the 1975 publication of Love and Addiction (co-authored by Archie Brodsky).


      Zach Rhoads is an author and educational consultant working with families in Vermont. He is also an addiction coach in Dr. Stanton Peele’s Life Process Program. He hosts the podcast FSDP Presents on behalf of Families for Sensible Drug Policy.

      Their book Outgrowing Addiction: With Common Sense Instead of “Disease” Therapy was published by Upper Access Press in May 2019.

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