Everything you think you know about addiction is wrong

Journalist Johann Hari

Journalist Johann Hari

A TED Talk by Johann Hari

Watch the video here.

0:11One of my earliest memories is of trying to wake up one of my relatives and not being able to. And I was just a little kid, so I didn't really understand why, but as I got older, I realized we had drug addiction in my family, including later cocaine addiction.

0:24I'd been thinking about it a lot lately, partly because it's now exactly 100 years since drugs were first banned in the United States and Britain, and we then imposed that on the rest of the world. It's a century since we made this really fateful decision to take addicts and punish them and make them suffer,because we believed that would deter them; it would give them an incentive to stop.

0:47And a few years ago, I was looking at some of the addicts in my life who I love, and trying to figure out if there was some way to help them. And I realized there were loads of incredibly basic questions I just didn't know the answer to, like, what really causes addiction? Why do we carry on with this approach that doesn't seem to be working, and is there a better way out there that we could try instead?

1:09So I read loads of stuff about it, and I couldn't really find the answers I was looking for, so I thought, okay, I'll go and sit with different people around the world who lived this and studied this and talk to them and see if I could learn from them. And I didn't realize I would end up going over 30,000 miles at the start, but I ended up going and meeting loads of different people, from a transgender crack dealer in Brownsville, Brooklyn, to a scientist who spends a lot of time feeding hallucinogens to mongooses to see if they like them -- it turns out they do, but only in very specific circumstances -- to the only country that's ever decriminalized all drugs, from cannabis to crack, Portugal. And the thing I realized that really blew my mind is, almost everything we think we know about addiction is wrong, and if we start to absorb the new evidence about addiction, I think we're going to have to change a lot more than our drug policies.

1:57But let's start with what we think we know, what I thought I knew. Let's think about this middle row here.Imagine all of you, for 20 days now, went off and used heroin three times a day. Some of you look a little more enthusiastic than others at this prospect. (Laughter) Don't worry, it's just a thought experiment.Imagine you did that, right? What would happen? Now, we have a story about what would happen that we've been told for a century. We think, because there are chemical hooks in heroin, as you took it for a while, your body would become dependent on those hooks, you'd start to physically need them, and at the end of those 20 days, you'd all be heroin addicts. Right? That's what I thought.

2:33First thing that alerted me to the fact that something's not right with this story is when it was explained to me. If I step out of this TED Talk today and I get hit by a car and I break my hip, I'll be taken to hospital and I'll be given loads of diamorphine. Diamorphine is heroin. It's actually much better heroin than you're going to buy on the streets, because the stuff you buy from a drug dealer is contaminated. Actually, very little of it is heroin, whereas the stuff you get from the doctor is medically pure. And you'll be given it for quite a long period of time. There are loads of people in this room, you may not realize it, you've taken quite a lot of heroin. And anyone who is watching this anywhere in the world, this is happening. And if what we believe about addiction is right -- those people are exposed to all those chemical hooks -- What should happen? They should become addicts. This has been studied really carefully. It doesn't happen; you will have noticed if your grandmother had a hip replacement, she didn't come out as a junkie. (Laughter)

3:25And when I learned this, it seemed so weird to me, so contrary to everything I'd been told, everything I thought I knew, I just thought it couldn't be right, until I met a man called Bruce Alexander. He's a professor of psychology in Vancouver who carried out an incredible experiment I think really helps us to understand this issue. Professor Alexander explained to me, the idea of addiction we've all got in our heads, that story, comes partly from a series of experiments that were done earlier in the 20th century.They're really simple. You can do them tonight at home if you feel a little sadistic. You get a rat and you put it in a cage, and you give it two water bottles: One is just water, and the other is water laced with either heroin or cocaine. If you do that, the rat will almost always prefer the drug water and almost always kill itself quite quickly. So there you go, right? That's how we think it works. In the '70s, Professor Alexander comes along and he looks at this experiment and he noticed something. He said ah, we're putting the rat in an empty cage. It's got nothing to do except use these drugs. Let's try something different. So Professor Alexander built a cage that he called "Rat Park," which is basically heaven for rats.They've got loads of cheese, they've got loads of colored balls, they've got loads of tunnels. Crucially, they've got loads of friends. They can have loads of sex. And they've got both the water bottles, the normal water and the drugged water. But here's the fascinating thing: In Rat Park, they don't like the drug water. They almost never use it. None of them ever use it compulsively. None of them ever overdose. You go from almost 100 percent overdose when they're isolated to zero percent overdose when they have happy and connected lives.

4:58Now, when he first saw this, Professor Alexander thought, maybe this is just a thing about rats, they're quite different to us. Maybe not as different as we'd like, but, you know -- But fortunately, there was a human experiment into the exact same principle happening at the exact same time. It was called the Vietnam War. In Vietnam, 20 percent of all American troops were using loads of heroin, and if you look at the news reports from the time, they were really worried, because they thought, my God, we're going to have hundreds of thousands of junkies on the streets of the United States when the war ends; it made total sense. Now, those soldiers who were using loads of heroin were followed home. The Archives of General Psychiatry did a really detailed study, and what happened to them? It turns out they didn't go to rehab. They didn't go into withdrawal. Ninety-five percent of them just stopped. Now, if you believe the story about chemical hooks, that makes absolutely no sense, but Professor Alexander began to thinkthere might be a different story about addiction. He said, what if addiction isn't about your chemical hooks? What if addiction is about your cage? What if addiction is an adaptation to your environment?

6:03Looking at this, there was another professor called Peter Cohen in the Netherlands who said, maybe we shouldn't even call it addiction. Maybe we should call it bonding. Human beings have a natural and innate need to bond, and when we're happy and healthy, we'll bond and connect with each other, but if you can't do that, because you're traumatized or isolated or beaten down by life, you will bond with something that will give you some sense of relief. Now, that might be gambling, that might be pornography, that might be cocaine, that might be cannabis, but you will bond and connect with something because that's our nature. That's what we want as human beings.

6:39And at first, I found this quite a difficult thing to get my head around, but one way that helped me to think about it is, I can see, I've got over by my seat a bottle of water, right? I'm looking at lots of you, and lots of you have bottles of water with you. Forget the drugs. Forget the drug war. Totally legally, all of those bottles of water could be bottles of vodka, right? We could all be getting drunk -- I might after this -- (Laughter) -- but we're not. Now, because you've been able to afford the approximately gazillion poundsthat it costs to get into a TED Talk, I'm guessing you guys could afford to be drinking vodka for the next six months. You wouldn't end up homeless. You're not going to do that, and the reason you're not going to do that is not because anyone's stopping you. It's because you've got bonds and connections that you want to be present for. You've got work you love. You've got people you love. You've got healthy relationships. And a core part of addiction, I came to think, and I believe the evidence suggests, is about not being able to bear to be present in your life.

7:37Now, this has really significant implications. The most obvious implications are for the War on Drugs. In Arizona, I went out with a group of women who were made to wear t-shirts saying, "I was a drug addict,"and go out on chain gangs and dig graves while members of the public jeer at them, and when those women get out of prison, they're going to have criminal records that mean they'll never work in the legal economy again. Now, that's a very extreme example, obviously, in the case of the chain gang, but actually almost everywhere in the world we treat addicts to some degree like that. We punish them. We shame them. We give them criminal records. We put barriers between them reconnecting. There was a doctor in Canada, Dr. Gabor Maté, an amazing man, who said to me, if you wanted to design a system that would make addiction worse, you would design that system.

8:23Now, there's a place that decided to do the exact opposite, and I went there to see how it worked. In the year 2000, Portugal had one of the worst drug problems in Europe. One percent of the population was addicted to heroin, which is kind of mind-blowing, and every year, they tried the American way more and more. They punished people and stigmatized them and shamed them more, and every year, the problem got worse. And one day, the Prime Minister and the leader of the opposition got together, and basically said, look, we can't go on with a country where we're having ever more people becoming heroin addicts.Let's set up a panel of scientists and doctors to figure out what would genuinely solve the problem. And they set up a panel led by an amazing man called Dr. João Goulão, to look at all this new evidence, and they came back and they said, "Decriminalize all drugs from cannabis to crack, but" -- and this is the crucial next step -- "take all the money we used to spend on cutting addicts off, on disconnecting them,and spend it instead on reconnecting them with society." And that's not really what we think of as drug treatment in the United States and Britain. So they do do residential rehab, they do psychological therapy, that does have some value. But the biggest thing they did was the complete opposite of what we do: a massive program of job creation for addicts, and microloans for addicts to set up small businesses. So say you used to be a mechanic. When you're ready, they'll go to a garage, and they'll say,if you employ this guy for a year, we'll pay half his wages. The goal was to make sure that every addict in Portugal had something to get out of bed for in the morning. And when I went and met the addicts in Portugal, what they said is, as they rediscovered purpose, they rediscovered bonds and relationships with the wider society.

10:00It'll be 15 years this year since that experiment began, and the results are in: injecting drug use is down in Portugal, according to the British Journal of Criminology, by 50 percent, five-zero percent. Overdose is massively down, HIV is massively down among addicts. Addiction in every study is significantly down.One of the ways you know it's worked so well is that almost nobody in Portugal wants to go back to the old system.

10:23Now, that's the political implications. I actually think there's a layer of implications to all this research below that. We live in a culture where people feel really increasingly vulnerable to all sorts of addictions, whether it's to their smartphones or to shopping or to eating. Before these talks began -- you guys know this -- we were told we weren't allowed to have our smartphones on, and I have to say, a lot of you looked an awful lot like addicts who were told their dealer was going to be unavailable for the next couple of hours. (Laughter) A lot of us feel like that, and it might sound weird to say, I've been talking about how disconnection is a major driver of addiction and weird to say it's growing, because you think we're the most connected society that's ever been, surely. But I increasingly began to think that the connections we have or think we have, are like a kind of parody of human connection. If you have a crisis in your life, you'll notice something. It won't be your Twitter followers who come to sit with you. It won't be your Facebook friends who help you turn it round. It'll be your flesh and blood friends who you have deep and nuanced and textured, face-to-face relationships with, and there's a study I learned about from Bill McKibben, the environmental writer, that I think tells us a lot about this. It looked at the number of close friends the average American believes they can call on in a crisis. That number has been declining steadily since the 1950s. The amount of floor space an individual has in their home has been steadily increasing, and I think that's like a metaphor for the choice we've made as a culture. We've traded floorspace for friends, we've traded stuff for connections, and the result is we are one of the loneliest societies there has ever been. And Bruce Alexander, the guy who did the Rat Park experiment, says, we talk all the time in addiction about individual recovery, and it's right to talk about that, but we need to talk much more about social recovery. Something's gone wrong with us, not just with individuals but as a group, and we've created a society where, for a lot of us, life looks a whole lot more like that isolated cage and a whole lot less like Rat Park.

12:15If I'm honest, this isn't why I went into it. I didn't go in to the discover the political stuff, the social stuff. I wanted to know how to help the people I love. And when I came back from this long journey and I'd learned all this, I looked at the addicts in my life, and if you're really candid, it's hard loving an addict, and there's going to be lots of people who know in this room. You are angry a lot of the time, and I think one of the reasons why this debate is so charged is because it runs through the heart of each of us, right?Everyone has a bit of them that looks at an addict and thinks, I wish someone would just stop you. And the kind of scripts we're told for how to deal with the addicts in our lives is typified by, I think, the reality show "Intervention," if you guys have ever seen it. I think everything in our lives is defined by reality TV,but that's another TED Talk. If you've ever seen the show "Intervention," it's a pretty simple premise. Get an addict, all the people in their life, gather them together, confront them with what they're doing, and they say, if you don't shape up, we're going to cut you off. So what they do is they take the connection to the addict, and they threaten it, they make it contingent on the addict behaving the way they want. And I began to think, I began to see why that approach doesn't work, and I began to think that's almost like the importing of the logic of the Drug War into our private lives.

13:33So I was thinking, how could I be Portuguese? And what I've tried to do now, and I can't tell you I do it consistently and I can't tell you it's easy, is to say to the addicts in my life that I want to deepen the connection with them, to say to them, I love you whether you're using or you're not. I love you, whatever state you're in, and if you need me, I'll come and sit with you because I love you and I don't want you to be alone or to feel alone.

14:00And I think the core of that message -- you're not alone, we love you -- has to be at every level of how we respond to addicts, socially, politically and individually. For 100 years now, we've been singing war songs about addicts. I think all along we should have been singing love songs to them, because the opposite of addiction is not sobriety. The opposite of addiction is connection.

14:27Thank you.


Relapse Prevention Video: Early Warning Signs and Important Coping Skills

Learn the stages of relapse and how to recognize the early warning signs of relapse. Learn coping skills to prevent relapse in the future. By Dr. Steven M Melemis MD PhD.

The Stages of Relapse

Relapse is a process, it's not an event. In order to understand relapse prevention you have to understand the stages of relapse. Relapse starts weeks or even months before the event of physical relapse. In this page you will learn how to use specific relapse prevention techniques for each stage of relapse. There are three stages of relapse.(1)

  • Emotional relapse
  • Mental relapse
  • Physical relapse

Learn More

Emotional Relapse

In emotional relapse, you're not thinking about using. But your emotions and behaviors are setting you up for a possible relapse in the future.

The signs of emotional relapse are:

  • Anxiety
  • Intolerance
  • Anger
  • Defensiveness
  • Mood swings
  • Isolation
  • Not asking for help
  • Not going to meetings
  • Poor eating habits
  • Poor sleep habits

The signs of emotional relapse are also the symptoms of post-acute withdrawal. If you understand post-acute withdrawal it's easier to avoid relapse, because the early stage of relapse is easiest to pull back from. In the later stages the pull of relapse gets stronger and the sequence of events moves faster.

Early Relapse Prevention

Relapse prevention at this stage means recognizing that you're in emotional relapse and changing your behavior. Recognize that you're isolating and remind yourself to ask for help. Recognize that you're anxious and practice relaxation techniques. Recognize that your sleep and eating habits are slipping and practice self-care.

If you don't change your behavior at this stage and you live too long in the stage of emotional relapse you'll become exhausted, and when you're exhausted you will want to escape, which will move you into mental relapse.

Practice self-care. The most important thing you can do to prevent relapse at this stage is take better care of yourself. Think about why you use. You use drugs or alcohol to escape, relax, or reward yourself. Therefore you relapse when you don't take care of yourself and create situations that are mentally and emotionally draining that make you want to escape.

For example, if you don't take care of yourself and eat poorly or have poor sleep habits, you'll feel exhausted and want to escape. If you don't let go of your resentments and fears through some form of relaxation, they will build to the point where you'll feel uncomfortable in your own skin. If you don't ask for help, you'll feel isolated. If any of those situations continues for too long, you will begin to think about using. But if you practice self-care, you can avoid those feelings from growing and avoid relapse. (Reference: www.AddictionsAndRecovery.org)

Mental Relapse

In mental relapse there's a war going on in your mind. Part of you wants to use, but part of you doesn't. In the early phase of mental relapse you're just idly thinking about using. But in the later phase you're definitely thinking about using.

The signs of mental relapse are:

  • Thinking about people, places, and things you used with
  • Glamorizing your past use
  • Lying
  • Hanging out with old using friends
  • Fantasizing about using
  • Thinking about relapsing
  • Planning your relapse around other people's schedules

It gets harder to make the right choices as the pull of addiction gets stronger.

Techniques for Dealing with Mental Urges

Play the tape through. When you think about using, the fantasy is that you'll be able to control your use this time. You'll just have one drink. But play the tape through. One drink usually leads to more drinks. You'll wake up the next day feeling disappointed in yourself. You may not be able to stop the next day, and you'll get caught in the same vicious cycle. When you play that tape through to its logical conclusion, using doesn't seem so appealing.

A common mental urge is that you can get away with using, because no one will know if you relapse. Perhaps your spouse is away for the weekend, or you're away on a trip. That's when your addiction will try to convince you that you don't have a big problem, and that you're really doing your recovery to please your spouse or your work. Play the tape through. Remind yourself of the negative consequences you've already suffered, and the potential consequences that lie around the corner if you relapse again. If you could control your use, you would have done it by now.

Tell someone that you're having urges to use. Call a friend, a support, or someone in recovery. Share with them what you're going through. The magic of sharing is that the minute you start to talk about what you're thinking and feeling, your urges begin to disappear. They don't seem quite as big and you don't feel as alone.

Distract yourself. When you think about using, do something to occupy yourself. Call a friend. Go to a meeting. Get up and go for a walk. If you just sit there with your urge and don't do anything, you're giving your mental relapse room to grow.

Wait for 30 minutes. Most urges usually last for less than 15 to 30 minutes. When you're in an urge, it feels like an eternity. But if you can keep yourself busy and do the things you're supposed to do, it'll quickly be gone.

Do your recovery one day at a time. Don't think about whether you can stay abstinent forever. That's a paralyzing thought. It's overwhelming even for people who've been in recovery for a long time.

One day at a time, means you should match your goals to your emotional strength. When you feel strong and you're motivated to not use, then tell yourself that you won't use for the next week or the next month. But when you're struggling and having lots of urges, and those times will happen often, tell yourself that you won't use for today or for the next 30 minutes. Do your recovery in bite-sized chunks and don't sabotage yourself by thinking too far ahead.

Make relaxation part of your recovery. Relaxation is an important part of relapse prevention, because when you're tense you tend to do what’s familiar and wrong, instead of what's new and right. When you're tense you tend to repeat the same mistakes you made before. When you're relaxed you are more open to change. (Reference: www.AddictionsAndRecovery.org)

Physical Relapse

Once you start thinking about relapse, if you don't use some of the techniques mentioned above, it doesn't take long to go from there to physical relapse. Driving to the liquor store. Driving to your dealer.

It's hard to stop the process of relapse at that point. That's not where you should focus your efforts in recovery. That's achieving abstinence through brute force. But it is not recovery. If you recognize the early warning signs of relapse, and understand the symptoms of post-acute withdrawal, you'll be able to catch yourself before it's too late.


1) The stages of relapse were first described by Terence Gorski. Gorski, T., & Miller, M., Staying Sober: A Guide for Relapse Prevention: Independence Press, 1986.

6 Common Fears in Addiction Recovery – and How to Face Them

Fear is normal at every stage of recovery. Everyone enters rehab with some trepidation, even if they’ve been in and out of treatment for years. Likewise, most people leave rehab full of worry. What will happen when they leave the one place they know they can stay sober? How will they cope when the feelings they’ve been medicating come flooding back?

When you think about how the average person responds to a horror movie or passing a traffic accident, it is clear that, in some cases, fear actually draws us in rather than repelling us. Fear makes us alert to danger; it helps guide our decision-making process. But too much fear can be paralyzing in life and, in addiction recovery, can be a precursor to relapse. Here are some of the fears common among people in recovery, along with suggestions for facing them:

#1 Fear of Sobriety

Getting sober means replacing your primary coping mechanism – drugs and alcohol – with new, unfamiliar ones. The process can be uncomfortable, particularly for someone who is afraid of feeling in general. Will all of the hard work be worth it? Will sobriety be boring, sustainable? Staying stuck in this fear generally means staying stuck in addiction.

What to Do: Nelson Mandela said, “The brave man is not he who does not feel afraid, but he who conquers that fear.” Rather than running from it, feel the fear and then take one step forward anyway – go to rehab, meet with a therapist or attend a support group where other people in recovery share their success stories. Once you try it, you may find that sobriety is not as scary as you once thought.

#2 Fear of Failure

Whether you have one day sober or 10 years, recovery presents challenges. There are times when you’ll doubt yourself and get pushed outside of your comfort zone. There are times when you will fall short of a goal. At this point, you can either conclude that you don’t deserve it or have what it takes, or you can try again.

What to Do: Many addicts are perfectionists who have difficulty accepting mistakes and taking strategic risks. True, about half of recovering addicts relapse at some point. But the other half doesn’t, and if you relapse and learn from it, you haven’t failed at all. Others have succeeded in spite of fear, and so can you. According to the Partnership at Drugfree.org, more than 23 million people in the U.S. have recovered from drug and alcohol problems.

#3 Fear of Success

The flipside of the fear of failure is the fear of success. Most people don’t consciously self-sabotage, but they have a deeply held belief that they don’t deserve to succeed and, in so believing, never really put forth their best effort. Feeling doomed from the start, many allow self-doubt and fears of what others think to keep them from trying.

What to Do: Fear is an emotion that is based on something we cannot control: the future. Instead of fretting over what might be, practice being mindful of the present. Feel the fear and breathe through it without resisting it or trying to change it – and then notice how the fear begins to dissipate.

#4 Fear of Rejection

Worried that they may be abandoned by the people they love or judged by others, some people refuse to admit that they have a drug problem or reach out to others for support. Yet without taking these steps, there can be no recovery.

What to Do: Fear of rejection can be overcome by pushing yourself to work a recovery program even when you don’t want to. Attend sober social gatherings, lean on family members and talk to people at support group meetings. Research shows that the simple act of putting your fears into words taps into the parts of the brain responsible for logic and emotional regulation, decreasing fear and anxiety.

#5 Fear of Losing Your Identity

After months or years of being fixated on drugs and alcohol, who are you if you aren’t an addict? What are your hopes, desires and values? These are some of the most difficult questions in recovery, and the answers may change over time.

What to Do: In recovery, you have a unique opportunity to redefine yourself. Spend some time thinking back to who you were before you started using drugs and revisit old interests. Also try something new, such as volunteering or taking a class, so you have a chance to develop new passions. Each of these steps will not only help you maintain your sobriety, but also move you closer to the ultimate goal of figuring out who you are.

#6 Fear of Perpetual Misery

Lurking in the minds of most recovering addicts is the question: What if I do the hard work of recovery and am still miserable? After drugs flood the brain with dopamine, some people find it difficult to feel pleasure from normally enjoyable activities. Others get clean and sober only to find that they still feel angry and depressed. Also known as “dry drunk,” these individuals erroneously believe that getting sober is where the hard work ends.

What to Do: Some of the damage inflicted by prolonged drug use will be repaired the longer you stay sober. Just as important as stopping the use of all mood-altering substances is actively engaging in a program of recovery. Only by investing in yourself and your relationships can life in recovery be truly joyful.

David Sack, M.D., is board certified in psychiatry, addiction psychiatry and addiction medicine. He is CEO of Elements Behavioral Health, a network of mental health and addiction treatment centers that includes Promises, The Ranch, The Recovery Place, The Sexual Recovery Institute, Right Step, Clarity Way, Journey Healing Centers and Lucida Treatment Center.

About David Sack, M.D.

Dr. David Sack is board certified in psychiatry, addiction psychiatry and addiction medicine. As CMO of Elements Behavioral Health, he oversees treatment programs for sex addiction and drug addiction at The Ranch in Tennessee and The Right Step in Dallas.

View all posts by David Sack, M.D. →

What Is Emotional Sobriety?

What is emotional sobriety? Some might think that it means being "happy, joyous, and free," a common adage in 12-Step meetings, taken from AA literature. Of course, people like this definition. It means that if they work a good program, they will achieve physical sobriety (abstinence) and become happy in the process. 

I hate to be the bearer of bad news but this definition puts a lot of recovering people in a tough spot. For example, what does it say about a person's emotional sobriety if they are having a hard time? What if they are afraid, anxious, sad, angry, confused ... the list can go on and on. Does this mean that they aren't emotionally sober? 

I believe that emotional sobriety is less about the quality of the feeling ("good" or "bad") and more about the general ability to feel one's feelings. Being restored to sanity isn't about getting the brass ring—or cash and prizes—or being "happy, joyous, and free" all the time, but it is about being in the present moment, whatever it happens to look like. What are you experiencing right now? And how about now? Can you be present to all of your feelings without any one of them defining you?

Sometimes emotional sobriety is about tolerating what you are feeling. It is about staying sober no matter what you are feeling. It means that you don't have to blame yourself or your program because life can be challenging. It means that you don't necessarily need to do something to make the feeling go away. Many people will take their bad feeling and try to pray it,meditate it, service it, spiritually distract themselves from it, thinking that this means they are working a good program. This experience is actually called spiritual bypass.

John Welwood coined the term spiritual bypass and defined it as "using spiritual ideas and practices to sidestep personal, emotional 'un-finished business,' to shore up a shaky sense of self, or to belittle basic needs, feelings, and developmental tasks, all in the name of enlightenment." The shorthand for spiritual bypass is when a person wears a mask or presents a false spiritual self that represses aspects of that person's true self. Spiritual bypass involves bolstering our defenses rather than our humility. Bypass involves grasping rather than gratitude, arriving rather than being, avoiding rather than accepting.

I am forever interested in how mind, body, and spirit interact for people in recovery and how the "ism" (alcoholism) is always trying to steal the show. "Ism" doesn't want you to acknowledge that you are scared, ashamed, lost, or angry. And let's face it, some people in recovery don't want you to acknowledge that either. Because then they would have to look at that stuff (and feel it), and they just might not be ready. So spiritual bypass becomes a tool for working a spiritual program that is really in service of controlling obstacles and outcomes. It provides the illusion that the addict can still manage their feelings even though they aren't using their drug of choice.

In my own spiritual journey, I have experienced spiritual bypass many times. As a defense mechanism, we are all susceptible to this unconscious drive to protect ourselves from our painful realities. And using spirituality as a defense certainly looks a lot better than usingdrugs or alcohol. But it is a defense mechanism nonetheless and most people in recovery want the ability to access all of their feelings, because being present to what is real is what enables choices, and choices propel people towards their most authentic and fulfilling sober life.

I have spent a great deal of time studying and researching the experience of spiritual bypass in 12-Step recovery. I've written a book called Recovering Spirituality: Achieving Emotional Sobriety in Your Spiritual Practice that goes into great depth on this topic. Every person in recovery who I have interviewed or worked with in my psychotherapy practice has gained tremendous insight by looking at their own experiences of spiritual bypass and I hope that you will gain similar results. If nothing else, give yourself permission to feel all of your feelings. Know that we don't have the sort of surgical precision to only feel the feelings that we enjoy. Happiness might be sitting right next to regret, joy might be right next to overwhelmed. That is just the human condition. And experiencing all of our feelings is true emotional sobriety.

Ingrid Mathieu, Ph.D. is a psychotherapist and author of Recovering Spirituality: Achieving Emotional Sobriety in Your Spiritual Practice.

The Importance of Honesty in Recovery

Honesty is a Moral Characteristic

Honesty is one of the most respected of all moral characteristics. If it becomes known that a respected individual has behaved dishonestly, it can cause devastating harm to their reputation. Some types of dishonesty are more acceptable than others. Most people tell fibs or white lies from time to time – there is even therapeutic fibbing. Other people would claim that all types of dishonesty are bad.

Those people who are trying to rebuild their life after an addiction need to pay particular attention to honesty. They need to not only be truthful with other people, but more importantly with themselves. Failure to establish honesty as a personal quality may mean that the individual will be more at risk of relapse. It could also mean that they live a life in recovery that is not fulfilling – it could lead to dry drunk syndrome.

Dishonesty in Addiction

Those who become addicted to alcohol or drugs will usually live a life that involves plenty of dishonesty. This is because substance abuse is going to bring them in conflict with many people. In order to avoid such conflicts the addict needs to lie. So when their boss wants to know why they are not at work they might claim that they’ve picked up some type of stomach bug. The life of an addict tends to involve telling one lie after another, and more lies to cover previous lies. The most damaging of all will be the lies that the addict tells themselves.

All addicts rely on self-deception and denial in order to keep abusing their favorite chemicals. The evidence of the destruction caused by their addiction is usually plain for everyone else to see, but the addict is able to hide from this truth. It is only when the evidence of the destructiveness of their behavior becomes too overwhelming to ignore that most will develop a willingness to change. Honesty is what finally leads people into recovery, and it is this that then keeps them there.

Reasons for Dishonesty in Recovery

There are a number of reasons why people in recovery will behave dishonestly including:

* They fear the consequences of their actions and so lie to protect themselves from these consequences.
* Lying is a habit. The more people do it the more they are likely to do it in the future. It is easy to slip into the habit of lying until dishonestly just becomes an almost automatic response.
* Dishonesty can produce desirable outcomes both socially and economically. There is therefore the temptation to use this as a tool to fulfill desires. The problem is that the long-term consequences of dishonesty are usually negative.
* Addicts tend to lie without even realizing it. This is because they are so self-deluded that they are unable to see the truth. Even those who give up alcohol and drugs can still become self-deluded again in the future.
* Some lies may be said to protect other people and so may be considered relatively harmless. For example, if a friend pays for an expensive new haircut it might be hurtful to say that they don’t look very attractive. Another example of dishonesty that would be considered acceptable is telling children that Santa Clause is coming.

The Dangers of Dishonesty in Recovery

Dishonesty in recovery is dangerous because:

* It is a common relapse trigger. It means that the individual is returning to old ineffective coping strategies for dealing with life.
* The most common reason why people relapse after a period of sobriety is that they become stuck in recovery. This often happens because they have stopped being honest with themselves and other people. They feel unwilling to face a challenge on the path before them so they try to hide from it in denial. No further progress can occur until the individual can clearly acknowledge what the problem is and be willing to take action to remedy the situation.
* If friends and family find out about this dishonesty it can destroy any progress that has been made in rebuilding relationships.
* Programs such as the 12 Steps require that people are rigorously honest. If the individual begins to behave dishonestly it will mean that they will unable to benefit from this program.
* Dishonesty can lead to feelings of guilt afterwards. The individual who is dealing with too much guilt in recovery can find it hard to discover real happiness.
* It was the failure of the individual to be honest with themselves that kept them trapped in addiction. If they allow self deception to once again take hold of their life then they are likely to question the value of sobriety and the need to refrain from alcohol and drugs.
* Honesty allows for healing of the individual and those close to them. If people continue to be dishonest then it means that this healing will not take place.
* If people are attending any type of therapy then it is vital that they are truthful during these sessions. If there is no honesty there can be little benefit from such treatment.

How to Increase Honesty in Recovery

Honesty is a key element of any successful life away from addiction. It is therefore important that people develop this moral characteristic. Here are a few ways to increase honesty in their recovery:

* The key to breaking away from dishonesty is to admit when it has occurred as soon as possible afterwards. Those who are in a Twelve Step fellowship will be asked to do this as part of step 10; continued to take personal inventory and when we were wrong promptly admitted to it. It can be hard to own up to dishonesty, but it makes it harder to be dishonest in the future.
* Developing honesty is like building up muscles; the more people do it the more honest they become.
* Keeping a journal is a useful way to track behavior. It gives people the opportunity to look back on their day to look for any examples of dishonest behavior. Journaling also reduces the risk of becoming caught up in self-delusion because things appear clearer when they are written down on paper.
* If people do not value honesty then they will not put much effort into living a life that is built upon it. Therefore it is vital that the individual has a clear understanding of the importance of honesty, and the dangers of dishonesty in recovery.
* It is usual for people to play down the significance of certain lies – they can justify the telling of white lies. While there are times when telling a lie might be the less of two evils it is not a good idea to view any type of dishonesty in recovery as acceptable. Ideally the individual should be aiming for complete honesty; although they are unlikely to ever achieve this.

On Kindness and Treating Addiction

On Kindness and Treating Addiction

By Edward J. Khantzian 09/01/16

One of the seminal figures in the theory and practice of addiction treatment reflects on the therapeutic value of kindness.

Much of the focus in the current dialog around addiction treatment is either theoretical (abstinence vs harm reduction) or focused on technique (motivational interviewing, cognitive behavioral, etc). So it can be easy to forget that addiction psychotherapy is, first and foremost, psychotherapy. A confounding variable in the psychotherapy of addiction is a punitive aspect that clients with addictive disorders often experience from others, as well as themselves, and sometimes from therapists. Dr. Edward Khantzian, a longstanding thought leader in the field of addiction, reminds us how powerful the stance of kindness can be in working with these individuals…Richard Juman, PsyD

Reading a manuscript recently about addiction stimulated me to think again about how I stressed in a 2012 paper (1) that among a number of elements that were crucial in treating addicted individuals, I put “kindness” at the top of the list. When I wrote the article, I immediately thought how naïve and simplistic that assertion might seem given the complexities of what needs understanding and remediation in addictively vulnerable persons. Among a number of other necessary therapeutic elements, I listed comfort, empathy, patience, avoiding confrontations, instruction, etc. At the time, I offered some good explanations why I though kindness was so important and not to be minimized. The two reasons I stressed were (a) traditions of impassivity and therapeutic neutrality with many psychotherapeutic modalities which are not readily relinquished, and (b) how our tendency to distrust our patient’s veracity render us to be less than benevolent in our attitude.

Beyond the reasons I explained at that time, I found myself rather impatiently reacting to an insufficient concern about kindness in our work. I found myself reacting “Is there any other way to be!” In addition to a pervasive, unyielding concern for my patients not feeling understood, shame ridden, lost, and stigmatized, I found myself further wanting to explore and explain why kindness is so unremittingly important in meeting our patients’ needs. I first looked up some definitions, which I condense as follows: Webster’s offers "quality or state of being gentle and considerate." Oxford adds, "friendly and generous." And the online Psychology Dictionary refers to "benevolent and helpful action." These definitions get to the heart of so much of the ungentle, unfriendly, un-benevolent attitudes that others heap upon the addicted—and the addicted heap upon themselves. From a psychodynamic perspective, I would add that in clinical care, kindness also involves sensitive, empathic attunement to affect.

In my work studying and treating addicted individuals over the past 5 decades, I have placed a major emphasis on how dysregulated addicted persons are with regard to their feelings, sense of self/self-esteem, relationships, and behavior, especially self-care. Exploring affects (feelings) and empathic attunement to the critical areas of psychological life in which they play out are vitally important in accessing and modifying these areas of dysregulation:

-Affects cut across all aspects of self-regulation in the development of addiction

-Affects are the organizing basis for self-experience (Stolorow et al 1995)

-Affects are the foundation for a sense of well-being (Kohut 1970)

-Affects are the currency for human connection and attachment (Bowlby 1973)

-Affects are the primary ingredient for guiding behavior, especially self-care (Khantzian and Mack 1983)

Navigating through the domains that we all face in regulating our lives is challenging enough. For those struggling with the developmental deficits of not knowing feelings, having insufficient self-love, troubled relationships, and poor self-care, the addictively prone are tragically ill-equipped to meet the human challenges of coping with their inner psychological life or external reality. Is it little wonder then, that those individuals so burdened resort to the inanimate solutions of addictive substances and activities?

Although the word “kindness” does not explicitly come up in the following vignette about Faith, it is clear how important a part it played in her gaining a better hold on how old and recent wounds so much governed her reliance on alcohol to fix her troubled sense of self and to alleviate her anxiety and depression:

The Case of Anxious and Melancholic Faith

Faith’s out-of-control drinking and a devastating depression were precipitated when she was terminated from a highly placed executive position in a major health care corporation. A hypercritical, intimidating senior officer was instrumental in her removal from her position. Much of her success and ambition was driven and compensatory. She was raised by an immigrant mother who was insufficiently supportive and, like her boss, hypercritical of Faith, but this was further compounded by mother taking to her bedroom for years at a time by her own immobilizing depression. For most of her growing up years, she says home was an unhappy place given mother’s depression, father's drinking, and her parents’ constant fighting.

She was referred by her psychopharmacologist for individual and group psychotherapy to deal with her heavy drinking. Although she did not adopt abstinence, almost immediately she was successful in significantly cutting back the frequency and amount of her drinking. In her own words, she said she was “self-medicating” her anxiety (in low to moderate doses), and when the anxiety and depression mounted to unbearable levels, she would drink to obliterating levels (e.g. the entire bottle of wine) and go to bed.

From the start of treatment, Faith quickly formed a positive attachment to her therapist and was openly expressive of her appreciation for the comfort and reassurance she was experiencing from the work with the therapist in her individual and group therapy. In a recent individual visit, even as she was wondering aloud why she was continuing to use alcohol, adding that she was no longer self-medicating, she spontaneously indicated that the antidepressant was relieving her sadness and despair. But she quickly added that her energy levels remained low and the alcohol energized her. She volunteered that she definitely felt better and that she was okay with the controlled drinking, but was aware that it was a “slippery slope” and realized she could get back to” numbing” herself with alcohol. The therapist wondered with her if she might think about what she might be numbing. She thought about how she used to get her “adrenaline lift” from the kudos and recognition she obtained from her position, but then offered that she derived little comfort or satisfaction currently from her reading group, arts and crafts, or prettying up her home. She ended the session wondering about what else might give her a “lift or pleasure.”

The progression from Faith’s unthinking compulsive drinking to ameliorate her immense suffering, to a relatively rapid development of a capacity to think and worry about her troubled state of being and her use of alcohol, was impressive. Her demeanor, especially early in treatment, was a melancholic and anxious one. In contrast, it was notable to witness the comfort, support, and clarification she drew from her individual and group therapy, as well as the opportunity to share her distress and gratitude in her treatment—interactions that were not likely or available in her family of origins. As much as her therapist was active in appreciating, validating, and supporting her gifts and decency, it was also evident that she was drawing on her individual and group contacts to begin to feel better about and within herself. With the help of her therapist, she was fruitfully considering alternative ways to find comfort and self-acceptance beyond the external praise and admiration she derived from her work performance and career. Literally, the therapeutic process activated her where she could begin to shift from deriving satisfaction from external accomplishments and admiration, to one where she was more and more appreciating that her comfort and better sense of self had to come from within. As they say in recovery, “it’s an inside job.” Put in terms of attachment theory, she was reversing the attachment to the inanimate (i.e. the alcohol) to the human ones afforded by her individual and group therapy. And of course, as she got better, she was also reconnecting to her loving husband and her three daughters from whom she had withdrawn as her alcohol use was progressively denying her these vital attachments.

It seems to me that kindness goes hand-in-hand with careful and empathic attunement to affect experience in helping clinicians and patients to gain inroads on the self-regulation deficits that predispose them to their addictive solutions. I would contend that a persistent attitude of kindness is one of the most important ingredients in establishing and maintaining a positive and trusting relationship. Such a relationship is the foundation and the most important ingredient for therapeutically accessing and modifying the problems that our patients face. It enables the task of dealing with the deficiencies involving affects, self-esteem, relationships, and self-care that are the most bedeviling challenges that addicted individuals face and need help to overcome.


(1) Khantzian, E. J. (2012). Reflections on treating addictive disorders: A psychodynamic perspective. The American Journal on Addictions, 21: 274–279.

Dr. Khantzian is Professor of Psychiatry, part time, at Harvard Medical School in Boston, and President and Chairman, Board of Directors, Physician Health Services of the Massachusetts Medical Society in Waltham, Mass. He is in private practice and specializes in addiction psychiatry. Full Bio.

Shame, Stigma, and Addiction

Lying and hiding seem easier.

Lying and hiding seem easier.

With addiction, stigma can crush you. Stigma is what says your drug and alcohol use is a character flaw. It’s what says you're a bad mother, it is what says you are a bad son, or a bad husband.

Lying and hiding seem easier.

It took me a while to get to rehab. I spent years bashing around, harming myself and the people around me before I finally went. I knew I had some serious issues with booze, drugs and sex that I could not get under control on my own, but still, at least people didn’t know I had those problems, and at the time that was all that mattered. It wasn’t like my parents, friends, employers, wives and lovers, knew I was a drunk, a freak and a loser. Sure, it might help if I went to rehab, but as ridiculous as it sounds to me now, the embarrassment of going, and the stigma attached to it, outweighed the fact that I actually might be able to get help. I was terrified of people finding out what my problems were. I had fallen victim to shame, that was perpetuated by stigma.

If you are suffering with an issue of addiction, stigma can crush you. Stigma is what says your drug and alcohol use is a character flaw. It’s what says you're a bad mother, it is what says you are a bad son, or a bad husband. It is what says you are weak, that you are crazy, that you are a piece of crap. It is why you are afraid to tell your boss that you need some time off to go get help. It is why you would rather lie than tell someone that you are not doing okay. It was why I would rather steal than let people know I needed help.

That was ten years ago. Now, when I look around at the people I know who are struggling with similar issues, there seems to be much less stigma attached to addiction and getting help for one's problems, at least when it comes to the younger people I know. I am a member of Generation X, my generation hid everything we could about our issues as a rule, but with the coming of Generation Y, otherwise known as millennials, things finally seem to be changing.

Mike Reis, CEO and Founder of DecisionPoint Wellness, had this to say to me about stigma and the younger generation over an email interview: “A big factor that prevents many people from getting the help they need is the stigma associated with being labeled an addict. This is especially true for older Americans who isolate and feel an overwhelming sense of shame. Surprisingly, millennials are leading the way to remove the social stigma. I’ve learned a lot from the millennials that have come through our intensive outpatient program at DecisionPoint in Johns Creek, Georgia. They are connecting to others in recovery through technology and social media. Millennials openly share their recovery stories and daily journey on the Internet too. Unlike previous generations that came into recovery through the anonymity of AA, millennials don’t feel the need to be shackled to those traditions. They are more focused being individuals, and building a community of support. It’s common to see them proudly posting their sober anniversary dates on Facebook. Millennials seem to understand that the way to maintain their sobriety long-term is to publicly share their personal stories as survivors, and bring truth to the spotlight while creating a community of support. In doing so, they help others realize that addiction is a disease, and it needs to be treated as such without shame.”

Many millennials just don’t care a whole lot about what anyone thinks. A good example of this is Kassia Kristoff, a 30-year-old woman who once went to rehab to get help with her heroin use. "Fortunately for me, I have never cared much if at all what 'society' thinks of me, and as a result, felt no shame going to rehab. My world by the end consisted of only other addicts, so the only shame might have been in throwing in the towel. What I do feel shame about is the fact that people in this country are judged so harshly for being addicts. As someone who now works in a rehab and works with addicts in my personal life as well, I have seen the devastation that addiction causes to all who suffer from it. Most addicts, when clean, are extremely loving, caring and productive people. They simply need to be taught how to live without using first. Rehab is very helpful in this regard, because it teaches addicts (a term I use for all who suffer from addiction to any substance, including alcohol) about their addiction, and ways to cope without the crutch of their substance. Rehab gives addicts an opportunity to temporarily thrive in a safe and compassionate controlled environment, and to allow their brains and bodies to 'sober up.'"

According to Karen Wolownik Albert, LCSW, who is executive director of Gateway Foundation Alcohol & Drug Treatment, social and traditional media has a lot to do with this change. She said to me in an interview: “More prevalent coverage of substance use disorder-related issues in media and depictions on television of individuals who are not only struggling with drugs and alcohol but also seeking treatment and sobriety, is helping reduce the shame and stigma associated with addiction. Younger generations are more likely to openly discuss the topic and be more transparent with their families and friends about their desire to seek help, compared to previous generations that kept their struggles private due the negative stigma of being an 'addict.'"

Of course, it isn’t easy to go to rehab, no matter what generation you are in. But the stigma is way harder to deal with when you are going to get help than it is once you come out on the other side. As an obvious example, I have gone from someone who was terrified about letting anyone know about my issues, to writing about them in forums such as this one. Someone else who has done that is Lindsey Hall, who writes for many websites about her experiences with her eating disorder, including her own.

She told me that “I do not feel stigma around my eating disorder. Not anymore, at least... but I also write about it publicly and have connected with hundreds of people who have been through what I experienced, and I think that has slowly worn away the fear of stigma. Also, we live in a world where opioid addiction and eating disorders are on the rise, so it's more likely than ever that you have a loved one or you yourself have experienced addiction. Due to social media, people talk about their 'issues' more openly than ever and for an eating disorder, there are so many body positive Instagram accounts as well as recovery websites and essays and blogs (including mine) about this exact topic that make you feel like you're actually in a community. However, before I went to rehab in 2013, I absolutely did feel stigma. I was terrified to tell people I was going. I wanted people to respect me and think of me as someone who had her life together, and I felt like rehab had this whole stigma of 'Oh, you went to rehab? You must be like super messed up. You're crazy. I can't take you seriously anymore.' At the end of the day, I'm not going to say it's easy to proclaim, when meeting new people, that I've been in rehab. But, it's just becoming more of an acceptable reality in a culture where drug addiction/binge drinking/and eating disorders are rampant.”

David Rosenbloom, PhD, is a professor of Public Health at Boston University where he directs Join Together, a program that helps communities prevent and reduce alcohol and drug problems.

Dr. Rosenbloom told me that he believes millennials are more tolerant of a much broader range of human conditions than their parents or prior generations. When I asked him what we could do as a society to decrease stigma, he said, “We need to significantly expand access to medication-assisted treatment and conduct a public education campaign in support of their long-term use. We also need to apologize for past excesses in the criminal justice system, and systematically review and release hundreds of thousands of people who are in prison or jail because of their substance use disorder. We should repeal all laws that prevent individuals with criminal records associated with drug or alcohol use from getting jobs, housing or education, and expand public investments to provide jobs for these people.”

When it comes right down to it, more and more people of the millennial generation are not only not ashamed of their seeking help for their issues, they make a point of that for all to see. One of those people is Seth Leaf Pruzansky, who is shopping a book about his spiritual awakening that came when he was incarcerated for a drug-related offense.

Seth told me that, “The stigma of being an addict shouldn't stop anyone from getting help. Taking responsibility for getting it is squarely in the lap of the addict him or herself. Until they really own the fact that despite the circumstances leading to their addiction, they are the ones who ultimately made the choice of devolving into their current station in life, they will remain in a state of not believing that help is available. They will continue to play the victim card because in the short run, it's a lot easier to stay in that rut rather than to get help and clean up. But in the long run, the continuing spiral into de-evolution and death is all but inevitable. I know. I personally climbed out of that hell.”

By Brian Whitney

Heroin, Poverty, and Politics in Rural America

Overdose and substance misuse aren’t moral or spiritual problems, they’re structural problems caused by institutionalized poverty and social isolation.

Overdose and substance misuse aren’t moral or spiritual problems, they’re structural problems caused by institutionalized poverty and social isolation.

Driving through much of Appalachia you’ll still see tar paper shacks, people living in dilapidated homes with no electricity, and scant signs of economic opportunity. I grew up in the mountains of Western Maryland, across the Potomac from West Virginia, in the dying days of the coal and manufacturing industries there. 

For the past two years I've lived in the foothills of Georgia’s Blue Ridge mountains. Not much is different. The economy in many towns is dependent on tourism. The best jobs—sometimes the only jobs—are at Wal-mart, state prisons, or the gas stations that dot the flawed Interstate Highway System, a project that the Appalachian Regional Commission pushed through the area to spur economic development.

This is a predominantly white area—almost entirely in some areas. It’s someplace we’d think should be prosperous. But it’s not. John Gaventa, who studied the exploitation of the region by coal companies in his book, likens the region to an “internal colony” of the United States.1 Billions of dollars have poured out of these mountains, but the people left behind are still suffering. And many of them have turned to drugs to dull the pain.

This region has been hit hardest by the recent heroin overdose crisis. Almost every county in Eastern Tennessee and Southern West Virginia had overdose death rates of >20 per 100,000 people in 2014. The rest of the region isn’t far behind.

The ‘White Working Class’ Problem

Last month New York Times columnist David Brooks wrote about the "white working class"—a demographic which has been hit hard by opioid misuse since at least the mid-1990s. Brooks lays the blame for this on the loss of an “honor code,” “a younger cohort that are more disordered, less industrious, more celebrity-obsessed,” and rampant consumerism. He neglects to mention the physical pain endured by blue collar workers in the region, or the mental and physical stress created by poverty, social isolation, and untreated mental illness.

In another recent article, J.D. Vance, a Yale Law School graduate and venture capitalistnow living in San Francisco, blames the region’s social problems—including misuse of substances—on a lack of proper religion, saying: 

In the white working class, there are far too many wolves: heroin, broken families, joblessness and, more often than we’d like to believe, abusive and neglectful parents. Confronted with those forces, we need, most of all, a faith that provides the things my faith gave to me: introspection, moral guidance and social support.

Brooks heaps praise on Vance's new book Hillbilly Elegy, which is described as “a passionate and personal analysis of a culture in crisis—that of white working-class Americans.” Vance, long gone from Appalachia, blames the people living “back home” for inviting heroin into the region. He likens Donald Trump’s appeal among the white working class to opioids, saying: “It enters minds, not through lungs or veins, but through eyes and ears, and its name is Donald Trump.”

Kevin Williamson of the National Review, an age-old conservative publication, tears into rural white America with a particularly bitter tone, saying: “The truth about these dysfunctional, downscale communities is that they deserve to die. Economically, they are negative assets. Morally, they are indefensible.” David French, of the same publication,blames rural America’s drug problems on government disability checks and a progressive “self-indulgent” culture.

In a post-Donald Trump world, even the most conservative writers and politicians find it fashionable to mock and ridicule these white working class Americans, who are traditionally among their most consistent supporters. These people latch onto Trump’s message because they feel abandoned. “White working class” now serves as a stand-in for poor, mostly rural Americans who now have more in common economically (and sometimes socially) with poor or struggling people of color than their white counterparts in Suburbia. 

Misuse of substances and large-scale social problems are not new developments. Urban areas have struggled with substance misuse and violence spawned by the War on Drugs for decades. American Indians, who face similar poverty levels, police violence, and social isolation, have overdose rates at twice the national average—more than any demographic. These aren’t moral or spiritual problems, they’re structural. They’re ingrained in our culture.

Picking Up the Scraps

Recently, heroin overdoses have crept into affluent, white suburban communities. The people who live there are seeing their children die at higher and higher rates. Their voices carry substantial political clout and local news sources are eager to share their stories—a privilege often denied those without resources and influence. This phenomenon, not the struggles in Appalachia, on reservations, or in our cities, has spurred the creation of President Obama’s National Heroin Task Force. Obama proposed spending over $1 billion to combat the US opioid problem in 2015, but his plan has failed to produce meaningful results.

We have effective solutions to the opioid crisis in rural America and other parts of the country, but lack of access to treatment remains a problem. President Obama’s plan calls for increasing access to naloxone and evidence-based treatment; as I wrote several months ago, medication-assisted treatment with methadone and Suboxone have shown great success at treating opioid misuse. Unfortunately, these medications are inaccessible in many of the places they’re most needed.

Even if the U.S. were able to expand its treatment and prevention resources to effective levels, most of these efforts would only serve as Band-Aids. Poverty and social isolation are strongly linked to misuse of substances. And a 2014 SAMHSA report showed that 40% of people with substance use disorders also live with a diagnosed mental health condition.

Screenings and brief interventions have demonstrated some of the highest rates of success at treating early substance use and mental health disorders. These are all tools we need in our arsenal, but they’re not enough to slow the rate at which substance use problems are growing. Our current solutions are almost exclusively reactive responses to a problem which demands proactive solutions.

Looking for Answers

We can’t depend on politicians and government officials to solve these problems for us.

Donald Trump’s focus on the economic devastation created by neoliberal trade deals like NAFTA has struck a chord with the white working class. He raised the opioid overdose problem during the Republican primaries saying, “We are gonna try and help the young people and the old people and the middle-aged people and everybody that got addicted,” Trump provides few specifics, though, as to how he plans to help, aside frombuilding a wall to keep drugs from crossing the border (presumably from Mexico).

Hillary Clinton has held a position similar to President Obama’s for most of her presidential campaign, but other than a grant for naloxone from the Clinton Foundation, she’s rarely spoken about addiction or mental health. Her economic policies, which have included support for free-trade deals like NAFTA and the Trans-Pacific Partnership, would do little to improve conditions for those on the expanding margins of the U.S. economy.

Congress recently passed a bare bones Comprehensive Addiction and Recovery Act (CARA), which calls for expanded naloxone access, Law Enforcement Assisted Diversion(LEAD), and greater access to evidence-based treatment. But the legislation fails to provide new funding for these services. President Obama signed it into law, but the White House acknowledges CARA falls short saying, “some action is better than none.” 

Some states continue to cut funding for detox facilities, state-funded rehabs, and MAT. This leaves rehab for poor Americans either out of reach or placed in the hands of faith-based organizations, which often place strict requirements on clients’ behavior and turn away people who refuse to conform to certain religious beliefs.

Many politicians have placed blame for social problems in communities of color on spiritual or moral failings. Now they’ve taken the “welfare queen” trope and alleged exploitations of the (extremely strict) Social Security Disability system to the white working class. These problems are actually caused by a system which reproduces poverty, suffering, and isolation across generations and exacerbated by a War on Drugs which has yielded mass incarceration, uprooted and displaced entire communities, and led to the school-to-prison pipeline.

Models for Developing Successful, Community-Driven Solutions

In the 1980s, when the State failed to take action, HIV and AIDS rights activists developed grassroots organizations to solve problems in their communities. More recently, grassroots harm reduction organizations have developed naloxone distribution networks, syringe exchange programs, and testing for hepatitis C and HIV. These programs have found great success where they’re available, even with limited (or no) funding.

The devastation left in the wake of the War on Drugs—lack of access to substance use or mental health treatment, social isolation, and structural poverty—are connected. We can’t approach the problem from just one angle. Solutions will have to come from people in the communities most impacted by these problems. And they are—slowly.

We see flickers of hope in the mountains of Appalachia, on the reservations, across the South, and in urban areas. Social movements and resistance to the status quo are sweeping across the U.S. in recent years, and they intersect with each other in ways we haven’t seen in decades, if ever. Change is coming, but let’s hope it’s not too late for those we leave hanging on the margins and those who continue dying from opioid overdoses at record levels. 

By Jeremy Galloway 


1. Gaventa, John, On Power and Powerlessness, 1980

Jeremy is Harm Reduction Coordinator at Families for Sensible Drug Policy, Program Director at Southeast Harm Reduction Project, co-founder of Georgia Overdose Prevention, and a state-certified peer recovery specialist. He lives in North Georgia with his wife and 3 cats. He writes and speaks regionally about drug policy reform, harm reduction, and the importance of including voices of directly-impacted people in policy decisions.