Dr. Gabor Maté’s Critique of the Surgeon General’s Report Facing Addiction in America

I read the Facing Addiction in America, the Surgeon General’s Report on Alcohol, Drugs and Health with a combination of enthusiastic appreciation and dismay. Those impressions were further reinforced recently on hearing the SG, Rear Admiral Vivek Murthy in person, at the Patrick Kennedy Forum on addiction in Chicago.

I see the report as a major step—a diagonal one. It moves us significantly forward, but it is also a movement sideways. It both fulfills and fails short of its humane intention to articulate an approach to addiction that is science-based and compassionate at the same time.

The impact is overwhelmingly positive. The report represents the first attempt by anyone in any U.S. administration to approach substance use and addiction not as an ethical issue or a matter of criminality, but as a human experience to be understood, as a human dilemma calling for a humane response. “Once viewed largely as a moral failing or character flaw,” the report says, addictions are “now understood to be chronic illnesses characterized by clinically significant impairments in health, social function, and voluntary control over substance use.” It sees addiction as a chronic illness, to be treated as other medical conditions such as diabetes or asthma.

Facing Addiction in America is also the first governmental attempt to ground policy not in prejudice but in research, not in conjecture but in science. It collates an impressive body of evidence to illuminate the pathological processes and impacts of substance addiction in the human brain and body, and suggests evidence-based practices for treatment and prevention. It recognizes that addiction is a societal phenomenon to be addressed not from a heavily punitive intent but from a social perspective. It calls for approaches that invite not just addiction specialists, medical or otherwise, but entire communities to confront the challenges of prevention, treatment and of integrating addicted people into healthy social life. It is a document to be respected. May it achieve its long-term goal of doing for addiction what a previous Surgeon General’s report did to reduce cigarette smoking and to educate the public about its dangers.

A major problem for this report is that the public does not need to be educated about the dangers of addiction. That is understood all too well. What is needed is education about what addiction actually is, its sources in life and society, how it arises, how it manifests in its many forms. Only from that understanding will effective treatment and prevention strategies arise. On that score, this report could have done much better. While refuting the calumny that anyone would willfully choose addiction and therefore merits condemnation, ostracism and punishment, the report confines itself to a narrow medical view of the problem.

Let’s look at its strengths and weaknesses in point form.

1. The report sees addiction purely in terms of substances. It shows in accurate detail how addictive substances “hijack” the brain, appropriating its pleasure-reward circuits to motivate addictive behaviors, hyper-activating its stress apparatus in the withdrawal response, and impairing the decision-making and impulse control systems of the prefrontal cortex. So far so good. But what about the obvious point that non-substance addictions, such as gambling, shopping, internet use, sexual roving, dysfunctional eating patterns also involve the same brain circuits?

In other words, there is much more to the addictive process than just drugs. Thus, obviously, drugs cannot themselves be the source of the pathology of the addicted brain. The report pretty much implies that it is drugs that impair the brain. They do, clearly, but they do not initiate the addiction process.

2. The report accepts the mainstream medical mantra that addiction is a neurobiological disease. Again, a huge move in the right direction: at least we do not punish people for having a disease, don’t jail them for having diabetes. And true enough, addiction has the features of disease: a dysfunctional organ, the brain; tissue damage; symptoms; chronic ill effects; cycles of remission and relapse. But having the features of a disease does not make a complex phenomenon such as addiction reducible to the disease model. It involves so much more than neurobiology: culture, pain, shame, economic status; race. The report mentions such factors but does not address them in sufficient detail.

3. The SG’s report buys into the medical myth that addiction is largely (40-70%, it says) owing to genetic inheritance—bad DNA. Scientifically, this is—at best—a vast exaggeration. The assumptions and studies on which it is based are child’s play to refute. At worst, it is misleading nonsense, as it points away from the real causes of addiction. And that, as we see next, is the greatest flaw of this otherwise forward-looking document.

4. TRAUMA. This is the word that receives at best a footnote mention in the report; it is also the word that sums up the most prevalent and universal basis for addiction. Childhood trauma—as in physical, sexual or emotional abuse, multi-generational family violence, parental addiction or mental illness, divorce or other loss—is the template for adult addiction. Sometimes the trauma is less overt, takes more subtle forms that cause a sensitive child to experience pain, but it is always pain that underlies addiction and it is always pain, conscious or not, that the addiction is meant to help a person escape. “Not why the addiction, but why the pain?” is my mantra. The report barely addresses pain—human pain, emotional pain, spiritual emptiness, the loss of self.

5. In accurately identifying the brain systems implicated in addiction, the report ignores the scientific fact that the brain is a social organ, shaped in its development by the emotional environment in which the developing child grows up. Thus, the brilliant brain scans that show the dysfunctionality of the addicted cerebrum are not the result of addiction originally, but of the childhood circumstances that predisposed the person towards addictive behaviors. The drugs didn’t cause the addiction—they only provided the most devastating outlet for it. Other addictions share the same brain circuits.

6. It follows that addiction-treatment systems addiction specialists and facilities must be trauma-informed to fully address the spectrum of addictive behaviors and the emotional/psychological dynamics that buttress addiction in human beings. The report would have been so much more powerful and effective if it had called for a trauma-based view of addiction and treatment, and for the trauma education of health care professionals. The astounding fact is that, despite all the evidence linking childhood adversity to addiction and mental illness—some of which is cited, if cursorily, in the report—the very word trauma is barely mentioned in the training of many counselors and not at all in the training of most physicians and psychiatrists. This leaves treatment programs bereft of the most powerful healing modality for addiction: the healing of trauma. It leaves them focused mostly on symptoms and behaviors, with the underlying causes untouched.

The Surgeon General’s report, in its humanity and commitment to helping people and communities, is a generous document, one to be hailed as an essential move in a positive direction. Its unawareness of the fundamental presence of trauma in human experience and in our culture, the prevalence of pain, is a missed opportunity.

This originally appeared in the Addiction/Recovery eBulletin.

  • Caron Block
    January 8, 2017 at 3:37 PM

    Dr. Mate, how do you account for the fact that many people if not most, suffer trauma in their early years and do not become addicted to something?

    • Celeste Mendelsohn
      January 14, 2017 at 12:59 AM

      Many people do suffer from trauma in their childhood. Some become addicts. Many more become family members of addicts in their adulthood either by marrying addicts or raising them. Addiction is a family disease. There is NO CHANCE that families of addicts are not also traumatized by living with violence, abuse and dysfunction. How do we grow up without major drug addictions? I am not the scientist, but I suspect it is much like Dr Mate said – substances are only one issue alongside gambling, sex, internet, shopping and anything else that we as human beings can use to ‘numb out’ and shut off our brains to numb the pain, including carrying on the legacy of trauma and abuse in dysfunctional relationships with others who have similar histories.

    • Tess
      January 16, 2017 at 8:30 AM

      My experience of “most people” is very different from yours. I can think of only one person who isn’t addicted to something in my circles. The rest of us are addicts of work, sugar, shopping and screens, at the very least. I am working on my trauma and addictions but find sugar and screens the hardest to quit. I’m off sugar right now but still feel I’m in its grips. And yeah, I’ve been told by a lot of people who are addicted that they’re not. But then why are they eating such a hugely ecologically and socially violent substance that is also known to cause cancer, feed tumors, cause diabetes, heart disease, depression, anxiety, candida, and a whole host of inflammatory diseases? If not addiction, stupidity?

  • Shayna
    January 8, 2017 at 4:54 PM

    I’m in complete agreement. The sooner the public can become aware of this information the better.

  • Bill Orr
    January 8, 2017 at 6:27 PM

    Addiction is not only caused by trauma but also by being trapped in a unacceptable lifestyle. This problem can not be attributed to a one-time event but to long slow continuing events.

  • Pat britten
    January 8, 2017 at 6:36 PM

    Slavery will do that to you, cause pain. Who is benefiting?

  • Judy Burton
    January 8, 2017 at 8:06 PM

    Excellent review. I agree 100%!

  • Connie Valentine
    January 9, 2017 at 11:44 AM

    This is an outstanding commentary. Trauma is the foundation, the “ground zero”. Addictions numb the pain. Once trauma is resolved, there is no need to be numb.

  • nicolas ruf
    January 9, 2017 at 12:11 PM

    The powerful negative reinforcement from the drug or addictive behavior, the self medication that works so well at first, may certainly be because of trauma or adverse childhood events, but might not the genetic roll of the dice result in the same vulnerability?
    I think of all the people in recovery who talk about never fitting in, or not being comfortable in their own skins, or being agonizingly self conscious who report no trauma or ACE history.
    Thank you for your many and invaluable contributions.

  • Ben Goerner
    January 9, 2017 at 12:29 PM

    I have been an addictions counsellor for almost 20 years. Added to that I had worked with teens for around 9 years. In total, I have been in the field for almost 30 years. I have always taught and based my practice on the impact of substances on the brain. In the last 4 years, I have challenged my position and knowledge through your work, and then most recently through Johann Hari and Dr Alexander. I believe I have a much broader and more informed understanding at this point than ever ( wish I knew then what I think I know now). Reading your article helps re affirm what I am learning at this stage of the game. I was going to ask though was the issue of focusing on trauma. Right or wrong, I hold the belief that we carry our traumatic experiences throughout our lifetimes. Not to say that we suffer with them. I believe that as we grow, our perspectives of our trauma change. As long as we are mindful of the trauma and its effects on our lives, we grow and learn how to manage in healthy ways given the right tools. Thus, when a client comes to me and says “I need to rip open this old wound and deal with my trauma”, I tend to first help them with finding existing coping tools and developing new ones. I encourage them not to open the wound until they have the confidence in their ability to manage pain in a healthy way. I imagine this might be similar to your work as well. Anyway, thanks for the insightful article and I will continue to view this field with an open mind, open heart, and willingness to explore the unknown.

  • Glenn
    January 10, 2017 at 12:40 AM

    Hear Hear,
    About time a document looks at this properly!

  • Cheryl Larson
    January 10, 2017 at 10:29 AM

    Love love love this part:

    It follows that addiction-treatment systems addiction specialists and facilities must be trauma-informed to fully address the spectrum of addictive behaviors and the emotional/psychological dynamics that buttress addiction in human beings. The report would have been so much more powerful and effective if it had called for a trauma-based view of addiction and treatment, and for the trauma education of health care professionals.

    As a PA, also formerly a Chem dep counselor, I worked for 11 years at the VA where providers and especially administration REFUSED to connect the dots! My supervisor in fact went so far as to tell me my former career had no place in my current career…. seriuosly! Meanwhile, I have watched a loved one go through Hazelden and not get any help with the underlying trauma! The ENTIRE system is broke. It remains set up to punish not help; the patient, the family and yes enemy the caregiver who truly care are all punished in this current system.

  • Rachel Cutler
    January 13, 2017 at 1:03 AM

    I absolutely agree that the stats on genetic inheritance are a “vast exaggeration.” It reminds me of a lot of the research noted in “Toxic Psychiatry” by Dr. Peter Breggin, as genetics help most in society to take a stance that society is not to blame and removes a lot of personal accountability from families and environmental factors. As for the brain being a “social organ,” this can most definitely be supported in other readings such as “An Invitation to Social Construction” by Kenneth Gergen.

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