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.