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 Bulletin
10 thoughts on “Dr. Gabor Maté’s Critique of the Surgeon General’s Report Facing Addiction in America”
I am in complete agreement with that the trauma of youth is the significant cause of addictions whether they be to substances or behaviours. The shadow side that develops in us as we age needs to directly addressed by the medical community now.
I couldn’t agree more with your remarks concerning trauma. The hardest to explore, but the most important to discover.
Our early research shows that coping mechanisms are utilized by the subconscious mind to circumvent the pain associated with stored emotional trauma. Imagine a continuum that starts with negative feelings and move into emotional trauma and eventually maxes out at PTSD. Our research indicates that negative emotion basically stick or freeze to memories that end up playing back 24 / 7 behind our conscious thoughts. These frozen memory emotional units function like a Window’s software application with connections to emotions stored in various organs in the body. It’s estimated that we each experience about 60,000 thoughts daily with only 2,000 thoughts originating in our conscious mind. That leave 58,000 thoughts cycling automatically in our subconscious mind. It’s estimated that 70% of our daily thoughts are negative in nature while over 90% of the thoughts we experienced yesterday are the same thoughts we will experience today. So, where do all the negative thoughts cycling in our subconscious mind come from? From birth to age-7 our immature brains operate in Theta wave / semi-hypnotic mode where everything a child is exposed to gets recorded. All the negative beliefs, fears, and emotional traumas from care givers make up the lion share of emotional trauma memory units that play back 24 / 7 as our operating software system we filter our experience of the world through. Our rose colored glasses. When emotional trauma units are released the corresponding coping mechanism subsides. One of our case studies involves a 52 year old male who experienced major sexual trauma at age 7 that later manifested in using alcohol as a coping mechanism to the tune of (2) fifths of Gin being consumed weekly for several decades. When the emotional trauma unit was released the participant immediately stopped craving and consuming Gin. Another case study involved a 32 year old male with pronounced ADHD behavior pattern. When the underlying emotional trauma unit was released his ADHD symptoms immediately subsided. Dr Gabor is right on the money with his research showing that addictions are basically coping mechanisms. These addictions are not genetic based disease conditions.
I would like to thank you Dr. Mate for your invaluable research round this dysfunctional aspect of society. I grew up in Belfast during the height of ‘The Troubles’ and was the second youngest of 10 children who lived in the thick of it. My mother (now passed) any some of my siblings have been in the grip of addiction, two of whom have now passed because of it, one through alcohol addiction and the other primarily through addiction to over the counter pain-killers. Another sibling had a chronic alcohol problem, but was stabbed to death having left himself in a vulnerable situation over a personal relationship. I have other siblings who are battling with either alcohol or prescription pill addiction. We grew up in a catholic ‘ghetto’ area called Ardoyne and after reading your book “In The Realm of Hungry Ghosts…” it was not hard for me to see how the Belfast Troubles had a devastating impact on my siblings due to the fear, social deprivation and uncertainty for the future it wove into their psyche. I am fortunate to have moved out of the area a long time ago and live in the Highlands of Scotland, a world apart from my upbringing. I am training to be a counsellor (am now doing work placement) and your book has given me much insight into an area I am all too familiar with but didn’t fully understand. I now have much more compassion for my siblings and less feelings of shame (I’m ashamed to say!) around what I used to consider was their weakness and greed. Such insight I know will serve me well with my future clients and I look forward to reading more around this subject area. Thank you.
Its sad that these underlying traumas are so under stated in the Surgeon General’s report but perhaps that is by design. If psychic and physical traumas were given the attention they deserve then ‘We’ would all have to recognize first how sometimes we are inhuman to one another.
It has to start somewhere and it is but sadly the Surgeon General’s report was an opportunity lost in shedding more light on addictions base cause. Thank you Dr. Gabor for your insight and empathy in your work.
Thank you for your wisdom and compassion on so many levels. I appreciate your family also being willing to share your stories to help others connect, and hear the tone of acceptance, love and non-judgement. I fear we must scream louder. I met people who felt we should limit those addicts to two doses of Narcan, then just let them go. The rage belies complete ignorance about the underpinnings you teach. People still suspect PTSD, let alone imagine the type of dynamics we refer to when speaking of proverbial infant trauma. People still believe we should beat children. There remains so much work to be done.
Thank you for your work, kindness and willingness to keep working. I will hold you as my model in my retirement.
With much gratitude.
Sara
At 60, my parents had the financial means to hire an attorney to send a letter stating I am not to contact them in any way or I will be cut out of their will. Physically and emotionally abused throughout my life, primarily by a mother I viewed as mentally unstable for her hatred & and unjust treatment towards me even in adulthood, just seeing me reminded her of these abuses. I have made it my focus to understand the trauma, fight the self-hatred and your work and comments I hope will illuminate for a better change of our youth & parenting.
It sees addiction as a chronic illness, to be treated as other medical conditions such as diabetes or asthma. I am crying as I read this. I lost my younger sister to alcohol use disorder on Sept 29 2021. She was only 42 and left behind a 14 year old son. I know she was in denial and ashamed of her addiction. She told people it was Wilsons Disease or Lupus. She never let me help her. My mom and I are devastated with her being gone from this Earth. Maybe if she felt that she did not have to hide her disease from everyone she could of reached out and told someone she needed help. Thank you for all the work you are doing Dr. Gabor.
Ko’szo’no’m Dr Garbo Mat’e .Through life’s journey I have struggled I came across your speaking on YouTube .Finally I found a connection to what I always knew deep down in regards to stress on the unborn child .With this among what you say in relation to Trauma it became relevant to me that like you I had a-mother in Hungary during the war whom suffered at a very young age .All her living relatives both her parents were killed along with a only brother. Her surviving a horrific time alone was I think pure luck . She immigrated to New Zealand there met my father and born 10 children . I am the middle child .My father Hungarian also a lot older than my mother at 72 he passed in the 80s of a heart attack a dedicated worker-never missed a day . 12yrs later my mother died at 65yrs of a anaphylactic reaction to gold injection she was having for rheumatoid and osteoarthritis.So what you speak about has hugely influenced me..I’ve always felt stress is a key denominator for illness along with trauma. Such information I am able to help my own children especially my son born at26weeks gestation and now a 30yr old man who has too struggled and searched for answers..
So I thank you for all the work you do by giving people like myself clarity and facts to the reasons why.
After 48 years of recovery, and working in the recovery field most of that time, I’m still amazed and dismayed at the “experts” thinking. The public sector “not the private sector” Are getting away from the most successful treatment model, the 12 steps. Only 6% of referrals into the 12 step programs come from clinicians. For God’s sake !, take the word god out of the model (if there is a problem there) and it is trauma-informed work. Build on a model that has been proven to work.