Bourdain enjoyed a lot of drugs in the summer of 1972. He had already acquired a “taste for chemicals,” as he put it. The menu included marijuana, Quaaludes, cocaine, LSD, psilocybin mushrooms, Seconal, Tuinal, speed, and codeine. When he moved to the Lower East Side of New York to cook profession - ally in 1980, the young chef, then 24, bought his first bag of heroin on the corner of Bowery and Rivington. Seven years later he managed to quit the drug cold turkey, but he spent several more years chasing crack cocaine. “I should have died in my twenties,” Bourdain told a journalist for Biography.
By the time of his visit to Provincetown in 2014, a wave of painkillers had already washed over parts of Massachusetts and a new tide of heroin was rolling in. Bourdain wanted to see it for himself and traveled northwest to Greenfield, a gutted mill town that was a hub of opioid addiction. In a barebones meeting room, he joined a weekly recovery support group. Everyone sat in a circle sharing war stories, and when Bourdain’s turn came he searched for words to describe his attraction to heroin. “It’s like something was missing in me,” he said, “whether it was a self-image situation, whether it was a character flaw. There was some dark genie inside me that I very much hesitate to call a disease that led me to dope.”
A dark genie: I liked the metaphor. I am a physician, yet I, too, am hesitant to call addiction a disease. While I am not the only skeptic in my field, I am certainly outnumbered by doctors, addiction professionals, treatment advocates, and researchers who do consider addiction a disease. Some go an extra step, calling addiction a brain disease. In my view, that is a step too far, confining addiction to the biological realm when we know how sprawling a phenomenon it truly is. I was reminded of the shortcomings of medicalizing addiction soon after I arrived in Ironton, Ohio where, as the only psychiatrist in town, I was asked whether I thought addiction was “really a disease. (...)
Addiction is powered by multiple intersecting causes — biological, psycho - logical, social, and cultural. Depending upon the individual, the influence of one or more of these dimensions may be more or less potent. Why, then, look for a single cause for a complicated problem, or prefer one cause above all the others? At every one of those levels, we can find causal elements that contribute to excessive and repeated drug use, as well as to strategies that can help bring the behavior under control. Yet today the “brain disease” model is the dominant interpretation of addiction.
I happened to have been present at a key moment in the branding of addiction as a brain disease. The venue was the second annual “Constituent Conference” convened in the fall of 1995 by the National Institute on Drug Abuse, or NIDA, which is part of the National Institutes of Health. More than one hundred substance-abuse experts and federal grant recipients had gathered in Chantilly, Virginia for updates and discussions on drug research and treatment. A big item on the agenda set by the NIDA’s director, Alan Leshner, was whether the assembled group thought the agency should declare drug addiction a disease of the brain. Most people in the room — all of whom, incidentally, relied heavily on NIDA-funding for their professional survival — said yes. Two years later Leshner officially introduced the concept in the journal : “That addiction is tied to changes in brain structure and function is what makes it, fundamentally, a brain disease.” Since then, NIDA’s concept of addiction as a brain disease has penetrated the far reaches of the addiction universe. The model is a staple of medical school education and drug counselor training and even figures in the anti-drug lectures given to high-school students. Rehab patients learn that they have a chronic brain disease. Drug czars under Presidents Bill Clinton, George W. Bush, and Barack Obama have all endorsed the brain-disease framework at one time or another. From being featured in a major documentary on HBO, on talk shows and Law and Order, and on the covers of Time and Newsweek, the brain-disease model has become dogma — and like all articles of faith, it is typically believed without question. (...)
Thomas De Quincey consumed prodigious amounts of opium dissolved in alcohol and pronounced the drug a “panacea for all human woes.” For Anthony Bourdain, heroin and cocaine were panaceas, defenses against the dark genie that eventually rose up and strangled him to death in 2018. But not all addicts have a dark genie lurking inside them. Some seek a panacea for problems that crush them from the outside, tribulations of financial woes and family strain, crises of faith and purpose. In the modern opioid ordeal, these are Americans “dying of a broken heart,” in Bill Clinton’s fine words. “They’re the people that were raised to believe the American Dream would be theirs if they worked hard and their children will have a chance to do better — and their dreams were dashed disproportionally to the population as the whole.” He was gesturing toward whites between the ages of 45 and 54 who lack college degrees — a cohort whose life-expectancy at birth had been falling since 1999. They succumbed to “deaths of despair,” a term coined by the economists Anne Case and Angus Deaton in 2015, brought on by suicide, alcoholism (specifically, liver disease), and drug overdoses. Overdoses account for the lion’s share. The white working class has been undermined by falling wages and the loss of good jobs which have “devastated the white working class,” the economists write, and “weakened the basic institutions of working-class life, including marriage, churchgoing, and community.”
I happened to have been present at a key moment in the branding of addiction as a brain disease. The venue was the second annual “Constituent Conference” convened in the fall of 1995 by the National Institute on Drug Abuse, or NIDA, which is part of the National Institutes of Health. More than one hundred substance-abuse experts and federal grant recipients had gathered in Chantilly, Virginia for updates and discussions on drug research and treatment. A big item on the agenda set by the NIDA’s director, Alan Leshner, was whether the assembled group thought the agency should declare drug addiction a disease of the brain. Most people in the room — all of whom, incidentally, relied heavily on NIDA-funding for their professional survival — said yes. Two years later Leshner officially introduced the concept in the journal : “That addiction is tied to changes in brain structure and function is what makes it, fundamentally, a brain disease.” Since then, NIDA’s concept of addiction as a brain disease has penetrated the far reaches of the addiction universe. The model is a staple of medical school education and drug counselor training and even figures in the anti-drug lectures given to high-school students. Rehab patients learn that they have a chronic brain disease. Drug czars under Presidents Bill Clinton, George W. Bush, and Barack Obama have all endorsed the brain-disease framework at one time or another. From being featured in a major documentary on HBO, on talk shows and Law and Order, and on the covers of Time and Newsweek, the brain-disease model has become dogma — and like all articles of faith, it is typically believed without question. (...)
Thomas De Quincey consumed prodigious amounts of opium dissolved in alcohol and pronounced the drug a “panacea for all human woes.” For Anthony Bourdain, heroin and cocaine were panaceas, defenses against the dark genie that eventually rose up and strangled him to death in 2018. But not all addicts have a dark genie lurking inside them. Some seek a panacea for problems that crush them from the outside, tribulations of financial woes and family strain, crises of faith and purpose. In the modern opioid ordeal, these are Americans “dying of a broken heart,” in Bill Clinton’s fine words. “They’re the people that were raised to believe the American Dream would be theirs if they worked hard and their children will have a chance to do better — and their dreams were dashed disproportionally to the population as the whole.” He was gesturing toward whites between the ages of 45 and 54 who lack college degrees — a cohort whose life-expectancy at birth had been falling since 1999. They succumbed to “deaths of despair,” a term coined by the economists Anne Case and Angus Deaton in 2015, brought on by suicide, alcoholism (specifically, liver disease), and drug overdoses. Overdoses account for the lion’s share. The white working class has been undermined by falling wages and the loss of good jobs which have “devastated the white working class,” the economists write, and “weakened the basic institutions of working-class life, including marriage, churchgoing, and community.”
Looking far into the future, what so many of these low income, under-educated whites see are dark horizons. When communal conditions are dire and drugs are easy to get, epidemics can blossom. I call this dark horizon addiction. Just as dark genie addiction is a symptom of an embattled soul, dark horizon addiction reflects communities or other concentrations of people whose prospects are dim and whose members feel doomed. In Ironton, clouds started to gather on the horizon in the late 1960s. Cracks appeared in the town’s economic foundation, setting off its slow but steady collapse.
Epidemics of dark horizon addiction have appeared under all earthly skies at one time or another. The London gin “craze” of the first half of the eighteenth century, for example, was linked to poverty, social unrest, and over-crowding. According to the historian Jessica Warner, the average adult in 1700 drank slightly more than a third of a gallon of cheap spirits over the course of a year; by 1729 it was slightly more than 1.3 gallons per capita, and hit 2.2 gallons in 1743.A century later, consump - tion had declined, yet gin was still “a great vice in England,” according to Charles Dickens. “Until you improve the homes of the poor, or persuade a half-famished wretch not to seek relief in the temporary oblivion of his own misery,” he wrote in the 1830s, “gin-shops will increase in number and splendor.” During and after the American Civil War, thousands of men needed morphine and opium to bear the agony of physical wounds. In his Medical Essays, the physician Oliver Wendell Holmes, Sr., a harsh critic of medication, excepted opium as the one medicine “which the Creator himself seems to prescribe.” The applications of opium extended to medicating grief. “Anguished and hopeless wives and mothers, made so by the slaughter of those who were dearest to them, have found, many of them, temporary relief from their sufferings in opium,” Horace B. Day, an opium addict himself, recorded in The Opium Habit in 1868. In the South, the spiritual dislocation was especially profound, no doubt explaining, to a significant degree, why whites in the postbellum South had higher rates of opiate addiction than did those in the North — and also, notably, one reason why southern blacks had a lower rate of opiate addiction, according to the historian David T. Courtwright. “Confederate defeat was for most of them an occasion of rejoicing rather than profound depression.” (...)
The germ theory of addiction: that is my term for one of the popular if misbegotten narratives of how the opioid crisis started. It holds that the epidemic has been driven almost entirely by supply — a surfeit not of bacteria or viruses, but of pills. “Ask your doctor how prescription pills can lead to heroin abuse,” blared massive billboards from the Partnership for a Drug-Free New Jersey that I saw a few years ago. Around that time, senators proposed a bill that would have limited physician prescribing. “Opioid addiction and abuse is commonly happening to those being treated for acute pain, such as a broken bone or wisdom tooth extraction,” is how they justified the legislation.
Not so. The majority of prescription pill casualties were never patients in pain who had been prescribed medication by their physicians. Instead, they were mostly individuals who were already involved with drugs or alcohol. Yes, some actual patients did develop pill problems, but generally they had a history of drug or alcohol abuse or were suffering from concurrent psychiatric problems or emotional distress. It is also true, of course, that drug marketers were too aggressive at times and that too many physicians overprescribed, sometimes out of inexperience, other times out of convenience, and in some cases out of greed.
As extra pills began accumulating in rivulets, merging with pills obtained from pharmacy robberies, doctor shopping, and prescription forgeries, a river of analgesia ran through various communities. But even with an ample supply, you cannot “catch” addiction. There must be demand — not for addiction, per se, but for its vehicle. My year in Ironton showed me that the deep story of drug epidemics goes well beyond public health and medicine. Those disciplines, while essential to management, will not help us to understand why particular people and places succumb. It is the life stories of individuals and, in the case of epidemics, the life story of places, that reveal the origins. Addiction is a variety of human experience, and it must be studied with all the many methods and approaches with we which we study human experience.
by Sally Satel, Liberties | Read more (pdf):
Image: Katherine Streeter for NPR
