vox.com: People are dying because we misunderstand how those with addiction think


Javier Zarracina/Vox



The American opioid epidemic claimed 42,300 lives in 2016 alone. While the public policy challenge is daunting, the problem isn’t that we lack any effective treatment options. The data shows that we could save many lives by expanding medication-assisted treatments and adopting harm reduction policies like needle exchange programs. Yet neither of these policies has been widely embraced.

Why? Because these treatments are seen as indulging an addict’s weakness rather than “curing” it. Methadone and buprenorphine, the most effective medication-assisted treatments, are “crutches,” in the words of felony treatment court judge Frank Gulotta Jr.; they are “just substituting one opioid for another,” according to former Health and Human Services Secretary Tom Price.

And as county Commissioner Rodney Fish voted to block a needle exchange program in Lawrence County, Indiana, he quoted the Bible: “If my people ... shall humble themselves … and turn from their wicked ways; then will I hear from heaven, and will forgive their sin.”

Most of us have been trained to use more forgiving language when talking about addiction. We call it a disease. We say that people with addiction should be helped, not blamed. But deep down, many of us still have trouble avoiding the thought that they could stop using if they just tried harder.

Surely would do better in their situation, we think to ourselves. We may not endorse the idea — we may think it is flat-out wrong — but there’s a part of us that can’t help but see addiction as a symptom of weak character and bad judgment.

Latent or explicit, the view of addiction as a moral failure is doing real damage. The stigma against addiction is “the single biggest reason America is failing in its response to the opioid epidemic,” Vox’s German Lopez concluded after a year of reporting on the crisis. To overcome this stigma, we need to first understand it. Why is it so easy to see addiction as a sign of flawed character?

We tend to view addiction as a moral failure because we are in the grip of a simple but misleading answer to one of the oldest questions of philosophy: Do people always do what they think is best? In other words, do our actions always reflect our beliefs and values? When someone with addiction chooses to take drugs, does this show us what she truly cares about — or might something more complicated be going on?

These questions are not merely academic: Lives depend on where we come down. The stigma against addiction owes its stubborn tenacity to a specific, and flawed, philosophical view of the mind, a misconception so seductive that it ensnared Socrates in the fifth century BC.

Do our actions always reflect our preferences?

In a dialogue called the Protagoras, Plato describes a debate between Socrates and a popular teacher named (wait for it) Protagoras. At one point their discussion turns to the topic of what the Greeks called akrasia: acting against one’s best judgment.

Akrasia is a fancy name for an all-too-common experience. I know I should go to the gym, but I watch Netflix instead. You know you’ll enjoy dinner more if you stop eating the bottomless chips, but you keep munching nevertheless.

This disconnect between judgment and action is made all the more vivid by addiction. Here’s the testimony of one person with addiction, reported in Maia Szalavitz’s book Unbroken Brain: “I can remember many, many times driving down to the projects telling myself, ‘You don’t want to do this! You don’t want to do this!’ But I’d do it anyway.”

As pervasive as the experience of akrasia is, Socrates thought it didn’t make sense. I may think I value exercise more than TV, but, assuming no one is pressuring me, my behavior reveals that when it comes down to it, I, in fact, care more about catching up on Black Mirror. As Socrates puts it: “No one who knows or believes there is something else better than what he is doing, something possible, will go on doing what he had been doing when he could be doing what is better.”

Now, you might be thinking: Socrates clearly never went to a restaurant with unlimited chips. But he has a point. To figure out what a person’s true priorities are, we usually look to the choices they make. (“Actions speak louder than words.”) When a person binges on TV, munches chips, or gets high despite the consequences, Socrates would infer that they must care more about indulging now than about avoiding those consequences — whatever they may say to the contrary.

(He isn’t alone: Both the behaviorism movement in 20th-century psychology and the “revealed preference” doctrine in economics are based on the idea that you can best learn what people desire by looking at what they do.)

So for Socrates, there’s no such thing as acting against one’s best judgment: There’s only bad judgment. He draws an analogy with optical illusions. Like a child who thinks her thumb is bigger than the moon, we overestimate the value of nearby pleasures and underestimate the severity of their faraway consequences.

Through this Socratic lens, it’s hard not to see addiction as a failure. Imagine a father, addicted to heroin, who misses picking up his children from school because he’s shooting up at home. In Socrates’s view, the father must be doing what he believes to be best. But how could the father possibly think that?

I see two possibilities. As Socrates’s illusion analogy suggests, the father could be grievously mistaken about the consequences of his actions. Perhaps he has convinced himself that his kids can get home on their own, or that he’ll be able to pick them up while high. But if the father has seen the damaging effects of his behavior time and again — as happens often to long-term addicts — it becomes harder to see how he is not complicit in this illusion. If he really believes his choice will be harmless, he must be willfully, and condemnably, self-deceived.

Which leads us to the second, even more damning possibility: Perhaps the father knows the consequences shooting up will have on his children, but he doesn’t care. If his choice cannot be ascribed to ignorance, it must reveal his preferences: The father must care more about getting high than he cares about his children’s well-being.

If Socrates’s model of the mind is right, these are the only available explanations for addictive behavior: The person must have bad judgment, bad priorities, or some combination of the two.

Our philosophy of addiction shapes our treatment of it — whether we realize it or not

OxyContin, an opioid painkiller.Lawrence K. Ho/Los Angeles Times/Getty Images

It’s not exactly a sympathetic picture. But I suspect it underlies much of our thinking about addiction. Consider the popular idea that someone with addiction has to hit “rock bottom” before she can begin true recovery. In the Socratic view, this makes perfect sense. If addiction is due to a failure to appreciate the bad consequences of getting high, then the best route to recovery might be for the person to experience firsthand how bad those consequences really are. A straight dose of the harshest reality might be the only cure for the addict’s self-deceived beliefs and shortsighted preferences.

We could give a similar Socratic rationale for punishing drug possession with decades in jail: If we make the consequences of using bad enough, people with addiction will finally realize that it’s better to be sober, the thought goes. Once again, we are correcting their flawed judgment and priorities, albeit with a heavy hand.


read more