June 21st, 2016
I met Ethan Nadelmann in the late 1980s. I was working at a think tank near Princeton, Mathematica Policy Research, and he was on the faculty of Princeton’s Woodrow Wilson School, when he called my office.
Ethan had heard I was nearby and wanted to meet, having been deeply impressed by my book, The Meaning of Addiction.* I told him I was appearing on Oprah that week, which he tuned in to see, before ever meeting me.
For the last several decades, I have had to listen to Ethan, with his New York accent, say, “Stannin, did you think your job was to piss everyone in Oprah’s audience off?”
Others found my confrontation on national TV over AA and the disease model of addiction quite bold for the 1980s. I think if something’s wrong, it’s always worth saying so. But Ethan is a more politically sensitive person than I am.
At this time, Ethan was beginning to be known nationally for his drug legalization and harm reduction ideas, which we often discussed. In the next few years, he went on to create what is now the Drug Policy Alliance.
Over these 10-15 years, Ethan and I became good friends, meeting every few months for long dinners in New York. I regularly spoke at Ethan’s seminars (more than anyone else, he often told me) and, in 1994, he and his organization granted me their Career Achievement Award for Scholarship.
Sometimes our families would get together. My younger daughter and Ethan’s daughter are about the same age, and my son worked for Ethan one summer.
One monumental summer evening, after a day spent at the beach with our partners, we all found ourselves, thanks to a personal connection, at the apartment of Albert Ellis, the legendary psychologist. I questioned Ellis for hours, late into the night, about his pioneering work in cognitive behavioral therapy.
Then there was the time we snorkeled together at Australia’s Great Barrier Reef!
I see less of Ethan these days, but we still hug and kiss when we meet.
Addressing the Disease Model: Confrontation vs. Consensus
So Ethan and I share a lot—including familiarity with each other’s families and intimate relationships. Obviously, we knew all about each other’s work. And I witnessed, with everybody else, Ethan’s rise to his position at the top of the drug policy reform movement, driving a range of dramatic improvements to our drug laws. No one else could have done what he has done.
That ascent wasn’t preordained. For years it wasn’t obvious that we would arrive where we are now—where marijuana will soon be legal nationwide, where the drug war is attacked from all sides of the political spectrum, and where some new conception for how society deals with drugs is emerging, although its ultimate shape remains unclear.
Ethan knows and subscribes to my views on addiction. (He once told me he tried to get George Soros to read Meaning.) But addiction is secondary for him. He’s about achieving political and social change around drugs.
In that context, I’m something of a hot potato: FromOprah to many of my public appearances and writings since, I have been happy to take a confrontational approach to what I view as the profoundly harmful dominance of the disease model of addiction.
Ethan, in contrast, has always sought to build the broadest coalition for change, including the recovery movement. He can point to some 12-step supporters of marijuana legalization.
On the other hand, some of his staunchest opponents are 12-steppers like Patrick Kennedy.
And then there’s this resentment, which Ethan expressed in a 2013 interview with Influence editor-in-chief Will Godfrey:
Where the 12-step thing has the most to own up to is its role in impeding harm reduction interventions to stem the spread of HIV/AIDS. Why was it that Australia and England and the Netherlands were able to stop the spread, and keep the number for injecting drug users under 5-10 percent, and the US was not? It’s that notion that abstinence is the only permissible approach, that we are not going to “enable” a junkie by giving him a clean needle. There has to be a kind of owning up to that role in hundreds of thousands of people dying unnecessarily. . . . [My emphasis].
That’s quite a serious charge! In the same interview, however, Ethan looks to rapprochement with the recovery movement through points of mutual agreement.
In that regard, I—the outspoken, confrontational opponent of 12-step programs and the disease model, who eschews cosy, live-and-let-live attitudes about these things—am problematic to Ethan, and cannot help him further his goals.
How the Times Are Changing
But the disease movement has gone beyond the 12 Steps. Now, addiction-as-a-chronic-brain-disease, spearheaded by the National Institute of Drug Abuse (NIDA), has superseded the more folksy 12-step approach as the leading-edge embodiment of disease ideas.
And quite a few drug policy reformers are not having it. At last year’s DPA conference in Washington, DC, I was struck by the degree of militant opposition to the brain disease model. On the panel where the idea was debated with a representative of NIDA, every drug policy reformer attacked the idea that addiction was locked into people’s brains.
As prominent harm reductionist Patt Denning pointed out during the panel (and as I have been noting for decades), it isn’t helpful to regard drug users, even if addicted, as victims of a brain disease. Most drug users don’t become addicted, and most of those who do become addicted for a time recover, usually on their own.
A Clash of Ideas in Congress Last Week
Which brings us to the recent Senate hearing on alternatives to the war on drugs, in which Ethan participated—along with Dr. Scott MacDonald, physician at the Vancouver clinic prescribing medical heroin (heroin-assisted treatment); Frederick Ryan, chief of police for Arlington, Mass., whose department puts people into treatment programs under threat of their otherwise being jailed; and David Murray, a former ONDCP official under George W. Bush.
As aptly reported by Sarah Beller for The Influence, three of the four strongly oppose the War on Drugs, and thus could be grouped together—Ethan, MacDonald and Ryan—with Murray the outlying villain who wants to continue, even expand, the war.
But this formulation misses the essential direction of things to come. Ethan’s presentation of course emphasized the financial and human costs, irrationality, and missed opportunities resulting from the drug war. The associations of heroin maintenance programs (which Ethan strongly supports) and criminal justice treatment alternatives (which Ethan doesn’t support when they are coerced) are clear.
Both the police chief and the doctor repeatedly stressed that addiction is a chronic disease and a medical problem, one amenable to addiction treatment. (That this is the wrong road to take is emphasized by the fact that drug warrior Murray was the most medically/biologically-oriented of the panelists!) Ryan said that the only alternative to death from addiction was long-term treatment.
Ethan would never say that. Ethan refers to addiction as one part of the spectrum of a public health problem. This difference in terminology is crucial, and underlies a fundamentally different conception of, and approach to, drugs in the 21st Century.
This became abundantly clear during the “discussion” following the four men’s presentations—and nowhere more than in Ethan’s opening salvo, which is a monument to a non-medical, non-disease conception of drug use, drug addiction and drug policy.
The discussion was begun by Senator Rob Portman. Portman, a Republican from Ohio, has long been involved with addiction. Like many who assert that addiction is a medical disease, he is looking for an illusory medical cure.
Portman began his questioning of the panel with a self-criticism. He observed how we keep “taking our eye off the ball”—we shift our focus from one drug to another, and then back again. Taking as a reference point basketball player Len Bias’s death and our focus on cocaine in the 1980s, Portman says now cocaine is back (along with methamphetamine).
Indeed, why are there such shifts in usage patterns? Can medicine explain this ever-changing landscape of drug demons? And, if each drug scare is a medical problem, why can’t each be permanently laid to rest, as we did malaria, smallpox and tuberculosis?
Portman’s next longing was to know what new “medical breakthroughs” are coming. He spoke about medication-assisted treatment (MAT), meaning buprenorphine, which, like methadone and heroin, is itself an opioid. Portman may share many people’s realization that although these drugs can assist people to manage their habits much more safely, relying on substitute opioids is hardly a medical cure for addiction.
Portman then referred to Vivitrol, the injectable version of naltrexone, which he said is being tried around Ohio because it controls craving. Is this a medical treatment for addiction?
We don’t treat diabetes with a drug that makes people not want to eat sweets.
“Craving” is a large concept, one unlikely to be reduced to some biological mechanism and treated with a pharmaceutical agent. And, in fact, a review of 13 randomized controlled studies found that “oral naltrexone, with or without psychotherapy, was no better than placebo or no pharmacological treatment” for treating narcotic dependence.
Portman finally asked the panel why prescription painkillers have risen to the forefront of the national drug and addiction landscape.
Ethan Publicly Agrees With Me, After All!
After MacDonald spoke briefly, Ethan launched into a rocket-fueled response.
Ethan praised Portman’s support of MAT, then took this one step further. He detailed the successful use of heroin maintenance programs like MacDonald’s, which don’t necessarily aim for abstinence, worldwide. Ethan emphasized how these programs allow people to maintain normal lives—a humanistic concern for heroin users that is absent from the American scene, as are any heroin maintenance programs.
Ethan then pulled up short: “There are a few things that are seriously missing here. When you look at your budget, it’s all well and good that you’re dealing with this brain disease stuff.” (Here, Ethan made a dismissive hand gesture.) But, he continued, “I would hire an army to hit the ground to find out what’s going on … Why are people using these drugs?”
Conclusion: Ethan wants to know about drug users’ lives, not their brains.
Ethan then spoke of the importance of people knowing how to use drugs safely. He is particularly concerned that most of what are called opioid overdoses involve simultaneous use of alcohol and other drugs, especially benzodiazepines. He regrets that drug users themselves are unaware of this—a dangerous form of ignorance.
Conclusion: Ethan wants drug users to be well informed about their drug use for their safety.
Lastly, Ethan warned, “What we are really dealing with here is an epidemic of pain in this country. It’s physical pain, it’s psychological pain, it’s emotional pain, it’s existential pain.”
This—asking a Republican senator to contemplate existential pain in America—was a bit much for Portman, who interrupted Ethan to go on to Murray.
Conclusion: Ethan is concerned about Americans’ and America’s soul more than their drug use.
So no, I wouldn’t say Ethan was on board with the thrust of the rest of the group, and of the entire Senate committee itself, that the War on Drugs must be replaced by approaching drug use and addiction as a medical problem and a brain disease.
There can be no doubt that he is on my side instead.
The Meaning of Addiction, which impressed Ethan so deeply in the 1980s, shows that how we, as individuals and a society, think and feel about addiction affects the course of addiction. Being trapped in the mistaken belief that addiction is an inescapable disease makes people unable to evolve out of it.
In 2015, in Recover!: An Empowering Program to Help You Stop Thinking Like an Addict and Reclaim Your Life, I applied this perspective in analyzing modern neuroscientific brain disease theories, while Ilse Thompson and I presented my different way of thinking in our mindfulness-based PERFECT therapy program.
I wonder if my vision has had some influence on Ethan over the decades.
*Ethan Nadelmann said about The Meaning of Addiction:
On the issue of drugs, there were two books that really had a significant impact on me. One was the Andrew Weil’s book, The Natural Mind, about why people use drugs. The second book that really made an impact on me was Stanton Peele’s book, The Meaning of Addiction, which I read in ’86.
My experience with books, whether I was reading John Stuart Mill, or Peele or Weil, is that, it’s not like you read a book and it flips you around, it’s more like, you start reading a book and you’re saying, “I was thinking that…and oh my, they came up with the same formulation I’ve been using. And then you see that the author took it beyond where your own thinking had gone.”
Stanton Peele is a columnist for The Influence. His latest book, with Ilse Thompson, is Recover!: An Empowering Program to Help You Stop Thinking Like an Addict and Reclaim Your Life. He has been at the cutting-edge of addiction theory and practice since writing, with Archie Brodsky, Love and Addiction in 1975. He has since written numerous other books and developed the online Life Process Program. His website is Peele.net. Dr. Peele has won career achievement awards from the Rutgers Center of Alcohol Studies and the Drug Policy Alliance. He is currently working on an e-book: How to Use Drugs. You can follow him on Twitter: @speele5.