The Surgeon General’s Addiction Report Repeats Old Bromides—Here’s What He Ought to Be Telling Us

Nov 21 2016

The Surgeon General’s Addiction Report Repeats Old Bromides—Here’s What He Ought to Be Telling Us

November 21st, 2016

Our policies and public proclamations around addiction resemble a slow-motion, inevitable car crash.

On November 17 a summit was convened in Los Angeles at which US Surgeon General Vivek Murthy sounded the latest alarm on addiction: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.

“Addressing the addiction crisis in America will require seeing addiction as a chronic illness, not as a moral failing,” said Murthy (pictured above). “Addiction has been a challenge for a long time, but we finally have the opportunity and the tools to address it.”

Finally! Alas, Murthy’s report largely recapitulates a long lineage of similar American efforts: Bill Moyers’ 1998 five-part PBS series “Moyers on Addiction”; Benoit Denizet-Lewis’s long 2006 New York Times Magazine article “An Anti-Addiction Pill?”; Nora Volkow’s 2007 HBO series “Addiction.” All combine chronic-brain-disease addiction theory with 12-step-disease-recovery mantras.

So we might well ask how Murthy’s “first-of-its-kind” report, heavily pushing treatment and prevention policies based on the conception of addiction as a brain disease and recovery groups (while giving a brief nod to some harm reduction measures to help “those who are not yet ready to participate in treatment”) improves the situation.

In fact, since Nora Volkow took over as director of the National Institute on Drug Abuse (NIDA) in 2003 and propelled the brain disease model to absolute dominance in the field, drug-related deaths (overwhelmingly multi-drug poisonings, but erroneously referred to as overdoses*) surged to record levels in 2014, increasing exponentially for heroin, tranquilizers and painkillers.

The surgeon general’s report is a tragic missed opportunity, one that will continue to hold us back. Here are five damaging themes on which Murthy and his allies are doubling down:

1. Scare people (even more!) about opioid “overdoses.”

If people were to consume pure doses of heroin or other opioids, their likelihood of accidental death is reduced to nearly naught. As Edward Brecher reviewed the research in Licit and Illicit Drugs in 1973, a lethal dose of narcotics is several orders of magnitude above a standard narcotics dose.  In countries where heroin is legally medically administered (e.g., Switzerland, Portugal, Germany, Vancouver in Canada), there have been no heroin-related deaths under medically supervised conditions.

Yet the myth that people typically develop an inordinate, insatiable desire for a single drug—when in fact those most at risk are mixing a variety of substances, in what can be considered either a chaotic pattern or an abandoned, intentionally self-destructive one—still fatally misinforms our policies.

 

2. Convince people that drugs cause addiction.

The headline news from the surgeon general’s report: “1 in 7 in USA will face substance addiction.” “We underestimated how exposure to addictive substances can lead to full blown addiction,” Murthy told NPR. “Opioids are a good example.”

Note to the Surgeon General: The definitive US psychiatric guide, DSM-5, no longer applies the term “addiction” to any substances, but only to non-drug activity. How he rationalizes his perspective that drugs have an insufficiently recognized special quality of addiction with the DSM-approved possibility of becoming addicted to gambling, or the non-DSM-approved but still-real possibility of becoming addicted to sex, love, the internet or any other compelling involvement, is anyone’s guess.

And let’s look at opioids: Very few lifetime consumers of heroin currently use the drug (about 10 percent) and far fewer of even current users, as drug scientist and Influence columnist Carl Hart points out, can be said to be addicted (10-20 percent)—translating to between 1 percent and 5 percent of those who have ever used heroin being currently addicted. The percentage of prescribed opioid users who are addicted is even smaller.

Addiction is not in the thing. Addiction is in the life. And when addiction is understood as being steeped in people’s lives, we recognize that myriad drug or non-drug experiences are liable to become compulsively destructive. The thrust of Murthy’s thinking—an impetus to further restrict access to certain drugs—is as flawed conceptually as it is unachievable practically.

 

3. Emphasize “prevention”—meaning avoiding substance use altogether.

“The earlier people try alcohol or drugs,” says the surgeon general’s report, “the more likely they are to develop a substance use disorder. For instance, people who first use alcohol before age 15 are four times more likely to become addicted to alcohol … than are those who have their first drink at age 20 or older. Nearly 70 percent of those who try an illicit drug before the age of 13 develop a substance use disorder in the next 7 years…” Prevention, to Murthy et al., means prevention of drug use, as opposed to what it should mean: prevention of addiction or death.

I don’t deny the accuracy of these US statistics, but they are meaningless when considered outside of people’s life context, a context I provide in my book, Addiction-Proof Your Child.

Consider that in Southern Europe, where people begin drinking legally at much younger ages (typically 16), rates of problematic drinking are far lower than in the US and other temperance (Northern European and English-language) countries. Consider that in the US, given restrictions on the use of alcohol and other drugs, people’s first experiences with them are likely to be binge episodes with their peers, rather than moderate use with older, experienced family members. Consider that despite “Just Say No” being repeated to kids for decades, 40 percent have used marijuana by the time they leave high school, and 33 percent have drunk alcohol in the last 30 days—the majority of whom, critically, have engaged in binge-drinking. Both of the numbers rise rapidly following high school and into people’s early 20s, as shown in the National Survey on Drug Use and Health.

Simply teaching people not to use drugs has gotten us where we are today.

 

4. Hype the supposed biological causes of addiction and minimize the social ones.

“We now know from solid data that substance abuse disorders don’t discriminate,” Murthy told NPR. “They affect the rich and the poor, all socioeconomic groups and ethnic groups. They affect people in urban areas and rural ones.”

This is quite wrong. Addiction does affect people from all backgrounds, but not at equal rates. It does discriminate. As discussed by Influence columnist Maia Szalavitz:

“Addiction rates are higher in poor people — not because they are less moral or have greater access to drugs, but because they are more likely to experience childhood trauma, chronic stress, high school dropout, mental illness and unemployment, all of which raise the odds of getting and staying hooked.”

This is a theme I have elaborated on:

“We are frightened to say that people in our country who are disadvantaged economically, socially, or, alas, racially, are more likely to become addicted … Instead, we satisfy our instinct for equality by emphasizing that people in upper-middle-class communities also take drugs — conveniently ignoring the very different rates of problematic drug use.”

Murthy instead pursues a line of thinking that has yet to produce a single meaningful diagnostic or treatment tool:

“Now we understand that these disorders actually change the circuitry in your brain. They affect your ability to make decisions, and change your reward system and your stress response. That tells us that addiction is a chronic disease of the brain.”

Murthy’s misdirection supports our heavily funded medical efforts to thwart addiction while we ignore the critical social levers for reversing our addiction epidemic—an approach which would instead require major social change to address the havoc in poor urban and rural communities which turns them into centers for addiction.

 

5. Expand our drug treatment industry and addiction support groups.

“We would never tolerate a situation where only one in 10 people with cancer or diabetes gets treatment, and yet we do that with substance-abuse disorders,” said Murthy, speaking of an estimated 20.8 million Americans with these disorders.

Contrary to this perceived shortfall, no other country in the world provides as much disease-oriented addiction treatment (i.e., 12-step and vaguely biomedical treatment—“vaguely” since no treatments actually directly address supposed brain centers of addiction) as does the US. Yet North America, as a global harm reduction report also released last week notes, has the “highest drug-related mortality rate in the world.”

Murthy’s report itself indicates that, “by some estimates, it can take as long as 8 or 9 years” as well as “multiple episodes of treatment” to achieve recovery in this way—and recovery, of course, is by no means guaranteed.

The report, despite its extended focus on 12-step and other support groups in the “recovery” section, notes that 25 million Americans have experienced some form of recovery from substance addictions—a figure that dwarfs the total membership of such groups (AA, the largest by a huge distance, has just over 2 million US members).

Government research repeatedly demonstrates that those addicted to drugs regularly solve their addictions given supportive life conditions. In fact, the large majority of dependent drug users reverse addiction on their own—most who ever qualify for a substance use disorder diagnosis move past it by their mid-30s. We note this all the time when considering the many ex-smokers we know (even though smokers, compared with those dependent on illicit drugs, require the greatest effort and longest time to overcome their addictions).

And so, Murthy is forced to implicitly acknowledge, while wishing to do no such thing, that most addiction treatment is no more effective than the ordinary course of the “disease,” and that recovery without treatment or a support group is the norm.

Don’t you think these might be important facts to include in a report on addiction?

 

Time for Something Different

What, then, are the messages that the US surgeon general should be spreading?

1. Loudly advertise the dangers of drug-mixing (in New York City, for instance, “nearly all (94%) of overdose deaths involved more than one substance”).  Spread this message widely, including in schools, along with other critical information about drugs, while teaching drug-use and life skills.

 

2. Call for legal regulation of heroin and other currently illegal drugs to protect users from unwittingly consuming the haphazard, fraudulent and dangerous combinations often sold on the street. Call for painkillers to be available to people who want them under medical supervision, along with heroin maintenance sites, while making medical or other trained supervision of use available.

It is worth noting here that just as the Surgeon General’s addiction report came out, the British Medical Journal issued a clarion call: “The war on drugs has failed: doctors should lead calls for drug policy reform.” The BMJ’s report does not contain the words “brain,” “disease,” or “addiction.” Instead, it asserts:

“…a thorough review of the international evidence concluded that governments should decriminalise minor drug offences, strengthen health and social sector approaches, move cautiously towards regulated drug markets where possible, and scientifically evaluate the outcomes to build pragmatic and rational policy.”

 

3. Proclaim (as the SG’s report does to a degree) the usefulness of medication-assisted treatment, including broad use of drugs like methadone and burprenorphine to assist in quitting heroin with greatly reduced risk (but add that medications are not necessarily required, nor are they sufficient in themselves, to permanently quit a drug or alcohol addiction).

 

4. Demand the full-scale deployment of other harm reduction services and supplies, from naloxone (Narcan) to syringe access to supervised drug consumption rooms—an expansion that will not only save many lives, but also do far more to reduce the stigmatization of people who use drugs than the empty words in the current report.

 

5. State that addiction is not a disease (and therefore, it is not escapable and not a lifelong identity!). Instead, point out, it is a phenomenon driven by psychological and social factors, and therefore inseparable from the realities of people’s daily lives. Publicly tell politicians that if they really care about reducing addiction, taking meaningful steps to address inequality and absence of opportunity would be the single best thing they could do.

 

6. Declare that we must abandon the futile goal of a drug-free society, which decades of efforts and billions of dollars have been unable to accomplish. Instead, recognize that we are all drug users—from caffeine and alcohol to prescribed medications to commonplace Adderall use by students. Affirm that drugs are a normal part of human experience, that they provide benefits, and that they are even enjoyed—despite their potential dangers. This is how we approach experiences and involvements—from driving to love and sex—that can have dangerous or overwhelming effects. It’s how alcohol is used throughout Southern Europe—indeed, how it is used by a majority of Americans.

Radical as this is to American ears, we must normalize and rationalize the reality of our drug use—as opposed to encouraging uncontrolled and chaotic use of drugs while simultaneously vilifying and demonizing them.

And we must do this soon. As Murthy’s report trumpets by way of perversely recommending more of what has long failed us: An American dies every 19 minutes from narcotics-related drug use.


*The overwhelming majority of such deaths are due to intentionally or inadvertently mixing heroin or opioid painkillers with one another, or with other drugs, including tranquilizers, alcohol, sedatives, and sometimes cocaine or amphetamines. One among many examples is the cause of death for Philip Seymour Hoffman. But first, the widely rumored cause of his death: “The autopsy and coroner’s report has yet to be released, but police are confident Hoffman died from a heroin overdose.”

Ah, when will those police ever learn? The actual autopsy? “Medical examiner finds heroin, cocaine, benzodiazepines and amphetamine in his system.” And, keep in mind, Hoffman had repeatedly participated in standard addiction treatment, and was actively attending a 12-step group at the time of his death, where he learned the mantra, “I am an addict.”


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 his memoir. You can follow him on Twitter: @speele5.

  • NutmegJunkie

    Prescription opioids, when taken on their own, are rarely a cause of death.

    The NSW Department of Forensic Medicine reviewed all cases of fatal oxycodone toxicity from 1999-2008 and concluded that “In all cases, psychoactive substances other than oxycodone were also detected” http://onlinelibrary.wiley.com/wol1/doi/10.1111/j.1556-4029.2011.01703.x/abstract

    A US review of over 1000 fatal overdoses reported that in 96.7% of cases at least one other plausible contributory drug in addition to oxycodone was detected, the most prevalent drug combinations were oxycodone in combination with benzodiazepines, alcohol etc. http://jat.oxfordjournals.org/content/27/2/57.short

    According to another US study rates of overdose death among those co-dispensed benzodiazepines and opioid analgesics were ten times higher than rates of overdose among people using opioid analgesics alone. http://painmedicine.oxfordjournals.org/content/17/1/85.abstract

    • Stanton Peele

      thanks for add-on!

  • “abandoned, intentionally self-destructive” – in fact this is the most common cause of overdose, and if you don’t believe it just go to your local AA/NA meeting. I’m fine with publicizing that mixing drugs can kill – if it is with the message that most overdoses are intentional. Which they are.

    Also don’t let your child catch you reading how to addiction-proof them. They will become an addict – guaranteed. (Would be like reading “How to prevent your child from growing up to become a sorcerer” or “What to do if you suspect your child is being radicalized to jihad”).

  • shelley

    Thank you so much, Dr. Peele, for addressing this misguided and, frankly, irresponsible report by the Surgeon General. One would think that the Surgeon General would be up to date with current scientific data, expert opinions, and at least with the definition of addiction in the DSM-V, but he is apparently living within a bubble of addiction mythology. I find it really irresponsible to put out a report which is not scientifically up to date and entrenched in myth instead of knowledge. So it is to our great advantage to have your response available to us so that lay people and professionals will at least have the correct information to work with going forward. Treating drug use as a disease, in my opinion, is no better than treating it as a criminal problem. The suggestions by the Surgeon General may well keep a few people out of the prison system, but they will be no better off in forced medical treatment facilities and labeled as mentally I’ll than they are now as fellons, for life. It really is time for this country to grow up and become enlightened to the fact that drugs are and will always be with us and that addiction is not a molecule with in any drug, but a set of behaviors picked up during a less than ideal upbringing and exacerbated by our disfunctional society.
    However, given the ideology of the incoming Trump appointee for DOJ and his fellow appointees in the incoming administration, I am gravely concerned that this enlightenment will not come soon and that what progress has been made in this area will now be set back considerably. I hope you will, non the less, keep on with the fight for sanity and freedom in the area of drug use drug law reform, because your voice will be needed more that ever now and in the four years ahead.
    Thank you, again for adding a knowledge based, sane response to this report.

  • Iamnotastatistic

    Thank you Stanton for being the voice of reason yet again.
    I find it absurd that the SG can claim that “…in other communities such as the AA fellowship, recovery is explicitly not
    religious…”, Ch. 5-3. Which completely ignores the opinion of the 2nd, 7th and 9th circuits of the federal courts of appeals and the US Dept. of Justice which states: “Is a twelve-step recovery program such as AA or NA an inherently religious activity? Yes.”, US-DOJ 12 Step FAQ.
    How can the SG, or the secretary of the DHHS, be unaware of this? Why is one branch of govt. completely unaware of that another branch of govt. has proven that this claim is false? Why did we waste our taxpayer dollars paying for the findings of the courts and US-DOJ if they are going to be completely ignored by the SG and the secretary of the DHHS?
    Is it maybe that the chapters in this report were written, not by the SG, but by the usual suspects: Humphreys, Moos & Moos, JF Kelly, Timko, White, Kaskutas, etc? Why is the direction for this incredibly important issue being left in the charge of a handful of incredibly biased researchers that publish nothing but glowing reports in support of the treatment and 12 Step status quo?

  • Iamnotastatistic

    What is very disturbing about this report is that it claims in Ch. 5-9 that “A substantial body of
    research indicates AA is an effective recovery resource.” Ref 61-65.
    Ref 64 is the 2006 Cochrane meta analysis which stated that: “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems.”
    Now, how in the name of Science, did the Surgeon General interpret that as providing support for the claim that “AA is an effective recovery resource”?
    If I made a mistake of that magnitude where I work – I would get fired, and deservedly so.

  • Anne Fuqua

    Excellent article! Thank you for being willing to speak the truth that drugs in themselves do not cause addiction. Murthy & and other government bullhorns on addiction policy would have far less support for their policies if
    Americans were aware of the the statistics presented by Hart and yourself and understood:

    “And let’s look at opioids: Very few lifetime consumers of heroin currently use the drug (about 10 percent) and far fewer of even current users, as drug scientist and Influence columnist Carl Hart points out, can be said to be addicted (10-20 percent)—translating to between 1 percent and 5 percent of those who have ever used heroin being currently addicted.”
    (Peele, 2016)

    The other very interesting point you make about the lack of research supporting the efficacy of 12-Step focused addiction treatment. This is very ironic, as Murthy and his counterparts at the CDC in the Injury Prevention Center bemoan the use of chronic s therapy, stating there are no statistics on efficacy of chronic opioid therapy!

    Me: psychiatric nurse turned wheelchair user and chronic pain patient secondary to primary generalized dystonia and arachnoiditis. COT X 17yrs c high, but stable dose & very significant sustained functional improvement. According to Murthy, Kolodny, Ballantyne, and I Frieden, I don’t exist (okay well patients like me!).
    I beg to differ. There ARE many patients with long term pain relief and sustained functional improvement on opioids – including a subset with success on high dose opioids. Though we do exist NOW, we ARE an endangered species thanks to the efforts of Murthy, his CDC buddies Frieden and Houry, Kolodny, PROP, and wealthy families who have lost children overdose who bankroll PROP through their CV financial support for the Steven Rummeler Foundation. Sadly fewer and fewer patients are to use the treatment that improves their quality of life and promotes their mobility. Why is this? Unfortunately some people have chosen to abuse a medication that wasn’t prescribed for them (or if prescribed it was taken in a manner other than intended). Part of this group of abusers developed Opioid Use Disorder (aka addiction). Tragically some of these individuals died from overdose.

    Due in part to efforts from recovering addicts and the families of overdose victims, our “FREE” COUNTRY has decided that protecting addicts and preventing addiction has greater importance than the needs of chronic pain patients who have used medications as directed and to improve their quality of life and ability to function. Patients are suffering. Some have committed suicide. Where is the outrage? Just look at the millions spent to save elephant, lions, Tigers, and other species. The area of chronic pain needs research funding desperately. In the meantime a moratorium on efforts that limit access to opioids and incite fear of prescribing opioids amongst physicians and nurse practitioners is urgently needed. I WANT TO LIVE I’m only 36…so do the thousands of other patients whose quality of life is being threatened or has already been stripped from them. Life without quality is not life, it’s merely existing in agony. Please don’t let chronic opioid therapy become extinct! This would leave the patients to exist in agony or commit suicide. The devastating effects of cardiac adrenal syndrome would shorten lifespans by years or decades. Promoting pain relief promotes life – life lived to the fullest extent in spite of physical limitations.

  • Pingback: Euthanasia for Addiction? A logical choice built on a false premise. - The Clean Slate Addiction Site()

  • Pingback: Prejudice kills: People who need lifesaving methadone continue to be degraded and blocked - Transnational Television()

  • Maria

    Excellent. Thank you. May I make one remark: under the hyperlink “longer applies the term ‘addiction'” I had expected a link to the DSM.

    I wonder how the Trump administration is going to deal with this report. Will it be consulted, welcomed, rejected or will it be shoved into oblivion without even one glance?
    Maria