When I slowed down posts two years ago, I was making a major career transition. Since we last spoke, I completed a fellowship in addiction psychiatry and joined the faculty at the University of Utah Spencer Fox Eccles School of Medicine. I love my new job, and it’s allowed writing to move back into my top 5 priorities.

I’m working on a lot of exciting posts surrounding the topics of sex, drugs and suicide. I’ve decided to stop updating this website for now, and will instead will be posting exclusively at SexDrugsAndSuicide.com.

Please consider subscribing to Sex, Drugs, and Suicide. I can’t wait to show you more.

-Jeff

There’s a movement to classify all mental health problems as brain disorders. And to some degree, these advocates aren’t wrong. All of human life is experienced by the brain. We can’t usually identify individual anatomical changes that distinguish one mental disorder from another, but there’s little pushback against the idea that the brain is at the center of our experience.

Brain-based explanations of mental health may also reduce some forms of stigma. And at the same time, we all have a natural tendency to be skeptical of recovery from brain-related deficits.

For example, we know that opioid use disorder (the clinical term for people who continue to misuse substances like heroin, morphine, or oxycodone despite negative consequences) can be convincingly modeled as a chronic, relapsing brain disorder. And at the same time, there are concrete behavioral changes that people can make to recover from opioid use disorder. 

My patients with opioid use disorder absolutely benefit from medications that stabilize the brain-based opioid system, just like someone with diabetes benefits from medications that stabilize blood sugar. At the same time, we can be so much more empowering by exploring behavior and providing coaching on ways to better manage the problem. For opioids, that might include education, changing contacts, identifying cravings, managing triggers, approaching trauma, and so much more. For diabetes, these interventions often fit the same mold. But to say “this is an insulin resistance problem” or “this is a brain-based opioid system problem” without saying “and I want to help you find ways to overcome this” sets people up for suboptimal outcomes. 

Like anything else in life, there are things we can change, and things we cannot. We can reduce stigma by normalizing the things we cannot change. And at the same time, we can empower each other emphasizing the depth, breadth, and reality of effortful improvement. Because at the end of the day, there is always some way we can improve our lives by changing our behavior.

Everyone is comfortable with applying the term addiction to people who repeatedly use injection drugs. Less problematic substance use is much harder to define. 

Here’s a relatively simple, non-technical definition that roughly coincides with the current psychiatric definition: addiction is the persistent use of unnecessary substances or gambling in a way that is harmful to the participant or others.

(There’s a lot more that needs to be defined. What about food, sex, video games, and the internet? There are clearly people who have problems with excesses in these domains, but defining boundaries turns out to be a difficult and contentious problem.) 

I like to think of addictive disorders as a broad spectrum of problems. The most severe (and correspondingly less common) addictions can cause disability, death, and chaos. Other problems are much less obvious. 

For example, is marijuana addictive? Yes. Some people have difficulty cutting back, damaged relationships, impaired work, drug tolerance, physical dependence, and the whole range of other problems we associate with addiction. The average harm from cannabis use is small compared to alcohol or tobacco, but it is not wholly risk free. (I’m not arguing that cannabis use results in addiction in everyone. That isn’t true of any drug. At most, cannabis use disorder develops in fewer than one in five people who use it; I suspect the number is closer to one in ten.)

That’s why I call some problems indolent addictions. Indolent processes usually start slow and cause little initial pain. Many benign tumors are indolent and never cause problems. Other indolent processes–like Alzheimer’s dementia–go unnoticed for years and yet still inevitably progress towards death. Indolence defines the process, not the outcome.

Cannabis use disorder (a very real addiction diagnosis) is generally indolent. Most cannabis users don’t use marijuana in a disordered way. Of those who do, the consequences of ongoing use tend to be relatively small. Is it still an addiction if the consequences are small? Technically? yes. Practically? That’s a risk-benefit decision for the individual to decide.

(I have treated people with florid, acute psychotic symptoms related to first-time cannabis use. Those people don’t typically return to the drug, which effectively prevents the development of addiction. I’m more concerned about the correlation between cannabis use and chronic psychosis in adolescents and young adults.)

Tobacco use disorder is another common, indolent addiction. In fact, the indolence of tobacco use led industry executives and lobbyists to argue that tobacco was not addictive at all. But make no mistake: indolence isn’t the same thing as harmless. Tobacco overdoses are rare, but the drug is still responsible for more ongoing deaths than any other psychotropic substance.

Is the distinction meaningful? I’m not sure yet. There are certainly some indolent behaviors in my life that are worth changing. I imagine that’s true for you too. Writing them off as “not a problem” because they are small doesn’t fix anything, and beating ourselves up because we aren’t perfect doesn’t help either. Let’s accept where we’re at and make small, consistent steps to reach our goals.

Now It might not work. Funds could be diverted. Treatment investments could follow special interests rather than data. Patterns of substance use might shift in a negative way. And of course, treating addiction solely as a medical problem (which isn’t anyone’s goal, by the way) can fail to address the full human needs of people with addiction.

But at the end of the day, the current system of treating addiction primarily as a moral issue hasn’t worked. The war on drugs is a catastrophic failure by almost any standard. Innovation at this level is a huge step in the right direction. Even if it fails, we’ll have data helping us understand why it failed.

There will be a loud contingent reminding us that substance use is a choice, and that people should face the consequences of their choices. Of course there is some level of choice involved–just like there is with almost every other possible health problem. But the natural consequences of addiction are already so severe that we don’t need to pile on any more shame. 

Is addiction a moral issue? That is a deeply personal question that everyone battling substance use gets to decide for themself. Who am I to judge? 

How we treat each other, on the other hand, is a deeply moral issue. And in the endless debates about what should and shouldn’t be a human right, we often forget to bolster our beliefs in inalienable rights with appeals to human decency. What world would I want to live in if my child dealt with addiction? One that leans on kindness, evidence, and a belief that people change if they get the help they need. It’s not perfect, but I like where it’s headed.