‘Some say that addicts are not responsible for addiction. But most addicts think otherwise.” With this opening salvo, Owen Flanagan signals his readiness to defy conventional wisdom about drug abuse in his new book, What Is It Like to Be an Addict? Understanding Substance Abuse. Having been addicted to alcohol and “benzos” for decades, Flanagan, a former philosophy professor at Duke and Wellesley, incorporates both a personal and a scientific (in the broadest sense) approach to the topic.

Flanagan recalls the experience of his first real drink (of hard cider) at the age of 12 at a friend’s home (the earlier you start, he notes about the research in this field, the more likely you are to become addicted):

I felt release from being scared and anxious. I felt un-scared, non-scared, not anxious, de-anxious. It was good. I would not have known to say, if asked at the time, that I was scared and anxious that day or that I was the scared and anxious type. Perhaps I didn’t know until that medicinal moment what it was like not to be scared and anxious.

Flanagan’s childhood was not an unhappy one. Hailing from a large Irish Catholic family, he associated drinking with warmth and family (though he had relatives with drinking problems). So he dislikes the tendency of “clinicians” to “generalize about [addicts] in ways we know to be inaccurate, such as that we are all self-medicating, or that all use is preceded by powerful craving, or that we were all victims of trauma.”

That all addiction is caused by trauma and that addiction itself is a “disease” are the most common ways you hear people on the front lines of social work and policymaking describe drug and alcohol problems. Both the causes of addiction and the way we should treat it are thereby placed within a framework that absolves the addict. Whether or not this might be accurate, the thinking goes, removing the “stigma” or the “shame” from addiction will encourage people to get help.

But, as Flanagan notes, this is not how addiction or recovery actually works for most people. First, most heavy drinkers and drug users recover, and many recover without getting any treatment. They experience shame about their situation, and because of that shame, they decide to alter it. Addiction is interfering with their lives too much, and they change their behavior. According to a survey from the National Institute on Alcohol Abuse and Alcoholism, “twenty years after the onset of alcohol dependence, about three-fourths of individuals were no longer physically dependent on alcohol.”

Flanagan argues that addiction can “feel all-consuming.” In other words, the addiction is not just one bad act, or even a series of bad acts. Rather, “it captures most of the addict’s energy as they plan for the next drink or fix, crave and obsess, strategize about skirting the disappointed survey of others and about how to keep track of the lies and the cover-ups.” And this is why shame “can be a powerful source of motivation to change the self and to recover.”

One of the reasons this is possible is that addiction is not a purely biological phenomenon. Flanagan calls it “psychobiosocial.” Yes, there are chemical reactions going on in the brain and body. But addiction is also clearly a product of a person’s inner psychological workings as well as the influence of the environment he lives in.

Flanagan also disputes the “dopamine” theory of addiction, which holds that every time someone gets high, the brain’s rewards system is activated and stokes a hunger for more. Not only do different drugs work differently on people’s brains and bodies, he writes, but even in his own experience, “it wasn’t that each and every time I used I experienced an irresistible desire. Sometimes it seemed that way. But other times it seemed more like sleepwalking or inadvertence.” Indeed, he argues that we should think of addiction more like cancer—in the sense that we have recently discovered cancer to be hundreds of different kinds of sicknesses that need very individualized treatment.

The author is a realist. His own experience and the experience of others he has spoken to has led him to certain ideas about human nature and human behavior. When it comes to Alcoholics Anonymous, for instance, he takes the view that the theories behind the program—particularly the idea that total abstinence is always necessary for recovery—are not always correct. But the program itself does seem to work, and it taps into important needs. Flanagan sees it as a form of cognitive behavioral therapy. Aspects of the program such as “contingency management” and “therapeutic communities” are practiced as a way of mitigating other psychological disorders, and they seem to work with addiction, too.

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Flanagan is less clear on what we should do to prevent addiction in the first place, beyond trying to keep kids from getting addicted. It’s therefore unfortunate that he takes up the argument for legalizing drug possession. His advocacy here undermines his own realist case. He acknowledges that the legalization programs in both Portugal and  Oregon have actually resulted in not only more drug use but also more drug overdoses. In the case of Oregon, he blames the calamity on a shortage of drug-treatment beds. This is wrong; the state had plenty of empty rehab places, but since addicts were not being arrested, there was nothing pushing them to get help. And he does not reckon with the fact that his stated goal of preventing kids from getting addicted has been hampered by America’s widespread experimentation with the legalization of pot, which is producing many juvenile users and abusers.

He argues that we need “political action to unseat the multiple inequities that create and maintain the social comorbidities that make addiction more likely and resistant to treatment among some groups.” What inequities? While some observers would argue the cause is poverty, Flanagan is clear that “mental illness” is one of the main problems, and that mental illness is often both a cause and an effect of addiction. “Alcoholism rates among people with bipolar disorder or bipolar tendencies are 50% and another 10% misuse other drugs.” Moreover, he writes, “people with personality disorders have three to four times higher-than-average addiction rates.”

Flanagan’s frank discussion is an important corrective to the increasing demand on ordinary urban dwellers that they simply treat the homelessness and crime that are associated with drug addiction as just another feature of urban life. This extends, tragically, to medical facilities that must deal with pregnant addicts. In recent years, hospitals and entire states have stopped requiring that substance exposure in infants be reported to child-protective services. Instead, they send addicted mothers home with newborn infants and offer them pamphlets about rehabilitation should they be interested in pursuing it. The results have been as dangerous as they were predictable.

Flanagan is clear about how addiction affects one’s ability to be a parent. In one of the most heart-breaking passages, he writes, “I had the thought on the day of the birth of my firstborn that this was the most amazing day in my life for a host of reasons including my first experience of the precious feeling of unconditional love.” Flanagan continues, “At the same time I thought that this event and those feelings were inconvenient because they were interfering with my drinking.” What Is It Like to Be an Addict? is a devastating but necessary antidote to elite conventional wisdom on a fiendishly difficult problem.

Photo: Photo by Matt Cardy/Getty Images

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