Agendas of addiction

Opinion Article

2008 March, 1

Prime Minister Kevin Rudd recently likened the abuse of alcohol, specially among young Australians, to an epidemic that is “starting to get somewhat out of control.

His interview with 4BC Radio’s Greg Cary in Brisbane last week was extraordinary.

Daryl Smeaton, chief executive of the Alcohol, Education and Rehabilitation Foundation, is right that the Prime Minister’s comments mark “a breakthrough in recognition of the scale of the problems created by alcohol abuse”.

“No prime minister has said anything like this before”, Smeaton says. The issue is now well on the agenda for the 2020 summit.

The most encouraging aspect of Rudd’s thinking on abuse of addictive psychoactive substances (and addictive processes such as gambling) is that he appears not to be captured by the widespread opinion that the magnitude of society’s addiction problems is roughly in proportion to society’s unresolved underlying issues such as poverty and inadequate mental health care.

Rudd’s thinking may be more in line with our analysis in Cape York Peninsula that autocatalytic addiction epidemics can become problems in their own right, rather than being symptoms of other problems.

Kelvin Gordon, from the Kimberley Aboriginal community of Yiyili, described in The Australian (26 February) how grog and drugs turned him into a psychiatric patient. When he was a teenager, his aunt taught him to have cannabis “for breakfast”.

The underlying issues in the Kimberley region (for example, indigenous dispossession, government neglect and boredom) are relevant factors in the analysis of Gordon’s story, but clearly society’s and the local community’s acceptance of a breakdown in norms and their acceptance of a free supply of drugs and money set the scene for substance abuse epidemics that are not merely symptoms of underlying personal and social issues.

My previous attempt (The Weekend Australian, 8-9 December 2007) to make the point that underlying issues should not be overstated to explain an individual’s descent into crippling abuse drew criticism from addiction medicine physician Matt Gaughwin (“Addiction fought by facing demons”, 26-27 January).

Many of Gaughwin’s observations are correct. “The river of grog and drugs runs wide and deep in Australia and has broken its banks,” Gaughwin said, “we are drowning in it.”

We who fight epidemics of addiction in our Cape York communities couldn’t agree more. Gaughwin is correct that “a principled autonomy” of individuals and communities is the right way to deal with addiction. I agree with Gaughwin that “the interventions to curtail alcohol use in the Northern Territory may seem draconian, but they are an example of a principled autonomy…The NT interventions should spur a policy rethink on what constitutes fair and reasonable coercion to stem the flow of alcohol and drug-related harm.”

Gaughwin’s contention that “we tolerate intoxication and addiction too much; our society does not say ‘enough is enough’”, is consistent with the key strategy of our Cape York substance abuse strategy, which is to “rebuild a social, cultural, spiritual and therefore legal intolerance of abusive behaviour”.

Contrary to what Gaughwin suggests, I also agree “that the brain itself matters when it comes to addiction and not just the chemicals we put in it”. Early in evolutionary history, our brain evolved to reward individuals who behaved in ways that increased the likelihood that they passed on their genes, which explains why it is pleasurable to eat and drink, advance socially and produce offspring.

In modern society, this internal reward system is easily short-circuited because pleasurable indulgence is within easy reach. Our brain’s reward mechanism is today easily hijacked, and we are therefore plagued by alcoholism, obesity, gambling and other addictions. I am not unaware, as Gaughwin suggests, that “addiction can be deeply biological”. Policymaking and policymakers would benefit from a deeper understanding of biology and evolution.

Gaughwin’s main critique of my column is that my “understanding of causality is Newtonian when it should be probabilistic”. By Newtonian, Gaughwin means an unsophisticated, mechanistic analysis that every effect must have a direct cause. This is not correct.

The analysis by the Swedish psychiatrist Nils Bejerot, which I have used and adapted to understand the recent history of indigenous Cape York, is actually a refutation of simple cause-and-effect thinking of the type “so and so became an addict because”, or “this community descended into drunken chaos because”.

Bejerot attacked the symptom theory of addiction – that addictions are a symptom of other more fundamental personal or socioeconomic problems – and separated five essential factors (which could be described as “the socially sanctioned opportunity to experiment and to later indulge”) from all of the other factors that are involved in addiction. Bejerot’s point was that all of these other factors should be understood as susceptibility or risk factors.  Therefore mental illness may make someone susceptible to drug experimentation and use, but it is not a causal factor. Similarly, poverty may increase susceptibility, but there is no automatic causal relationship with addiction. Many poverty-stricken communities are free of addiction epidemics, as are many people with mental illness.

Bejerot’s analysis was that the presence of five factors on their own constitutes a risk that an individual will become an addict, or that a community will be affected by an epidemic of addiction:

• Availability of the addictive substance  

• Money to acquire the substance  

• Time to use the substance  

• Example of use of the substance in the immediate environment  

• A permissive ideology in relation to the use of the substance.

My basic contention about the nature of addiction and why people are drawn into behaviours that result in addiction is this: we can control for all other risk factors (biological predisposition, trauma, disadvantage and so on), but if the above factors are present, they are sufficient for addiction problems to develop.

Gaughwin wrote that “even apparently ideal childhoods do not prevent addiction absolutely”. This statement may seem like a concession to my analysis that the material and social opportunity to abuse a substance presents a danger even if all risk factors are minimised to the best of our ability.

However, Gaughwin’s apparent concession formed part of an argument that genetic susceptibility is a risk factor that can cause addiction even if other variables are favourable. In Gaughwin’s view, the overwhelming risk factors for addiction are genetic predisposition and experiences in the early years of life that establish “the foundations of addiction within individuals”.

Gaughwin’s analysis may be plausible to people who live in the mainstream, where addiction and dysfunction is less common than in remote Aboriginal Australia. However, my experiences and observations in Cape York tell me that this model is deficient.

My home community was built on the ruins of historical dispossession. Our people rebuilt relatively stable families and worked hard in a discriminatory society and economy, while retaining an indigenous cultural identity and languages.

Then our people were given welfare money, free time and more access to addictive substances and processes. Epidemics of addiction and a corresponding collapse of social norms ensued.

When the epidemics gained momentum, they became the primary cause of recruitment of novice substance abusers and gamblers. The social chaos in some communities is more severe than can be explained by underlying issues such as inherited trauma. Too many people from relatively stable backgrounds were sucked into the vortex of dysfunction.

Genetic susceptibility on the part of some individuals and negative formative experiences cannot, in my opinion, explain the magnitude of the Cape York disaster.

The symptom theory of addiction (of which the self-medication hypothesis is the most extreme special case) is the most damaging idea for Cape York communities when they try to reverse their descent into dysfunction. No matter how isolated from progressive mainstream debate, every dysfunctional person in the backstreets of Cape York communities can give an account of some variant of the symptom theory as the explanation and the excuse for their behaviour: “I drink because…”.

This is why I rejected in my article of 8-9 December former footballer and drug addict Gary Ablett’s contentions (The Australian, 29 November) that use of psychoactive substances is “basically self-medicating, a coping mechanism” and that “it’s time we realised that drugs are not the problem but a symptom of far deeper issues, both in people’s lives and in our society”.

Gaughwin conceded that Ablett is wrong to reduce and simplify the problem of addiction to one dominant construct (that addiction is treating psychic pain). But he maintained that my criticism was insensitive and cruel because it denies people such as Ablett the tolerance, understanding and empathy that are crucial to their recovery from addiction.

Ablett has my empathy and my support in his decision to remain drug-free. I did in fact conclude my article by stating that it is possible that “the initial susceptibility to experimentation on the part of an individual such as Ablett is explained in his need for relief from (psychic) pain”.

My criticism of Ablett is that he advocates a social theory of self-medication as the main cause of addiction. Patently, the general public’s ability to take a principled stand against abuse of addictive substances and processes is compromised if they are led to believe that experimentation is generally a symptom of deeper problems.

Interestingly, Gaughwin shares my belief that, in spite of the biological and neurological basis of addiction, “the ideas and values we hold about freedom and free will” are the most important determinants of the spread of addiction in society: “If there is a root cause of addiction, it is ethical,” Gaughwin concluded.

The symptom theory is a hideous idea that is deeply embedded in our society’s consciousness about substance abuse (how many times have you heard a colleague or family member or a professional on television say “The drugs are just a symptom of…”?). It is hideous because it furnishes those who are engaged in substance abuse with a perfect justification for their indulgence. Beyond its crippling effect on individual users, it has a devastating social effect: it debilitates any decisive social response because it discourages a social response to addiction as the problem in its own right, and instead deflects attention towards a vast array of so-called underlying factors, most of which are beyond the reach of social policy. So we are left sitting on our hands while the addiction epidemics continue to grow.

Considering that Gaughwin recognises the decisive role our ideas and values will play in the struggle to curb Australia’s addiction epidemic, I am surprised that he so strongly attacks my criticism of Ablett’s dangerous promotion of symptom thinking. I would expect Gaughwin to understand why it is necessary to argue against symptom thinking such as Ablett’s if we are to win the battle of ideas and values.

Agendas of addiction