Is addiction primarily an individual affliction?
My biggest issue with the disease model of addiction is that it completely negates society’s role in causing addiction by solely framing addiction as an individual affliction. Many believe that addiction is a primary disease: meaning that it is not caused by any outside influences and is a disease that someone is born with. There is plenty of evidence that shows that addiction is rooted in biology and genetics, while systems of privilege and oppression are ignored.
I’m not saying that addiction is not biological but it is worth considering the responsibility that society plays in how people use drugs and, more importantly, how people find addiction recovery. In this article, I will discuss some of my feeling about the role that racism plays in the perpetuation of addiction and recovery. Then, we invite your comments and feedback in the section at the end.
What is Racism? Systemic vs. Individualistic
Racism is an ever present force in our world; a force that effects all aspects of life. I do not have the space, time, or the level of knowledge to write an accurate description of what racism is. The definition of Racism that I have come to understand is one that ascends far beyond individual interactions, and manifests in the political climate of society at every level. However, it is reasonable to assume that addiction is not exempt from being perpetuated by a system of racism.
We have a political and bureaucratic system that has created power disparities along racial lines; placing white people at the highest level of privilege and other racial groups at varying degrees of power below. My working definition of racism is anything that maintains, ignores, denies, perpetuates, reinforces, exacerbates, or builds upon that system of power.
The greatest accomplishment that white supremacy achieved was convincing society that racism is an inherent personality trait of individuals as opposed to being systematic. Denying that racism exists is the definition of racism.
As a clinician, I cannot ethically ignore this fact. We cannot afford, nor can our clients, to perpetuate this ignorance by not addressing it.
People of color in 12 Step meetings
The city where I attend my 12 step meetings has a large African American population. The city has fallen to the phenomenon of white flight: meaning that, as people of color have moved in, white people have moved out. As I sit in my meetings, in a town verging on a 50% black population, I see a room full of white faces. I’ve often wondered why more people of color, particularly African Americans, are not attracted to the 12 Step fellowship.
One reason could just be that people of color don’t feel welcome in the meetings. This could be from micro aggressions or overt racial bias from the white members or the overall mistrust that people of color feel about white people.
Another theory is the idea of powerlessness, which is so central to the ideology of the twelve steps, does not work well with people of color. White people love the idea of powerlessness. It’s a new intriguing concept for us and we run with it. On the other hand, minorities’ life experience is powerlessness. By definition, racism means that people of color are given less power––they are powerless.
If this is true, then people of color would respond better from treatment that is based in empowerment. Even within an oppressive environment, they have the power to choose; to change their life even in the face of endless obstacles. This could be a new and refreshing message of hope for people of color while also acknowledging that oppression is a real force in their lives.
Stress: The portrait of a killer
In the 2008 National Geographic documentary, Stress: A Portrait of a Killer , filmmakers examine how one’s position in the social hierarchy effects stress levels. The film demonstrates how people who are lower on the hierarchy have higher levels of stress; which leads to mental health and physical health problems.
Although the documentary doesn’t address race specifically, it is a logical conclusion considering that race is the largest systematic hierarchy that there is. The masses of people of color who are at the lower end of the power hierarchy have higher levels of stress that could adversely affect their mental health. Self-medication, being a valid addiction theory, would lead us to see that higher levels of stress, and high levels of mental illness, could cause high levels of substance use.
The real gem of the study comes from looking at the unlikely observation of the animal kingdom. Animals, like humans, also have a hierarchy of power that can be observed by watching their interactions. Baboons were studied in their natural habitat and the hierarchy was constant over time; as in, those in power stayed in power and those who were submissive remained at the bottom of the power structure. These baboons were given brain scans and it was shown that the subordinate baboons had much lower levels of natural dopamine than the baboons at the top of the hierarchy
Dopamine response to racism?
What does this have to do with addiction? Dopamine. Dopamine has everything to do with addiction. Dopamine is the brain chemical that allows us to feel pleasure, and it’s the brain chemical that is most involved with substance use.
If humans experience this same dopamine depletion as a response to oppression, then it explains a lot about drug use in the impoverished urban intercity. Crack cocaine is one of the most addictive drugs because of the intense dopamine surge that it creates. It is also one of the most used drugs in the poor African American community. Is this a coincidence? If black people, who are systematically oppressed and segregated into impoverished urban areas, have a neurological response of dopamine depletion, then it is a valid argument that oppressed people are using crack cocaine to self-medicate their low levels of dopamine.
Methamphetamine is also a big dopamine drug that is used particularly in poor white communities. It’s hard for me to write about oppressed white people, as it directly contradicts the thesis of this article. Regardless, there are many white people who also fall at the low end of the social hierarchy. The trailer park is to the stereotypical poor white community what the so called ghetto is to the stereotypical poor black community. It could be argued that poor white people are also segregated in trailer parks where methamphetamine is often widespread. The same application of the self-medication theory, in response to dopamine depletion caused by oppressive forces, would apply to these poor white communities.
Minority Stress Theory
Elevated stress levels in minority groups are well documented and social scientists even have their own social paradigm known as minority stress theory. Higher levels of stress in minority groups are not only contributed to larger systems of oppression but also occur at the interpersonal level. The theory focuses on the stress in the day-to-day interactions that minorities have when interacting with the dominate culture. Discrimination in the workplace, school and other public settings cause anxiety for minorities when interacting socially because of the negative response they accumulate over time. Stress and anxiety could cause people to use drugs to help alleviate their symptoms when having to deal with hostile situations, or to feel better after hurtful interactions.
Studying animals as a way of understanding addiction is not new to the field of addiction science; in fact many of the assumptions that we have taken as gospel have come from these animal studies. You put a rat in a cage, by himself, and give him a choice between tap water and water with cocaine and inevitably the poor little drug addict rat compulsively consumes cocaine until it dies.
But in the 1970’s Bruce Alexander questioned the validity of the rat studies because the rat was all alone in the cage. I mean, if I was locked in a cage by myself forever, I would use cocaine too. These rats weren’t drug addicts; they were committing suicide to escape their dire existence. So Dr. Alexander built Rat Park. Inside Rat Park were all the things that a little rat would want to do, plus they were among other rats. They could play, eat, run around, and have multiple sexual partners. What was discovered was that the rats in Rat Park used significantly less cocaine than the rats that were held in isolation. These rats now had options besides drug induced suicide.
What does this have to do with racism? Well, Rat Park shows us that addiction has less to do with drugs and biology and more to do with the cage. We know that people who have more opportunities in life, such as economic and personal fulfillment, have higher recovery rates. Racism creates an environment, a cage, with fewer opportunities for people of color by placing them lower on the social hierarchy than whites. People of color are segregated to areas that are less than ideal for living a fulfilling life by limiting opportunities in:
- Health care
- Social activities
Segregation may not cause addiction, but it certainly hinders successful recovery. Since a definition of addiction includes continued drug use over time, then addiction and having a lack of recovery options are synonymous.
And who builds the cage? We do.
People, places, and things
It is common advice in substance use treatment for addicts to avoid the people, places, and things that they associate with drug usage. For a recovering substance user, being around drug using friends can be very triggering and often leads them back to using. HBO’s series on addiction shows drug users who were given brain scans while viewing pictures of drugs and drug environments. When a substance user is shown a picture they associate with drugs, say an image of their drug dealers house, their brain lights up like a Christmas tree with dopamine. These images only have to last a fraction of a second to trigger brain chemicals that send a substance user into drug seeking behavior.
Because visual cues are so triggering for substance users it can be necessary for the substance user to completely change everything about their life so they have the best chance at stopping their use. This means finding new friends, new places to hang out, new hobbies, new grocery stores, basically new everything. Changing everything about one’s life is easier said than done and, for some, impossible. Substance users whose drug using life has been separated from their conventional lives will be able to do this more easily. For those who already live somewhat of a conventional life, they will just simply drop those drug using friends and environments, and fall back on the conventional life they have kept away from their substance using life.
People whose drug use is ingrained in their life and environment will not only have to separate out those people, places, and things; but rather completely reinvent themselves. Creating a whole new life requires resources that may not be at their disposal. Living in impoverished, high density, urban areas that are often blighted with drug use is not conducive to recovering from addiction because of the constant triggers and drug cues that are copious in the community.
By definition, racial segregation pins marginalized people to a geographic location that is lacking in opportunities and mobility; guaranteeing them an endless cycle of the same people, places, and things. Middle class substance users simply have to avoid drug triggers by not going to them; whereas people of color who have become segregated may be forced to live and interact with the exact same environments in which they used substances. This should be an obvious obstacle in changing one’s relationship to substances, since they have little option where they spend their time.
Unmanageability: The Chicken or the Egg?
I have already written about what unmanageability means to the treatment field in my previous article Unmanageability: A.A.’s Greatest Contribution to Addiction Treatment, where I discuss this more in-depth.
Basically, people seek treatment for substance use, not because of the amount of substance they use but, because they are not able to sufficiently manage their life. When substance users are able to use substances without interfering with their life goals, they don’t have a need to change their substance use. Traditional substance use dogma believes that addicts cannot manage their lives, solely because they use substances. Of course substance use can interfere with one’s ability to control their life but this theory completely ignores outside factors like racism.
Systematic racism and oppressive forces create a disparity in the quality of opportunities in education, employment, healthcare, housing, and everyday interactions that prevent a person of color from managing their life regardless of whether or not they use drugs. It has been shown that people with less education, who are unemployed, or have less socioeconomic status, have greater and longer problematic relationships with substances. So are these people’s lives unmanageable because they use drugs or do they use drugs because their life is unmanageable? It’s a chicken or the egg question. I believe that there is sufficient evidence to suggest that prolonged substance use is a result of lack of resources to manage one’s life; which is commonly caused by systematic racism.
Opportunities and Recovery Equality
It is said that addiction is an equal opportunity disease that affects all people equally regardless of their status in society. This is simply not true and especially not true about the equality of people’s opportunity to recover from problematic drug use. Sure, any individual can potentially become addicted to a substance, but how that addiction effects one’s life is greatly dependent on social status because of the resources necessary to stop using drugs.
Taking a holistic approach to addiction recovery is the newest and most effective treatment for addiction; meaning that for a problematic drug user to change their relationship with substances they need to treat their mind, body, spirit, and environment. For example, to treat one’s mind would require psychotherapy and to treat one’s body requires healthy diet and exercise. To treat all areas of life concurrently would require changing several, if not dozens, aspects of one’s life
Marginalized people of color often do not have the extra time, money, or resources to accomplish a holistic treatment approach. Marginalized people struggle to just to make ends meet so thinking that they can afford, in both money and time, to buy better food, join a gym, attend support groups, and do meditation everyday is unrealistic. Middle class people, often white people, are more likely to have the money and time to holistically transform their lives.
In fact, most middle class people are often able to stop using drugs without any help from the professional community. It has been shown that most people who meet the criteria for substance use disorder stop using drugs on their own once it begins to interfere with their life goals. As drug use interferes with a person’s conventional life they often stop or moderate their drug use.
In the United States, people of color are systematically barred from having a conventional life by being afforded fewer opportunities to participate in our capitalist and achievement oriented society. When looking at the impact of addiction on communities of color, it’s not a question of who uses drugs, but rather a question of who is able to stop using drugs. When looking at the white middle class, I think we will learn that those people who stop or moderate their substance use do so because they, not only have the resources to do so, but also, have the realistic opportunity to rejoin conventional life which has been built for them to succeed.
Unfortunately, we live in a society that ignores and outright denies the existence of racism and white privilege. It’s hard for white people to admit, even to ourselves, that we have been awarded unearned privilege based on the color of our skin. In the United States, this has been in existence since the founding of our country. It began at least with the birth of slavery. White people who are alive today are not directly responsible for the emergence of racism but it is a responsibility that we have inherited nonetheless.
Often, as clinicians, we try and assist clients in adapting themselves to their difficult life environment. I believe that it is equally important to advocate changing the oppressive system to adapt to our clients. When working with a person of color who uses substances and has life challenges due to systematic oppression, it is our job to ask what role racism plays in the client’s life. It needs to be acknowledged and fought against. It needs to be changed. Sadly, racism is so entrenched in the world that it would take a complete disassembling and rebuilding.
As we wait for that day to come, substance use clinicians must begin to have a conversation about the reality of the world we, and our clients, live in. That conversation needs to begin with the facts that:
- Resources and opportunities lead to successful addiction recoveries.
- Racism, by definition, creates less resources and opportunities for people of color.
- Therefore, racism perpetuates addiction.