Wishful thinking about addictions

When wishes are horses...

“If wishes were horses, beggars would ride.

If turnips were watches, I'd wear one by my side.

If "ifs" and "ands" were pots and pans,

There'd be no work for tinkers' hands.”

Scottish nursery rhyme / proverb, first recorded about 1628

I’m no expert on the subject of addictions, nor am I an expert on the structure of logical arguments, so I’m going way out on thin ice here by writing a post about the logic being used to justify our societal approaches to addictions.

Bear with me (or watch me drown)!

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First, a little bit of logic!

IF-THEN arguments are the workhorses of deductive reasoning. They contain a hypothesis (the “if” part) and a conclusion (the “then” part).

“If wishes were horses” is the hypothesis, and “beggars would ride” is the conclusion. The nursery rhyme makes the unspoken assumption that beggars make wishes. Technically, it should read “IF wishes were horses AND beggars made wishes, THEN beggars would have horses to ride”, but that mucks up the rhythm and rhyme.

When the argument is correctly structured and the hypothesis is true, it follows that the conclusion is true. However, logic doesn’t exclude the conclusion from becoming true for other reasons. Beggars could ride for many reasons, like somebody gifting them a horse (or maybe a bus ticket!), even when they made no wishes at all.

In a well structured argument the hypothesis should be “testable”, meaning that it should be possible to determine if it’s true or not, based on some form of experiment. After all, you need to be confident that the hypothesis is actually true before you act on the conclusion. As a beggar, you could sustain an injury jumping on a non-existent horse, having been assured that wishes were horses.

Taking it further, the scientific method is fundamentally based on the continuous formulation, testing, and modification of hypotheses, as new information comes to light. To move forward, realizing that we don’t always have all the facts, we often base our conclusions on a “working hypothesis”, our best understanding of something at the time.

I’m guessing that no experiment has ever demonstrated any situations in which wishes are in fact horses, so the current working hypothesis is more like “wishes aren’t horses and probably never will be”, with the conclusion being “those who want to ride should stop wishing and try something else”. All subject to change, of course, as new information becomes available!

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So what?

In a lot of public discourse these days, it seems to me that people make IF-THEN arguments, but they leave out the IF.

This isn’t new. Flat Earthers might once have said:

“The Earth is flat, so when you sail far enough out to sea you’ll fall off the edge”.

They saw no need to say:

“IF the Earth is flat and you sail far enough out to sea, THEN you’ll fall off the edge”.

The flatness of the Earth was simply a matter of faith (or fact). They didn’t see it as a working hypothesis, subject to testing and modification. The conclusion seemed obvious. To think otherwise would be lunacy, denying either religious doctrine or scientific dogma.

Nowadays, examples are everywhere, when you look.

For example, the Nova Scotia Public Health website still says:

“Wearing a mask can help prevent the spread of COVID-19 and other respiratory illnesses. A mask helps stop droplets spreading when someone speaks, laughs, coughs or sneezes.”

Technically, it should say:

“IF COVID-19 and other respiratory illnesses ARE spread by droplets, AND IF the mask you are wearing is worn properly, AND IF that mask is constructed of materials that stop droplets, THEN wearing a mask can help prevent the spread of COVID-19 and other respiratory illnesses”.

So basically you have THREE testable hypotheses, each preceded by an IF in the above statement. It’s a complicated argument, in which all three working hypotheses must be true in order for the conclusion to be true. I think it’s pretty obvious that the conclusion doesn’t hold in 2024, which probably makes me a lunatic! However, this isn’t an article about COVID-19, so I won’t belabor the point that our Public Health people are Flat Earthers!

Lunatic or not, however, I stand by my assertion that the modern default is to leave out the IF, and, when challenged, to state categorically (and often incorrectly) that the hypothesis HAS been tested and proven to be TRUE beyond all doubt, leaving no room for the possibility that it might just be a “working hypothesis”. The words you’ll hear are “the science says” or something similar, and to question it means you’ll be labelled a “denier”, a “heretic”, or worse.

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Which leads us to consider psychoactive substances…

Psychoactive substances are those which affect the functions of the brain, including consciousness, perception, mood, thinking, and behaviour.

It’s a broad grouping, including:

• substances found in nature (including things like caffeine, nicotine, cocaine, alcohol, psilocybin, mescaline, and some opioids like heroin and morphine), and

• man-made compounds (including such things as ecstasy, amphetamines, LSD, antidepressants, benzodiazepines, and synthetic opioids like methadone and fentanyl).

All psychoactive substances bring some pleasure and carry some risk of harm.¹

There are many ways to think about the harms of psychoactive substances. This example found in ”Development of a rational scale to assess the harm of drugs of potential misuse” by Nutt et al 2007

In general, for ALL of these substances, there’s a spectrum ranging from “casual use” through “risky or hazardous use (like drunk driving)” to “Substance Use Disorders (SUDs)”.

Obviously, it’s more than a bit subjective deciding when you’ve crossed the line from casual use to risky use, or from risky use to having a substance use disorder. However, the general idea is that you have a Substance Use Disorder when you can’t stop yourself and are using the substance compulsively despite harmful consequences. SUDs can be mild, moderate, or severe, although again the differentiation between those gradations is rather subjective.²

The term “addiction” is somewhat vague and maybe even outdated, but probably best describes those with moderate to severe SUD, particularly those who exhibit “tolerance” and/or “withdrawal”. Tolerance reflects the need for increasing amounts of the substance in order to achieve the desired effect, or, conversely, a markedly diminished effect with continued use of the same amount. Withdrawal is reflected by a characteristic syndrome when the substance is no longer taken, the symptoms of which can be relieved by taking the same or a closely related substance.³

So, for example, regular smokers have Tobacco Use Disorder. They reach a point when they crave cigarettes, they smoke more than they want to, and they can tolerate far more cigarettes per day than they did when they first started smoking. They know it’s harmful, it costs money, they’re stigmatized and relegated to the “butt hut” for their breaks, and they want to quit. However, quitting triggers nicotine withdrawal symptoms such as restlessness, irritability, anxiety, and weight gain. Smoking a cigarette or chewing nicotine gum relieves the withdrawal symptoms. Regular smokers are therefore “addicts”!

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Addiction, isn’t that a Brain Disease?

Consider the following statements, drawn and paraphrased from multiple sources explaining that which is known as the “brain disease model of addictions” (BDMA):

Addiction is a severe, chronic, relapsing brain disease with a biological basis that results from the prolonged effects of psychoactive substances on the brain.

As with many other brain diseases, addiction includes important behavioral aspects. For example, addiction involves a substantial loss of self-control, as indicated by compulsive substance use despite harmful consequences and the desire to stop taking the substance.

For a person to be responsible for their actions, they must be in control of them. Because addiction “hijacks the brain”, addicts have lost control over their addictive behavior, and thus, for the most part, they cannot be held responsible for it.

Addiction is NOT the result of moral failings, lack of willpower, or character defects, therefore addicts should not be judged, stigmatized or criminalized.

Even though addiction prevents addicts from making certain decisions effectively (such as whether or not to use substances, or when and where to take them), the clinician’s must respect the autonomous choices of the patient.

Addiction being a disease, the main concern should be how to treat or cure it, using the evidence-based treatments currently available as well as others which could result from research.

To deny that addiction is a disease is to deny access to treatment.

In summary: Addiction is a biological disease of the brain with behavioural features. As with any other disease (e.g. cancer), addicts should be free from stigma and blame, have access to the “sick role”, and receive sympathy, all while being supported to make their own decisions about their treatment, which should be evidence-based.

Left unsaid is the big "IF”.

It doesn’t say “IF addiction is a biological disease of the brain…”, or even “Our current working hypothesis is that the brain disease model is the best way to look at addictions…”. The BDMA is “the science”!

So what?

The Brain Disease Model of Addiction has been kicking around for decades. It’s the dominant model, exerting a profound effect on the efforts of clinicians, policy makers, researchers, and research funders.

In the addiction literature you’ll find all sorts of meaningless pictures of brains, like this one. Somebody once showed that people are more likely to believe ANY message that includes a picture of the brain, even if the message has NOTHING to do with brains. So, now do you believe me?

Unfortunately, you might ask yourself whether addictions really are like other diseases, and whether the BDMA is in fact the right model to guide our work.

Cancer survival is steadily improving. The disease model works!

Addiction rates and overdose deaths are steadily increasing. The disease model doesn’t work!

Look at drug policy in British Columbia and you’ll see the BDMA in action. It is taken to be established scientific fact, rather than working hypothesis.

For instance, looking at Prescribed Safer Supply (PSS), B.C.’s Provincial Health Officer recently acknowledged that:

• “serious concerns have been raised regarding the benefits and harms of the PSS approach for both individuals accessing PSS and the broader population.”

• Potential benefits include preventing toxic drug poisonings and deaths, improving access and engagement in health and social services as well as reducing associated healthcare costs.”

• “… the evidence base of benefit for PSS is quite limited” and “…promising as it is largely positive, but not at this point strong enough for this intervention to be described as fully evidence-based.”

• “harms of the PSS approach may include potential population level harms such as diversion to non-intended populations, expanded access and availability of opioids for youth, and normalization of this access leading to risky use, and reduced incentives for recovery.”

• Indeed, “Some diversion is occurring; however, the extent and impacts are unknown.”

• “Diversion should be understood as indicating unmet needs for [People Who Use Drugs] (both medical and social needs) and therefore efforts to mitigate diversion should begin with efforts of the health and social service system to better meet those needs.” (In other words, diversion is actually a GOOD thing! Who knew?)

• and “…more needs to be done to investigate the potential for harm at the population level”.

All that didn’t stop her from calling on the B.C. government “… to broaden the availability and types of drugs that can be prescribed under the province's controversial safer-supply program.” In other words, never mind the lack of evidence! Don’t worry about the harms!

Sound familiar? “Safer supply” is the wish. “Saves lives” is the horse. “Prescribers” are the beggars.

“Safer supply saves lives, prescribers should be prescribing!”

And there’s no IF! She’s saying “Wishes ARE horses”, without evidence, and she’s confident that the evidence will magically appear!

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How does this happen?

Interestingly, nearly 30 years ago Alan Leshner, the director of the US National Institute on Drug Abuse, wrote a seminal article entitled “Addiction Is a Brain Disease, and It Matters”, in which he noted:

“…some of the people who work in the fields of drug abuse prevention and addiction treatment also hold ingrained ideologies that, although usually different in origin and form from the ideologies of the general public, can be just as problematic. For example, many drug abuse workers are themselves former drug users who have had successful treatment experiences with a particular treatment method. They therefore may zealously defend a single approach, even in the face of contradictory scientific evidence.”

WOW! People working in the addictions field have problematic beliefs? Some zealously defend a single approach, even in the absence of evidence, or in the face of contradictory scientific evidence? NEVER!

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There is another way to look at this!

Some are brave enough to question the BDMA dogma, including a European group known as the Addiction Theory Network.

In launching that network, they commented:

“The National Institutes of Health, the American Society of Addiction Medicine and a recent Surgeon General's report make the identical case based on scientific evidence of addiction as a brain disorder. Proponents of the BDMA often defend the model by referring to respected organizations that endorse it but this merely illustrates how influential advocates of the BDMA have been and that it has been unquestioningly accepted in many quarters. But this is not a good reason for dismissing criticisms or alternative approaches. The pronouncements of these august bodies are precisely the views of addiction that should be challenged in the interests of a proper scientific understanding.”

In other words, the BDMA is “group think”, and maybe it’s time for the group to change its thinking.

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In my next post(s), I’ll go into this in greater detail, looking at the history and mis-application of the BDMA, as well as some of the alternative approaches. Along the way, we’ll ponder:

• what evidence is there that addiction really is a brain disease?

• if addiction is a disease, then why is it more prevalent in some places and less prevalent in others?

• what is the natural history of addictions?

• why is it that abstinence is the preferred approach for smokers and alcoholics, but opiate replacement is the preferred approach for opiate addicts?

• what other treatment approaches are there for addictions?

• why can’t you smoke or drink in a public space, when it’s OK to do drugs there?

• if the BDMA is the best model, then why are we failing to overcome the opioid crisis?

Stay tuned!

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In the meantime, you I highly recommend the following posts, written by my friend and former colleague, Chris, of Pairodocs:

Is there Harm in Harm Reduction

Is there Harm in Harm Reduction? Part 2

1. As do most medications!

2. A Mild SUD is sort of like being “a little bit pregnant”!

3. Again, tolerance and withdrawal are not unique to psychoactive substances. Many drugs (like blood pressure drugs, for example) behave similarly, in that they have a marked effect when you first start taking them, you develop tolerance over time, and there’s some sort of “rebound” effect when you stop taking the drug. This is why doctors often prescribe low doses to start, gradually increase doses as tolerated, and wean people off drugs slowly.