Drug-related moral panics rest so deep and so enduring within American history that they could be thought of as part of our national character. The latest focus of concern is the opioid epidemic as indicated by the more than 100% increase in opioid prescriptions, 2.5 million U.S. citizens who have a substance use disorder involving prescription or illicit opioids, 1.3 million opioid-related hospital admissions in the U.S. each year, and more than 33,000 opioid-related deaths per year. Yet, this opioid epidemic is far more than it appears to be. The focus of this brief essay is on our professional and public propensity to focus on one drug (or one drug category) at a time in isolation from broader and more enduring patterns of psychoactive drug consumption that connect and influence particular drug surges.
The one-at-a-time drug focus, whether on alcohol, marijuana, LSD, cocaine, prescription opioids, or tobacco, has engendered numerous unintended consequences, including inconsistent and contradictory drug laws and regulatory policies, drug-specific treatment approaches plagued by problems of "secondary drug use," and narrow clinical and personal definitions of problem resolution (e.g., diagnostic remission or abstinence from one's primary drug of choice without regard for broader patterns of drug use).
This one-drug-at-a-time professional and public fixation is challenged by rarely acknowledged conclusions drawn from scientific studies and decades of cumulative clinical experience.
*The majority of drug-related deaths in the United States result from the simultaneous or time-contiguous consumption of multiple drugs, particularly the combination of opioids, alcohol, and other depressant drugs (particularly benzodiazepines).
*The majority of people admitted to addiction treatment in the U.S. present with a pattern of concurrent or sequential involvement with multiple drugs.
*Patients discharged from addiction treatment who abstain from use of their primary drug are vulnerable to develop other drug dependences and related process addictions.
*Patients discharged from addiction treatment who experience a recurrence of addiction to their primary drug often do so after first consuming other psychoactive substances, e.g., resuming heroin use while under the influence of alcohol.
*Macro-level drug epidemics, rather than spontaneously remitting or responding to policy or professional interventions, most often morph into something else, e.g., cocaine and methamphetamine surges setting the stage for subsequent surges in opioid use.
*Cultural panics over an illicit drug surge often serve as a smokescreen for even more significant shifts in consumption and consequences of socially-celebrated drugs, e.g., current preoccupations with opioids masking dramatic increases in alcohol use, risky drinking, and alcohol use disorders. Everyone working in the treatment and recovery support fields should read the latest alcohol-related problems survey results just published in JAMA Psychiatry. It is available for free download by clicking HERE.
There have long been efforts to transcend this single-drug focus. At a clinical level, the concepts of inebriety, chemical dependency, substance abuse, drug dependence, addiction, and substance use disorder have all sought to define a common underlying process connecting various drug dependencies. At the recovery mutual aid level, this is best exemplified within the early history of Narcotics Anonymous. When discussions occurred in the early 1950s about how to adapt the Steps of Alcoholics Anonymous to recovery for those addicted to other drugs, Jimmy K., variably described as the founder or co-founder of NA, argued for a unique wording of NA's first step. Rather than framing the first step in terms of "powerlessness over narcotics" (a primary drug choice among early NA members) or "drugs" (alcohol was not culturally considered a drug at this time), Jimmy argued for "powerless over our addiction" which embraced the whole spectrum of addictive substances (with the exception of tobacco/nicotine which at that time was also not viewed as a "drug"--and still isn't!).
Jimmy's revolutionary proposal was threefold: 1) vulnerability to addiction involves a spectrum of substances, 2) the problem was best defined not in terms of one's pet poison but in terms of this larger process of addiction, and 3) full recovery requires more than abstinence from a single substance (and more than abstinence from all drugs). His definition of addiction as the central problem requiring an enduring recovery process was decades ahead of its time. As the opioid epidemic evolves, all of us involved in the front lines of policy responses and clinical or recovery support interventions should remain aware that it is more than an opioid epidemic and that we must be prepared to respond as it continues to evolve in ways not yet clear.
What are the personal implications of Jimmy's conceptual breakthrough? It perhaps lies in this: personal kryptonite comes in many forms, and such awareness is a crucial step in the long-term recovery process. Even superheroes have vulnerabilities. Know thyself (and the many masks of your demons).