Archive for addiction


Posted in WAR ON DRUGS with tags , , , , , on April 14, 2015 by drjgelb

I came across a discussion via comments online today, in which the participants were becoming increasingly hostile and aggressive with each other, as some denigrated people suffering from drug addiction as “scumbags” who “deserve everything they get” and others tried in vain to explain that addiction is a chronic brain disease. The scientific evidence has progressively mounted in favour of the chronic disease explanation and studies using the latest brain imaging technology, together with an increasingly sophisticated  understanding of molecular biology, has meant that the disease model has prevailed and solidified.

Social and governmental forces continue to be directed at opposing the disease model of addiction, in order to justify the continued labelling of addicts as criminals who require punishment for their bad behaviour and rotten choices. This allows the government to incarcerate addicts, rather than treat them as medically unwell citizens, deserving of medical treatment.

Countries like Portugal and Uruguay have ceased criminally prosecuting users because of the overwhelming scientific evidence that drug addiction is a public health problem and NOT a criminal justice problem. Let me spell it out: Countries like Australia, where harshly punitive criminal sanctions are preferred to drug addiction treatment and rehabilitation, deliberately ignore the recommendations of their own expert advisors, insisting in terribly misguided fashion that any chage in approach to the War on Drugs, “sends the wrong message to youth”. This ignorant and irrational viewpoint continues to be trotted out by politicians unaware that they are seriously damaging our nation’s youth with their retrograde policies.

The American Society of Addiction Medicine, arguably the peak world body in the Addiction Medicine field, has released its updated definition of addiction:

“August 15, 2011 – The American Society of Addiction Medicine (ASAM) has released a new definition of addiction highlighting that addiction is a chronic brain disorder and not simply a behavioral problem involving too much alcohol, drugs, gambling or sex.” The headline in their report was: “Addiction Is a Chronic Brain Disease, Not Just Bad Behaviors or Bad Choices”

“The new definition resulted from an intensive, four‐year process with more than 80 experts actively working on it, including top addiction authorities, addiction medicine clinicians and leading neuroscience researchers from across the country. The full governing board of ASAM and chapter presidents from many states took part, and there was extensive dialogue with research and policy colleagues in both the private and public sectors.”

“The new definition also describes addiction as a primary disease, meaning that it’s not the result of other causes such as emotional or psychiatric problems. Addiction is also recognized as a chronic disease, like cardiovascular disease or diabetes, so it must be treated, managed and monitored over a life‐time.”

“Research shows that the disease of addiction affects neurotransmission and interactions within reward circuitry of the brain, leading to addictive behaviors that supplant healthy behaviors, while memories of previous experiences with food, sex, alcohol and other drugs trigger craving and renewal of addictive behaviors. Meanwhile, brain circuitry that governs impulse control and judgment is also altered in this disease, resulting in the dysfunctional pursuit of rewards such as alcohol and other drugs. This area of the brain is still developing during teen‐age years, which may be why early exposure to alcohol and drugs is related to greater likelihood of addiction later in life.”

“the disease creates distortions in thinking, feelings and perceptions, which drive people to behave in ways that are not understandable to others around them. Simply put, addiction is not a choice. Addictive behaviors are a manifestation of the disease, not a cause.”

Before the argument re how “bad” addicts are, please carefully read the science at the link above. Much better than all this hostility.




Posted in WAR ON DRUGS with tags , , , on October 5, 2013 by drjgelb

Today, comes news from “” that adds a further increment of hope to the mounting pile slowly accumulating on politicians’ doorsteps.

“Defelonization”–The Next Step in Winding Down the Drug War.

Defelonization (with an “s” in Australia!) of drug possession is starting to take hold across the country. California looks set to join the list of states easing up, and Washington state could be next. Thirteen states, the District of Columbia, and the federal government have already passed laws making simple drug possession a misdemeanor instead of a felony, and the momentum appears to be growing. A bill in California to do something similar has passed the legislature and is currently sitting on the governor’s desk, and efforts are afoot to push a defelonization measure through the Washington legislature next year.

An overcrowded California prison (

Such measures are designed to ease prison overcrowding, ease pressures on budgets, and help drug users by avoiding saddling them with felony convictions. They also reflect increasing frustration with decades of drug prohibition efforts that have failed to stop drug use, but have resulted in all sorts of collateral costs. In California alone, even after Gov. Jerry Brown’s (D) prison realignment scheme, more than 4,000 people remain in state prisons on simple drug possession charges. At $47,000 per inmate per year [8], that comes out to more than a $200 million annual bill to state taxpayers. Under current California law, people convicted of a drug possession felony can be sentenced to up to three years in prison. More than 10,000 people are charged with drug possession felonies each year, although many of them receive probation if convicted.

California state Sen. Mark Leno (D-San Francisco) moved to redress that situation with Senate Bill 649 [9], which passed the legislature on the final day of the session. The bill is not a defelonization bill per se; instead, it makes drug possession a “wobbler,” meaning it provides prosecutors with the flexibility to charge drug possession as either a felony or a misdemeanor. “Our system is broken,” said Lynne Lyman, California state director for the Drug Policy Alliance [10], which supported the bill. “Felony sentences don’t reduce drug use and don’t persuade users to seek treatment, but instead, impose tremendous barriers to housing, education and employment after release — three things we know help keep people out of our criminal justice system and successfully reintegrating into their families and communities.”

Even Republicans got on board with the bill, helping to get it through the Assembly earlier this year.

California state Sen. Mark Leno (; “I am proud that we got bipartisan support in the Assembly,” Leno told the Chronicle. The bill currently awaits Gov. Brown’s signature, and although his signature is not required for it to become law, Leno said he believed the governor would act on it, and he urged supporters to let the governor know now that they want him to sign it. “Anyone can go to the governor’s web site [11] and offer support through an email communication,” Leno said. “I am always hopeful he will sign it.”

While Californians wait for the governor to act (or not), activists and legislators in Washington are gearing up to place a defelonization bill before the legislature there next year. Sensible Washington [12], the activist group behind the effort, says it has lined up legislative sponsors for the bill and will pre-file in December for next year’s legislative session. State Rep. Sherry Appleton (D-Poulsbo) will be the primary sponsor of this proposal in the House. Reps. Joe Fitzgibbon (D-Burien), Jim Moeller (D-Vancouver), Jessyn Farrell (D-Seattle), and Chris Reykdal (D-Tumwater) have all signed on as official cosponsors, with more to be announced soon. Sensible Washington hopes to have a companion bill filed simultaneously in the Senate.

Under current Washington law, the possession of any controlled substance (or over 40 grams of cannabis) is an automatic felony. Under this new proposal, the possession of a controlled substance — when not intended for distribution — would be reduced from a felony charge, to a misdemeanor (carrying a maximum sentence of 90 days, rather than five years). Laws regarding minors would not be affected. “Removing felony charges for simple drug possession is a smart, pragmatic approach to reducing some of the harms associated with the war on drugs,” said Anthony Martinelli, Sensible Washington’s communications director. “The goal is to stop labeling people as felons, filling up our prisons and ruining their lives in the process, for possessing a small amount of an illegal substance.”

He elaborated in a Tuesday interview with the Chronicle.

“We support full decriminalization, like the Portuguese model, but defelonization is a big step forward, and we feel that the public and lawmakers are ready for it,” he said. “We have to find a way to deal with the dangers of the war on drugs. Another reason is the massive disparity in our cannabis law — an ounce is legal, but an ounce and a half is a felony. This would remove felonies for cannabis possession, but we don’t think anyone should be hit over the head with a felony for personal drug possession.”Martinelli said Sensible Washington and its allies would be spending the next few months preparing to push the bill through the legislature. “We will be building public and legislative support, continuing to work on garnering media attention, activating our base, and getting more lawmakers on board,” he said. “We’re really trying to form a bipartisan coalition and get other organizations involved as well.”

One of those groups is the ACLU of Washington [13]. Sensible Washington and the ACLU of Washington were bitter foes in the fight over the state’s successful I-502 marijuana legalization initiative — Sensible Washington opposed it as a half-measure that endangered medical marijuana, a claim that ACLU and other advocates contested — but appear to be on the same page when it comes to this sentencing reform. “We support the decriminalization of drug use”, said Alison Holcomb, criminal justice project director for the ACLU of Washington. “We’re looking forward to working in collaboration with Sensible and its allies to achieve that goal.” Martinelli said he could now announce that the proposed bill has picked up its first Senate sponsor, Sen. Jeanne Kohl-Welles (D), to add to its growing list of House sponsors.

Missing from that list of House sponsors is one of the most prominent drug reformers in the House, Rep. Roger Goodman (D-Kirkland), the chairman of the House Public Safety Committee, but that’s not because he opposes the idea, Goodman told the Chronicle Tuesday. “As chair of the committee, it’s important for me to be an honest broker to get legislation through,” Goodman explained. “My position as chair is weakened if there is a potentially controversial issue and I’m seen as being on one side of it. It’s not that I oppose it, and I certainly will hold a hearing on it and move it, but my role is more to facilitate negotiations on provisions of the bill without being an interested party,” he said. “It is an idea that is certainly worth pursuing”, he said. “We need to reprioritize. The tough penalties we impose on people for merely possessing drugs is so arbitrary compared to the penalties for other offenses where there is direct physical harm perpetrated against others,” Goodman said. “And by now, we all acknowledge that drug possession is not merely an indiscretion, but might be linked to behavioral health issues. Our approach should be to facilitate therapeutic interventions. We have deferred prosecution programs already, but only for alcohol. Those arrested for drug possession are not eligible because it’s a felony. If we could make deferred prosecution available for drug cases, we could make much more headway on the problem,” he said. “And doing so would only codify what is already often existing practices”,he said. “Many or most courts and prosecutors are already pleading down felony drug cases to misdemeanors because of budget constraints and space limitations in the jails,” Goodman noted. “We can change the law to conform with that practice without an additional threat to public safety. Beyond that, we could remove the prejudicial effect of a felony conviction when it is so evident they hinder people from reintegrating into the community.”

While Sensible Washington and its allies are moving full steam ahead, passing the bill could be a multi-year effort, Goodman warned. “I anticipate prosecutors saying that if we set a certain possession threshold, drug dealers will make sure they possess no more than that amount and will play the system,” he said. “We have to figure out a way to find a threshold or divide possession cases into degrees. I hear the concern, but I’m not sure what the solution is. But this is a next important phase of drug policy reform: cranking down the drug war yet one more notch and doing what’s rational and fiscally responsible.” “There is lots of work to be done. We’ll see how this plays out in the legislature. It’s probably going to need more lobbying and more background discussion among more legislators,” he predicted. “So far, it’s not a real prominent topic, so it might end up being a work in progress. But who knows? It might catch on fire, and we’ll get a quick consensus.”

Defelonization News Feature State & Local Executive Branches State & Local Legislatures Washington Initiative 502 • P.O. Box 18402 • Washington DC 20036
Phone (202) 293-8340 • Fax (202) 293-8344 • Email • Privacy Policy
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Posted in WAR ON DRUGS with tags , , , , on September 2, 2013 by drjgelb

Victoria Sutherland is a 34-year-old mother of one and a former manager of a McDonalds in Sacramento. She has a drug conviction on her record from an incident in Portland, Oregon 13 years ago, when she lied to police and said her friend’s drugs actually belonged to her. Though she has served her sentence, because of her drug conviction, Sutherland is now banned from accessing food stamps for the rest of her life.

“I’m now living with my five-month-old son in a homeless shelter,” Sutherland told AlterNet.

As a result of welfare reform, enacted 17 years ago this month, Sutherland and other poor Americans in 12 states are banned from accessing food stamps because they have made mistakes with drugs at some point in their past. While Sutherland’s son does qualify for food stamps and welfare, the total comes to $500 per month in assistance, which barely pays for his food and diapers.

The ban on Sutherland’s food stamps as well as her welfare benefits impacts her much more deeply than just accessing food on a daily basis. “Since I don’t qualify for benefits, I do not qualify for welfare to work, which would offer childcare services,” Sutherland said. “So I’m also not able to work at all right now because I have nobody to care for my kid.”

Well before the current, direct attack on federal funding of food stamps—also known as the Supplemental Nutrition Assistance Program (SNAP)—there have been systemic, state-imposed barriers to accessing food stamps that have been in place for nearly two decades. Several states require fingerprinting of recipients and reams of paperwork, or are stalled by outdated technology. The Los Angeles Times recently reported on the onerous barriers food stamp recipients face in California.

But the ban barring drug convicts from accessing food stamps is one of the most problematic state-imposed barriers faced by poor people like Sutherland. Twelve states still ban convicted drug offenders from accessing SNAP benefits. A relic of welfare reform, the food stamp ban is an example of the political interplay between the drug war and the movement to reform welfare which in reality became a double indictment of the poor: People of financial means who made mistakes with drugs would not be rendered vulnerable to hunger for the rest of their lives.

“This penalty on food stamps stretches beyond period of your criminal sentence, beyond probation or parole,” said Jessica Bartholow, Legislative Advocate at the Western Center on Law and Poverty in Sacramento. “It applies even when a person has turned his life around and is now just trying to prevent his family from going hungry.”

California now has a bill under consideration, SB 283, that would repeal the food stamp ban for any convicted drug offender who is now complying with the conditions of his or her parole.

“This bill is different than what has gone before any governor in the states,” Bartholow said. “In years past, we tried to just repeal the ban completely but past governors have opposed this idea. So we worked hard to identify a compromise that would work for everyone.”

During debates over welfare reform in 1996, former Sen. Phil Gramm (R-FL) introduced legislation banning convicted drug felons from accessing food stamps. Sen. Gramm argued “if we are serious about our drug laws, we ought not give people welfare benefits who are violating the nation’s drug laws.”

Gramm’s policy required that any person who is convicted of drug use, possession or sales be banned from accessing food stamps for life; the ban was then added during Senate floor consideration of the bill and was the subject of only limited debate.

Though the food stamp ban is written into federal law, states may opt to waive or modify the requirement. As a Congressional Research Service report published in July explained, “Both TANF and SNAP are subject to the statutory ‘drug felon ban,’ which bars states from providing assistance to persons convicted of a drug-related felony, but also gives states the ability to opt-out of or modify the ban, which most states have done.”

Twenty one states have completely done away with the lifetime ban and an additional 30 have modified it. In California for example, the food stamp ban has been modified only to include people convicted of selling drugs, not those convicted of use or possession.

But the original food stamp ban is still in effect in 12 states, making life that much harder for poor people well after they’ve completed drug-related sentencing. According to the ACLU there are an estimated 575,000 people behind bars in the United States for drug-related offenses. The food stamp ban is even more problematic given how tough drug sentences tend to be. The socioeconomic and racial disparities of drug sentencing are clear as well: the ACLU also tells us that African Americans are incarcerated on drug charges at a rate that is 10 times greater than that of whites.

The lifetime ban on food stamps affects many other people besides the felon, particularly children, like Victoria Sutherland’s son. As the Western Center on Law and Poverty has pointed out in its advocacy for SB 283, “Many households impacted by the ban have other household members who are eligible for benefits but will receive a lower-total household benefit as a result of the lifetime ban on benefits for one of the household members. As a result, the ban results in higher rates of hunger and food insecurity for the entire family, not just those who have been convicted of a crime.”

The ban also makes food access harder for elders and those with health problems. Vaughn Cotton, age 51, began using cocaine in the early 1980s. He started selling cocaine to pay for his addiction. Now out of jail, he has completed programs with the Salvation Army and has been off drugs for two years. Cotton also struggles with diabetes and high blood pressure.

“I’ve been in and out of jail, but I’ve cleaned up my act,” Cotton told AlterNet. “I’ve been clean for two years now, but the food stamp office said I couldn’t have benefits—and they wanted me to pay back the little bit of money they did give me in the past.”

Aside from its impact on the poor, the food stamp ban does not make economic sense. Every dollar spent on SNAP benefits generates $1.72 in the economy. And a study released in June shows that SNAP recipients helped keep grocery stores afloat during the economic crisis. Thus cutting the spending ability of thousands of drug offenders has implications for the economy as well. (Former Sen. Phil Gramm, the architect of the food stamp ban, has been named by CNN as number seven in its list of the 10 individuals most responsible for the 2008 economic crisis.)

If California’s SB 283 passes this year, it will be an important step in alleviating the poverty-prison trap for drug offenders which the Obama administration has also begun slowly to address, at least from the bully pulpit. Bartholow feels confident Gov. Jerry Brown (D-CA) will sign SB 283 into law.

“The governor is a good man, he understands fairness,” she said. “Because of this lifetime ban, people are being denied crucial support to meet their basic needs.”

Sheila Bapat is an attorney and writer covering economic and gender justice. Her work has appeared in Salon, Reuters, Slate, AlterNet, Truthout, and many other publications.


Posted in WAR ON DRUGS with tags , , , , on June 14, 2013 by drjgelb

I was excited to receive a response to my letter re Krokodil and the failed policies of Prohibition from Jean-Paul Grund, Senior Research Associate @ CVO—Addiction Research Center, Utrecht. I was even more pleased to read that Prohibition appears to be slowlyy crumpling!

Dear Dr. Gelb,

Cannot agree with you more!

Is lack of compassion not a sign of another mental/brain desease – Anti social personality?

I just returned from the International Harm Reduction Conference in Vilnius. You sound like someone who would fit well in this mixture of esteemed researchers, activists, providers and policy makers.

Best regards,

Jean-Paul Grund

I responded as follows:

On Thu, Jun 13, 2013 at 2:19 AM, JEROME GELB wrote:

Dear Jean-Paul,

Thank you for responding. We have had in Australia, what I suspect is commonplace elsewhere, namely a progressive takeover of government by lawyers………now 85% of Parliamentarians!!

This ensures the breakdown by stealth of the separation of powers so essential for a healthy democracy & entrenches conservative, punitive Prohibitionist policies on a range of matters once considered “personal ” or “private” choices”.

It appears to be exactly as you suggest, the psychopaths have taken control!! The primary features all fit: disregard for the needs or rights of others & the inability for empathy!! Add shallow, fatuous, cold & the ability to mimic emotion for personal gain and Voila! Perfect lawyer/politician. All the lawyers I went to school with or knew at university used recreational drugs and/or alcohol & plenty still do. Who knows what goes on in politicians’ private lives??? Hypocrisy of breathtaking dimensions has been revealed by people like Julian Assange but casting an eye over the history of alcohol prohibition in the U.S. 1919-1932, shows that the Mafia made a profit of US$2 Billion (the dollar then was backed by gold and paper money could be converted to bullion. If you had done so, that 2 Billion would be worth $70million for each million $ at today’s gold price!!)
That money found its way to the pockets of politicians from Presidents to local councillors and to the Judiciary, Cops & Juries and it flowed for nearly 75yrs, buying favours, freedom & protection for vicious killers & thugs who preyed on the public & introduced all the illicits using the identical business model.

Will we ever learn from history? Einstein doubted we ever would!

And who am I to argue with Einstein!

Kind Regards,

Jerry Gelb

Finally I received this!

Dear Jerry,

Its a sad world we are living in. But, we are fighting back and the gathering in Vilnius that I just came from is a good crowd and an example that we can make a difference. Although the pendulum seems to be swinging in different directions at once (QM? ;), overall the system of prohibition is slowly crumbling. Check out some of the presentations on international drug policy that will be uploaded to the website of the conference/HRI (

Are you on Facebook?

Have a nice day,


Jean-Paul Grund, PhD
CVO – Addiction Research Center, Utrecht
Department of Addictology, 1st Faculty of Medicine, Prague


Posted in WAR ON DRUGS with tags , , , on June 9, 2013 by drjgelb

Overseas, the synthetic opioid “Krokodil” has been banned……in which country, I can’t recall but there are so many new compounds being rushed onto the street that a new one is out in the time it takes to spell “prohibition”!! Our legislators and policymakers will one day hang their heads in shame for shuffling the deck chairs on the Titanic, instead of leading the charge to drug policy reform! The article quoted another out of touch, cold-hearted clone, towing the company (government) line. They stick to it until addiction knocks on their door or the doors of their kids…….Then they suddenly see the light as they pull all possible strings to keep their family members out of jail……..pathetic really!!

“Dear Sir,

Another synthetic compound, made in filthy conditions where each batch contains anyone’s guess of combinations of toxic chemicals and social & medical harms rapidly appear & ravage the lives of young users.

And the typical response of governments, law enforcement & so-called drug policy experts?
More useless, dangerous, criminalising and irrational prohibition!! Why can’t the truth be told? That prohibition has a long historical record of failure, as predicted by all we know of human psychology. What I find remarkable is that prohibition proponents are able to continue to dismiss experts with a wave of the hand or as the Premier of our State wrote to me in response to my call for a supervised injecting facility similar to the over 650 existing world facilities, that whilst he is in power, we “will never, ever” have such a facility and that the death of heroin addicts is not as serious as “sending the wrong message to our youth”.

With ethics like that & lacking compassion commensurate with our current understanding of addiction as a disease of brain dopaminergic reward systems, it’s no wonder progress has been at a snail’s pace. Scientists, medicos, psychologists and all professionals educated about the drug problem at the coalface, must unite and demand an end to the war on drugs and begin the determined introduction of decriminalisation, rehabilitation, education & regulation as the four pillars of future drug policy in as many countries with the courage to bite the bullet and dismantle the status quo.

If this overview is rejected, it can be guaranteed that all other drug-control strategies will fail as prohibition continues to funnel huge profits to the variety of criminals involved – traditional, corporate and governmental.”

Yours Sincerely,

Dr Jerome Gelb


Posted in WAR ON DRUGS with tags , , , , on May 23, 2013 by drjgelb

An article in The Conversation today raised my ire & had me tapping at my iPad’s virtual keyboard with furrowed brow!

The article, titled “Deep Brain Stimulation: The hidden challenges of a technological fix”, can be found here:

Below is my comment, obviously tinged with annoyance and frustration.

“This article draws invidious comparison between psychiatric illness and disorders of movement like Parkinson’s disease, perpetuating the artificial Cartesian division that has proven so detrimental to sufferers of mental disorders for centuries. DBS is not proposed to be trialled on those suffering addiction responsive to less invasive treatment approaches but to those with intractable addiction who have failed conventional treatment. The ethical & other considerations highlighted are universally applicable to proposed use of novel treatment strategies in humans, as every ethics committee would be very aware of and the author’s discussion of cost effectiveness is shallow & meaningless. Health economists have proven long ago, that psychiatric conditions predominate in tables of disease cost burden, drug addiction certainly being a massive financial burden to the community. The cost of criminal activity undertaken to support an addiction is an health cost, because criminality is a side-effect of addiction only in the presence of Prohibitionist drug policies and is rapidly eliminated in nations where decriminalisation has occurred or where addicts unresponsive to alternative approaches, are prescribed their drug of choice, supervised in administering it safely & encouraged into more intense rehabilitation via increased engagement with health providers. Switzerland’s highly successful heroin prescription program caters to 1500 intractable addicts and has been enormously cost-effective. Addiction specialists are as aware of and as cautious of new treatment technologies as any other medical researchers and operate within the same funding, ethical, oversight and governance systems as the rest of medicine & there is no evidence whatsoever of higher rates of research misconduct in this specialty as any other. DBS may or may not hold promise in addiction. That remains to be discovered by ethical & meticulous research, publication, peer review, debate, the necessity for replication & extension of studies by others & the author’s premature foray into comparisons with psychiatry’s well-known historical scandals is really neither relevant or helpful in 2013.”


Posted in WAR ON DRUGS with tags , , , on May 18, 2013 by drjgelb

Dear Premier,

FYI, an interview with a world renowned author, whose son died from the disease of addiction

Yours Sincerely,

Consultant Psychiatrist

David Sheff’s Addiction Manifesto

Authors in the addiction and recovery space don’t come a lot bigger than David Sheff. The journalist entered this field involuntarily when he endured a parent’s nightmare, as his son, Nic, became addicted to crystal meth and other drugs.

“My Addicted Son,” a 2005 article by Sheff Sr. for the New York Times Magazine, resonated so much with readers that it gave rise to a memoir, Beautiful Boy. Published in 2008, that account of one family’s struggle with an addicted member was a critical and commercial smash, topping the New York Times bestseller list and earning Sheff a nod in Time magazine’s 2009 list of the world’s most influential people, among other accolades.

He says he considered writing his next book about something completely different, like architecture. But a sense of unfinished and urgent business drew him back. His new book, Clean: Overcoming Addiction and Ending America’s Greatest Tragedy, tackles the subject in a very different way from Beautiful Boy. It’s Sheff’s comprehensive, meticulously researched analysis of the national problem and his call for potential solutions—with social, scientific and political dimensions. “His forbearance and clearheadedness could serve as an example for America as it confronts its drug problem,” wrote Mick Sussman in the New York Times review.

David Sheff was interviewed as part of a special event in his honor hosted by The Fix in Newport Beach, California.

As the author of Beautiful Boy and Clean, you’re inevitably seen as a standard-bearer for the US addiction-recovery movement. Is that a role you embrace willingly?

It’s uncomfortable for me, so I don’t like it. I’m someone pretty quiet at home. I’m a writer who works in a small room with a computer and I come out once in a while for a cup of tea, and that’s pretty much it. So to go out and be in this situation is overwhelming. [The recent book tour] was intense. I can’t tell you how many people I met—you can tell, they just have this look in their eyes—they come up and tell you that their kids didn’t make it. Over and over again. What do you say? I just give them a hug and tell them how sorry I am. That gets hard. It happened so often and I was starting to find myself getting depressed.

On the other hand, it’s the greatest thing in the world to go out and talk about addiction and recovery. It feels really gratifying to be part of a conversation that needs to happen. Addiction comes with all this stigma and shame and guilt, so people don’t talk about it. So the idea of coming to a place where they can be with people who get it—because we’re there too, or we’ve been there—feels very powerful.

One major theme of Clean is that addiction must be seen as a disease. The relationship between addiction and choice is a tricky one for lots of people though, isn’t it? People might accept that active addicts use because they’re compelled. On the other hand, some people say you can “choose” recovery. How would you explain this apparent contradiction?

This is one of the most important things that all of us in this world have to help communicate. I was one of those people: I heard talk about the “disease” and thought it was almost pathetic, an excuse for unconscionable behavior. Because it looks like a choice to use, to keep using even when your life is falling apart, or you’re breaking into your family’s home, as my son did. I started to research this and spent time with scientists, and saw pictures of the difference between addicts’ brains and non-addicts’ brains, and the explanation. I started to get it over time.

“Our silence equals death with addiction. If nobody knows how many people are affected, that people they love are affected and people they work with, why should they care?”

Once I started realizing that my son was not making choices, I went from being angry and judgmental to being able to look at him with compassion: He’s sick; he needs help. It also allowed me to figure out what I needed to do: He’s sick; he needs to be treated. I understand the resistance, because it doesn’t look like other diseases. Cancer doesn’t make you break into people’s houses. People who have cancer want to get help. Addicts most often probably don’t. But that’s the nature of the beast.

They’ve done surveys and even doctors, even psychiatrists and psychologists wrestle with this. A lot don’t get it; they just don’t buy it. A lot of people who’ve gone to see a doctor, the doctor will scold them: “Just stop!” or, “Just go to a few AA meetings.” These are people who are shooting heroin, and probably have other problems. It’s not enough.

Is addiction a yes-or-no proposition? Are you either addicted or not? Or is addiction more accurately viewed as a spectrum, with a lot of grey areas in the middle?

I think it’s a really hard question and a really good question. I have come to believe that there is a spectrum. What’s the difference between somebody who goes into recovery—they’ll go into a program, or to AA meetings and then they’ll be fine, they won’t relapse—and someone like my son, who is in treatment 10 times and ends up on the streets, shooting drugs and overdosing? What’s the difference? That looks like there’s a scale, that some people have a more severe case of addiction.

The researchers that I’ve spoken to sort of affirm that. There’s been a lot of talk about the new definition of addiction in the community of psychiatrists—the DSM-5. It talks about a spectrum: It talks about “mild” addiction, all the way up to “severe.” I think it’s really useful. It explains more about why it’s a disease; if some people can choose to get well, why can’t others? Well, sometimes somebody has a really mild form of cancer and it goes away, or a very brief treatment will help. And sometimes that’s not the way it works.

Here’s one that Fix readers often fight about: Does “recovery” always mean total abstinence, or can it take other forms?

Nic was addicted to every drug. He went through tons of treatment programs. He got out, and would be sober for a while. Then he would think, like a lot of addicts do, “Yes, I’m addicted. I can’t shoot heroin, I can’t do crack, but, I can smoke pot and if I get stressed out it sort of evens me out.” And he would smoke a joint. Then he would smoke another joint. And as he describes it, within a few days, he’d be out scoring some more meth. So he can’t. Most of the researchers describe the way the brain works like a switch. And drugs, whatever kind, flip the switch, so craving begins.

But we don’t know a lot. Let’s say somebody ends up in treatment, and they don’t use and they stay sober for a few years; I know people that [now] smoke pot or have a drink occasionally. Does that mean that they weren’t addicted in the first place, or did they have a much milder form? It’s a hard one. The ultimate answer is that everyone’s different—but I think it’s pretty risky to assume that it’s ok.

Let’s talk about AA. Again, our readers love arguing about the effectiveness and validity of 12-step programs. In Clean, you cite some figures, but conclude, “Nobody really knows how often AA works and for whom.” Will we ever know?

One of the doctors I interviewed, this guy at UCLA, Steve Shoptaw, said “This is the place where science meets people.” It’s not an exact science. I think that AA, the 12 Steps, is profound—one of the most miraculous inventions, if that’s what you call it, ever. It’s saved millions of lives. It saved my best friend, who’s been in recovery for 35 years.

I started to look at this again because of all the people I heard from—hundreds—who said that they, or the person in their family, relapsed over and over again and would not go back into treatment. Kids were just, “I’ve been there; I’ve done that. AA does not work for me.” These teenagers are being told through the program to admit they’re powerless and turn their lives over to a higher power. Part of being a teenager is, you’re not going to turn your life over to anybody; teenagers feel all-powerful.

Does AA work? I’ve spent time talking to all the scientists who’ve researched this, and the conclusion I got is that yeah, AA works—for some people. For some people, it doesn’t work. For some people, it’s part of a program that includes other treatments too.

The only complaint I ended up having is about the insistence of some counselors in some programs that AA is a requirement and that it’s the only way to get sober. That alienates people. They won’t return to treatment, because they don’t want more of the same thing. Counselors yelled at [Nic], like it was his fault because he wasn’t doing it their way. Here’s this kid who’s sick, yet he’s being yelled at—and if you don’t practice the Steps, you’re out. He was kicked out. And I was begging them to keep him, and they said, “No, you’ve gotta do it our way, and if you don’t, here’s a black garbage bag, you put your stuff in it and take a walk.”

On the whole anonymity-in-AA debate, you write that strict interpretations of the 11th Tradition can have negative consequences for the recovery community, by keeping it in the closet. You add that addicts shouldn’t be “outed.” Do you applaud those AA members who choose to go public?

I think it’s essential. As you said, I can’t make that choice for any individual. But I lived in San Francisco during the ’80s when AIDS hit. It wiped through our community and killed two of my dearest friends. There was stigma; people hid. And there was a community that said, “We won’t accept this any more.” There was the whole “Silence equals death” campaign. Our silence equals death with addiction. If nobody knows how many people are affected, that people they love are affected and people they work with, why should they care?

I did an interview for a magazine of one of the hippest young movie stars in the country. Beautiful Boy had come out and he said, “I love your book. How’s your son?” We talked and he said, “If it wasn’t for the program, I wouldn’t be alive today.” We talked about how he learned that you can have a great life, a better life than you ever imagined, when you’re sober. He talked about the community of AA and the meetings he goes to. Then we continued and finished the interview.

“I endorse needle exchange completely. All of those things. Safe-inject sites are brilliant.”

The interview was published and the phone rang. He’d gotten my number from his publicist, and he was freaking out. He said, “You betrayed my trust about me being an addict in recovery and it was all off the record. I cannot believe you did that.” I would never print anything that was off the record; he insisted that it was. So I made a copy of the tape and sent it to him. He called up and apologized, and I said, “Why? You are a role model to kids. Wouldn’t it be cool if you were to come out and say, ‘I’m in recovery, and it’s great?'” He was like, “No, it’s a violation of the principle.”

It’s an individual choice. But I’ve been hearing people over and over again talking about this, and making the decision: I’m tired of hiding in the shadows. And I’ve never heard of anybody having a bad experience—it’s the opposite. They’re embraced and they’re supported. It helps people in recovery because it affirms their recovery. It’s awesome.

One program that has profoundly influenced you is Al-Anon. Could you tell me a bit about that?

When Nic got addicted, people said to me all the time, “Go to Al-Anon.” I was like, “There is no way I am going to go to Al-Anon.” I had this image of people sitting in a circle whining in this pathetic kind of self-help thing.

But eventually—and it was a measure of how desperate I was—I went. As soon as I did, it was the first time I’d been in a room where I felt safe. People understood what I was going through. It was the support, but also lessons. About this idea that addiction is a disease. About how bad it can get. About how other families felt the same bafflement. A lot of the things you hear over and over become clichés and lose the weight of what they deeply are. This idea that addiction is a family disease—I didn’t get it. I did get [that] this is a disease that devastates a family—we were devastated—but I didn’t understand the part about the system that exists in a family. Over time it was life-saving.

In your book you note that harm reduction programs like needle exchange and safe-inject sites are associated with positive outcomes. Do you fully endorse them?

I do endorse needle exchange completely. All of those things. Safe-inject sites are brilliant. There’s one in Vancouver: Insite. When this doctor wanted to start this program there was uproar, you know, “It’s going to be a center where you’re condoning drug use, you’re making it easier.”

People protested [but] they were able to set up a pilot project. They thought it was going to bring up crime in the neighborhood, all kinds of calamities. The opposite was what happened. Crime went down. More addicts went into treatment and stayed in treatment. People were able to be in a place where they had a clean needle, and were with people that were going to take care of them. If there was an overdose, there was somebody there to save their life. They were trained people, therapists who would gently—not forcibly, people wouldn’t have come—guide people into treatment. That whole neighborhood is now safer.

In the US, when somebody was suggesting a clean injection site the then-drug czar [John P. Walters] said, “This is state-sponsored suicide.” It’s not going to happen here for a while. Needle exchange programs are here and they work. They’ve been shown to save lives. They don’t encourage drug use. Other experiments are going on around the world that are profound. It’s insane that we don’t consider them. This goes back to the same problem; we’re stuck in this world that says these are bad people, they have to be stopped and punished.

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You agree with most in this field that the US war on drugs has been a failure. You agree with most Americans that marijuana should be legalized. Yet you write that you don’t advocate legalizing other currently illegal drugs. Why should the arguments that apply to marijuana not also apply to those?

I feel like we’re just not there yet. There’s a practical fact: Pushing for legalization of other drugs right now would kill any progress that’s being made on marijuana. And marijuana should be legalized for a million reasons—social reasons, health reasons.

There are experiments now in different parts of the world with legalization or decriminalization of other drugs, and the returns aren’t in—but it looks really promising. It looks like it doesn’t increase drug use, and fewer people die. So I am hopeful that we will evolve to a place where we will look at those things. But the returns aren’t fully in. I can’t imagine a time when we’re going to legalize crystal meth; maybe there will be some way to make it work, so people can get safe. There’s arguments even for crystal meth, or heroin: You’re going to get cleaner drugs, you’re not going to get people dying because they’re taking drugs that have been tainted.

And drug dealers don’t ID…

Yeah—but we’ve got to do a lot of research and education before that will happen.

In Clean you’re quite damning about the US addiction treatment industry. You use words like “pseudoscience,” even “voodoo,” and write that “addiction medicine is 40 years behind where it should be.” What’s behind this disaster?

Everything goes back to this: If addiction is a disease, there’s a system that we know to rely on, the medical model. You go to the doctor when you’re sick. But if addiction is something else, if it’s about morals, choices, then it’s a completely different universe. This goes back forever: Addicts look like bad people; they’re the criminals. Most crimes in America are related to drugs and alcohol. There’s a whole treatment system that built up over the years based on this model that people need to be chastised. Nic was in programs where he would break a rule—not going to enough meetings or not cleaning up the dishes well enough. He’d have to get a toothbrush and go to the floor of the bathroom and clean the grout. If you’re sick, it doesn’t make sense.

“There’s no monitoring: In some states you need a license to open a coffee shop or laundry, but anyone can open a treatment center.”

A lot of the programs that I’ve been to are started by the loveliest people; they so badly want to help. But their only training is that they’ve been in recovery for a long time. They hit bottom maybe and were desperate to get well. That’s all they think will work—their whole model is based on someone has to hit bottom. It’s just haphazard. I heard all kinds of things: Somebody told me to send Nic to boot camp. That’ll straighten him out—get him marching in the desert! It’s a system in disarray. There’s no monitoring: In some states you need a license to open a coffee shop or laundry, but anyone can open a treatment center.

Earlier today we were also talking about some of the exploitation and unethical practices involved in the treatment industry. How prevalent do you think that is?

I would say most in the industry are good people who want to help, but there are people who are just cashing in. Nic was in bad shape—the police were there and I convinced the officer to let him get into treatment. He was on meth and shooting heroin and pretty psychotic, and I didn’t know what to do. I called a program and they were way, way expensive and I couldn’t afford it. They gave me the name of another program and said “This is a good program”…I only later learned that they owned this other program they referred me to.

Nic ended up in sober living houses after treatment. Nobody told us but there were kickbacks: “If you go through my program, what do you do next? Well, there’s this great place down the road…” These people are making 10k a month. A lot of people aren’t being helped and are leaving treatment. Too often they relapse and die.

You emphasize the importance of prevention and early intervention. To what extent has the very structure of the US health care system disincentivized these desirable approaches?

Don’t get me started! It’s something I could rant about for a long time. Health insurance companies traditionally have not covered addiction treatment. Maybe they’ll pay for somebody to get off drugs, to be in the hospital for seven days to detox, but that’s it. Then they end up paying for liver disease, or accidents they get into.

My sister-in-law’s a nurse and she told me about these “frequent flyers.” They come into the emergency room; she told me that 70-ish percent of people are in there because they’re addicts. They get patched up, if they have an infection, a broken bone, and they’re sent back out. There’s no attention to the fact that the real reason they’re there is because they’re addicted. They come back over and over again. She looked up the charts of one patient, and his costs in this emergency room over a year and a half were over a million dollars—on one patient. If we got him the first time…they say every dollar spent on treatment saves us $18 in other costs. The system has been set up backward and it’s costing a fortune. Plus it’s killing people.

One of the hopeful things is that under the Affordable Care Act, Obamacare, for the first time, in theory, insurance is going to pay for addiction treatment.

Somebody with cancer, you’re treated for a month. They evaluate, do you need more time? Maybe you need to stay another month. After two months, you’re doing better, you go home, keep seeing your doctor. Then it hits again. You go back into the hospital and insurance is there; it has to be.

“Insurance has to pay whatever it costs to help people who are ill with this disease.”

With addiction, that doesn’t happen. Now, in theory, it will. It will have the potential to transform the whole treatment system. Because when insurance companies pay for treatment, they want results. They want programs to be using evidence-based treatments, and they’ll monitor them. The ones that don’t do it will either do it, or they’ll go out of business.

The last chapter of Clean is called “Ending Addiction.” You write about the medical, social and political advances that could contribute to that. We might all hope, but what do you think will happen? How far will we get?

I think the idea of ending addiction completely is a quixotic dream. But who knows? I’ve spent time with scientists who are showing that it may well be possible to create vaccines that will effectively prevent certain drug addictions, cocaine for instance—there’s some real evidence that that’s possible.

But that’s not going to happen for a while. In the meantime, my hope is that we start to treat this differently. We have to support treatment; we have to support prevention; insurance has to pay whatever it costs to help people who are ill with this disease. [When] the treatment system is regulated so that we know that programs are good, the numbers will go down. It’s within reach to imagine a time when fewer people become addicted, and when more addicts are treated. It’s about science and policy. Also the other piece of it, that goes back to something you asked earlier: I think that now is the time—something is shifting and I feel it—when people are just tired of hiding this problem.

We’re not going to take it any more. We are not going to suffer in silence, and we are going to demand of our legislators that they reject what we’ve been doing in the past. Stop spending money on programs that aren’t working. Spend more money on programs that work; get them into our schools, our communities, educate parents. And have treatment programs that are accessible to anybody who needs them. All those things coming together are going to cause a shift. Are we going to end addiction? Not tomorrow. Maybe someday. But in the meantime, we’re going to start saving lives.

The Interviewer is the Editor of “The Fix”

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