A wise colleague who works as a family recovery support specialist in a program for parents of young children recently identified a core contradiction. If we say that addiction is a biological disease, where do we place the role of trauma into the narrative? Could it be that this well-intentioned effort to reduce stigma, in large part a response to the criminalization of drug abuse, has the unintended consequence of silencing stories of massive developmental and relational disruption that then reappear to exert their influence in other forms?
I have heard from many parents that Medication-Assisted Treatment, or MAT, saved their lives. Methadone and its newer relative Suboxone offer a safe alternative to the harsh, brutal sickness of opioid withdrawal. Countless people released from the grips of opioid addiction by these drugs have been able to successfully return to fully engage in the world.
So why do we now see a rise in stimulant abuse, including among the very group of people who rely on MAT? This includes prescription stimulants such as Adderall and Ritalin, cocaine, crack, and increasingly synthetic methamphetamine.
According to the Massachusetts Department of Public Health, deaths involving stimulants have increased 25% per year since 2010, and most deaths involving stimulants also involve opioids. In contrast, the count of deaths involving stimulants without opioids has declined by almost 7% per year since 2000. The problem raises some troubling but necessary questions. And the answer may lie, in part, in the overly simplistic model of addiction as a disease no different from any other medical disease.
In my work with mothers in recovery from opioid use disorders, I hear story after story of lives tragically derailed. These women describe alcoholic parents who never thought about them or even seemed to notice their existence. I hear about their younger selves hiding in their rooms while listening to violent fights. Some were raised by a string of relatives or foster parents while their own parents were in jail. They tell stories of their mothers in active addiction, selling drugs under their nose while they struggle in the early stages of recovery. The deep pain of losing their own children to child protection becomes almost unbearable with the recognition that they have unintentionally inflicted a similar kind of pain. Their profound love for their children as they battle day after day, week after week, year after year, to regain custody shines through. Some succeed. Others do not. Some die from overdose, leaving young children behind.
While certainly genetics play a role, as with all other forms of emotional suffering, substance use disorders represent a complex interaction of biology and environment. At a recent presentation about this growing crisis, a professor of family medicine at UCSF included one slide about the need to address ACEs, or Adverse Childhood Experiences, as well as building community resilience through organizations that offer a sense of connection and belonging. He referenced an article, Opioid Crisis: No Easy Fix to Its Social and Economic Determinants, that includes the powerful sentence, “Suffering” may be a better focus for physicians than “pain.”
We need not stigmatize emotional suffering to appreciate its complexity. Acknowledging developmental and relational context should not be shaming. The unintended consequence of the relatively quick fix of medication, whether MAT for opioid use disorder, or psychiatric medication for other problems of emotional suffering, is that motivation to repair the massive tears in social fabric that underlie this suffering may be lost.
One mother described a 3-month wait for an appointment with a psychiatrist following her release from jail for driving under the influence, during which time she had been taken off all her medications. A therapist at the overtaxed and under-resourced mental health center was inconsistently available. With both her former partner and her mother still in the grips of addiction, she felt very much alone. Counseling paired with her daily dosing of MAT felt rushed and superficial.
A parenting group with other mothers facing similar challenges provided a critical patch of support. But having lost custody of her young child, following decades of a life derailed by loss and addiction, one or even a few patches might still prove insufficient to hold the burden of her suffering and prevent her from descending into what has been referred to as a “death from despair.”
One author speaks of connection as the opposite of addiction. In my recent book co-authored with renowned developmental psychologist Ed Tronick, a chapter titled “Healing in a Mosaic of Moments over Time” addresses the need to build a network of multiple healing relationships when lives have been derailed by loss of connection, especially when that loss occurs very early in life.
The rise of stimulant abuse with no clear treatment available analogous to MAT for opioid use disorders must be a kind of wake up call. 2020 presidential candidate Pete Buttigieg often speaks of what he terms a “crisis of belonging.” Creating a sense of belonging and connection for families struggling with substance use disorders must be front and center. These approaches are not extra, but rather must be the core of meaningful prevention and treatment. In particular, infusion of resources for parents of infants and young children just may prevent transmission of addiction to the next generation. Investing in a network of healing relationships for all forms of emotional suffering could save a whole segment of the population from falling through the cracks.