|N. N. DE ORATION AWARD 2019
|Year : 2020 | Volume
| Issue : 4 | Page : 270-276
Of mice and men.....The unforgettable narrative of how social factors shape substance use, addiction, and recovery
Department of Psychiatry, Drug De-Addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||29-Oct-2020|
|Date of Acceptance||29-Oct-2020|
|Date of Web Publication||31-Dec-2020|
Dr. Debasish Basu
Department of Psychiatry, Drug De-Addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
The currently predominant model to explain addiction is the brain disease model of addiction, which emphasizes drug-induced brain changes at the individual level, producing an uncontrollable, chronic relapsing disease. It tacitly de-emphasizes the complex sociocultural, contextual, and other environmental determinants of substance use and addiction. In this oration, I challenge these assumptions with a hop-and-stop tour of five countries: Canada, the USA, India, Vietnam, and Iceland. The journey covers five narratives: isolation, pain, frustration, and then the positive narrative of recovery, and finally the narrative of hope. The socially enriched rats in the “Rat Park” in a laboratory in Canada consumed much less morphine than the isolated, caged rats. People dying of opioid overdose in the worst-ever opioid epidemic in the USA might be using opioids as an escape from broadly defined “pain,” where pain is an emblem of deeper societal isolation and suffering. In Punjab, India, frustrated youths due to complex socio-political-economic reasons are falling easy prey to the profiteering drug mafia. On the positive side of the narratives, most of the Vietnam war veterans who had been using heroin heavily while in Vietnam quit after returning to the comfort of their home, family, and friends, thus providing the narrative of recovery. Finally, the Icelandic Model, a series of pro-social policy measures at the government level targeting the children, the parents, the school, and the environment in Iceland, where teenage substance abuse had been peaking alarmingly in the mid-1990s, demonstrated the preventive prowess of these measures. All in all, this journey teaches us vital lessons not to forget the social psychiatry of addiction. It also teaches us that it would be a wise investment to improve the social determinants of health, including mental health and addiction.
Keywords: Addiction, recovery, social factors, substance
|How to cite this article:|
Basu D. Of mice and men.....The unforgettable narrative of how social factors shape substance use, addiction, and recovery. Indian J Soc Psychiatry 2020;36:270-6
|How to cite this URL:|
Basu D. Of mice and men.....The unforgettable narrative of how social factors shape substance use, addiction, and recovery. Indian J Soc Psychiatry [serial online] 2020 [cited 2021 Jan 18];36:270-6. Available from: https://www.indjsp.org/text.asp?2020/36/4/270/305947
It fills my heart with pleasure and humility to stand before you to deliver the prestigious Dr. N. N. De Oration 2019. Dr. Nagendra Nath De is perhaps most well known as the Founding Editor of the Indian Journal of Neurology and Psychiatry in 1949, the predecessor of the Indian Journal of Psychiatry. It is less well known that he also took an active role in framing the medical curriculum, psychoanalysis, drug trials, and was an advocate and protagonist for the humane treatment of mentally ill patients, including the improvement of mental health services in India and amendments of the then Indian Lunacy Act. Dr. De, incidentally, was also a trained specialist in tropical medicine and bacteriology! He was interested in the social aspects of psychiatry and was probably the first Indian psychiatrist to ponder on “preventive psychology,” a topic about which he wrote in 1949, and which has implications for today's talk.
The topic for this oration was inspired by the famous classic novel “Of Mice and Men” by the American novelist and playwright John Steinbeck in 1937, describing the travails of two migrant ranch workers traveling to look for job in the great depression era in the USA. The themes are of loneliness, and the sense of powerlessness generated by intellectual, economic, and social circumstances. It depicts, among other things, how the ecological (social, cultural, economic, and environmental) factors can shape human behavior at individual and community levels.
I thought of extrapolating this theme to the area of psychoactive substance use, addiction, and recovery as well as prevention. The currently predominant model to explain these phenomena, especially addiction, is the “brain disease model of addiction” (BDMA). Strongly supported by the National Institute on Drug Abuse, USA, and many others, this model emphasizes drug-induced brain changes at the individual level, producing an uncontrollable, chronic relapsing disease. It essentially says that addictive drugs cause addiction by inducing long-lasting brain changes, irrespective of, or despite, other external factors. While influential in creating a powerful narrative and public discourse aimed at reducing stigma and facilitating medical models of treatment, it tacitly de-emphasizes the complex sociocultural, contextual, and other environmental determinants of substance use and addiction. As a corollary, it focuses on supply reduction as the logical best way for prevention and biologically based medications as the logical best way for treatment. It also suggests that recovery can be very difficult because of very long-lasting brain changes caused by addictive drugs. Not surprisingly, the BDMA has its critiques, who argue that the above assumptions and implications of the BDMA are not necessarily valid in all circumstances, and that the BDMA may, ironically, actually contribute to stigma because of its emphasis on long-lasting and potentially irreversible brain changes.,
In line with these critiques, I challenge some of the assumptions and implications of the BDMA, by exploring this neglected landscape with a hop-and-stop global tour of five scenarios from five countries: Canada, the USA, India, Vietnam, and Iceland. I would like to take you through this tour through five narratives: the narrative of isolation, narrative of pain, narrative of frustration, and then the positive narrative of recovery, and finally the narrative of hope.
| The Narrative of Isolation (or, the Story of the Rats)|| |
Our tour begins in Vancouver, Canada, in the 1970s. Submerged in an ethos of experiments utilizing behavioral operant-conditioning paradigms with rats where the experimental animals, housed in tight, small isolated cages without any scope of free roaming, playing, mating and socialization, would quickly become severely compulsive alcohol or morphine users by pushing levers to self-administer the substances, Bruce Alexander, then a young researcher at Simon Fraser University in Vancouver, wondered if “enriching” the housing environment could alter the substance-using behavior of these rats. Alexander et al. improvised an innovative “Rat Park,” with the provisions for free roaming, playing, and socialization. These rats housed in the Rat Park were called the “rats in the social group.” To quote from the original study:
”The rats in the social group lived together since weaning in an open-topped plywood box with 8.8 m2 of floor area, a layer of sawdust on the floor, about a dozen, small open-topped cages that the rats could freely explore, and a 0.7m climbing pole.” More importantly, they could play and socialize with other rats and were not isolated in their respective cages.
The rats living in the Rat Park consumed morphine much less than those living in isolated cages when provided with a choice between water and morphine solution, after a period of forced morphine consumption. Alexander et al. noted that: “A possible explanation for the environmental effect is that for the isolated rats the reinforcement value of morphine ingestion was enhanced by relief of the discomfort of spatial confinement, social isolation, and stimulus deprivation.”
This result was repeated even in drug-naive rats irrespective of their age at housing in the enriched environment. Although not always replicated and dubbed as over-simplistic, these findings nonetheless were far ahead of their times and strongly suggested that compulsive drug use can be modified by social-environmental factors, thus creating a new narrative for the story of addiction.
Alexander extrapolated from these animal experiments to theorize that drug use and addiction (not only to drugs but also to various maladaptive compulsive behaviors) were the results of progressive isolation of man from his/her natural enriching environment by way of displacement and globalization. In his book and website, he writes emphatically:
”The view of addiction from Rat Park is that today's flood of addiction is occurring because our hyperindividualistic, hypercompetitive, frantic, crisis-ridden society makes most people feel socially and culturally isolated. Chronic isolation causes people to look for relief. They find temporary relief in addiction to drugs or any of a thousand other habits and pursuits because addiction allows them to escape from their feelings, to deaden their senses, and to experience an addictive lifestyle as a substitute for a full life.…. Maybe our fragmented, mobile, ever-changing modern society has produced social and cultural isolation in very large numbers of people, even though their cages are invisible!”
So that was the narrative of isolation. Now, for the next narrative.
| The Narrative of Pain (or, the Story of the Opioid Epidemic)|| |
We move to the USA. According to a conservative estimate by the Centers for Disease Control and Prevention, from 1999 to 2018, almost 450,000 people died from an overdose involving any opioid, including prescription and illicit opioids. It identified three waves in this tragic opioid overdose crisis: the first one starting in the 1990s with lavish uncontrolled prescription of potent opioids for a widening range of pain indications; the second one starting in 2010 following restrictions on the availability and use of prescription opioids and a subsequent sharp rise in heroin use; and the third wave starting in 2013 comprising of the increasing use of illicitly marketed fentanyl and related extremely potent synthetic opioids. The Pandora's Box has been opened!
While there exists a huge literature on this subject already, and it continues to expand, the common thread is pain. Opioids are very useful for severe pain associated with cancers and the like. However, the market for potent opioid prescriptions expanded to cover several nonmalignant or nonsevere pain conditions in the 1990s, due to a combination of market forces, touted low addiction potential of potent opioids, prescription pressure and reward, recognition of pain as a fifth vital sign that needed to be treated aggressively, consumer pressure, fear of litigation, role of various administrative and oversight agencies, and so on.
However, in this blame-game, what are often overlooked are some of the more basic issues and drivers of “pain,” for which the opioids are prescribed in the first place. Pain, as is well established, is much more than a sensory phenomenon mediated by the nociceptive system. There is a large psychological, cognitive, and even sociocultural substrate of pain perception, pain behavior, and pain consequences. It has been argued that the focus must also widen to the root drivers and determinants of both pain and addiction – their social, class, race, and economic substrates.,, In a highly cited article, it has been proposed that:
”The accepted wisdom about the US overdose crisis singles out prescribing as the causative vector. Although drug supply is a key factor, we posit that the crisis is fundamentally fueled by economic and social upheaval. Its etiology is closely linked to the role of opioids as a refuge from physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness.….Overreliance on opioid medications is emblematic of a healthcare system that incentivizes quick, simplistic answers to complex physical and mental health needs. In an analogous way, simplistic measures to cut access to opioids offer illusory solutions to this multidimensional societal challenge.”
A seminal national report echoed very similarly:
”Overprescribing was not the sole cause of the problem. While increased opioid prescribing for chronic pain has been a vector of the opioid epidemic, researchers agree that such structural factors as lack of economic opportunity, poor working conditions, and eroded social capital in depressed communities, accompanied by hopelessness and despair, are root causes of the misuse of opioids and other substances.”
Finally, Graham notes that in the governmental response to the opioid crisis management:
”What is missing is an approach that addresses the epidemic's root causes by dealing with both demand and supply issues... For such interventions to be effective over the long run, they must help address the underlying causes of despair, such as lack of employment, sense of purpose, and hope for the future.”
Pain can be seen here as an idiom of social distress and suffering. Indeed, the “Total Pain Concept” views pain as an amalgam of physical, psychological, social, economic, and cultural distress or suffering. Market forces (both legal and illegal) play on this multidimensional suffering to increase drug intake by the society on a mass scale.
And an addiction and overdose epidemic is born and maintained.
| The Narrative of Frustration (or, the Story of the Punjabi Youth)|| |
This narrative is based in Punjab, India. The opioid crisis in Punjab is very well known to the Indian reader, and well documented too.,,, Not surprisingly, it has become a highly politicized issue, with contrasting appreciation of the magnitude and attributes of the problem. Undoubtedly, with Punjab sharing a long international border with Pakistan and domestic borders with Rajasthan, and Jammu and Kashmir, there are many geopolitical issues which are well known, including the cross-border smuggling of heroin, opium and synthetic opioids, and narcoterrorism. However, less is talked about to explain the rapid increase of nontraditional opioid use and the high prevalence in rural areas of Punjab. A purely medical approach cannot explain these features, for which one has to cast the net much wider and deeper, with an in-depth analysis of the historical, sociocultural, political, and economic factors that created a fertile and vulnerable backdrop which made it easier for potent opioids to reach the inner rural Punjab at an alarming speed and magnitude. Socioeconomic and political analyses of the roots of the problem in Punjab are not widely available, other than in grey literature in media reports, which are plentiful and often providing first-hand qualitative insights,,,,, and a few scholarly publications.,
Although a tremendously complicated and multifaceted problem, a simplified version would run something like this.
Punjab, one of the erstwhile wealthiest states in India fuelled by its strong agrarian economy courtesy the Green Revolution of the late-1960s and 1970s, earning Punjab the name of “Bread Basket of India,” gradually started slipping since the 1980s–90s due to a combination of factors – overuse of pesticides and fertilizers, market factors, a slowing economy, and most importantly, lack of alternative economic infrastructure. The 1980s were also marked by violent insurgency, which though crushed later left its mark of destruction. The education of the traditional farming and rich youth was either suboptimal or not suitable for high-quality jobs in an atmosphere of stagnation. The 1980s and 1990s also witnessed the introduction of heroin in the Indian market. An unholy nexus of “people in position and power” at various levels fanned the fire. In this backdrop, the new millennium saw the rise of a young generation which was directionless, frustrated, achievement-oriented but unemployed or under-employed, reasonably educated but either not finding the job or not interested in the job but also not in the traditional farming occupation. This “lost generation” of Punjab provided the rich soil in which the seeds of an opioid epidemic were sown by various national and international players.,,
Again, as in the previous narratives, highly addictive drugs were necessary, but not sufficient, to adequately explain the situation. A narrative of frustration, based on long-standing complex issues as cursorily sketched above, is needed.
However, we have had enough of these depressing scenarios. After these three “negative” narratives, let us move on to two “positive” narratives: the narrative of recovery, and the narrative of hope.
| The Narrative of Recovery (or, the Story of the Vietnam Veterans)|| |
From 1955 to 1975, an extremely long, complex, and bloody war raged between North and South Vietnam, supported by their respective allies, of which the USA supported South Vietnam and waged a proxy war against the communist allies of North Vietnam. There was a huge toll on both sides. However, our narrative is based on the account of the very young war recruits from the USA, often in their late teens or early twenties, who went to (or, rather, pushed to) war. They also found a large and cheap supply of pure heroin in Vietnam. Estranged from family, stressed by the war, and fearing death or mutilation, they rapidly became addicted to it. This was not surprising, given the brain-changing effect of a powerful opioid like heroin. What was surprising was the outcome of such addiction after the Vietnam veterans returned home to their family, friends, and familiar environment. The chronicle has been abundantly and accurately documented by Robins et al., then a young sociologist and epidemiologist who studied this remarkable phenomenon.,,
Lee Robins et al. selected a random sample of 450 enlisted men who returned to the United States in September 1971. They also obtained a sample of 450 men who screened positive for opiates in the same month. These men were interviewed 8–12 months after their return to the United States about their drug use before, during, and after their service in Vietnam. Another follow-up was done 3 years after their return.
So what did they find? As quoted verbatim from Hall and Weier.
”The most surprising finding was the very low rate of heroin addiction reported by veterans in the 8–12 months after their return to the United States. Only 10% reported any heroin use, 2% reported using heroin more than weekly for more than a month and just fewer than 1% reported becoming re-addicted (a rate confirmed by urinalysis). This remained the case in the subsequent 2 years: only 2% were re-addicted at follow-up (although 5% had been addicted at some point in 3 years).”
And what explained these remarkable findings, flying in the face of the “intractability” and “irreversibility” notion of heroin addiction? What explained the recovery? But before that, what explained the genesis of the problem in the first face? In the words of Robins herself:
”Their remarkable rate of use was a response to market conditions—both the high availability of opiates and the lack of alternative recreational substances, to the absence of disapproving friends and relatives, and to the fact that serving in Vietnam was not seen as part of their real-life career.” Thus, when these external sociocultural contingencies were reversed, there was recovery, naturally. As emphasized by Hall and Weier, the natural experiment of Vietnam returnees “Directly challenged the notion that heroin addiction was a chronic and intractable “brain” disorder... Despite being a study of a unique scenario, the study sets out in microcosm many of the key factors that play out in the development and maintenance of substance addiction beyond the pharmacology of the drug: price, availability, the route of administration of the addictive substance, the availability of other substances, social norms, education and life circumstances.”
After this extraordinary classic tale of recovery from addiction, let us wind up the global tour in one of the most exotic places on the earth – Iceland. And this time the narrative is...
| The Narrative of Hope (or, the Story of the Icelandic Model)|| |
This exotic and sparsely populated island in the northern hemisphere noted for its natural beauty and geological wonders, was nonetheless plagued by the problem of adolescent substance abuse and associated behaviors in the 1990s. Iceland ranked quite high on various parameters of adolescent substance use and abuse among the European countries. Alarmed by the rising trend, a visionary group of policy makers, researchers, and practitioners – strongly supported by the local government – decided to gather their strengths, try out a new approach, and see whether it might be possible to reverse this negative, upward trend in substance use among young people. This gave rise to what is called the Icelandic Model or the Icelandic Prevention Model (IPM) for primary prevention of adolescent substance use. “The core idea behind this prevention approach was to strengthen a host of community protective factors, e.g., parental monitoring, parental co-communication and social involvement and adolescent participation in organized sports, and to decrease risk factors such as adolescent party life-style and unsupervised idle hours.”
Over 20 years, the application of the IPM at a national level brought down the indices of adolescent substance use and hazardous behavior such as binge drinking to a large extent, with the clear formulation and implementation of the guiding principles, which have been well documented recently.,
In her latest article, the protagonist of this IPM, Prof. Inga Dora Sigfúsdóttir, emphasizes the role of sociology in the early conceptual development of IPM. In her own words:
”Dr. Thorolfur Thorlindsson, Professor of Sociology, led the study and other study personnel were faculty or his students at the University of Iceland. The IPM's roots in sociology were important for two reasons. First, the theoretical pillars of the study were based in classical theories of adolescent deviance that come from sociology and criminology. Collectively those theories assume that the roots of risk behaviors originate in the environment rather than in individual differences. Second, sociological studies tend to be population focused rather than individual focused—generating an emphasis on population-level, cross-sectional data collection and assessment of environmental change—rather than longitudinal studies tracking changes in individual behaviour among smaller samples over time.”
The concepts behind IPM are simple and powerful: role of peer influence in substance use; role of family involvement; role of school environment; role of community participation and engagement in sports and cultural activities; and the collaboration among behavioral and social scientists, policy makers, and local key stakeholders. Importantly, one of the “core strategies” adopted in the IPM is “building a long-term community-level commitment to curtailing adolescent substance use and creating an environment that is low in risk factors and high in protective factors for substance use, thus promoting the social construction of an environment in which the default choice of adolescents is to select behaviors and activities that confer protection and reduce the risk of substance use.”
It is to be noted that the IPM has now been tried in several countries and areas in Europe and also in non-European countries like Chile, demonstrating its robustness. What Sigfúsdóttir et al. wrote more than 10 years ago still holds true: “Our experience suggests that prevention efforts need to simultaneously activate the peer group, the school, the family and those who organize youth activities to reduce substance use.….Thus, in a broader context, our findings point to the enduring importance of social relationships, parental social support and social control in particular and the importance of meaning in the everyday social world of adolescents.”
Thus, this model documents and emphasizes the role of social factors in planning and implementing primary prevention of substance use in adolescents.
| So What Have We Learned?|| |
We have completed our whistle-stop global tour, for now. Through this journey and this story “of mice (rather, rats) and men,” what I have learned is how various social factors shape substance use and its prevention, addiction, and recovery from addiction, by providing:
- The narrative of isolation
- The narrative of pain
- The narrative of frustration
- The narrative of recovery
- The narrative of hope.
The BDMA, though a powerful model to buttress neurobiological research and treatment development efforts at an individual brain-based level, should not make us lose sight of the important social-cultural-environmental-economical-ecological forces that impinge upon the individual brain to make it vulnerable, or resistant, to drug use and associated behaviors, which are often learned, to the extent that the brain changes in addiction have been better explained as a learning process rather than a disease. As a Letter to Nature, written by 94 signatories, emphasized:
”Substance abuse cannot be divorced from its social, psychological, cultural, political, legal and environmental contexts: It is not simply a consequence of brain malfunction. Such a myopic perspective undermines the enormous impact people's circumstances and choices have on addictive behaviour.”
Another letter in the same issue of Nature put it rather elegantly in perspective by using an excellent analogy: “…addiction is the car crash and the brain is the vehicle: The person driving it contributes a psychological component, the others on the road represent social factors, and road conditions correspond to the environment. To promote any one of these as the prime cause of addiction, as in the brain-disease model, overlooks the importance of the other components.” A recent editorial in this Journal also echoed this context-based model by emphasizing that “social psychiatry has an important role to play in bridging the artificial sociopolitical division between the brain disease and free will models of addictive behaviors.”
Our journey teaches us not to forget the social psychiatric dimension of substance use and addiction, at all phases: prevention, initiation, maintenance, and recovery. It also teaches us that it would be a wise investment to improve the social determinants of health, including mental health and addiction. This would be like investing capital in the present to reap sustainable gains in the future!
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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