There are reasons, plural, why some people get addicted to opiates and some do not, just as there are reasons why some people suffer from depression and some do not, and why some people tolerate alcohol just fine while others end up breaking people’s noses in brawls and then blacking out. The shocking news is: Brains, genes, metabolisms and environments are varied. I know, it’s a lot. And for my super-well-intended buddies on the socials who pontificate about how addiction is “a choice,” I’ve got a PBS program I recommend you take a gander at. Because I am super sick of this conversation, in all its shades of raging ignorance.
Please watch “Addiction,” the new documentary from NOVA. Please? It has the unmistakable tang of non-fake news and it will relieve you of the burden of believing the opioid crisis is occurring because record numbers of especially dumb or weak-willed people have awakened on a random Wednesday morning and decided to buy black tar from the twitchy dude under the freeway overpass just to see what’ll happen. Legions of people are probably both dumb and weak-willed, but it isn’t the determining factor in addiction. Even if you really, really want it to be, for whatever reason. It can happen to anyone, and for most people it starts in a doctor’s office or an ER.
A while back, I was treated to a Showtime trainwreck about the opioid crisis. It was classist, arguably racist, and outrageously misleading, other than one truth it put forward loud and clear: People who are addicted to painkillers are abandoned by the system and criminalized. That part was spot-on.
NOVA’s new program is not sensationalist and it isn’t about gangs in Mexico. It’s a calm, educated look at how opiate addiction happens, why it’s surging in certain areas, and what needs to change if we want that trend to reverse. It tracks doctors at Stanford, public health officials in West Virginia, controversial safe injection sites (in particular, one in Vancouver; they’re not currently legal in the U.S.), a teen with an improperly diagnosed disorder who got taken on a seriously nasty roller coaster ride courtesy of conventional medicine and its attitudes toward “addicts,” and a scion of upper-tier privilege who was also misdiagnosed and whose resources, education and attentive parents could not save him from his own dopamine receptors. There is some agonizing footage of what happens when babies are born in opioid withdrawal that’s still making my skin crawl as I write this. There’s a lot of detailed, clear-headed research into how addiction works, how humans have evolved to respond to dopamine (the neurotransmitter that mediates pleasure and “reward” responses) and how chemicals that bind to dopamine receptors can, over time, reduce their function and even their numbers, creating a vicious and verifiably not-choice-based circuit of escalating need for those chemicals. Since we know this, it’s curious to note that people who become addicted to opioids are not considered medical patients with a medical problem. They become pariahs, criminals, outcasts. That’s generally when Mr. Thousand Yard Stare under the highway starts to seem like an option, because there aren’t any legitimate ones left. And if that guy’s selling something tainted with the elephant tranquilizer Fentanyl—or, hey, cut with rat poison-well, the odds of respiratory arrest are kind of high.
Dr. Rahul Gupta, a public health official dealing with this crisis in West Virginia, notes that overdose deaths are happening at the rate of “a Boeing 747 crashing every day.” And addiction is really very equal-opportunity, even though treatment outcomes are not. Places that are hit especially hard by opioid overdose deaths correlate with socio-economic depression in a lot of cases (if the only gig in town is in a coal mine, guess what, you’re at really high risk of things like crush injuries and crippling chronic joint pain), but addiction doesn’t recognize class, race, gender or education level, much less “willpower.” It’s a biological process. Where demographic differences come into play is in what resources are available to you if, after your surgery, your injury, your illness, you are having trouble with things like nerve and bone pain, incessant vomiting and blinding rage (for example). But even if you are wealthy and well-educated, or, you know, a rock star, the odds are good that the medical system will mishandle you and predispose you to long-term and potentially terminal misery.
The truth is, there’s a lot we don’t really understand about pain, and the tools we have for managing it are relatively crude and relatively limited. A cynical person would also be prompted to note that it is… lucrative when large numbers of people are addicted to things and that it’s theoretically possible that, say, the pharmaceutical industry isn’t in a raging hurry to stop dispensing those meds. “Addiction” presents a very compelling case for a major revision of opinion on what addiction is and how to heal it—and it starts with actually accepting that “heal” is the right word. Not “sack up.” The documentary is oriented toward non-scientists (though I especially think physicians should be watching it), it’s logically presented, clearly directed, well-paced (it covers a lot of ground smartly and thoroughly in an hour), and it will in all likelihood challenge some of your preconceptions about who becomes an opioid addict and why—even if you already know a good deal about it.
I’m also psyched and grateful that there was some attention devoted to the question that started troubling me about halfway through, which was whether the observable damage to the prefrontal cortex of the brain was permanent, whether even a recovered addict would have permanently diminished capacity to… feel OK. Happily, this is being researched, and the answer appears to be, “No, it can be reversed.” But in order to make that happen, the medical system needs to acknowledge addiction as an actual illness, not a “bad choice” or a moral failing.
NOVA “Addiction” premieres tonight at 9 p.m. on PBS. (Check your local listings.)
Amy Glynn is a poet, essayist and fiction writer who really likes that you can multi-task by reviewing television and glasses of Cabernet simultaneously. She lives in the San Francisco Bay Area.