Reclaiming Lost Talent by the Millions

It's time to treat the chronic brain disease called addiction.

Posted Feb 22, 2018

Charlie was making his rounds. Dressed in his pride and joy, the navy blue pin-striped suit he’d found in a dumpster years ago (chalk white stripes now barely visible at all), wearing the crumpled once-spiffy dress shirt he’d actually washed in a public restroom last week, shuffling along in his usual broken down brown loafers that looked more like slippers than shoes, he sidled up to a stool and asked Mickey for the usual, a double shot of bar whiskey with a short beer chaser.

Mickey was Charlie’s buddy. They both loved the track, Robert B. Parker novels, and Shakespeare, as well as complaining about the latest scandal in local and national politics. Their friendship had endured Mickey’s quitting drinking years ago, a trick Charlie had passed on. Why should he? A drink was the one sure pleasure life offered him.

“Long day?” Mickey asked Charlie as he slid him the glass of cheap whiskey and the short draft. 

“Long enough to make me thirsty,” Charlie said with a long laugh. “but what day isn’t?” Charlie loved to laugh and make other people laugh. “You know, John Bear was a drinker. He gave some of his best lectures drunk as a skunk.  How come he could get away with it?” John Bear was a professor in the college they’d both attended, both majoring in English, both graduating in 1972.

“Must have been the genes,” Mickey said, “or the luck of the Irish.”

The two of them would talk through the evening until Charlie ran out of the money he’d made leafleting from 4 a.m. to 8 a.m., a job he did faithfully every day, hangover be damned. He preferred to spend his money in Mickey’s bar than save toward an apartment. He knew how to be homeless, knew all the angles because  he’d been doing it around Boston since his wife kicked him out 25 years before.

"The gout is killing me,” Charlie said. “I’m telling you, Sir John Falstaff is the picture of health compared to me. But what can I do? I can’t live without my sojourns to see you and get my cup of courage.”

“Listen,” Mickey said leaning forward across the bar, “I’m serious, don’t piss on the sidewalk again. The cops are cracking down. They’ll run you in for indecent exposure and if you get a few of those you’ll be on the sex offenders list.”

“Don’t worry, don’t worry, I’ll find a nice secluded spot to empty my bag.”

“You would if you had to piss right now,” Mickey said, “but after you’ve had your fill, you’re liable to forget. So use our latrine before you leave, promise me? I’ll take you there myself.”

“And you’ll hold my johnson for me no doubt,” Charlie said, slamming his shot glass down with a loud laugh.

According to Nora Volkow’s review article in the New England Journal of Medicine (Jan. 28, 2016), at least 20 million people suffer from addiction in the United States, and the cost to our economy is a staggering 700 billion dollars per year. What’s worse, 90 percent of them get no treatment.

People like Charlie, people who once were bright-eyed, ambitious children exploring the field of youth find their way during adolescence or young adulthood to drugs that fundamentally, drastically change their brain. They soon suffer from a brain disease called, in Charlie’s case, alcohol use disorder (AUD).

Contrary to what most people believe, it is a treatable disease. We now have the knowledge and tools to offer Charlie a more than decent chance at a rewarding life.

But instead, as a society, we leave him to shuffle around homeless, living by his dimming wits, and jailing him if he urinates in a spot others can see.

Imagine if we did that with other chronic diseases—because that’s exactly what AUD is, a chronic disease. Imagine if we let diabetics die on the sidewalk when they went into ketoacidosis, or if we told people with asthma to suck it up, or if we told people with arthritis that they should be grateful that they have arms and legs at all.

But that is exactly what our “moral model” does with AUD. We blame the sufferer for having the disease. We see the disease not as a disease at all, but as a moral failing. We scorn the sufferer, exclude him, avoid him, and avert our eyes when he panhandles. “Don’t give him money,” we say to dismiss the smidgen of guilt we might feel, “because he’ll only drink it.”

But what if the drink is his only way of finding relief? For most people with serious AUD, the drink no longer gives pleasure, it merely alleviates the misery of the state of no-drink, somewhat.

Instead, what if we found a different way? What if you or I walked into that bar, sat down next to Charlie, and treated him with a soupcon of respect? What if we bought him a shot and a beer and joined him by having one ourselves? Oh, perish the thought, the critic says, that’s enabling, co-dependent behavior at its worst!

Or is it? What if, after we had a couple of shots with Charlie, we said, “Charlie, my friend, how about if you and I walk across the street and see if that hospital is serving good whiskey tonight?”

What if we knew enough about AUD treatment, and what if we knew that Charlie was not scum of the earth but a good man struggling with a pernicious, chronic disease of his brain, so that we could explain to him in terms he could accept, that while the people at the hospital across the street probably would not set him up with a shot and a beer, they could tell him when to come back tomorrow to get the help he should have received many years ago, before his wife threw him out.

Problem is, 25 years ago we were so mired in the moral model that even doctors, even specialists in what was then called alcoholism, would have had little to offer beyond trying to “break down his denial” and shoo him off to AA, there to do the best he could, which most of the time, God bless AA, was not very well.

But now in 2018, now the main obstacles to Charlie’s standing a damn good chance of finding a whole new life and using his Shakespeare-loving brain to his advantage and society’s as well are ignorance, stigma, and good old-fashioned stupidity. 

It’s not lack of science but rather prejudice that keeps these people homeless, and a society that chooses to spend far more money on punishing addicts than in treating their underlying disease.

It’s like incarcerating the person who goes off his high blood pressure medicine. When someone who has AUD gets drunk, he needs to get back into treatment, just as surely as the person who goes of his blood pressure meds needs to get back on them. Most people, including many doctors, still don’t “buy” or “believe in” the disease model of addiction. But that model is not a religious principle. It is not a matter of believing in it. The science behind it is compelling. The main reason it gets rejected has nothing to do with science and everything to do with prejudice, lack of knowledge, and a primitive desire to remove from sight the suffering person we don’t know how to help. Most people still blindly adhere to the centuries-old moral model. Scorn the addict. Punish the addict. He made his bed, let him lie in it.

And what benefit has that model given us? 90 percent of the people who suffer from AUD (and other substance use disorders, including behavioral addictions) get no help, or worse, they get punishment, ridicule, incarceration and the benefit of an early grave.

The simple solution—scorn and punish—brings to mind H. L. Mencken’s remark made in 1915: “Explanations exist; they have existed for all time; there is always a well-known solution to every human problem—neat, plausible, and wrong.”

It’s time to bring Charlie—and Falstaff for that matter—in from the cold. Falstaff may have been Shakespeare’s greatest creation, a character so rich, so complicated, so talented, so unforgettable, that he stands out as perhaps the most vivid of all the characters that the greatest creator of characters of all time gave to us.

He had big-time AUD. He was a stumble-down drunk, to use the pejoratives we save for sufferers of AUD. He was a scoundrel, a womanizer, a subverter of the Prince’s virtue, a disruptive force in society, a coward in battle, and a thorough-going blight upon civilized life. 

And yet he stole the show. He stole our hearts. We loved him even when he embodied everything we were supposed to despise, not so much because he was lovable (he stank, he puked, he staggered, he belched his way through life) but because of what he did to us. He humanized us.

He snapped us out of our righteous delusions and hypocrisy not by preaching to us—although he could summon up a great sermon on demand—but by showing us what we, as human, all have in us.  And he did it—or Shakespeare did it—in such a way that we felt not fear or pity but rather laughter, love, and relief.  Ah, what joy, at last, to revel in being so bad, so human!

That is not to say we should laugh with Charlie or even love Charlie rather than help him. But it is to say that the “addicted population,” the tens millions of people who have the chronic brain disease called a substance use disorder can help us a lot by showing us life as most of us never see it or see it only dimly.

These people are so often the artists, the poets, the dreamers, the innovators, the creators of beauty, humor, and surprise that we all need so badly.

It’s time to bring them all in from the cold, literally from the homeless itineraries they trudge day and night, trying to find a sequestered spot to pee, or a cardboard box to put up as shelter against a biting, cold wind.

They do not need our pity, any more than they need pity’s cousin, scorn.

What they do need, and do deserve, is enough of our respect to offer them the benefits of our science, the benefits of what we’ve learned about how to treat the chronic, usually crippling, sometimes fatal brain disease called AUD.

When we offer that not only will these millions at last get help, but our entire society will grow in stature, dignity, and strength.