Editorial Comment:  A voice from seven centuries past

Coincidentally in the time of the Great Plague, 700 years ago, Giovanni Boccaccio wrote of how a thing – a substance – may have both evil and beneficial essences:

“Who does not know that wine is a most excellent thing, if we may believe Cinciglione and Scolaio, while it is harmful to a man with a fever? Are we to say wine is wicked because it is bad for those who are feverish? Who does not know that fire is most useful and even necessary to mankind? And because it sometimes destroys houses, villages, and towns, shall we say it is bad? Weapons defend the safety of those who wish to live in peace, but they also kill men, not through any wrong in them but through the wickedness of those who use them ill.” [Giovanni Boccaccio, The Decameron, 1386, “Conclusion”]

Substance use disorders appear unique. Alone among the illnesses that dwell in the house of medicine, those relating to addiction are characterized phenomenologically, behaviorally; and yet are the outcome of toxic exposure.  They do not, unlike lead poisoning or the dementia that develops from diabetes, induce sympathy in the observer. It is quite difficult to get an interested body, such as a jury or a legislature or a third-party insurer, to listen attentively to the impact of substance use on someone’s: involvement in commission of a crime; vulnerability to an industrial accident; methamphetamine-induced cardiomyopathy; or requirement for hepatic transplant.  Controversial still in some states is the insurer’s practice of denying coverage benefits to those seen in emergency departments with alcohol intoxication, following a motor vehicle collision.

And indeed, while there are times when the consequences of the use of substances deserve no sympathy, it is rare that one gets drunk with the intent of committing crime. The dislocation of judgment from normal planning is a consequence of the substance abuse that arises later. Let’s use as another example what happens when you get very drunk, and suffer a hangover: your intent was to develop a sense of pleasure certainly, a moment of euphoria maybe, and initially that happy outcome was realized.  But later, at three in the morning, when you are feeling wretched and miserable and nauseated, your head nearing critical mass, at that point you were not actively drinking; and so there was no association between drinking and the misery. If anything, the learned association is between not drinking and feeling miserable (drinking = good; not-drinking = bad).

This, of course, applies to pretty nearly the whole range of substances that are used to manage unpleasant affect, to cause euphoria, or simply to detach from reality. And we should be shy to scorn people who use substances for those purposes because there is not so very much difference between doing so for the inoffensive reasons cited, and using them to the point of intoxication and oblivion. The difference, at some point, becomes a matter simply of degree. That single cigarette, that single cup of espresso, that glass of wine, that draught of sleeping medication - all hold in common a desire to shift from what is to what is not. 

So for those who have never had that single cigarette or that shot of whiskey or wish to gamble, and for whom this desire for change in mood may be incomprehensible, they may be forgiven their lack of understanding or of empathy. But for the rest of us, we risk hypocrisy, or at the least a lack of imagination if we cannot extend our limited experience of the substances to understanding the domain of the person with an addiction.  Ours is a discipline of empathy.

How is empathy developed and put it to use? That is the essence of the therapeutic interviewing process, motivational interviewing and ultimately contingency management: proceeding by steps to understand where the patient truly dwells and propose choices that lead her/him away from that place.

- Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM