Ideas - Wait, so addiction might not be a brain disease?

Episode Date: March 3, 2026

That’s what Hanna Pickard argues. After analyzing the scientific research, and working with those who’ve stopped self-destructive drug and alcohol use, the Johns Hopkins philosopher sees addiction as a complex behavioural disorder. She argues it’s driven by individual psychology and social circumstances, and should be treated that way. Jowita Bydlowska and Michael Kaufmann, both memoirists of addiction, weigh in.Guests in this episode:Hanna Pickard is the author of What Would You Do Alone in a Cage with Nothing but Cocaine? A Philosophy of Addiction (2026). She is a professor of philosophy and bioethics, as well as psychological & brain sciences, at Johns Hopkins University.Jowita Bydlowska is a writer of fiction, as well as two memoirs of addiction: Drunk Mom, and Unshaming: A Memoir of Recovery, Relapse, and What Comes After (2026).Dr. I. Michael Kaufmann is emeritus medical director of the Physician Health Program of the Ontario Medical Association. He is a retired family doctor, a retired addiction doctor, and the author of Drugs, Lies, and Docs: A Doctor's Memoir of Addiction (2024).

Every day, your eyes are working overtime, from squinting at screens and navigating bright sun to late-night drives and early morning commutes. They do so much to help you experience the world. That's why regular eye exams are so important. Comprehensive eye exams at Spec Savers are designed to check your vision and overall eye health. Every standard eye exam includes an OCT 3D eye scan. Advanced technology that helps your optometrist detect early signs of eye and health conditions. like glaucoma, cataracts, or even diabetes. It's a quick, non-invasive scan that provides a detailed look at what's happening beneath the surface.

Don't wait. Give your eyes the care they deserve. Book an eye exam at Specsavers from just $99, including an OCT scan. Book at Spexsavers.cavers.cai.a. Eye exams are provided by independent optometrists. Prices may vary by location. Visit Spexavers.cavers.ca to learn more. This is a CBC podcast. I developed this.

condition, disorder, disease, call it whatever you want, that took me far away from the person that I was meant to be. Addiction can be hard to fathom. To me, it's a sort of lifelong investigation on a personal level and as someone who writes about it. Better understanding can shape more effective treatments, lessen damage to families and communities, and it can save individual lives. I've heard someone say that addiction is suicide and installments, and I do believe that you don't do these things

if you aren't thinking about death consciously or subconsciously. Welcome to Ideas. I'm Nala Ayyad. Making sense of addiction is a high-stakes real life matter. I don't think any of us today don't live with people we know who struggle with drugs, So there certainly, for me, have been people in my life who I've cared about and who've had those sorts of struggles. And that's part of the background. That's Hannah Pickard, Canadian-born, Oxford-educated, and based in the U.S. She's a philosopher at Johns Hopkins University with appointments in bioethics, as well as psychological and brain sciences.

Her approach to understanding addiction is cross-disciplinary. I draw on the natural sciences, the social sciences, the humanities, law and medicine. But I also think that for me, the anchor in the clinic that I have based on my own experience has been very important. For a decade, she assisted in a therapeutic community, a public health clinic in England treating people with addictions and mental health issues. But it's philosophy that she credits with offering a clear, and careful way to think about addiction. Part of that is just a kind of really long-standing commitment to the interrogation of ideas and assumptions

that we often take for granted and the demand for rigor and clarity and thinking. But part of it is a kind of big picture orientation. Sometimes philosophers do that about topics, which are a little bit ivory tower, but it's perfectly possible to use that kind of orientation and methodology to think about things in the real world. And that's what Hannah Pickard has done.

She's considered addiction research for 25 years and written a book about it, intended for reading in the real world. It proposes a view of addiction based in individual psychology and circumstances. It relocates it away from a brain disease model, which can then admit of all sorts of different explanations. nations. That's at odds with a mainstream view that's been around for decades. It's also a counterpoint to recent research around medications predicated on that brain model. Hannah Pickard's book is called What Would You Do, Alone in a Cage with Nothing But Cocaine? A Review in the Journal

Science called it a brilliant and compelling contribution with the potential to reframe the public's understanding of drug use and addiction. Hannah Pickard walked ideas producer Lisa Godfrey through her argument. So we'll get deeper into the neurobiological model in a minute, but first let's define the terms. What actually constitutes addiction in your view? So I like to start by thinking not about addiction, but about drug use. Because I think one of the things that's gone wrong in our understanding, understanding of addiction is a failure to recognize how prevalent and ordinary and intelligible

drug use is today and indeed across human history. So a substance we ingest that has a psychoactive effect and that can be used for medical, religious, personal or cultural reasons. Nicotine, caffeine, alcohol. So it's an expansive notion of drug. And they do things for us that it's perfectly natural to want, experiences of pleasure, euphoria, transcendence, but also heightened cognitive awareness, in some context, heightened spirituality, relief from all sorts of negative feelings like anxiety, boredom, loneliness, anger, rage, despair. And so drugs just serve this panoply of functions that we use them for all the time. in our lives without very much ill happening to us in the majority of cases. And I want us to start

there because I think it brings to the fore something really important and indeed distinctive about addiction, which is that addiction is a form of drug use where that kind of basic intelligibility, that psychological sense we can make of why we and others use drugs, has been lost. The costs start to ratchet up. Loss of jobs, friends, family, social standing, housing, financial well-being, loss of physical and mental health, in jurisdictions that criminalize drug possessions, sometimes the loss of freedom, sometimes even, you know, the greatest loss of life itself. So what happens in addiction is that people keep using drugs despite these costs. And that that creates what I like to think of as a puzzle, right? I think of it as a puzzle of addiction. And

the puzzle is, why would anyone keep using when whatever the benefits are that remain, they're outweighed by the costs, right? There's every reason to quit, and yet people don't. And so the way I think about addiction is really as a kind of behavior, namely drug use, which has lost the psychological intelligibility that ordinary drug use has. And then the really essential question that we need to ask that any theory of addiction ought to be trying to answer and that we often try to make sense of in our ordinary interpersonal relationships with people with addiction is,

why is someone doing this? Why is someone using drugs in a way that's so self? self-destructive. That's so against their own good. And so that's the, in some sense, the new definition of addiction I give. It relocates it away from a brain disease model, away from the idea that addiction involves all and only something wrong with the brain and sees it as a pattern of behavior, which can then admit of all sorts of different explanations, different explanations and different people. Can you explain where that brain disease model manifests today?

Well, I think the dominant places you can find it articulated are both in addiction science, addiction neuroscience, and to some extent cognitive science, and also, I think, in public discourse. Addiction is a chronic brain disease. And we can't see the brain from the outside, but it sort of looks like a person's lost control of their drug use, so then lost control of their life. lives because of that. The 20th century saw a number of theoreticians circling round and beginning to articulate a brain disease model. It sort of got its public statement and defense in 1997 when Alan Leshner, who was then director of the National Institute on Drug Abuse in the U.S., wrote this really seminal short paper called Addiction is a Brain Dism, disease and it matters. And in that paper, Leshner defined addiction as a chronic relapsing neurobiological

disease of compulsion. And he did that in part with a sense of optimism that neuroscience was discovering a single neural cause underlying all addiction, but also with the host. But also with the hope that that relabeling of addiction would serve to combat addiction stigma and increase public support for research and treatment. So there are in consequence two different ways in which we might approach and think about the brain disease model. One is whether it really is true, right? Is it right that all cases of addiction involve compulsive drug use caused by brain pathology, which is the essence of what addiction is. But we can also ask whether the model has had the social consequences that Leshner hoped. Does the model do good and is the model true? You have chosen a long title for your book.

So could you walk us through? What would you do? alone in a cage with nothing but cocaine. So the seminal experiment that I allude to in the title put rats alone in a cage with nothing but cocaine permanently. And perhaps unsurprisingly, what happened to those rats is that they took a lot of cocaine. Cocaine is an aderectic, so it suppresses hunger and thirst, and in consequence they also stopped eating and drinking.

And within a month, about 90% had died. So that experiment I really see as such a powerful illustration of the brain disease model of addiction as a chronic relapsing neurobiological disease of compulsion. Because if you ask, what would make an animal take so much cocaine at the expense of food and water to the point of death, the natural idea is, well, it's the power of. drugs to hijack the brain and compel use. Addictive drugs all cause dopamine to flood the reward pathway 10 times higher than a natural reward would. Over chronic use, nothing else natural is quite as rewarding. Subsequent experiments have really shown that that's not the right interpretation. One of the things you might notice about that early experiment is that it's an extremely unnatural

environment for a rat to live in. Rats are highly social animals. They forage. They're used to living in complex environments where they make lots of choices. And in that environment that they were in, there was literally nothing but cocaine. So you might wonder what happens if we give rats a choice between cocaine and another reward. And that is exactly what a number of scientists did over the course of a couple of decades of extremely highly controlled, beautifully designed experimental work. The basic idea is that instead of there just being a lever, you can press for cocaine, the rats are in a chamber where there are two levers, one for cocaine and one in the first set of studies for saccharine water, and in the second set of studies, the lever is for social

reward. And the rats are trained so that they know what they can get by pressing each leaf. In the experiment, both levers come out at once and they're given a choice. The amazing finding is that even when the rats show every indication of addiction like behavior, and they're not hungry or thirsty, and they're not socially deprived, 90% of them take the saccharine over the cocaine, and 100% of them take the social reward over the cocaine. So it's this incredible finding from science which really ought to make us question whether what was going on in that original experiment was that drugs were hijacking the brain or rather that the rats were alone in a cage with nothing but cocaine, right? That's what's explaining their behavior, the poverty of their environment and the psychological impact that's having on them. So the book really invites the reader at various points consistently throughout it.

and beginning in the title, to imagine themselves as a person with addiction in the circumstances in which we know many people with addiction live, and to think about what that would be like, not only what they would do, but what in that context drugs might mean for them. Can you be more explicit about the cage that some people find themselves in? It involves coming from backgrounds where there are things like poverty, bullying, war, social isolation, often migration, where education and employment opportunities are limited, potentially even non-existent, and where people just live with a great deal of distress and suffering. So there's anxiety and depression and some of the sort of cognitive

thinking and lack of self-esteem and lack of self-worth that can characterize many forms of mental disorder, especially when people have lived in conditions where they felt deeply ostracized and indeed mistreated by mainstream society. You've come up with three reasons that you think people might work against their own good when it comes to drugs. Self-medication, I think would be rather obvious to people through this discussion and just through anecdotal experience. You also point out that there's a kind of self-identity at times that people can be in a community of people with addiction. And there's actually a sense of purpose around obtaining drugs and being with those people. But I wanted to ask you about the third one, which you say is self-harm.

Can you talk about that one? That is an incredibly painful thing to start to think about. Self-harm and suicide are very dark, difficult bits of human psychology for us to begin to reckon with. But I think part of what we have to do to understand addiction is recognize that sometimes people do things that are self-destructive on purpose and addiction, the use of drugs in addiction. can be one of those things. And why that matters is that if that's what's going on with a person, then first of all, we won't be able to help them if we're insisting that they have a brain disease of compulsion or we're thinking that really they're doing this to make themselves feel better, right? It's a form of self-medication. In fact, they're doing the very opposite. They're doing it

to harm themselves. But at the same time, we're doing it. We're doing it. We're doing it. We're doing it. We're We do have clinical tools to help people with self-harm and to help people with suicidal ideation and the sense of self, which often underlies both of those self-destructive desires. And so it allows us to take those resources and bring them to bear in appropriate cases with people with addiction. In the treatment of addiction, when I looked into how widespread the brain disease model was in Canada, I saw a number of research centers and rehab facilities that sort of combine the two ideas, that addiction is a mental health issue and a brain disorder. Does that work for you?

So the key thing to the way I want to think about addiction is that it's not one thing for everyone. So one of the benefits of thinking about addiction as a pattern of drug use that's gone wrong, If you want to label for this, we could call it a behavioral disorder, is that the explanation of why it's gone wrong and what's going on with a particular person can really differ person to person. And I think this is tremendously important. People are different. We are different from each other. People with addiction are no different from the rest of us in this way. They're different from each other.

So I suppose what I worry about, about the way you have just sort of described the conceptualization of addiction within some treatment facilities is that it's going to be a mental health condition, which is a brain disease. And that is narrowing even if it's the right way of seeing it for some people. So part of my really deep concern in writing the book is to make sure that. that we tailor our research attention and our treatment initiatives to everyone and try to help people whose problems may not be best addressed through the brain disease model. But that doesn't mean that when that model is appropriate for someone else, we shouldn't use it. So it is part of our thinking in contemporary society. society that most mental health conditions, I think, are brain diseases, right? In the 1980s,

we had the broken brain decade where that kind of idea of mental disorder really took off and started to propagate. And many of the concerns that I identify in relation to addiction in the book also hold in relation to other kinds of mental disorder. I mean, we just haven't proved very good at finding the underlying brain mechanisms or in finding treatments for them. Addiction seems like it can run in families. Is there a genetic component there that has to do with the brain? I'm not a geneticist, so what I'm about to say needs to be checked and taken with a grain of salt, but I think about 15 different genes have been identified that predispose, but they're not uniquely identifying of any particular mental disorder, including addiction. It's also the case that a

predisposition is not the same as an addiction or a disorder, right? A predisposition means that when genes interact with certain kinds of socioeconomic contexts of the sort you just mentioned, people are at heightened risk. And that means that we all are, ought to take heightened precaution in relation to that risk. But a predisposition is not the same as necessarily inevitably getting the disorder or indeed having it, right? So the answer is yes. There is an important genetic component, as I understand it, to mental disorder in general. But let's not be reductionist about that, right? Let's not. take the truth of that finding, whatever exactly it is, to begin to narrow our focus and rule

out the way that finding is probabilistic. It's only likely to be expressed in conjunction with certain kinds of cultural and socioeconomic contexts. And it's really not the whole story. There's so much more to say and to add to that picture. And substances themselves are some not more habit-forming than others. There is a way that we can be confident that some drugs, when used regularly over long periods of time, will produce dependence. But dependence is not the same as addiction. You can be physically dependent on a drug without being addicted. So to give a clean example of this, think of something like the use of opioids in palliative care, where we think of these opioids as, of course, producing physical dependence, but they often enable people to maintain cognitive function,

to live without pain, to have relationships, and an end-of-life period, which is meaningful and, you know, really of great value for them. So we don't think of them as addicted, because despite being dependent on the painkillers, the painkillers are really doing something good. Withdrawal symptoms are associated with certain substances, and that seems. very much in the body as opposed to psychological or social, does that not indicate that it's a medical condition, even if not based in the brain? It's a medical condition, and withdrawal is really important because withdrawal when you go through it is one of the reasons why people are motivated to keep using, right? So it can be one of the mechanisms by which people are stuck in a cycle.

But it's also the case that something that we might call psychological withdrawal is really important. You know, in the book, I really spend a lot of time thinking about the value of drugs to people with addiction and what drugs mean to them, how they relate to them. And when you're trying to do without drugs, if drugs have a really deep value or meaning for you, they're the thing that takes away the pain. They're the thing that you've been able to rely on when no other person has been a person who you could rely on. Maybe they are wrapped up in your identity, your sense of self. There's a kind of natural fear and anxiety that comes with doing without all of that, which is also part of taking the decision to quit and seeing it through. Yes, we should acknowledge the importance of physical withdrawal while also, of course, acknowledging that for

most of the substances which have a physical withdrawal syndrome, we can now medically manage that, so it's much more bearable for people to go through. That's really important. It's part of it. But again, it's not all of it. There's also this psychological component, which we really need to be spending more time attending to and fail to do that at our peril. Because one of the things that people with addiction will often say is that, yes, withdrawal is hard to get through. But what's really hard is once you're through withdrawal, living without drugs. That's what we need to understand more. The aftermath of addiction is the focus of the next part of this episode on Making Sense of Addiction with Hannah Pickard.

She's an author and a philosopher with experience in the lab and the clinic. She's based at Johns Hopkins University. This is Ideas. I'm Nala Ayad. Every day, your eyes. are working overtime, from squinting at screens and navigating bright sun to late-night drives and early morning commutes. They do so much to help you experience the world. That's why regular eye exams are so important. Comprehensive eye exams at Spec Savers are designed to check your vision and overall eye health. Every standard eye exam includes an OCT 3D eye scan. Advanced

technology that helps your optometrists detect early signs of eye and health conditions, like glaucoma, cataracts or even diabetes. It's a quick, non-invasive scan that provides a detailed look at what's happening beneath the surface. Don't wait. Give your eyes the care they deserve. Book an eye exam at Specsavers from just $99, including an OCT scan. Book at Spexsavers.cairs.cavers.cai.a. Eye exams are provided by independent optometrists. Prices may vary by location.

Visit Spexsavers.cavers.ca to learn more. Keeping on top of the incredible number of developments unleashed by the U.S. and Israel's attack on Iran can be tough. So if you want to know what's going on but feel overwhelmed by that prospect, I'm Jamie Poisson and I host the Daily News podcast Frontburner. We're going to be covering this story all week, one story a day, great guests, clear information, lots of context. Follow Frontburner wherever you get your podcasts. Step one. we admitted we were powerless over alcohol and drugs that our lives had become unmanageable. Step two, we came to believe that a power greater than ourselves could restore us to sanity.

Step three, we made it to see. Walk past a church where a 12-step recovery meeting has just happened, and you'll see people discreetly exiting, merging, merging back into the neighborhood and their daily lives. Inside, they've told each other their stories, first names only. There are laborers and white-collar workers, artists and the unemployed. They are Canadians, indigenous people, newcomers. People who are parents or just out of adolescence themselves. The poor and the privileged, the spiritual and the secular.

Each person with their own life history. but united and self-defined in what those in the meetings would call the disease of addiction. Philosopher and author Hannah Pickard is non-judgmental about drug use broadly defined. She argues it has always been a normal, comprehensible human behavior, but that when it does go wrong and works against a person's good, there is no single cause. Which can then admit of all sorts of different explanations, different explanations. different explanations and different people. If one person's causes of addiction are, in her words,

a world away from another's, then she says, helping one person may require intervening in a completely different way from another. That may be true of the two other people in this episode about addiction. It's funny, I used the disease excuse when I was trying to evoke compassion in my loved ones because I thought, okay, if I have this thing,

they will hate me less or they will, you know, be mad at me less, et cetera. And I probably talked myself into believing it. Yovita Bedlavska and Michael Kaufman have both written memoirs about self-destructive drug use. But each has come to different insights and experienced recovery in their own way. I guess I was maybe nine or ten years old. I developed appendicitis. I was away with my grand. grandfather and I got back to the hotel and felt sick and nauseated and pain in my belly.

And I was diagnosed on the spot with appendicitis and flown home. And from the airport straight to the hospital, as does happen in the preoperative setting, a nurse came in and gave me a shot in my rear end. And a moment or two later, my dad was in the room and I looked at him and I thought, oh my God. I don't hurt. I'm not afraid. In fact, I don't think I've ever felt better. And that was my first real experience of euphoria.

I didn't abuse drugs or certainly not opioids through high school and my undergraduate training. But once I got into medical school, especially the clinical phase of it, exposure to opioids became a little easier. I also got coughs and colds more readily. And I was able to ask not only my own doctor, but other doctors that I was working with or training under for an opioid prescription to manage my cough. And always I found that taking the opioid made me feel calmer. It didn't put me to sleep. It made me feel energized.

It made me feel more comfortable and less afraid. So when I finished my family practice residency and moved on to a small town in rural Ontario with a primary care hospital and a wonderful family practice with good colleagues to join, I found myself over my head. And when I say that, I mean working in the hospital, working in my clinic, taking care of inpatient, taking care of emergency patients, delivering babies, assisting the operating room, dealing with mental health problems. In short, it was just all too much. And I really felt afraid. Oftentimes I felt afraid.

And the opportunity to obtain and use opioids went up like tremendously when I got into practice because I could prescribe them for patients and then they would bring back the leftovers for me or I could get a hold of strong drugs like Demerol for office use, quote unquote, morphine, all of those sorts of drugs. And eventually more often than not, those drugs found their way into me more often than they did my patients. Some of my colleagues eventually noticed, of course, what was going on. They approached me several times. I was usually able to dodge their interventions and keep using until finally one day and by then I was probably using opioids intravenously for a year or two but at any rate one day on my way into the hospital

a colleague met me at the door and I was just back from a vacation and I was tired and I asked him if he would help me cover my practice because I was solo doctor at the time. And he said, no, he wouldn't help me with that. But he would help me with my actual problem. He says, we all know what's going on. And he says, we know you're using the drugs, and I did not argue with him this time.

He reached into his pocket, and he gave me a phone number, just scribbled on a piece of paper. And he says, you have to call this number today. You have to call it by later this afternoon. and I'm going to check. And if you don't call this number, I will report you to the College of Physicians and Surgeons of Ontario,

and that's the regulator. And boy, oh boy, I did not want that. I did want to stop using the drugs. I didn't know how, but mostly I didn't want to be reported. And that did it. To this day, I attribute that interview.

that man, that action with having saved my life because I turned around and left the hospital and I went back to my office, which was empty at the time. And I gave myself one last injection, to be honest. And it was the last one. That was in the, I guess, March of 1986. My name is Dr. I, Michael Kaufman, and I am a retired family doctor and a retired addiction doctor. and the former and founding medical director of the Physician Health Program of the Ontario Medical Association, and I am also an author. The book I wrote is called Drugs, Lies, and Docs, a doctor's memoir of addiction, recovery, and more. I think like many of us, before I started working with people with addiction or thinking seriously at all about the nature of the condition, I just assumed it was a brain disease.

I believe that's the way my own doctor saw it as well. Moving on to recovery rooms, the concept of addiction as a disease is certainly built in. But then I found myself working in contexts where things were helping the group members I was working with that really undermined the idea that addiction was a brain disease. So in particular, as a very young novice clinician by the success and beauty of behavioral contracts. So let me just say what those are and also say right away that they don't help everyone, but they do help some people.

So in our group, we always made people come off drugs. I include alcohol here under the label of drugs before embarking on serious therapy. Because typically in therapeutic context, people often do it to me. mask, difficult emotions to suppress and dampen difficult emotions. And it really interferes with the therapeutic task of allowing yourself to feel them, to reprocess them, to manage, to think differently. So one of the first planks in therapy is often to get people to come off drugs. And typically we would do that by asking people to write a contract where in effect they take a piece of paper and they write on it something like this.

I so-and-so commit to not using drugs. If I find myself tempted, I will make a support call and I will come back to group next week and report on how it went. And then they sign that, and as do we, the therapists and also all the other members of the group, and everyone writes messages of support, things like, I know you can do this, I believe in you,

I'll be thinking of you, I know this is going to be hard, but you really well get through it. You really deserve this. You deserve a better life. And people go away with those contracts and they read them and keep them with them. They, of course, make support calls if they need to, but regularly come back having for the first time in years, potentially decades, not used. And I guess it was the power of those contracts which first made me really questioned the dominant idea of addiction we have and get interested and excited and also feel it was very important to figure out what the truth might actually be because a brain disease can't be cured by a piece of paper. There was a point in my life where I thought I had it sort of figured out, especially after I got sober for the first time and then I relapsed. At the age of 13, so before I moved to Canada, I tried alcohol for the first time, and it was also the first time I went into a blackout. And it was also the first time I thought, I really want to do this again.

I like the oblivion. My name is Yovita Bidlovska. I'm the author of Unshaming, a memoir of recovery, relapse, and what comes after. I'm also the author of a similar memoir called Drunk Mom, which came out in 2013. Maybe I just liked, you know, not being a straight-a-student and having a night out on town, like a newly non-communist Poland. And then I will go on to say that at the age of 15, I immigrated to a small town called Woodstock, Ontario, from a big town called Warsaw in Poland. And when I was a teenager, I started using alcohol to cope with my sense of isolation and depression and anxiety and all those things. and definitely a language barrier

because I believed myself to be a fluent speaker of English when I had a couple beers in me, and that was not the case. And then, yeah, and I think I drank sort of in a party way in university. It was quite encouraged. This is what you did on a weekends. Then you did it on a weekdays, and then people like me who I was definitely prone to doing it more.

I just did it all the time. So I remember the first time I said, oh, I'm going to have to go to here. It was when I was 25. So just as a joke, but then I went to a 27. And then I stayed sober for quite a few years. And I relapsed after I gave birth to my son at the age of 31. Long periods of sobriety and then long periods.

And when I started relapsing, like, there was nothing too too dramatic and too scary, which was a blessing and a curse because I was always at the risk of losing everything. Definitely my relationship with my son. For as long as I can remember, I felt shame about it. And I would just resign myself to, you know, this is how I'm going to, that's going to be my, you know, my story. I'm just going to relapse and I'm going to get sober and I'm going to relapse again, et cetera. I sort of twisted that on its head when I started to think about all those times that I did get sober as being, you know, having hope and staying hopeful and staying healthy and staying in recovery. So now I've been in recovery for quite some time.

I don't take a single day for granted, and I hope it stays this way, but I also, I'm never going to have the hubris and say, and I'm going to stay sober forever. That's, and I don't think anybody can say that. Something that addiction does is it strips away or robs a person that certainly did me of integrity and a sense of values. Increasingly, I behaved in,

ways that I was never proud of and would never normally do, deceiving people, manipulating people, essentially stealing drugs too, and beyond that even working when I shouldn't have been, working when I was intoxicated or working when I was in withdrawal and not bringing my best self. What I try to do in the book is provide some tools to help people think about managing relationships with people who use drugs in ways that are destructive to them and to others. The real idea here is one of finding ways within a caring relationship to hold responsible, but without blame. That idea of asking for agency of the other person, asking for recognition, for the impact that their drug use is having on you, but of doing it in a way which is committed to them and to the relationship rather than blaming and punitive, we need tools that hold both people equally in mind as opposed to oscillating from the good of one or the good or the other, the good of one, the good of the good or the good the other. You say it avoids a rescue blame cycle and is more future-oriented. It's an idea that for me really grew out of my experience as a novice clinician when I was struggling with how to

hold people responsible, say for holding their behavioral contracts, for keeping to their behavioral contracts, or for anything they were doing in their lives or in group, which felt destructive and harmful. I was struggling to see how to engage their agency and hold them responsible and ask them to make these changes which were really essential to their therapy and well-being, but without blame, without judgment, without a kind of condemnation of them for those behaviors. And what I sort of saw was that it was very, very easy as a clinician to sort of worried about how working with agency and responsibility could lead you to blame, made you recoil into this alternative stance that I call the rescue part of the trap, where you basically deny

agency and responsibility and say that, well, because people say have a brain disease, they have a mental disorder originating in the brain, they can't help it and have no agency, and so they're not responsible and hence not to blame and condemnation and judgment would not be appropriate. The truth is those changes have to come from them in their agency. Coming out of addiction requires someone to do an awful lot of really hard work over a long period of time. Even when re-exposed to opioids for an appropriate therapeutic indication many years later, I still felt stirrings of those things. So that does make me think that there's an element to my brain that renders me cessation.

that renders me susceptible to the misuse of opioids. And if I'm at risk, it means I learn to do certain behaviors that mitigate the risk and protect me. And I suppose there's another element to using a model of a disease, in this case, a chronic disease. That's important. Because it does help me, and I do believe it's the case that, quote-unquote, once addicted, always addicted, That doesn't mean living in life of active addiction. It just means the relationship that I have, mediated, of course, by my brain as everything is, is lifelong. So my susceptibility and my risk is present in me right now as I share these ideas.

The difference being I have. no interest in using opioids today. And I do all of the things I've been taught in recovery to not reintroduce my brain to opioids. And that enables me to live to my full potential. I originally got sober in AA, and so I was familiar with the AA model and the idea of powerlessness and the idea of, you know, the sort of paradox where you were powerless over your addiction, alcohol, drug use, but you're also responsible for your recovery. And I kept getting stuck in that, like, you know, just in terms of practice and just in terms of how I thought about it. I'm all for AA, mostly because it is the first thing that most people tend to think about.

It is worldwide. It's, you know, the book, the book of alcoholics has been translated into more than 80 languages. You know, you can find a meeting anywhere. I can find them online. There's agnostic meetings. There's even satanic meetings. So it's great. It's great as a sort of first way of people finding recovery. But I think inquiry is also important. And A very much tells you this is it. There's no inquiring, you know, like inquiring is dangerous.

You know, there's we have slogans in rooms that say things like stinking, thinking, think, think, which sort of make fun of this idea that, you know, it's not up to you to investigate, you know, let go and let God. I like one day at a time because that one's practical. And, you know, I did have let go and let God on my first year medallion. It didn't work for me. So I arrived at the point of not knowing anything and sort of continuing to be curious about it and searching and realizing that there's no one-size-fits-all. Once I got sober and became public about it, I did have an opportunity to hear from all kinds of people.

are not just people who used the 12-step model, but people who got sobered on their own and who did quite well with it. And that was kind of what confused me because I was taught in a very sort of dogmatic way of, you know, AASD only way. And there's no other way. They are quite strict about that.

I think that's changed a little bit. And this idea that, you know, only that addiction is a spiritual malady that only God, aka higher power, can, you know, can relieve you from it. And then there was also the disease model that believe, you know, it's a neurological condition. And, you know, it's funny because there used to be a line that said, like, the opposite of addiction is not sobriety, but connection. And that's how I think A is founded on this idea that people are in a room. They're all the same or similar. And I think that's what possibly works for majority. But I have also met, I just talked to someone recently who said, the only way for me to get sober was to isolate and frankly,

to isolate from his environment that was, you know, causing him to use, et cetera. But he got sober in nature completely on his own, you know. So there's there's so many different versions. And I think, you know, especially with things like internet and online communication that we have, we get to know other people's ways of recovering. If you think about addiction, as I learned to do, as, biological, psychological, social, and even spiritual, a condition that affects all of those domains of life. And if recovery also focuses on all of those domains of life, from the most basic, eating and sleeping well, getting some exercise, to the most complex say, a spiritual sense of who I am in the world and what my meeting and

purposes and how I fit and to be right-sized in the world. Recovery embodies all of those things and wonderfully in the context of being with others. So when I was living a life of active addiction, that was done in absolute secrecy. In recovery, the opposite is true. From my first day in treatment to this day, as I said, nearly 40 years later, there has never been a week that's gone by that I haven't been sitting in one group room or another, oftentimes three or four per week. Because it's something I do in a shared way. I'm offered the expertise and the wisdom and the support and the love and the forgiveness of everybody that I meet in those rooms. And I in turn can offer what I've learned.

Groups work, right? Groups work because somehow that sense of belonging in community is something which is missing from so many people's with addiction's lives and also the capacity where not only can they begin to receive something from others, but they can offer something back. And that kind of reciprocity is built into how all groups function and extremely important. So social services are being cut back. Healthcare is in crisis.

and politicians tell us there's only so much money to go around. As someone who's looked at all the research around addiction and has this new paradigm, what would you say to the people who are formulating policy right now? My expertise is not in policy. So really everything I say needs to be taken with a grain of salt. But I will say this, that psychology and social support groups and community centers, that build relationships and allow people to have a sense of belonging are not the most expensive of medical interventions. You know, again, talking about what motivated me to start thinking and writing

about these topics. It was the personal experience of forming relationships with people and who I cared about and seeing their lives improve through these really quite basic, down-during. earth means. And so I really do have hope that we know what to do to some extent, and it's not that expensive, comparatively speaking. We just need to get people to put the money in the right places. First of all, you have to house people and you have to feed them and you have to make sure that they're not cold and people have to feel secure and safe and fed in order to sort of attend to to their more emotional and mental. But, you know, yeah, if I had all the money in the world, I would certainly invest in therapy and just people having access to more services.

It's very difficult in Canada. And this is still the case. And it was the case 10 years ago and 15 years ago. It's very difficult to find a bed in rehab. Even if you think rehabs are not useful and I would argue that there aren't necessarily being able to step out of your environment that's causing you to use or to drink and getting that break is crucial to recovery or just to the idea that you have. have that option, you know? So, so, yeah, having more beds, having more rehab places, just having more psychological services for people. Like, I don't understand why mental health is the last thing that we attend to. Like, it's baffling to me because I think everything stems from mental health,

like, including physical health and whatever, well-being in relationships. So, yeah, I would, I would throw all the money at mental health workers and training them properly. And Yeah, I think that would be amazing, but it's never going to happen. Yovita Bidlovska's cynicism isn't without cause. Some of us rage about open drug use in our streets, even as our neighbors discreetly drink and use behind closed doors. And still others die alone, unsupported, in alleyways and tents. Meanwhile, the experts ruminate and debate,

while officials fund the solutions that answer their supporters' opinions. I'm inclined to think that the more in which we allow politicians to politicize these questions, which affect all of us on both sides of the political spectrum equally, the more we allow that, the less we end up with good policy and money going to where it should. But I really think to understand addiction right and to begin to help everyone who struggles with it, we have to get better with the uncertainty and the complexity. Philosopher of addiction, Hannah Pickard,

author of the book, What Would You Do, Alone in a Cage, with Nothing But Cocaine? Writer, Yovita Bedlaska. I'm the author of Unshaming, a memoir of Recovery, Relapse, and What Comes After, and Dr. I. Michael Kaufman. The book I wrote is called Drugs, Lies, and Docs, a doctor's memoir of addiction, recovery, and more. This episode was produced by Lisa Godfrey. Lisa Ayuso is the web producer for ideas.

Technical production, Sam McNulty. Senior producer Nicola Luxchich. Greg Kelly is the executive producer of ideas, and I'm Nala Ayad. For more CBC Podcasts, go to cBC.ca slash podcasts.