Gabor Mate on the Opioid Crisis
As President Trump says he’ll declare opioid overdoses a national emergency, physician and author Dr. Gabor Mate says an effective response would address the emotional pain and adverse conditions at the root of addiction
AARON MATÉ: It’s The Real News, I’m Aaron Maté. The opioid drug crisis is the deadliest in US history. On Thursday, President Trump indicated he will formally declare it a national emergency.
DONALD TRUMP: The opioid crisis is an emergency and I’m saying officially, right now, it is an emergency. It’s a national emergency. We’re going to spend a lot of time, a lot of effort, and a lot of money on the opioid crisis.
AARON MATÉ: Joining me now is Dr. Gabor Maté, a physician and author of several books, including, “In the Realm of Hungry Ghosts: Close Encounters with Addiction.” Full disclosure, he is also my father. Hello there.
GABOR MATÉ: Hi.
AARON MATÉ: Thank you for joining us. Let’s start first with what this crisis is. The figures on overdose deaths in the US are something like 140 every single day, two-thirds from opioids. Describe for us what kind of crisis we’re dealing with here.
GABOR MATÉ: As the President’s Commission said, every three weeks in the US you have the equivalence of a 9/11, so that every year, currently, you have 14, 15 9/11s happening. In that sense, it’s reasonable to speak about it as an emergency. Another sense, of course, it’s been going on for a long, long, long time, it’s just that the numbers have increased in the recent years.
AARON MATÉ: The numbers and also in terms of who the victims are, right, demographically?
GABOR MATÉ: Yes. It’s now been found that the life expectancy of the white, working, and middle class is decreasing because of alcoholism and drug overdoses. It’s a question of who it’s hitting. It was always certain sections of the population, but now it’s hitting the mainstream.
AARON MATÉ: The implication there is that that’s the reason why it’s perhaps getting so much more attention and resources now?
GABOR MATÉ: Well, there was an article in New York Times earlier this year which said exactly that, that because it’s now hitting the white middle class, people are really starting to wonder what it’s all about, and what else can you do beside the usual ineffective responses. It’s interesting enough that, in the 2016 election, Trump got some of the biggest support in areas that are hardest hit by alcoholism and the opioid crisis and suicides.
AARON MATÉ: Why do you think that is?
GABOR MATÉ: That speaks to the very heart of addiction and what drug use is all about. It’s all about an attempt to escape from desperation. Those areas are the areas of the country with the greatest desperation. Those are the ones that most were susceptible to Trump’s message.
AARON MATÉ: Okay, let’s talk about that. You talk about addiction being an attempt to escape desperation. You’ve worked with addicts over many years. You were a physician at the Portland Hotel Society, which is a residential and hospice service for residents of Vancouver’s downtown east side, an area with a huge drug problem. Talk more about that, addiction being rooted in an attempt to escape adverse conditions.
GABOR MATÉ: If you look at the opioids, what are they? The opioids have been used in medicine for thousands of years. Used for what? Used for pain relief. They’re the most powerful pain relievers that we have. They don’t only soothe physical pain, they also soothe emotional pain. It turns out that the same area of the brain that experiences suffering from physical pain also experiences suffering from emotional pain. In other words, the primary question in any addiction, but especially in opioid addiction, is not why the addiction, but why the pain?
We have to look at what is the pain that people are trying to escape from. For that, there are two major causes. One cause is childhood trauma. We talk about how childhood trauma actually affects the brain in such a way as to make it more susceptible to addictions later on. Childhood trauma is one source of deep pain and all the addicts I worked with have been traumatized significantly so. That’s what the large scale studies in the US shows about it, the more trauma in childhood, exponentially the greater the risk of addiction. Childhood trauma is a huge problem in our society and in American society.
The other question is, what’s going on right now? That’s stress. What we also know is that stress makes the brain more susceptible to addiction and stress also makes people more desires of escape from the stress. If you look at what’s happening socially, economically, politically, culturally, is increasing insecurity, increasing stress, increasing uncertainty, increasing difficulty for people. Therefore, people will turn to short-term measures to escape those difficulties, or at least the awareness of them, by escaping into addictions, including drug use. What we’re looking at is, A, childhood trauma, and B, severe social stress. It’s not surprising that the areas where Trump got the greatest support are areas of great social stress.
AARON MATÉ: Right. Taking your analysis and looking at this response now, Trump poised to, it appears, declare this a national emergency. Looking at how this problem is discussed, what do you think is missing from the conversation and from the actual policy choices that are being made to respond to it?
GABOR MATÉ: The conversation in the mainstream media and political circles, and I would say even in medical circles, largely excludes the central importance of trauma and stress. They talk about the problem of addiction as it was simply a matter of a choice that somebody makes, in which case, two things you can do. One, is you can try to deter people or at least dissuade them from making that choice. That’s what your attorney general, the American Attorney General Jeff Sessions talked about, about reviving the old Nancy Reagan “Just Say No” ethic, where you’re just telling people how bad drugs are and then they won’t use them [crosstalk 00:06:30]-
AARON MATÉ: You know what? I’m going to cut in. It wasn’t just Sessions, it was also Trump. This is him speaking just a few days ago. Let’s hear what he says and you can respond to this as well.
DONALD TRUMP: The best way to prevent drug addiction and overdose is to prevent people from abusing drugs in the first place. If they don’t start, they won’t have a problem. If they do start, it’s awfully tough to get off. We can keep them from going on and maybe by talking to youth and telling them, “No good. Really bad for you in every way.” If they don’t start, it will never be a problem.
AARON MATÉ: “If they don’t start, it will never be a problem.”
GABOR MATÉ: Yes. That, again, is based on the view that just telling people how bad drugs are will keep them from using them. If that strategy worked, why do we have the crisis right now? If the Nancy Reagan “Just Say No” and telling people how bad it is to use drugs strategy worked, why has the heroin use rate in the US gone up five-fold in the last 10 years and why the current crisis? Clearly, that doesn’t work.
The reason it doesn’t work is is drug addiction is not a choice that anybody makes. Nobody chooses to do that. The real question is, how do we get that information across? The problem is that the children, the young people who are listening to adults, are not the ones at risk. The ones who are at risk are not listening to adults. It doesn’t matter what we tell the kids, because again, the ones that don’t need it, they’ll get it, and the ones who need the information won’t get it, because they’re the hurt ones, and the abused ones, and the alienated ones to whom this kind of message falls on deaf ears. Yes?
AARON MATÉ: No, go ahead.
GABOR MATÉ: Well, the second perspective is that addiction is this disease that people inherit. Again, that excludes looking at people’s lives, looking at their childhood trauma history, at the family history, of modern generational trauma perhaps, and looking at all the social factors that put stress on people. While the addiction to the brain looks like a disease to the brain, it’s truly not.
What the disease [inaudible 00:08:44] is that that disease is the result of life experiences and social factors. Simply talking about trying to stop or prevent the addiction without looking at those social factors and those personal historical factors and then when you treat people without treating their trauma and treating their pain, you [inaudible 00:09:08].
AARON MATÉ: What about the side, though, that says the main problem is the supply, especially from in the case of opioids from big pharmaceutical companies? Purdue Pharma, it’s well known that they entered Oxycontin into the market in the mid ’90s. They concealed some of the impacts of it and that did lead to a huge spike in addictions and overdoses.
GABOR MATÉ: It’s certainly true that the pharmaceutical companies profit, and very happily, over the overuse of pharmaceuticals. That’s true. It’s also true that Purdue, which engaged in subterfuge that contributed to the deaths of hundreds of people, paid a very small price and none of their executives went to jail, contrary to a small-time drug dealer who’s responsible for much less degradation.
That’s true, however, as an American judge very astutely said that you can no more control or suppress the law of supply and demand than you can suppress or control the law of gravity. The real issue is not just the availability, because people will use something. People that need to escape will use something. If they will not use available prescription drugs, they’ll use illicit heroin. There’s a lot of cheap heroin available in the United States right now.
If they will not use that, they’ll use crystal meth. They’ll use cocaine. They’ll use alcohol. They’ll use something. Ultimately, while it’s certainly true that the pharmaceutical companies have contributed to this, and it’s also true that physicians have contributed to it because of their insufficient understanding of chronic pain and how to deal with it, ultimately we still have to look at the broad social factors. In individual cases, we have to address those factors when we’re treating people.
AARON MATÉ: Right. On the issue of treatment, I went to a event recently where I heard people who have experienced dealing with rehab facilities, having loved ones who are in rehab facilities. It was just a series of complaints about these facilities did not properly address their loved ones’ issues. Specifically, there was very little therapy and attempts to address people’s internal pain. I’m wondering your thoughts on that, the issues that the rehab approach and then treatment in general might face?
GABOR MATÉ: The problem is that most addiction specialists, physicians, psychiatrists, and counselors do not get trained in trauma. In fact, it’s quite possible, for most training physicians in the United States or in my country, Canada, to graduate without ever hearing the word “trauma,” let alone learning how to deal with it.
It’s not surprising that, when people go to rehab facilities, the attention and the emphasis is put strictly on the behavior of addiction and trying to get them to stop the behavior and not on the causes that made them addicted in the first place. People go to rehab and then they’re never helped to integrate and deal with their emotional pain, with their trauma. They’re never given the help to learn and to help them rewire their brains in such a way that they can go out there and deal with stress more effectively and more consciously, with more awareness.
AARON MATÉ: Right. As we wrap, I have two questions about the psychological dynamics of addiction. The first is one that you touched on a bit earlier. What is the neuroscience of addiction? Why is someone with trauma, with unaddressed childhood pain, more wired to become addicted?
GABOR MATÉ: Well, first of all, because of the pain itself. All addictions, in my view, are an attempt to escape from emotional pain, discomfort, distress. The more distress, discomfort, pain, shame you have, the more likely you’ll want to escape from it through addictions. That’s an impact of trauma. Secondly, the childhood experience itself wires the brain. This is not controversial, this is just state of the art brain science, how the human brain develops depends very much on your early environment and, particularly, the emotional atmosphere, so how connected and attuned and emotionally present or, on the contrary, how stressed, absent, perhaps traumatized themselves the parents are will actually affect the wiring of the brain.
For the healthy brain development, you need a calm, connected and non-stressed parenting environment, which is less and less available to American kids or with social circumstances. Then, thirdly, if you look at the brain circuits involved in addiction, the opioid circuits where the opioid medications work, over the incentive motivation circuits where all the drugs and all the behaviors of addiction, from gambling, to sex tend to network, if you look at the circuits of emotional stress regulation and self-regulation, if you look at the circuits of impulse regulation, where we can make decisions not to engage in something even though we want to, if we know that it’s bad for us, all these circuits develop or don’t develop in response to the early environment.
In other words, the greater the early stress and the trauma and the less calm and supportive the early environment, the greater the risk that person is at for addiction later on. Not to mention not only for addiction, also for mental health problems. As this interim report by the President’s Commission pointed out, about 40% of substance users also have correlated mental health issues, which also need to be addressed. By the way, I would say 40% is a gross underestimate. It’s probably closer to 80, 90%.
AARON MATÉ: Quite likely, they’re using drugs to deal or cope with those mental health issues?
GABOR MATÉ: Very often drugs are, apart from the general escape that provide from stress and emotional pain and distress, they’re also specifically self-medications for diagnosable mental conditions such as post traumatic stress, such as depression, such as anxiety, such as attention deficit hyperactive disorder, such as bipolar illness, such as social phobia and so on. Again, these conditions and their basis in trauma all have to be addressed if we’re to help addicts, addicted people really overcome their problem.
AARON MATÉ: Okay, so a final question, and it’s also about psychology, I’m curious your thoughts on what is the psychology of those who stigmatize addicts, who have a hard time seeing them as people in need, people with pain, more seeing them from a criminal perspective? What, in your view, is going on there?
GABOR MATÉ: That’s a great question. I think there are three levels that we can distinguish here, one is on the level of thought. They just don’t understand. They haven’t actually looked at what drives addiction. They see it as a moral question, because this is how they’ve been taught, and they have no other perspective. [inaudible 00:16:59], it’s just shallow thinking based on a lack of information.
On the level of emotion, though, there’s a tremendous hostility towards drug users and addicts in a part of a lot of people. What is that all about? I think what that’s all about is something that Jesus talked about, when he said, “Don’t judge, lest ye be judged.” Basically, he points out that all the judgements you make of others are always, in the end, come back to ourselves.
If you look at American society or Western society in general, it’s a highly addictive culture. People have all kinds of addictions. There’s not really a deep difference between drug addictions, and sex addiction, and gambling addiction, and shopping addiction, and eating additions, in terms of their causes, in terms of their brain circuits, and in terms of negative impact. What I’m saying is [crosstalk- 00:17:52]-
AARON MATÉ: Well, but listen, a lot of people would push back on that and say, “You can’t compare the impact of heroin use to the impact of gambling or sex or whatever else.”
GABOR MATÉ: Well, first of all, we can make a more direct comparison if we look at cigarettes use or alcohol use. You can make a direct comparison between cigarette use and alcohol use and, on the one hand, in heroin use and the other. You know what the comparison says? The comparison says that heroin use is far safer. In other words, if you take a thousand people who smoke or drink heavily or who inject heroin, as long as they don’t overdose, 30 years from now, there’ll be a lot more disease, a lot more death in the alcohol and cigarette groups than in the heroin group.
AARON MATÉ: This is assuming, though, that the heroin is clean, right? Obviously, street heroin is far different.
GABOR MATÉ: That’s what I’m saying. We have this arbitrary decision as to what drugs are acceptable and what drugs are not. What I am saying is that people don’t have the same [inaudible 00:18:59], the same negative, hostile response to smokers and people who drink. In fact, drinking is publicly advertised on the Superbowl. It’s totally arbitrary.
In other words, it’s fueled in emotional reaction. What I’m saying is that the emotional reaction is based on the fact that addictions are so rife in our society, we just don’t want to admit it, so we want to see the addict as somehow different. We want to see them as inferior to us. Now, if we want to judge them, and then we can feel superior, and that’s on the emotional level.
On the neurological level, this part of the brain here, in the front part of the brain, the mid frontal cortex, has a function which is called “response flexibility,” which means that when we are confronted with the situation, we can consider the facts. We can calmly evaluate what’s best and respond from a flexible, rather than an emotional reactive point of view.
Now, for a lot of people in our society, that response flexibility is not available. They tend to react from an emotional-based patterned reactive ground. They don’t have the equipment themselves. They’re not mindful enough to really consider what’s actually going on. Instead of being responsive, they’re being reactive. That reaction is an emotional one of hostility.
AARON MATÉ: Okay. Very quickly as we wrap, because we haven’t talked about it yet, but it relates to what we’re talking about right now, which is that clean heroin is provided to people at safe injection sites, like the one that you worked at in Vancouver’s downtown east side. I’m wondering if you could talk about that quickly and the impact that that has had on the community?
GABOR MATÉ: Well, the first thing you have to realize is that much of the negative impact of drug addiction is due to the illegal situation, where people have to use unreliable supplies polluted by whatever, what medication, particularly fentanyl, which is lethal. Nobody’s advocating that drugs should become legal, in the sense of being freely available on the streets or corner stores, like cigarettes or alcohol is, but there are programs in Canada and in Europe, which have provided clean heroin to confirmed addicts who cannot be helped by methadone or suboxone or other medications. These people actually get a prescription, not that they take home, but they inject in the clinic.
It’s been shown over and over again that people who are given access to such programs have much less disease, passed on much less disease to other people, far more economically viable, they have better family lives and far fewer health risks and incur far smaller health cost to the system.
What I’m suggesting is that, although supplied heroin will not be the answer to most people or certainly not to everybody, but there needs to be response flexibility in the healthcare system. Right now, the approaches are way too narrow, way too reactive, and way too limited. If we actually looked at all the possible ranges of what we already know is available to us and all the programs that we could actually use here, we will do much better than we’re doing right now.
AARON MATÉ: Just to clarify, in Vancouver, there’s two facilities, right? There’s the facility where people are provided with prescription heroin and one where they’re not provided with heroin, but they can go and inject safely. I believe, in both these facilities, the overdose deaths around that area have declined sharply, right?
GABOR MATÉ: There are two clinics, yes. One is the Supervised Injection Site, where people bring their illegal drugs, but they inject them under supervision with no harassment from the police. They’re given clean needles, sterile water. In other words, they don’t pass on or receive disease from other people. If they overdose, they’re actually resuscitated. A lot of lives have been saved.
At another clinic, just one clinic in Vancouver, they prescribe and supervise prescribed heroin to people under the principles I just explained. Now, unfortunately, Vancouver’s also seen a great increase in the overdose deaths and the clinics have not been able to keep up with that because of the introduction of fentanyl and still because of the retrograde drug laws that drive people underground. We’re far from having solved the problem in Vancouver, but those two initiatives have demonstrated, in many studies, a lot of promise.
AARON MATÉ: Dr. Gabor Maté, physician, author of several books, including, “In the Realm of Hungry Ghosts: Close Encounters with Addiction,” thanks very much.
GABOR MATÉ: Thanks for having me.
AARON MATÉ: Thank you for joining us on The Real News.