By Dr David Laing Dawson
Social worker, Alexander Polgar, writing in the Hamilton Spectator suggests that the current opioid epidemic and death by overdose can be traced to “adverse childhood events”. This of course is patent nonsense. Some children do suffer terrible things that affect them their entire lives. But, from a statistical view point, the children growing up in the last 30 years (in Canada) will have experienced the fewest adverse events than any generation in history before them. (prenatal care, safe childbirth, child protection laws, diminishing physical punishment, plentiful food, no measles, mumps, smallpox, polio, pertussis, fewer sibling deaths, available medical care, safe toys, safe playgrounds, safe pools, safe beaches and lakes, accommodation in schools, organized play, sports, new safety rules for everything, child labour laws…). Sure, the parents may be more likely to divorce, but they are much less likely to die.
In the late 40’s and early 50’s my classes of 35 or so always had one kid with scars from a boiling water accident or a fire, another not coming back to school after a summer of polio, one on a cane or crutches or with a withered arm, another pockmarked from some communicable disease or other, and another two or three undernourished, lice ridden and dirty. Not to mention the shaming and physical punishment some teachers used to control behaviour. And in those decades many children grew up without fathers who had been lost to them in the war.
While one might be able to trace a specific addict’s misery to childhood trauma, to blame the current epidemic on an epidemic of childhood trauma is nonsense.
I could make a case for the problem being the opposite.
Clinically I have many discussions about “motivation”, as in “my child is not motivated.” or the teenager saying “I’m just not motivated” with respect to going to school, getting a part time job, joining anything. With some I joke that I don’t have a pill for motivation. With many of course I look for the anxiety or depression or circumstances underlying the apparent lack of motivation, now redefined as avoidance. With others I engage in a longer discourse about the nature of “motivation”.
Now, it is pretty clear to me that the prime motivator for humans and human children throughout history has been necessity. Without necessity we fall back on, I suppose, pleasing our parents, keeping up with our social group, plain old curiosity, immediate sensory gratification, the pleasure of an adrenaline rush, and perhaps, occasionally, finding an inner flame of ambition or artistic seeking or even altruism.
The other day I had a quite interesting conversation with a very bright, self educated, articulate 15 year old. Not in school, and as he said himself, not motivated to do anything. He rationalized that any “motivation” was pointless because life itself was pointless. He could talk about existentialism, absurdity, about the expanding universe, even the nature of consciousness.
So with him I engaged in a rather intellectual discussion about the nature of “motivation”. Of course from a social perspective, a “lack of motivation” equates to “not being willing to do what someone else thinks you should do.” But when we talked of the prime motivator for most humans being necessity (to avoid being cold, starving, hurting, wet and banished) he agreed, and pointed out that he faced no such necessity. Nor did most of his peers. They dressed as they liked from a selection of clothes in their closets; they always had a roof and a bed in a heated home; food in the refrigerator; much more than a penny in their pockets; and no one who could “make them go to school, or work”.
He was “motivated” to seek a few days a week of instant pleasure from weed, MDMA, mushrooms or acid, the chemical compositions and history of which he knew at least as well as I.
Now I may also get the opportunity to treat this young man’s depression, once he has done his own research on SSRI medication, but, thinking of this generation as a whole, I can go back to my main point. Which is that we have removed necessity as a motivator for many of our children and teenagers and young adults.
They are not experiencing more adverse events but fewer, and they are always ensured of their basic needs being met without any effort on their part, and, with the safety and esteem building tone of today’s parenting and pedagogical methods, coupled with the proliferation of things and activities that offer instant gratification (Good boy, wonderful picture, nobody fails, every child is special, dress as you want, here is an Iphone and a laptop, video games, information by clicking a mouse, substances that eliminate anxiety and stimulate the pleasure centers of the brain), the necessity of an extended period of work and discomfort to achieve something seems almost anachronistic.
I have said at times to some of the teen boys refusing to go to school, “But that’s where the girls are.” only to realize that, no, today, naked women reside 24/7 on the laptop in his bedroom. So even the vaguely formed wish and longing hope of sexual gratification after a lot of struggle, social embarrassment, attending school, joining the drama club, staring at, avoiding, talking to, asking on a date…. has been replaced by no-effort instant gratification without having to shower, brush your teeth and get dressed.
Blaming a 21st century problem on a 19th century scourge is not helpful.
It is very hard to understand and assess the vectors and forces that affect one’s own time, but the causes of teenagers doing stupid and dangerous things, and the causes of adults injecting themselves with something that offers equal odds of a pleasurable few hours or death, probably lie elsewhere.
Psychosis impairs brain function beyond the apparent symptoms. Depression impairs brain function, the scanning, filtering, perceiving functions. Depression eliminates perspective. Similarly, once addicted, the addiction impairs brain function. It seems to eliminate any sense of time and perspective, any way of thinking about long and short term priorities; it clearly impairs the brain’s ability to assess risk; it impairs the brain’s ability to consider short term pain for long term gain. It wipes out empathy. Once addicted the human brain becomes as if a shark’s brain with a solitary single purpose.
So we must treat addiction itself as an illness, offer detoxification and rehabilitation services and reduction-of-harm care. And this includes safe injection sites, and maintenance programs.
Secondary prevention of relapse should be another focus, and we know of several groups we could target for this: recently discharged from hospital, psychiatric hospital, drug treatment centers, jail, or prison.
Primary prevention is much more complicated. But there are some factors that could be addressed:
- Physician over-prescription of Opioids, both in dosage and length of time.
- Illegal availability of these drugs from a variety of sources, including the internet.
- Self medicating for something better treated by professionals in other ways: anxiety, depression, PTSD
- The simple fact that this is a very profitable business for many in the chain of supply.
1.Education, guidelines, controls for physicians, pharmacists.
2. Taking a look at ways to stem the flow of drugs across borders (other than another “war” on drugs).
3. More readily available mental health treatment, sensible pain management.
4. And perhaps consider removing the profit motive by legalizing and providing opioids for addicts in a controlled fashion. Is this approach working in Portugal?
And then teenagers, early twenties. Though they have newly acquired logical thought processes and information at their fingertips, they do not have perspective, experience, and fully developed frontal lobes. They take risks uninhibited by the knowledge of a 10 or 20 or even 40% probability of a disastrous outcome. They often respond to warnings in a paradoxical fashion. They still need parents, and parents who are willing to intervene in a strategic fashion and not give up.