what does addiction mean to us?

I was in Livingston, Montana. On a narrative level, I was jolting, abruptly, from town to town in rural America. Looking for a rock to turn over. Looking for a thread to loosen. On an academic level, I was conducting interview-based sociological research regarding attitudes toward addiction and substance use in rural communities. And, on a literal level (which is the most useful for our purposes), I was, at this precise moment, opening the door of the headquarters of a southern Montana church network. 

As I opened the door, the sounds of children’s laughter filled the air. A waiting room greeted me. I had been in this waiting room a hundred times before, as I have sat for a dozen dentist appointments, have waited in the entrance way of a congregation during a dozen Christmas-eve church services, have sat in a dozen school lobbies- have listened to children’s laughter with tree-covered mountains peering through the window a hundred times over, dozens of times with annoyance, dozens of times with pleasant acceptance. 

Rural America is not hegemonic. But, if you’re from a small town in Vermont with its own left-leaning political entrenchment, its own cultural sensibilities, and its own implicit philosophy of neighborhood belonging, then you can’t help but feel a little poetic when you slink yourself into a small, rural, conservative community two and a half thousand miles away. You can’t help but think that the exhausted campaign-slogan calls for national unity (albeit made in a vain attempt to unite the “simple rural mob” into one pliable voting block) might have been on to something. Yes, although it sends my internal cliche-o-meter through the roof to say it, we’ve got a lot more in common than we think. 

Low population density and formerly-prosperous industrial sectors don’t guarantee common ground, but after a cursory glance at the flyers requesting algebra tutors on the tables, the size five velcro-secured Skechers next to the door, and the advertisements for sunday school clinging to the walls for dear life, I am reminded once again that something woven into the warm fabric of my home is fundamentally linked to something woven into the warm fabric of this one. 

That all hardly makes for a well-honed research topic. However, the idea that rural communities carry distinct cultural features that warrant some sort of directed scholarship nevertheless undergirded my work this past summer. The real reason I was walking into this laughter-filled church union’s office was to take one small step to, in the words of my abstract,

(1) qualitatively examine the specific personal beliefs and attitudes (“belief factors”) among rural residents that contribute to their support or opposition to medication-assisted treatment for addiction and 

(2) qualitatively examine the factors of rural social life which could influence those beliefs and attitudes.

I was, at this point, about ten days into my work. I had completed 13 interviews, some with doctors, some with people working in the hospitality industry- most with a sense of excitement, some with a sense of caution. I had started to recognize a curious habit of slow self-acclimitization in the interviewees. As I asked them questions intentionally designed to be repetitive, things like “what is your community’s level of support for community members entering MAT?” immediately followed by “what is your level of support for community members entering MAT?”, almost all of them seemed to undergo a slow crescendo of confidence. Whatever timidity may characterize their initial opinions regarding addiction (of which there exist, I can attest, a multitude), such shyness inevitably gave way to a hardened, consistent philosophy as the interviewees were forced to stake out hard-lined premises- premises which are neither morally neutral nor easily abandoned. 

My research was directed specifically at medication assisted treatment (MAT), both because I am a supporter of MAT and because specificity is currency in academia. I was trying, essentially, to put together a “belief framework” of the attitudes and ideas which can contribute to an individual’s support (or lack thereof) for MAT and MAT funding (seen above). The fact that I was researching MAT and not some other, less medicalized treatment method certainly adds some nuances to the framework that wouldn't otherwise exist- for example, trust in medical institutions emerged pretty quickly as one of the most important determinants of an individual’s attitude toward the treatment, and I’m fairly confident that factor wouldn’t receive the same level of consideration if I was researching Alcoholics’ Anonymous or Narcotics’ Anonymous. However, even with the caveat of my research’s specific focus, the question I sought to answer was much more philosophically generalizable than my overly-wordy literature review might suggest. The question that occupies most of my mind, and has occupied all of my academic focus for the past three months, is more simple. 

What are we talking about when we talk about drug addiction in the United States? 

From my vantage point, most of our mass media, both on the left and the right, seems very eager to empathize with any substance users whom they can identify as “not at fault.” Veterans, those with past trauma, people who became addicted to substances after workplace injuries– these are the stories we want to see and hear, the stories that make us say to ourselves: “somebody ought to help them out.” The initial empathy we may feel gets loaded up with a whole load of scientific and sociological justification, and our internal calculator lights up like a Christmas tree as we give ourselves a pass to discuss an individual’s suffering with compassion. 

In absence of such justification, we stretch out our arms, searching for some reason for the suffering. And here is where we land on discipline. “Not my addiction, not my problem.” That sort of thing. 

a little guy I met. totally unrelated, but it’s a heavy topic.

The respondents who gave that sort of response were by no means lacking in personal empathy; no participant said anything to indicate that this sort of mentality indicates a psychological inclination toward dispassion. I think that humans are naturally inclined toward empathy, but empathy is difficult to maintain. It comes from a pretty rapidly-filling well, but that well can regenerate too slowly if we’re emotionally exhausted, which is pretty much a forgone conclusion at this point for a lot of Americans. If every person everywhere has problems that fulfill our standards for empathy, then we are left overwhelmed. It’s easy to be washed away by a deluge of solvable problems that will never be solved, fixable sorrows that will never be fixed, and tragedies that need not occur but nevertheless persist in our hearts and our headlines. As a result, we tend to tighten our criteria for empathy. In order for us to act on our empathy, or even allow our empathy to become expressed as a political conviction, we add some requirements. 

These requirements are familiar. Immigrants only deserve empathy when facing deportation if they came here “the right way.” Nonviolent criminals condemned to serve egregious prison sentences only deserve empathy if they have some past psychological or socioeconomic justification. Those with substance use disorder only deserve empathy if they are traumatized, were coerced into addiction, or are “trying to get better.” These are by no means equivalent issues. I know that. Each has its own nuances and social connotations. But I do think it’s valid to point out that, in our urge to avoid becoming overwhelmed by society-wide dilemmas, we have a habit of limiting our empathy, and therefore our empathetic policy responses, to a strict set of criteria. In my research, for example, findings suggested that those who view addiction as perpetuated by biochemical changes are incentivized by this view to support funding for medication-assisted treatment. Because they view those with SUD as struggling against a medical condition, rather than from a psychological defect, these participants were more likely to interpret addiction with the empathetic attitude one might apply to a cardiovascular condition. 

So, when we talk about the issue of addiction, we are implicitly talking about the issue of justification. We are implicitly referring to a set of criteria by which we may judge how compassionate and effective we want our policy responses to be. I’m well aware, in fact, that I (and other proponents of harm reduction) frequently refer to justification in our arguments. For example, when I discuss the issue of addiction treatment funding, I often refer to overdose rates. In doing so, I subconsciously attempt to appeal to the extreme end of the spectrum of SUD-related harms. I can thereby transform the conversation from a discussion of whether an individual’s psychological suffering would be justified to a discussion of whether their death would be justified. And, because “justification for consequences” is a subjective concept which shifts depending on the consequence at hand, the standards for justifying compassionate intervention can thereby be lowered. So, yes, cold calculus regarding empathy justification is absolutely a strange behavior I engage in as well. Nevertheless, the disposition deserves scrutiny.

I have no political or social proposal to change the way we implicitly involve justification in our conversations about addiction, because, like I said, this is a problem caused by the danger of exhausting our collective pool of empathy. I do think, however, that it is a good and noble thing to do to continuously fight against one’s urge to analyze every harm befalling others as either “justified harm which doesn’t warrant empathy” brought on by their personal defects or “unjustified harm which warrants empathy” brought on by their struggles with a tangible barrier. 

So, what does this have to do with rural areas? 

My final research paper contains a more hyper-specific discussion regarding the specific aspects of rural social life that could prevent support for those with substance use disorder. But, in terms of our internal efforts to confront empathy, I think there’s a pretty simple secondary lesson to draw. As I over-poetically gushed in the introduction paragraphs, geography and socioeconomic structures related to population distribution can unite across political barriers- rural cultural and institutional similarities can make it easier to empathize with people who would otherwise be too distant. But it’s also important for us to keep this in mind when considering the struggles of people across different levels of rurality. If it’s easier to empathize with “people like us” living in “towns like ours”, we must be vigilant in order to avoid lacking empathy toward “different people” living in “different towns”. Just as people with struggles, whether we view those struggles as “justified” or not, are still people with struggles, “country folk” and “city folk” are all, well, folk. No matter the location, no matter our judgement, it is both morally right and socially useful to operate with the most lax possible criteria for compassion.