Month: May 2020

Isolation and Addiction

Isolation and Addiction

Posted on by jabittan
American’s are isolated, and it’s not just because we have all been asked to work from home, stay inside, and intentionally distance ourselves from others to prevent the exponential transmission of COVID-19. We have been isolated for a while, so much so that former Surgeon General of the United States, Vivek Murthy, recently published a book about loneliness and the importance of human connection. Loneliness and isolation are new problems that we are starting to look at in new ways. In his book Dreamland, Sam Quinones connects isolation and addiction in ways that change the discussion we have about addiction and our values as Americans.

 

Quinones is critical of how our society interacts today, or rather how our society doesn’t interact. He writes, “the most selfish drug [opioids] fed on atomized communities. Isolation was now as endemic to wealthy suburbs as to the Rust Belt, and had been building for years. It was true about much of a country where the streets were barren on summer evenings and kids no longer played Kick the Can as parents watched from porches. That dreamland has been lost and replaced, all too often, finally, by empty streets of bigger, nicer houses hiding addiction that each family kept secret.”

 

To atomize means to convert into very fine particles or droplets, and is used by Quinones to show that we have separated our communities into individual, isolated nuclear units. We hide inside our houses, rarely venturing outside to just be outside. We drive to our suburbs, stop at the mailbox from our car, park in our garages, and rarely spend any time outside. If we do get out, we are in our private backyard where we cannot be seen. We have cut out everyone else, leaving us with just ourselves in our ever larger houses filled with ever more things for our individual enjoyment.

 

Quinones argues that this lifestyle has been brought on by our own selfishness. We want our own stuff, we want to show it off, and it holds more value today than it did in the past. Consequently, we are also more jealous of those who have more than us, and more guarded of our things. We lock out other to protect our stuff, but in the process we locked out a crucial part of our humanity: our connections and community.

 

Community shows us that there is more to life than just our desires. Isolation and addiction are linked because when we withdraw from community, when we focus only inward on what we want, our purpose of helping others and interacting with others disappears. Quinones believes that a lack of interaction with others fueled the opioid crisis. We hid addiction in our homes, withdrew from community, and and took away the joys and connections that made us human. We left ourselves vulnerable to pain killing addictions, and took away the best tools to cure the epidemic we now face.
Constructive Thoughts on Wellness

Constructive Thoughts on Wellness

Posted on by jabittan
There is an argument in the world of public health that the American medical system is too focused on solving problems rather than preventing problems. This argument that is presented in Sam Quinones’ book Dreamland, expressed by Dr. Alex Cahana, “The U.S. medical system is good at fighting disease, … and awful at leading people to wellness.”

 

The difference between fighting disease and leading people to wellness has to do with where you step in to help with people’s health. Our country generally focuses on providing medical care and attention after someone has gotten sick. We ask doctors, nurses, and medical professionals to correct a huge range of problems, many of which stem from bad habits, unhealthy environmental factors, and conditions that are generally beyond the control of an individual, and not open to medical interventions. Attacking the problem once it has already developed, once a set of factors have set in that promote the health problem, makes any real changes expensive and difficult.

 

Wellness requires that we think about medical care, costs, and health further upstream, before anyone ever gets sick. Consider the idea of wellness in the context of car maintenance (I know, I know, I just wrote about the problems with comparing ourselves to cars, but this will be helpful).

 

If you regularly change your oil, rotate your tires, and drive as if your grandma was in the car with you, then your vehicle is going to operate more smoothly with fewer major costs (in general) throughout its entire life. You are making small interventions along the way to make sure your car is operating optimally. The costs of changing your oil and putting in the necessary effort to keep it working well are not trivial, but we know that those costs are less than what we might face otherwise.

 

Failing to maintain our vehicle could lead to a catastrophic engine failure. Driving our car like a teenager that just downed two Redbulls is going to put a lot of strain on the vehicle, wearing out our tires and breaks much faster. When things wear our quicker, when unexpected failures occur, we suddenly have to pay a lot more money to keep the car going.

 

Our bodies are similar, and whether it is our national Medicaid or Medicare systems, or our private health insurance systems, the cost we pay for healthcare is interconnected with where we step in to try to make people healthy. Paying for interventions downstream, once we already have health problems is expensive. It is equivalent waiting until our human check engine lights turn on before we consider doing anything to help our health. The solution that many medical professionals and many public health researchers encourage is moving upstream from the actual health problems that develop to focus on interventions before anyone develops terrible disease. The idea is to focus on wellness first, and hope we don’t have to pay for as much medical care for the prohibitively expensive diseases down the road. Rather than focusing all our effort on solving disease, we can redirect some of the money and effort into improving our environments, finding new ways to help people adopt healthy lifestyles, and finding more ways to connect and help us share in wellness as a community.
Technology & Pain

Questioning Our Confidence in Technological Solutions

Posted on by jabittan
Sam Quinones interviewed Alex Cahan, a pain medicine specialist in New York, for his book Dreamland. He is quoted in the book talking about the approach that most people have toward pain and alleviating their pain. Many people want an immediate solution that comes from technology and allows them to continue living their life as they always have.

 

Quinones writes, “Cahana saw stuff [Author Note: unproven medical treatments, more surgeries, more pills, etc…] as the problem. Our reverence for technology blinded us to more holistic solutions.” The holistic approach is not one of mystic arts or managing ones energy, but is an approach focused on how we live and what health habits we have. Smoking, minimal exercise, and living with stress that we can’t regulate are all parts of our life that can make the physical pain that we experience much worse, or can lead to worsening health and pain developing from other real medical conditions. An approach to pain medicine that doesn’t consider our actual lifestyle cannot help address the root of our pain.

 

Quinones continues with a quote from Cahana, “We got to the moon, invented the internet. We can do anything. It’s inconceivable to think there are problems that don’t have a technological solution. To go from I can do anything to I deserve everything is very quick.” 

 

Cahan’s argument is that our technological innovations and the stories we tell about our scientific progress blinds us from the reality of the human body. We are not machines, we are not our own technological innovations, even if we like to believe that we can all be Iron Man. The reality is that we have to think about how we live, about the things we do, and about what could be changed, adapted, or included in our lives to help us be more healthy and experience less pain. We don’t have to believe in a mystical energy around our bodies. We don’t have to turn to medical treatments that are not proven to be safe or effective. But we do have to think about what is important in our lives, what values we hold, and how we can make changes that help us align with  those values in a healthy and reasonable way. Once we have seen where we can make changes in our actual lives and what habits can help us improve our health and reduce our pain, it is up to us to live accordingly, not up to technology to instantly solve our problems.
Developing Self Esteem

Developing Self-Esteem

Posted on by jabittan
One of the reasons I write this blog is because I believe that we need deeper conversations about minor aspects of our lives. I think we need to be more considerate about what is truly important, and we need to think more deeply about how we can remove some of the less important things, so that we spend more time engaging with what is meaningful. I want to pull out the crucial ideas within the aspects of our lives that go overlooked and that are under-discussed so that hopefully someone can have a more thoughtful conversation about these important topics.

 

One topic, which came to mind from Sam Quinones’s book Dreamland, is the development of self-esteem for adolescents. I’m not a parent, so I am sure that I am missing some important points here and I’m sure that my perspective is limited, but from my experience and observations I feel  confident to say that important conversations about meaning, value, and expectations are not taking place with adolescents. What I’m thinking about now is how parents, coaches, and people in society can help young people develop a sense of self-esteem aligned around meaningful values that help make the world a better place.

 

Quinones quotes Ed Hughes, the former executive director of The Counseling Center in Portsmouth, OH, “You only develop self-esteem one way, and that’s through accomplishment.” Quinones himself is critical of parenting in the 90’s and 2000’s writing, “Parents shielded their kids from complications and hardships, and praised them for minor accomplishments – all as they had less time for their kids.”

 

The critique that Quinones and Hughes make is that parents have gone through great lengths to give their kids everything and to try to ensure that their children are never bored, never unhappy, and never potentially harmed – either physically or mentally. The result, according to Quinones and Hughes, is that children are unprepared for real life. They lack self-esteem because any accomplishments that they have are minor, and were parent assisted or directed. Many kids did not struggle on their own, did not learn from mistakes, and were propped up with empty praise. This left them feeling bored, empty, vulnerable, and inadequate, which made drug addiction all the more likely.

 

What I hope we can do, not just as parents but as a society, is talk about real opportunities for taking meaningful actions in our lives. I hope we can back away from terrible work schedules and the pursuit of ever more money and consumer goods, and move toward a society which encourages real interaction and contribution toward involvement and engagement. This can be done starting with our youth, with the opportunities we provide them to be engaged in something meaningful, and with the conversations we have with them about what is important in life.

 

If we don’t have these conversations with our youth, if we don’t help give them opportunities to do something meaningful, then they will look to TV, celebrities, and our own actions to determine what is good and important. Often that will be the same empty vision of happiness presented in our consumer culture focused on buying products and showing off our wealth. Quinones and Hughes would likely argue that this is only going to exacerbate our loneliness, emptiness, and the potential for drug use and despair.
Thoughts on Personal Responsibility

Complex and Conflicting Thoughts on Personal Responsibility

Posted on by jabittan
I’m really hesitant to criticize others for not taking sufficient personal responsibility for the ways they live and the outcomes of their lives. A lot of factors influence whether you are economically successful or whether you are fit and healthy. Some things we seem to have a lot of control over, but many things are matters of chance and circumstance. Placing too much blame on the individual doesn’t seem fair, yet at the same time, there is clearly an element of personal responsibility involved. I’m not sure where I land on how we should think about this division.

 

What is clear, however, is that there can be negative consequences when we take away people’s agency in their decision-making and life outcomes, and when we erode the authority of those who are reasonably critical of negative lifestyles and ways of thinking and being, we can put ourselves and societies in vulnerable positions.

 

Sam Quinones writes about these tensions in his book Dreamland and he highlights how patient responsibility and physician authority devolved between the 1980’s and twenty-teens as a quick fix, there’s-a-drug-for-that mindset took hold of the American healthcare system. He writes, “…patients were getting used to demanding drugs for treatment. They did not, however, have to accept the idea that they might, say, eat better and exercise more, and that this might help them lose weight and feel better. Doctors, of course, couldn’t insist. As the defenestration of the physician’s authority and clinical experience was under way, patients didn’t have to take accountability for their own behavior.”

 

I’m usually hesitant to say that the problem is people’s lack of accountability, because how often do we really control how much exercise we can get when many of us live in places where walking is difficult because our streets are not safe, or are not well designed for pedestrian use, or because half the year it is dark early and we get lots of snowfall? How often do we not know what kinds of exercises we should do, and how often do we have people who are only critical of our current state rather than supportive and encouraging? How often have we had a bad break and poor advice on how to get back, only leading to a further defeat, deflating our sense of self worth? In addition to all this, how often have we seen people use the personal responsibility argument in bad faith? To justify not helping others or to rationalize their greed or excessive self-aggrandizement?

 

But at the same time, as Quinones shows, responsibility is important. We need to think about what we can and should be doing to help improve our own lives, without hoping for an easy fix in the form of a miracle pill. We can’t just throw out the opinions of experts and devalue their authority because they are willing to say things that are discomforting for us, but are likely correct in terms of how we can make our lives better. Somehow we need to work together to build a society that recognizes the barriers and challenges that we face toward becoming the successful and healthy people that we want to be, but encourages us to still work hard and overcome obstacles by taking responsibility for our actions and (at least some percentage of) our outcomes. I don’t know what this looks like exactly, and I’m not sure where the line falls between personal responsibility and outside factors, but I am willing to have an honest discussion about it and about what it all means for how we relate to each other.
Humans are Not Automobiles

Metaphors and Similes of the Human Body

Posted on by jabittan
Human beings think in metaphors and similes, especially when it comes to thinking about ourselves. We come to understand one thing by comparing it to another, and we describe something as being like something else, to help us understand how we should relate to it. A metaphorical way of thinking that Sam Quinones is critical of in his book Dreamland is the description of the human body as an automobile, or more generally as a machine.

 

We think of ourselves as if we were the most advanced technologies we have developed. We imagine that we could have parts swapped, that we just need little tune-ups here and there, that all we need is a mechanic to tinker with a few things and we will be back to running smoothly if we are ever out of whack. However, this metaphor, like all metaphors, is an incomplete way to understand the reality of what we are.

 

Our minds are only so good at holding lots of complex information. We use metaphor and simile to simplify our thought process. Metaphors and similes serve as heuristics to understand and conceptualize complex structures and relationships, but they don’t actually capture the full scope of reality. To say that the human body is an automobile, or operates as an automobile, misses key aspects of human dynamism, plasticity, adaptability, and function. We respond to the world and our environments, change and adapt to new settings and structures, and move in ways that no machine that we can create today can. We share some things in common with machines, but we are not machines.

 

In Dreamland, Quinones quotes a physician at the University of Washington Center for Pain Relief named John Loeser who explains why this type of thinking is dangerous, “Usually the patient says, ‘I come to you, the doctor. Fix me.’ They treat themselves like an automobile. People become believers in the philosophy that all I need is to go to my doctor and my doctor will tell me what the problem is. That attitude has been fostered by the medical community and Big Pharma. The population wants to be fixed overnight. This is the issue we addressed with chronic pain patients. They have to learn it’s their body, their pain, their health. The work is done by them.”

 

The automobile metaphor manifests falls apart when we project a quick scientific and technical fix for ourselves. The idea that all we need is a special additive to make our body work better is what fuels our desire to have a pill to solve all our medical problems, and it is emboldened by the idea that we are basically automobiles.

 

We always compare ourselves, our brains, and our bodies to the highest technology of the time. If we don’t consider ourselves automobiles anymore, we probably think of ourselves as technical space ships or precision fighter jets. Humans once thought of the brain as a complex system of pulleys and levers, and now we think of our brains as supercomputers.

 

What Quinones uses the quote from Loeser to show is that we are living systems. We are not machines that can be isolated from our environment, tinkered with, and tuned for optimal performance. We have to be responsible for how we live and the systems, structures, societies, and institutions that we all build and live within. If we don’t truly think of ourselves as more dynamic than machines, and if we don’t consider our interconnectedness, we will never understand ourselves properly, and we will never fix the problems we face, like chronic pain. We will turn to cheap tricks and remedies, and we will face the consequences of living in a way that praises quick fixes and pills to try to solve our problems.
A Different Take on Chronic Pain

A Different Take on Chronic Pain

Posted on by jabittan
In his book Dreamland Sam Quinones includes a quote by Dr. John Loeser, Professor Emeritus of Neurological Surgery at the University of Washington in Seattle. Quinones spoke with him to better understand chronic pain and how chronic pain can be approached without the use of opioids. Loeser has an approach to treating chronic pain that doesn’t rely purely on drugs and is more centered around the patient, their environment, and their social supports. Loeser describes his approach as a bio-psycho-social approach and Quinones provides the following quote:

 

“Chronic pain is more than something going wrong inside the person’s body. It always has social and psychological factors playing a role.”

 

What I think is interesting with this quote is how far it is from the experience that many of us have with doctors and medicine today. Much of our medical care comes in tiny ten minute packets, where we go back and forth with a doctor for a few minutes before they write us a prescription for something and send us on our way. The providers often don’t end up doing much to help us through our current issue, and we rely on a pill to suddenly make our lives better. The approach completely misses many other factors of health.

 

Where we live matters. Who we have in our lives matters. What our diet is like, what stress factors exist around us, how easily we can get outside or to a gym for physical activity matters. A ten minute conversation and a pill cannot address these issues and certainly cannot change them.

 

I’m not introducing this all to suggest that chronic pain isn’t real, or that it is all in a person’s head. I’m also not introducing it to suggest that people suffering from chronic pain simply are not trying hard enough, need to take more personal responsibility, or just need to move to fix their pain. Often these social determinants of health are beyond the control of any one person. Before criticizing another person, and if we want to help them, we must also consider their environment, and whether we ourselves are a factor that helps or hinders the health of another.  Our world is too connected to say that someone’s health is purely a matter of their own choices and behaviors, even if personal responsibility does have a role to play in managing health. Approaching health from this angle helps us understand that an opioid is never going to be sufficient in truly alleviating chronic pain. There have to be more efforts to understand the bio-psycho-social realities of the person’s life and the chronic pain they experience.
Limits in What We Do

Do We Need Some Type of Limit?

Posted on by jabittan
I’ve recently watched The Hobbit trilogy, and images of Tolkien’s dwarf kings consumed with greed and gold have stuck with me. For whatever reason, the image of King Thror spinning around in a state of dazed confusion among his treasure, and the image of Thorin becoming corrupted by the same gold bounty have replayed through my mind. Tolkien and the artistic creators of The Hobbit are using the dwarf kings to show the negatives of greed, of lust for power, and the danger in pursuing wealth over people and relationships. They also show what can go wrong in the mind when we have everything.

 

The Hobbit came back to mind as I looked over quotes I highlighted and notes I took in Dreamland by Sam Quinones. My last two posts were about our efforts to avoid pain, suffering, and negativity and about how we try to fill our lives with consumer products that promise to make us happy. Mixed in with those ideas, Quinones adds, “man’s decay has always begun as soon as he has it all, and is free of friction, pain, and the deprivation that temper his behavior.”

 

Thror and Thorin show us what Quinones means. When the kings were at the top, when there were no constraints in their power or wealth, they used other people for their own gain. Their minds turned to selfish impulses, and turned away from doing what was right for the good of their people. When they reached the top, they atrophied, with nothing to work toward but the preservation of their own grandeur.

 

A curious phenomenon that Quinones highlights throughout his book is how opioid addiction cuts across all socioeconomic status levels. The sons and daughters of esteemed judges and doctors just as well as men and women who have grown up in poverty all seem to be victims of opioid addiction. For some reason we expect addiction among the second group, but find it inconceivable that the first group might face the same challenges. In some ways, the quote above from Quinones answers part of why we see addiction among middle class families and among the children of talented professionals.

 

When we have no limits in what we do, when our lives are tailored, curated, but isolated, we begin to lack purpose. Our lives might look full from the outside, but be void on the inside. When we seem to have it all, the value of our lives can decay, and without friction under our feet to push us forward, we can’t move anywhere. Just as our excesses produce terrible externalities, our having it all, or at least thinking we can buy it all, produces a feeling of purposeless that can lead to drug use to blunt the meaninglessness of self-indulgence.

 

My recommendation is to remember Thorin and his grandfather. To remember that our selfish desires can become our own downfalls, and to turn instead toward community building and relationships with others. To strive for our own greatness will leave us on an empty throne, but to work with others for shared goals will help us develop real structures in our lives that last and have real value.
Excesses and Externalities

The Problem with our Excesses

Posted on by jabittan
My previous post was about our desires to live a life that never involves any pain or suffering. We try to build a life for ourselves and our loved ones where every moment is happy, and where we never have to engage in drudgery, never experience physical discomfort, and never face any obstacles. Today’s post looks at another related aspect of our lives and mindsets that Sam Quinones highlights in his book Dreamland as part of our current opioid crisis: excesses.

 

Quinones is critical of our capitalistic culture that creates a message of buying things to find happiness, fulfillment, and meaning. The marketing departments of everything from soap companies, life insurance companies, to take-out restaurants suggests that happiness is right around the corner, as long as we are willing and able to buy more of what they offer. It is owning something bigger, having more, and expanding our consumption that is branded as a good life. But as Quinones sees it, “Excess contaminated the best of America.”

 

I studied public policy and I spend a lot of time listening to podcasts with economists. A common idea in the world of public policy and the mind of economists is the idea of externalities, secondary consequences of policies and peoples actions. Some externalities are positive, such as people developing a sense of civic pride after participating in an election, but many externalities are negative, such as green house gasses polluting the planet as we drive to and from work. What Quinones describes with the quote above, is the reality that our drive for excesses produces negative externalities that damage our planet and ultimately ruin the lifestyle that we chase.

 

By always wanting more, wanting it faster, and wanting it more tailored to our specific desires to make us feel like royalty, we have put ourselves in a place that is unsustainable. Our single use plastic bags have trashed our cities and open spaces. Having our individual cars to drive to everyplace we want to go emits more pollution than a well developed public transportation infrastructure. Over-purchasing consumer goods produces more garbage that has to go someplace.

 

This post has simply highlighted the reality that we live with negative externalities, and that our consumer driven culture is creating externalities which poison the planet. Quinones throughout his book focuses on the idea that our culture’s excesses have fueled the opioid epidemic by turning us inward toward our own wants versus encouraging us to think of others and how we can work together as part of a community. I think he is correct, and I think the space to start in making a change is by getting people to truly reflect on their lives, their purchases, and what they pursue. As Ryan Holiday put it in Stillness is the Key, “Eventually one has to say the e-word, enough. or the world says it for you.”

 

The way out of our opioid crisis, and indeed the way out of so many of our problems today, is to say enough to our own selfish desires. We need to stop the negative externalities that we produce when we purely pursue our own selfish ends, and instead we need to embrace our communities and put others first, to create more positive externalities which can heal our communities and fill the empty holes that consumerism leaves inside of us.
Interconnected Inequalities

Interconnected Inequalities

Posted on by jabittan
Inequality isn’t something I have thought of at a truly deep level, but its consequences are becoming more apparent to me the more I learn about the world. I grew up believing that anything was possible for anyone, and that anyone could become president of the United States or successful in their own endeavors as long as they worked hard. While I still do believe that we can all become successful through hard work, and while I do think we should still encourage some form of this myth, I don’t fully believe the myth myself. I think that luck and structural factors of our lives play a huge role, in other words, inequalities matter.

 

In the myth that I grew up believing is that inequality was purely a result of one’s natural skills and how hard one worked. It was an end product, not an input. Many people choose to see the world this way, especially, in my experience, if they themselves are lucky, wealthy, and privileged. Inequality simply doesn’t matter in this worldview, and it is in some ways a good thing, reaffirming that the successful people are smart, hardworking, and deserve what they have.

 

I now think that our interconnected inequalities are much more serious that I had believed. Inequality is visible, and it is understood across the globe. It shapes how people think about themselves, about their futures, about the way other people value them, and about what they can and cannot be. A character introduced in Sam Quinones’ book Dreamland: The True Tale of America’s Opiate Epidemic speaks to this reality. A character by the name Enrique opens the book and Quinones writes, “Growing up in a poor Mexican village had attuned Enrique to the world’s unfairness. Those who worked hard and honestly got left behind. Only those with power and money could insist on decent treatment.”

 

From this mindset Enrique chose the only way out of his situation (being the son of a poor sugar cane farmer in Mexico) that he thought could get him money, prestige, and power. He chose to become a heroin dealer. His story is told in the book, and in the opening introduction we see Enrique feel guilty about his life choices, but confirm to himself that it was his only way out of destitute poverty as he watches a group of farm-hands/construction workers be deported in an airport.

 

It is global inequality that drove Enrique to drug trafficking. Through no fault of his own, Enrique was born into a family in a poor village, and the clearest path toward employment for him was pursuing his family’s sugarcane business. A career that meant hard work, near subsistence wages, and little respect. Sure, he could have found other options and become a rags to riches/slumdog millionaire story, but expecting everyone to do so ignores the reality of the message that inequality pushes in the face of those born into such adverse situations. Enrique learned that people didn’t treat him and his family with respect, but saw the respect shown to people in the town with more means.

 

Enrique eventually came to the United States to chase money and status back home in Mexico. The inequality he first saw in his home village never left him. He found inequality everywhere, and the interconnected inequalities between the United States and Mexico in many ways created his lifestyle and enabled his drug dealing.

 

I don’t have a solution to our interconnected inequalities, but I think we need to acknowledge them. I am sure that some level of inequality is inevitable, and likely even healthy, but I’m also convinced that the inequality we see between people and between nations is part of what drives much of our global conflict and grief. So much of the world’s inequality seems completely unnecessary, and in many ways should be addressed head-on, so that people at the bottom don’t believe that the only way to improve their lives is through illicit means, and so that people at the very top don’t use resources in such wanton ways to signal how wealthy and successful they are at the expense of others.