Addiction

“When you talk to people who do not have addicts, they don’t understand.” Donna, however, does understand. She has an addict, her 23-year-old daughter Aubrey. In Susan Froemke and Albert Maysles’ “A Mother’s Desperation,” one of nine segments in Addiction. the remarkable first installment of HBO’s The Addiction Project, Donna makes plain her sense of loss, worry, and determination. Her phrasing and framing here — that you can have addicts, much as you can have addictions — articulates one of the series’ premises, that addiction is a social phenomenon. Her daughter’s experience reveals another, that addiction is a brain disorder, at once fearsome and treatable.

Neither idea is prevalent in public responses to addiction. In fact, most addicts are faced with depressingly old-fashioned judgments, that they’re weak, immoral, and selfish, that their “problems” are individual, that they are abnormal. In fact, as revealed in this first episode, premiering tonight, addiction has cultural, political, and economic contexts, as well as physical causes. Produced in partnership with the Robert Wood Johnson Foundation, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism — and supplemented by extensive online materials — the episode describes current options for diagnosis and treatment.

Addiction‘s nine segments, directed by leading documentary-makers, take different approaches, all focused on drug and alcohol addictions (as opposed to other sorts of behaviors, like gambling or overeating). The episode begins with a consideration of effects, in “Saturday Night in a Dallas ER,” directed by Jon Alpert (Baghdad ER). At Parkland Memorial Hospital, Dr. Larry Gentilello oversees treatment of injuries (sometimes terminal) incurred by patients who are drunk or high. With the camera close on bloody gashes, broken limbs, or screens listing multiple substances in someone’s system, the chaos of the ER gives way to a kind of fatalism. “I had about a six pack,” confesses one man on a gurney, his words still slurred even after he’s fallen and snapped his ankle. “I honestly don’t think this was because I was drinking too much,” he tells the camera, “I think it was the way I stepped.” As Gentilello sets to work on another case (“The main thing is to stop the bleeding”), he observes, that addiction is “one of the most expensive diseases we face in modern society.” Sadly, illustration is right at and: the bleeding patient dies. “You never get over seeing young people die,” says Gentilello as the segment ends.

“Saturday Night” begins Addiction with effective visual and emotional jolts, leading directly and indirectly to following segments focused on recent developments in diagnosis and treatments. Most of these segments also work to debunk abiding myths about addiction, that parents are to blame for their children’s diseases, that relapse indicates moral failure, that, as Kathleen Brady, Professor of Psychiatry Medical University of South Carolina, puts it, “An individual needs to reach rock bottom before they can get any help.” In “A Mother’s Desperation,” Donna finally has Aubrey arrested in an effort to stop her downward spiral. She asks her daughter what it will take for her to reach a “rock bottom.” Aubrey ponders for a few seconds, then says, “I don’t really know what a bottom is, it’s different for everybody.”

Her insight speaks to the problem in seeking or waiting for the “rock bottom” to appear. Such thinking lays responsibility — attached to guilt, remorse, self-loathing — at the patient’s feet rather than considering the broader, ongoing complications of addiction. Dr. Nora D. Volkow, director of the National Institute on Drug Abuse, lays out a key question: “How can we comprehend the concept of a person that wants to stop doing something and they cannot, despite catastrophic consequences?” Her explanation, at least in part, is medical: brain scans show the devastating effects of addiction on the brain. According to DR. Charles O’Brien, Professor in the University of Pennsylvania’s Department of Psychiatry, notes that reactions to triggers often can’t be measured by individuals, even those in the throes of addiction: “It’s an uncontrollable reflex that happens very, very quickly in the brain,” he says. Treatment includes medication that slows down such reflex, so that individuals can be aware of what’s happening and be able to make decisions.

William, a crack addict, offers an instructive example. Looking out on the street outside his Philadelphia home, he stretches his arm across the entire frame: “This is the trigger,” he says, “All of this.” In Eugene Jarecki and Susan Froemke’s “The Science of Relapse,” Anna Rose Childress, Research Associate Professor of Psychology in Psychiatry at Penn, explains that relapse is part of the disorder, not a failing. “At the level of the brain,” she says, “there are a lot of cards that are stacked in the wrong direction.” In her conversations with William, he describes his sense of “losing” the battle and depression, as well as the stigma attached to addiction. When he sees pictures of his brain responding to triggers, he can see that the speed of the reaction — brightly illustrated on screen in “red” — as Childress explains the usual interactions between the brain’s ancient “go system” and evolved “stop system.” In addiction, she says, “go” becomes a “rogue system… not interacting in a regular, seamless, integrated way with the stop system.” She believes that medication and behavioral treatments “can combine to literally reset the brain.”

This notion is extended in other segments, including “The Adolescent Addict,” “Brain Imaging,” and “Opiate Addiction: A New Medication.” Barbara Kopple‘s “Steamfitters Local Union 638” considers as well the cultural contexts for addiction and recovery. Interviewing and observing members of the union in Long Island City, Queens, the film focuses on Don Perks, who says right off, “Drinking was like having a soda on the job.” Working in pairs (“like a marriage, without divorce”), the men “watched out for each other by enabling.” On seeing that their “long tradition” was in fact alcoholism, the union now conducts meetings to work through their addictions, such that they “take responsibility for each other.”

Such an attitude stands in admirable opposition to that offered by too many insurance companies of late, whose managed care systems have “taught despair to families.” Froemke’s “Insurance Woes” shows families testifying in efforts to change such systems, whose denial of treatment leads to increased crime, broken families, and the belief that addicts can never recover. As the Addiction website indicates, “There is no specific or consistent criteria for approval and the standards used to determine if an individual is eligible to receive care vary. The medical necessity criteria used to deny access treatment will not be revealed.” In other words, most insurance policies are not written to benefit patients. Froemke’s segment displays the grief and outrage that result from banging heads against insurance policy walls: as parents hold up photos of their children, the costs of addiction are made visible far beyond what insurance companies call “medical expenses.”

Providing a range of information through verité documentary as well as the more familiar means of talking heads and website links, Addiction is both an outstanding resource and film series. While its impetus — to save lives, to dispel myths — is unambiguous, the project’s many nuances and insights are also extraordinary. Exposing the disease from multiple angles, it insists on collective responses. “Denial,” says David Rosenbloom, Director of Join Together, at Boston University’s School of Public Health, “is not sort of unique to this disease… Part of the disease itself, of course, is to deny that you have it.” The project makes it impossible to deny effects on anyone who has addictions, addicts, or any measure of compassion and understanding.