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Costa Mesa, California, isn’t a particularly big city. About 40 miles southeast of Los Angeles, it boasts a population of slightly over 100,000, and it’s affluent enough to be home to South Coast Plaza, a big, luxury shopping mall that includes stores like Nordstrom, Macy’s, Jimmy Choo, Bulgari, and Cartier. It is also, however, home to some 98 sober living communities (as of November 2016, according to Costa Mesa’s Planning Commission, most of which are attached to treatment centers) with which it has a long, contentious history. With a number of residences located in neighborhoods with single-family homes, Costa Mesa has, for some time sought to limit the number of sober-living residences.

For Jeremy Broderick, who came to Southern California from the East Coast after his own struggle to become sober, Costa Mesa is a personal battleground. Broderick is the founder of two of the most reputable treatment centers in California; one for men (Windward Way) and one for women (Casa Capri) both located in Costa Mesa. Both have 5 star ratings on review sites like Yelp and Facebook, and the same for treatment center review sites like AddictionUnscripted.com and Rehabs.com

In an impassioned speech during a Costa Mesa Planning Commission meeting this November, convened to discuss permits for additional sober living facilities, Broderick urged the community as well as Planning Commission officials, to try and reconsider their opposition – suggesting that the city ought to reframe itself as a leader in rational treatment for addiction rather than a victim; and saying,

 “Let’s (not) rewind it back and go kind of barbaric and medieval, let’s not take this stance that we’re not going to have these people here, and move them out to the desert … let’s remove some of that stigma.”

The situation in Costa Mesa is a microcosm of the divided state of treatment for drug and alcohol in America. The AMA defined alcoholism as a disease in 1959, and in 1991 endorsed a definition of alcoholism as both a psychiatric disorder and a physical illness. Today the disease model of addiction is accepted almost universally by the medical community, but the stigma attached to those who suffer from that disease continues to affect public policy, and to impede the adoption of rational policies.

Alcohol addiction offers an interesting picture of the evolution of the divide between the disease model, and the opposing view that alcoholics suffer from some sort of moral weakness or failure of willpower rather than from an organic disease. The notion that alcoholism may be a disease is not a new one; it was first suggested, more or less simultaneously, by the Scottish physician Dr. Thomas Trotter, and by Dr. Benjamin Rush (a signer of the US Constitution, no less) at the beginning of the 19th century.

Trotter wrote that “’the habit of drunkenness is a disease of the mind” in his 1804 essay; while Rush wrote, in An Inquiry Into The Effects Of Ardent Spirits Upon The Human Body And Mind (1808) that “habitual drunkenness should be regarded not as a bad habit but as a disease.”

By the end of the 19th century, however, urbanization combined with the development of industrial methods for producing “ardent spirits” (distilled alcohol) had produced profoundly divided views; on the one hand were those who, with Rush and Trotter, argued for a disease-based model; on the other hand were those who viewed alcoholism in particular, and drug addiction in general, in moral and spiritual terms. In the years leading up to Prohibition, a number of factors contributed to the view that laws needed to be enacted to reduce drinking in America, with many couched in moral terms.

Drinking itself, of course, was attacked on moral grounds and it wasn’t just viewed as a sign of moral laxness; alcohol and drinking were characterized as sinful by a number of churches as well, and the temperance movement also insisted that the social component of drinking tended to corrupt character. The drive to limit drinking was also given further impetus by the widespread public perception that excessive drinking was partly due to the post World War I influx of immigrants. This combination of xenophobia, conspiracy theorizing, and religious fervor fed a tide of anti-drinking sentiment culminating in Prohibition. (Prohibition did create a big decline in drinking, but it also fed a huge underground economy, criminalized the importation, sale, and consumption of alcohol, and created criminal empires.)

Though Prohibition itself is long gone (it was repealed in 1933) the tendency to frame alcoholism in particular, and addiction in general, as an aspect of a life lived sinfully and immorally, has remained a part of the American psyche. 

That the moral stigma associated with addiction is an issue up to the present day, and that it exacerbates an already severe public health problem, is a view held by many medical professionals even now, including US Surgeon General Vivek Murthy. Dr. Murthy recently released a landmark report, “Facing Addiction In America,” in which he argues for a wholesale revision of America’s views on addiction treatment – and for rationally, medically based treatment policy.

Murthy sounds the alarm for recognizing the severity and incredible economic and human cost of substance “misuse” in America. The numbers are, well, sobering. In 2015, “nearly a quarter of the adult and adolescent population reported binge drinking in the past month” and “over 27 million people in the United States reported current use of illicit drugs, or misuse of prescription drugs.” Alcohol abuse alone cost the United States about $249 billion in 2015.

“We … need a cultural shift in how we think about addiction. For far too long, too many in our country have viewed addiction as a moral failing. This unfortunate stigma has created an added burden of shame that has made people with substance use disorders less likely to come forward and seek help. It has also made it more challenging to marshal the necessary investments in prevention and treatment. We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer.”

“Not In My Backyard”

Now to the residents of Costa Mesa, and other communities considering how and where and if they should allow an increased number of care centers, all of this may sound like an abstraction; the kind of argument that a public official can afford to make because the treatment centers, residences for those in recovery, and community impact of such facilities can be conveniently ignored in an office in Washington, DC. However, the fact that the problem of addiction continues to grow in the United States, and the enormous cost we incur due to its impact, would seem to argue continuing to expect solutions to meeting the problem to be invisible may not be sustainable either.

The stigma of moral laxity attached to addiction, says the Surgeon General, is a sword that cuts two ways: it makes public policy on addiction treatment punitive rather than preventative or curative in orientation, and it makes those suffering from substance abuse problems less likely to seek treatment – both out of shame at admitting they have a problem, and at least in some cases, because of the fear of legal consequences.

Murthy notes, “ … few other medical conditions are surrounded by as much shame and misunderstanding as substance use disorders. Historically, our society has treated addiction and misuse of alcohol and drugs as symptoms of moral weakness or as a willful rejection of societal norms, and these problems have been addressed primarily through the criminal justice system.”

The word “stigma” is a very old one – originally it was from ancient Greek, and meant the mark made by a pointed instrument. Over the centuries since, however, it has come to mean many other things – including a mark of shame. A clinical note published in the Western Journal of Medicine illustrates all too clearly the reality of this burden.

The report is from a pediatrician who, along with a third-year intern, examines an 18 month old girl named Angel, whose mother had described to ER staff her struggle with addiction, achievement of abstinence, and struggle to regain custody of her daughter. Angel had been brought in with a persistent cough and fever and while the pediatrician examines her, she notices a birthmark, which she points out to the medical student. The mother is stunned to hear that the mark is a birthmark.

‘“I always thought it was a mark they put on my baby in the hospital,” she said.
I must have looked confused. “Because I was an addict when she was born … I thought the nurses took some ink and put a mark on her so people would know.”
“You thought they did that in the hospital nursery?” Now I was the wide-eyed one.
She explained the way “they all talk about the addicts” on the maternity ward … it just always seemed obvious to her that the nurses would want to brand Angel as an “addict’s baby”.’

The doctor’s explanation did away with a few words the persistent conviction Angel’s mother had that her daughter was marked for life as an addict’s child. But the hardest stigmas to remove in addiction may the ones we can’t see. 

Costa Mesa’s reluctance to accept more treatment centers and residences isn’t hard to understand, because it’s a reluctance shared by many American communities. At the same time, though, the cost of addiction isn’t something that can be avoided, in Costa Mesa or anywhere else, and perhaps at least in part, the path to better treatment can be made clearer by realizing that substance abuse isn’t a problem of the morally weak – it’s everyone’s problem.

-Regina Walker