Dr. Harrison, just a few months shy of the five-year anniversary of founding Eleanor Health, your book, Un-Addiction: 6 Mind-Changing Conversations That Could Save a Life was published.  What inspired you to write this book? 

I’ve been taking care of people with Substance Use Disorders for over 20 years now, and what I found in medical school when I became passionate about these folks is that silence really does kill. We’ve experienced this in the past with other conditions that have been highly stigmatized like HIV, suicide or in the way, way past, even epilepsy and asthma.  The more we can make it safe to talk about addiction, the easier it will be for people to seek support. The more we can understand that addiction is a chronic medical condition no different than diabetes or high blood pressure or asthma, the more we can approach it with compassion and evidence-based interventions, and then I think we’ll start to see this addiction crisis turnaround.

It seems like a compassionate approach for people with addiction should be table stakes, but has that not been the case? 

Unfortunately that has not been the case.  The way we treat people with addiction has historically been punitive and controlling - not just in healthcare, but in everyday life.  We’ve made a lot of progress in understanding addiction as an illness, but when the symptoms of a medical condition are emotions and thoughts and behaviors, it’s easy to mistake symptoms of the illness for who that person is.  This is why you often hear people talk about the “addictive personality” when really they are referring to a person with many risk factors for the illness that is addiction.  And so to your question, we very naturally develop compassion for a person who is suffering from an illness. We also very naturally develop judgment towards a person that we believe has bad moral character or is repeatedly making bad decisions. The medical literature is unequivocal. Addiction has the same risk factors as every other chronic medical condition and has the same or lower relapse rates as every other chronic medical condition.  So if we can understand addiction as a chronic condition, I think that will naturally develop our compassion to want to help people who are suffering rather than perpetuating judgment against people we believe are choosing to make bad decisions. 

You  mention that substance use disorders have the same risk factors as every other chronic medical condition.  What do you mean? 

For every chronic condition, addiction included, there are three types of risk that you are born with, and you acquire more of those same three types of risk over your life.  The book is organized into 6 chapters, each delving into one of those inherited or acquired risk factors, and providing a script for how to have a conversation about it.   The three types of risk factors are biological, psychological and environmental.  Let’s start with the risk factors we inherit.  Most people don’t know that 40 to 60% of our risk for developing addiction is coded in our DNA the day we are born.   That is equal and/or higher than asthma, diabetes and high blood pressure.   Psychologically, the experiences we have as young children predict our risk of chronic conditions in adulthood including asthma, diabetes, cancer, premature birth, depression, anxiety, and yes, addiction.  Environmentally, including the physical environment as well as the cultural environment, the zip code you are born into, or your ZNA, predicts your adult health more than the zip code you currently live in.  So if we explore our personal history as it relates to those three inherited risk factors, we can do our childhood risk assessment for developing an SUD 

This makes a lot of sense.  And you said those same risk factors repeat in adulthood? 

Yes!  Biologically, as we age from childhood to adolescents to young adults to older adults, we develop illnesses and injuries that may put us at risk for a substance use disorder.  Think recreational alcohol use turns to alcohol use disorder in the face of insomnia, or prescription opioids turn into opioid use disorder.  Psychologically we accumulated traumas including experiences with racism and discrimination that steer us towards coping strategies - sometimes which may be alcohol or other drugs.  Finally, environmentally, we deal with stressors in our physical environment to a pervasive culture of drug use (It’s wine o’clock somewhere) that increase the chance social use turns into risky use.   

So every person has a set of risk factors for developing addiction that you can categorize as inherited and acquired biological, psychological and environmental factors.  What does this mean for how we should be approaching SUD treatment? 

Understanding that each person with addiction has a unique combination of inherited and acquired biological, psychological and environmental risk factors, leads us to a concept of treatment and intervention that I call the magic formula.   What I love about the magic formula, is that it’s not magic!  

Traditional addiction treatment is chopped into disjointed episodes -  a 5 day inpatient stay, followed by a 30-day residential stay and on to a three week Intensive Outpatient stay, with the person having to re-tell their trauma each time to a new stranger doing the intake process. The majority of individuals do not get connected to longitudinal outpatient care.  Traditional treatment is siloed, treating only a subset of SUDs (ie only OUD), not addressing co-occurring mental health disorders, not addressing physical health needs and ignoring the impact of trauma including racism and discrimination on a person’s health.  As a result, traditional SUD treatment is ineffective leading to record high numbers of people suffering and dying from overdose and suicide.  

If we understand the magic formula, then we know that as treatment providers, payers and investors who seek the best outcomes for the people we serve, we have to ask ourselves: 

How are we evaluating inherited biological, psychological and environmental risk factors including adverse and positive childhood experiences?  

How are we evaluating acquired biological, psychological and environmental risk factors, including the impact of experiences with racism and discrimination or a work culture that makes it hard to say “I don’t drink” when your colleagues are all headed to happy hour?  

How are we validating the experiences individuals have had, empowering them with information to keep themselves safe, and supporting them with compassion in developing their own individualized magic formula for recovery?  

How are we investing in longitudinal care relationships that offer the opportunity to  periodically evolve the magic formula as their needs and goals change rather than discontinuing care in the face of continued substance use?

How are using data and technology to individualize care given the scarcity of human beings available to do this work? 

Basically you’re saying that there is no one size fits all formula to this, right?  

That’s exactly right.  Just imagine there was only one chemo regimen for cancer.  No matter what kind of cancer you have, no matter how old you are, no matter what your family situation is, no matter your genetics - there’s only one regimen.  If we give you that chemo regimen and your cancer doesn’t go into remission, that’s because you did not want your cancer to go into remission. I think we all agree, that approach is absurd. And yet, that is what our approach to SUD treatment has been.  So how do we change that?  The answer is individualized, longitudinal, evidence-based care based in compassion and equity. 

Tell us about the book!

I mentioned earlier that the book is divided into 6 chapters - each chapter dedicated to one of the risk factor categories.  This is not a textbook!  It’s an easy read with education given through personal and professional stories,  For example, the book opens with the story of the drunk monkeys on St. Kitts island, and what they’ve taught us about alcoholism.  I also teach about Adverse Childhood Experiences (ACES) by telling the story of my own score.   46% of Americans have had an SUD themselves or experienced an SUD with a loved one, so really, I wrote this book for everyone.  My hope is that it will change the way we think about Substance Use Disorders and that will motivate us to change the way we treat the people who experience them. 

 Un-Addiction: 6 Mind-Changing Conversations That Could Save a Life, is available everywhere you buy books online and in stores.  It’s available in both print and audiobook. 

Eleanor Health provides longitudinal, whole-person substance use disorder care grounded in equity and compassion, reimbursed in value-based care models.

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