What is “Sobriety,” Anyway?

Over on HuffPost, @jasoncherkis has written a brilliant and provocative look at the state of opioid addiction treatment here in the U.S. It’s long, but well worth your time, especially if someone you care about is struggling with addiction and sobriety. The article outlines the inadequacies of our current approach to treating addiction, and hammers home the point that the consequence of failed treatment is often death. It asks whether our moralistic thinking about addiction gives a punitive cast to our treatment choices. And it cites modern medical science to suggest that addiction is at least in part the result of a malfunctioning brain (in the same way diabetes results from a malfunctioning pancreas), and wonders what’s wrong with using medication to repair that malfunction.

But for me, the most interesting question this article raises is: What does it mean to be sober? Surprisingly, a quick Google search, including a visit to the Big Book, reveals that there does not appear to be any agreed-upon definition of “sobriety” among 12-step and other recovery programs! (Here’s a definition that, paradoxically, emphasizes the many possible definitions.) Given that sobriety is the central focus, indeed the goal, of these programs, this seems odd. Some of the definitions my search uncovered include:

• Being free of all intoxicants (which, as you’ll know if you’ve ever attended a 12-step meeting, apparently don’t include coffee and cigarettes).
• “Not being intoxicated,” which is not the same as not consuming intoxicants.
• Living a certain kind of life: responsible, ethical, and with healthy strategies for coping with stress.

I’m sure there are more. The definition is important: how you think of sobriety dictates how you achieve it. This becomes obvious when you consider buprenorphine: the article cites several instances in which people are excluded from treatment because their use of buprenorphine means they aren’t sober. But buprenorphine is designed to suppress cravings and prevent withdrawal symptoms without providing the intoxicating effects of heroin; in other words, when used correctly, it is not an intoxicant. So how is using it breaking sobriety, unless you define sobriety as being free of all psychoactive substances, even life-saving, prescribed medications like antidepressants or anti-psychotics?

This discussion isn’t abstract, but goes directly to the question of how we help people who are suffering from addiction be healthy, happy and productive. Cherkis’ story details over and over again that our current model of addiction recovery works well as long as you are in a controlled setting like a sober living center. But the story makes a strong case that hard-won sobriety often cannot survive in the outside world. Indeed, often the addict cannot survive in the outside world. There’s something worrisome about using a model that insists on limiting itself to using self-discipline, introspection, social support, and spiritual appeals, when so often that model fails, and at times catastrophically. Sure, it’s better when addicts are able to be sober without relying on medications. But it seems misguided to pursue that ideal when the price for failure can literally be death, and there’s an alternative that, while less “pure,” preserves life.