Useful presentation of research and evidence testing some traditional beliefs about addiction and recovery by Zach Siegel.

We looked into the concept of “once an addict, always an addict.”

Zachary Siegel

Amid the outpouring of praise and admiration for Anthony Bourdain after his apparent suicide in France on June 8, a few outspoken members of the addiction recovery community zoomed in on his “demons,” and scorned his drinking on the shows that made him famous.

Poet and memoirist Mary Karr, best known for her beautiful books about her own alcoholism, went so far as to blame the 61-year-old’s suicide on untreated alcoholism, and called Bourdain out for not being 100 percent sober. Bourdain had a nasty run with heroin and cocaine in his early 20s, about which he was an open book, and to which he credited his propensity to root for the underdog, and respond compassionately to suffering and injustice around the world.

Karr, on the other hand, seems to view addiction as Bourdain’s demise. “Watching him drink on screen was like watching a slow motion car crash,” she tweeted. “He looked so desperate for every shot. I couldn’t watch after a while.” Karr’s tweets invited her fans, many of whom appear to have sustained abstinence through self-help groups like Alcoholics Anonymous, to speculate about the causes of Bourdain’s suicide: Had Bourdain been sober like us, he’d still be around. Karr tweeted, “…it was avoidable if people didn’t give him a pass for being a drunk just because he was ‘healed’ from using heroin.”

Yes, we saw Bourdain drink during his episodes, and occasionally use cannabis, like in Uruguay and Amsterdam, where he enjoyed the lax laws. During a 2013 Reddit AMA, Bourdain called himself a “VERY unusual case,” acknowledging that oftentimes people have to give up everything—alcohol included—to get their lives back on track. Rather than give it all up, he chose to find his own path.

After reading such judgmental and unforgiving characterizations—like derisively calling Bourdain a “drunk” and a “junkie”—I wondered if Karr and others were watching the same show as the rest of us. During a 2016 episode of Parts Unknown, when Bourdain clinked beers with then-President Barack Obama in Hanoi, Vietnam, where was this “desperate,” shaking fiend? Where’s the “car crash” that repulsed Karr to the point of having to shield her eyes?

Putting aside that no toxicological tests for drugs and alcohol have been released to the public; putting aside that the local French prosecutor in charge of Bourdain’s case said there’s no indication he was drinking at the hotel in the days before he was found dead; putting all that aside, the commentary from Karr and her ilk flies in the face of everything we’ve come to learn in recent years about how addiction and recovery plays out over the span of one’s lifetime.

The disdain with which Bourdain’s drinking has been met taps into a much larger debate between two competing camps: the old school vs. the new school. I’d describe the old school as essentialists, comprising people like Karr, for whom a diagnosis of substance use disorder (addiction) is an essential part of one’s identity—an identity that is self-preservative because, remember what happened last time you drank? Why gamble? Demonizing the thing that almost killed you will keep you away from it.

Moreover, Karr tweeted that addiction is “always progressive and always fatal,” which is foundational to the essentialist framework, largely informed by the abstinence-based, 12-Step tradition, which dominates America’s unregulated treatment industry. From that thinking springs phrases like “once an addict, always an addict.” Addiction is not an illness, but rather a fixed, static identity that functions as a protective shield against using substances.

The old-school group also believes in what’s called “cross addiction.” They think that because Bourdain had a heroin addiction in his 20s, he’s putting himself at risk for a new addiction by drinking alcohol. For the essentialists, Bourdain’s death confirms a grim prognosis: “The only alternative to AA is jails, institutions, or death,” according to the “Big Book” of Alcoholics Anonymous.

Kenneth Blum, who coined the concept of “reward deficiency syndrome” during research that first correlated the A1 allele with dopamine in cases of severe alcoholism, tells me that someone with diminished dopamine is indeed at risk of becoming cross addicted. “The fact you [could] become an alcoholic later in life, after being interested in cocaine and heroin earlier in life, that is no surprise to me at all,” Blum, who’s currently an adjunct professor at Western University Health Sciences in Pomona, California, says. He added, “It’s well-known that people move from one addiction to another throughout their lives.”

But the new school says not so fast. I call this group contextualists, because they dispense with such absolutes, and recognize that a complex tangle of variables are at play in compulsive drug use, and are by no means permanent. They recognize that human beings are dynamic creatures who are capable of transforming and maturing out of their past addictions.

Rather than clinical anecdotes and conventional wisdom picked up in AA meetings, contextualists’ thinking is backed up by gigantic surveys with nationally representative samples, like this one from the Recovery Research Institute housed in Massachusetts General Hospital, which found that about half of people naturally recover (spontaneous remission) without any formal treatment, and without informal self-help like AA.

The rate of “unassisted recovery” is even higher when it comes to alcohol. About 75 percent of people who recover from alcohol dependence do so without any help, including treatment or AA, according to a 2009 survey from the National Institute on Alcohol Abuse and Alcoholism. This may come as a shock to essentialists like Karr, but about half of people who meet the criteria for “alcohol use disorder” actually return to controlled drinking, per the survey.

To be sure, I’m unaware of Bourdain ever claiming to have moderated his heroin and cocaine use. But, the essentialists would argue that he became cross addicted to alcohol. I’ll respectfully refuse to speculate about Bourdain’s drinking patterns, but in general, there’s ample evidence that people can safely return to social drinking after kicking a drug addiction, especially one that occurred early in one’s life.

Ian McLoone, lead therapist at the evidence-based Alltyr Clinic in St. Paul, Minnesota, says cross addiction is a myth. He pointed to a 2014 study published in JAMA Psychiatry where Columbia University researchers determined the phenomenon to be “clinical lore.” He says, “The myth of cross addiction is founded upon the idea that someone with the addictive personality is clearly more likely than any non ‘addict/alcoholic’ to be addicted to anything—heroin, cannabis, exercise, food, etc. But what we know from the evidence is that this simply doesn’t hold up under scientific scrutiny.”

“It’s like, as soon as someone’s been branded with the Scarlet H [for heroin], they can never be seen through any other lens than a ‘junkie’ on his way to his next relapse,” McLoone says.

That same JAMA study also found that serious addiction early in life can actually become a protective factor for developing a second addiction later in life—the opposite conclusion of Blum’s dopamine theory. During Bourdain’s AMA, he sort of said exactly that: “Maybe cause [sic] my experiences were so awful in the end, I’ve never been tempted to relapse.”

But all the science and surveys in the world showing that people who experience addiction early in life are not doomed to oblivion is unlikely to convince someone like Karr. Because what this debate boils down to is identity.

Only 46 percent of people who’ve overcome their addiction considered themselves to be in recovery, according to the same survey conducted by Mass General’s Recovery Research Institute. Of course, this may be the result of stigma: Openly admitting you’re in recovery could damage your career. People may judge your character because, after all, doing drugs is a crime, and to be addicted means to be a criminal. But, Bourdain didn’t really identify as being in recovery because, well, he’s not really welcome among that group if he’s also drinking and smoking weed!

Because Bourdain continued to drink and smoke after kicking heroin with methadone and cocaine through sheer will, he called himself a “VERY unusual case.” But, after looking at the research cited in this article, it’s clear that he’s actually not that unusual. In fact, it’s about a 50/50 split between those who commit to abstinence and identify as being in recovery, and those who find their own way without abstinence. But because media often sensationalizes addiction—highlighting severe cases, and featuring teetotaler abstinence as the morally acceptable way to recover—it only feels like he was unusual.

Bourdain was a hero to a lot of us for various reasons. For me, he was my recovery anti-hero. Like him, I had a nasty run on heroin in my late teens and early 20s. I turned 23 inside treatment, and after a few years of total abstinence, I decided it wasn’t for me. Three or four years ago, I found myself at a Swedish bar in the Andersonville neighborhood of Chicago, sitting next to my partner, and together we drank glögg—a warm, mulled wine, which I found utterly disgusting. We joke to this day how I “relapsed” on glögg. But that’s where my abstinence ended. Today I enjoy gin and tonics at the dinner table, and I learned that the world has a lot to teach me.