Showing posts with label race. Show all posts
Showing posts with label race. Show all posts

Sunday, November 24, 2024

The Most Important Thing I Learned in the 8th grade….

 


I grew up in the northernmost regions of Wisconsin on the shore of Lake Superior. I also grew up a relatively long time ago. There were no wealthy people around – you were either a working-class family with a regular pay check or a working-class family with an irregular paycheck. It all depended on the work.  My father was a railroad fireman (he shoveled coal in steam engines) and later an engineer on diesel locomotives.  Even though he was in his forties work was very irregular due to the seniority system used by railroads.  The oldest people got their selection of jobs and there were more people than jobs. Many people at the top refused to retire creating a lot of anger and controversy by younger people wanting to work more hours.

The entire population of my home town was from European ancestry – everyone was white. Irish and Scandinavian derived families clustered on the west side of town and eastern European, German and Polish families on the east side of town.  We lived on the east side about 7 blocks from the lake.  

The town was located between two reservations inhabited by the Red Cliff and Bad River Tribes of the Lake Superior Chippewa. It was rare to encounter anyone of Native American ancestry unless you played sports and competed against some of those teams or until you were in middle school or high school. I used to fish on the Bad River Reservation with my grandfather and we got to known some of the men who ran a local boat landing.

Racism was overt and it was everywhere.  That may sound odd given my description of the place, but it would not take much to set people off.  An image on television like Muhammad Ali talking in his usual provocative manner or Willy Mays showboating in center field was all that it took. Racial epithets followed at a rate and intensity that was quite unbelievable.  There were a few cooler heads.  My grandmother was one.  All that she could do was to insist that people not talk like that in her presence.  As a boy – it was a mystery to me that the rest room facilities on trains were segregated – even though we were practically in Canada and there were no black people around.  I asked my father why the porter had to have a separate bathroom and he could not give me an answer.  At the time I had never seen a porter.    

The time frame of my youth coincided with the American Civil Rights Movement (1954-1968) but there was no discussion of it in schools, churches, or the public discourse.  The only place where it came up at all was in my 8th grade biology course.   On a day back in 1965 – I learned the best lesson I ever learned in high school and possibly in my life.

I was a definite nerd back then and extremely interested in science – especially biology.  It was the only class that seemed to be interesting.  That was probably fueled by being a neurotic kid and always wondering if I had an undiagnosed disease or not.  My imagined symptoms at the time seemed limitless and I would find myself in the library researching rabies and various cancers primarily.  It seemed that cancer was always a dinner table topic for my parents.  A relative with exploratory surgery and the ultimate ending: “They just sewed him back up – there was nothing more they could do.”  There was not a lot available to an 8th grader with those interests so I ended up picking up a lot of biology on the side. That could be useful or not depending on who the teacher was – so I kept most of it to myself.

I can still recall the excitement of learning that our biology course had been changed to Modern Biology and there was a new textbook (1). Our teacher told us the course would be more relevant and it could also form the basis for a college trajectory.  All I can remember about it today is frog dissections, the genetics of taste testing and tongue rolling, and the idea that race was a social construct that had nothing to do with biology.

That’s right – the social construct bomb was dropped in the middle of the Great White North in 1965 and it did not make a sound. There was no emphasis about it.  There were no lessons seeking to connect it to the culture at the time and the Civil Rights Movement.  There was no controversy at school board meetings. It was right there in the book.  A biological definition of races and a description that the isolated groups that were called races would probably intermix at some point and the artificial, color-based designations would just disappear.  We would all be one big happy Homo sapiens family. That information was as rational as it was profound when I read it the first time and witnessed how the idea was repeatedly violated over the next 50 years.  I had seen it violated so many times I went back and found the original biology text that I read in the 8th grade.         

Some of the key quotes from that text are on the following graphic.  The basic idea is that the species originated and subpopulations migrated over thousands of years and were geographically isolated. During that isolation mutations occurred in those populations that led to some alterations in physical appearance but the genome wide similarities were still much greater than any between population differences. One standard species definition is the ability to interbreed between populations and that was sustained.  Even though populations were named by different physical characteristics they were biologically identical. In the modern era, the longstanding physical barriers to population mixing are no longer present and we should expect a more homogeneous population over time.




Flash forward to 2024.  I just read a paper (2) that should be read by everyone and combined with my personal experience is the impetus for this post. The additional impetus is the recent election in the US and a political cultural movements that are overtly racist, anti-racist, and anti-anti-racist. There are some common interests.  As a clear example, the overtly racist and anti-anti-racist movements coalesce around the central idea that the white race will be “replaced” by non-white races and this will result in significant loss of political advantage. That theory is called the Great Replacement Theory and it plays out at several levels not the least of which is the claim that one party seeks to use it to their advantage to get more voters and they will do this by illegal immigration. Never mind the fact that non-citizens cannot vote.  And never mind the fact that the current political landscape is a small blip in geological time. 

The paper is written by two evolutionary and theoretical biologists.  Expectedly it contains an abundance of modern theory about human genetics, evolution, and most importantly modes of transmission between individuals in populations. The most interesting focus for biologists and physicians is that there are ways to transmit behaviors between generations that are outside genetic transmission and that there are potential interactions between these modes and individual genetics.  The authors use an example of dairy farming and the persistence of lactase alleles.  Dairy farming can select for those alleles in the population but cultural adaption like the use of milk fermentation can also be successful in the absence of lactase persistence.  The main drivers of non-genetic inheritance are depicted in the graphic at the top of this post from the authors’ paper. 

In the body of the paper, they discuss cultural evolution (CE) and gene culture coevolution (GCC) models.  The lactase allele in the context of dairy farming is an example of GCC.  They discuss common errors made in suggesting that race is biologically based and introduce how cultural factors explain some of the differences attributed to genetics.  Intellectual differences are cited as one early example that was attributed to genetics – but modern genetic studies and combining cultural factors shows that there are no clear genetic differences between comparison populations and that all of the differences in educational achievement can be attributed to cultural factors like cultural role models, parental expectations, resources, social roles, and environmental niche.  Negative factors like racial discrimination and adverse life experiences can also play a role.  This paper is a reminder to carefully look for other sources of variance in large in genome wide association studies (GWAS) and whether cultural factors were studied.  My speculation is that the commonest cultural factor in play these days is childhood trauma because the Adverse Childhood Experiences (ACE) checklist is available and considered a measure. This paper would suggest that is only part of the story.      

So here it is nearly 60 years after I read that race has no biological basis and that it is a social construct - it is still being used to divide citizens, suppress the vote, ration resources, stereotype people, direct violence at people, and actively discriminate against them.  I don’t know if reading this paper will be helpful at all so I provided the slides comparing my 8th grade biology text and a current state of the art paper in abbreviated form.

I did not touch on the rhetoric involved and that is long, detailed, and discussed in other places on this blog.  Very briefly – philosophers and other rhetoricians have taken an anti-science stand in the past because they believed that science was given too much power.  That came about as philosophical musings gave way to more predictable scientific explanations. The problem is that science is an evolving process rather than a book of clearcut answers with some areas less evolved than others.  Eugenics and even more recent claims that race and associated cultural characteristics and endpoints are genetically based could be considered part of that process.  But many of these arguments still persist and like other areas of science have been politicized.  The authors here present all the reasons those arguments about race as a biological property are wrong.      

It was known in 1963 and it’s even more well known today.

 

George Dawson, MD, DFAPA


Supplementary 1:  In terms of cultural factors and educational attainment I was reminded of one from my background - the Medical College Admissions Test (MCAT).  Back when I took it there was a general knowledge section that was supposed to show that the applicant had a knowledge base outside of science.  It was heavily weighted to the arts and humanities.   It was eventually eliminated because it was shown to favor students in large cities where there was access to art galleries and museums.  The closest museum was 200 miles away.  My family rarely left town.  When they did it was usually to pick up my father from a train station about 30 miles away.  

Supplementary 2:  It is interesting to consider the political rhetoric of the last election as it applies to the concept of race as a social construct.  It was common to see minority groups that in some cases were extremely small being scapegoated for political purposes.  Some of it had to do with long standing racism and some of it had to do with cultural factors.  The whole point of this blog post is how can any of that be acceptable if we are all members of the same race with trivial differences in appearance and behavior?      

 

References:

1: Botticelli CB, Erk FC, Fishleder J, Peterson GE, Smith FW, Strawbridge DW, Van Norma RW, Welch CA (Biological Sciences Curriculum Study). Biological Science: Molecules to Man. Revised Edition. Boston: Houghton Mifflin Company, 1963: 671-674.

2: Lala KN, Feldman MW. Genes, culture, and scientific racism. Proc Natl Acad Sci U S A. 2024 Nov 26;121(48):e2322874121. doi: 10.1073/pnas.2322874121. Epub 2024 Nov 18. PMID: 39556747.        

3:  Creanza N, Kolodny O, Feldman MW. Cultural evolutionary theory: How culture evolves and why it matters. Proc Natl Acad Sci U S A. 2017 Jul 25;114(30):7782-7789. doi: 10.1073/pnas.1620732114. Epub 2017 Jul 24. PMID: 28739941; PMCID: PMC5544263.

 

Graphics Credit:

From reference 2 Copyright © 2024 the Author(s). Published by PNAS. This open access article is distributed under Creative Commons Attribution License 4.0 (CC BY).

 


Monday, May 14, 2018

Addiction Narratives Versus Reality.......





I recently posted my take on this issue of race in addiction treatment. The main argument that I was responding to was that the current opioid epidemic is whitewashed so to speak. In other words white opioid addicts are considered to be "victims" of the opioid epidemic and black addicts are considered just to be addicts at best and criminalized at worst.  Part of the way that white people are framed as victims is by calling addiction a disease.  The author who I was critiquing at the time suggested that the opioid epidemic was marketed to white people along with the medication (buprenorphine) that would "cure" them.  Further, that buprenorphine was more easily available to white people by the nature of the prescribing requirements.  The article went on to selectively highlight one segment of the population where "non-Hispanic blacks" had a higher rate of overdose deaths, despite the fact that the majority of people dying in most categories were white.  I consider my counterargument to be a solid one and that is - there is no known difference in the biological predisposition to addiction of any kind that is based on race and if that likelihood is equal - the only consideration is who is exposed to the drug.

The racialization of the opioid epidemic picked up more speed over the weekend.  One of the theories proposed was that there were no previous "epidemics" of opioid use and that this is another way to sanitize the problem and make it more acceptable to white people.  The article was written for a newspaper - the Guardian and the headline says it all:  "Amid the opioid epidemic, white means victim, black means addict."  That is the basic thesis that runs through the entire essay.  You are either a white, Christian, Republican racist, who considers himself to be a victim of prescription opioid tablets or drug dealers or the hypocritical structure of American society insults you for being black and an addict.  It is suggested directly in the article that common rationalizations of addicts - the ones that everybody uses irrespective of race or substance are the exclusively used by whites to deny responsibility for addiction.  Self-loathing of the addict is described as though that never happens with white people.  Guilt, shame, and self loathing happens to everyone with an alcohol or drug misuse problem.
          
A couple of the arguments can be debunked at the outset. The idea that the term epidemics is applied only to white people so that they can rationalize being victims ignores the medical literature of the 1970s.  In those days researchers were using the terms epidemics and microepidemics and applying the terms across racial groups (3-6).  Successful naturalistic studies were conducted in both white and black neighborhoods and the success in a Chicago study (6) was  correlated with use of the term medical management.  Those same authors used what they called an infectious disease model for intervening in heroin epidemics (5).  The Chicago study was so successful that it was suggested as an alternative to involuntary treatment (4):

 "This work suggests that heroin addiction can be prevented in many who are at risk; it further suggests that prevention may be possible by using psychological and social concepts based on humanist principles without the use of coercion. The authors' approach deserves close attention not only because it offers hope in the face of a mounting national tragedy but also because of its relevance in the current high-level and little-publicized debate over the use of compulsory urine testing and compulsory treatment of drug dependent persons."   - p.1156
     
It appears that at least in psychiatry - humanism was emphasized as the critical element in treating drug dependent persons (not addicts) as far back as 46 years ago.  The design of the naturalistic study in question was impressive and methadone maintenance treatment was used in a majority of the patients.

The issue of differences in the story about the self perception of a white versus black addict does not have the equivalent empirical basis.  I can say unequivocally that any attitude in treatment about being a "victim" of substance use of any type  would be vigorously confronted by treatment staff.  It is not possible to actively participate in treatment with that attitude.  The same is true of the self loathing patient.  Guilt, shame, and self loathing need to be actively explored and corrected to allow participation in the recovery process.  Both attitudes can lead to distress or increased cravings to use drugs and alcohol and relapse.

What about the contention that cultural differences and disparities are the primary problem with treatment differences.  I refer any interested reader to an in depth analysis of the issues by Coleman Hughes (2) and what he describes as the disparity fallacy - in other words that the difference in outcomes between blacks and whites (or any two groups) is due to discrimination being the causal factor.  He lists an impressive number of examples, but I see the underlying principle as being one of undeterminism (7) that is there are multiple theories to account for differences, and people tend to have a favorite and ignore all of the other possibilities.  There is probably no better example than the race rhetoric around addiction.  The promotion of these arguments ignores the primary causes of addiction - a biological predisposition and exposure to the addictive substance.  I am not suggesting disparities are irrelevant to exposure or treatment access but focusing on them as casual ignores the major factors.           

The continued stories about racial differences in treatment and self perception are not really conducive to reshaping America's addiction treatment landscape.  It misses the big picture that there are no differences in race when it comes to addiction.  Any reasonable treatment approach would disabuse anybody coming through the door who believed they were either a victim or a self-loathing addict.  Identical treatment modalities should be offered irrespective of race and that includes medication assisted treatment of all types, necessary psychiatric and psychological treatment, medical evaluation and treatment, and drug and alcohol counseling focused on recovery.  One of the reasons why addiction is viewed as a chronic illness is the high likelihood of relapse and need for ongoing recovery services and support.  One of the main tenets of any 12-step recovery program based on the AA model is that nobody is turned away. The only requirement for membership is a desire to get sober.   

The real problem with drug and alcohol treatment is not racial disparity. It would be fairly obvious if racial discrimination was occurring in any comprehensive treatment program.  The real problem with drug and alcohol treatment is the lack of standards and consistency in treatment.  The most clear cut example is the availability of detox services.  Some forms of withdrawal are life threatening and need to be immediately recognized and treated.  I doubt that the majority of treatment programs in any state have that capability.  Hospitals have been defunded from providing detox services from anyone who is not experiencing life threatening withdrawal for about 30 years now. That has led to a proliferation of subpar and non-medical county detox facilities where limited to no medical care is rendered.  These kinds of inconsistencies in care occur across the board and it is common to see patients who have not received even basic addiction care - completing a treatment program and being released back to their home setting.

Racism has no place in medicine.  I have discussed the advantages of therapeutic neutrality on these pages before and certainly any physician who is not able to do that should not be practicing medicine in the 21st century.  The psychiatric standard for neutrality is higher.  Psychiatrists in particular are trained to understand cultural differences, but it is not possible to be an expert on every culture.  It is possible to appreciate the person in the room and proceed cautiously enough to assure that culturally sensitive care is being provided.         

In the end, there are clearly ways to prevent and treat addiction. Suggesting that race and the narratives around race are the primary factors that account for addiction or recovery is unfounded.


George Dawson, MD, DFAPA


References:

1:  Brian Broome.  Amid the opioid epidemic, white means victim, black means addict.  April 28, 2018.

2:  Coleman Hughes.  The Racism Treadmill.  Quillette May 14, 2018.

3: DuPont RL, Greene MH. The dynamics of a heroin addiction epidemic. Science.1973 Aug 24;181(4101):716-22. PubMed PMID: 4724929.

4: Freedman DX, Senay EC. Heroin epidemics. JAMA. 1973 Mar 5;223(10):1155-6. PubMed PMID: 4739378. 

5: Hughes PH, Crawford GA. A contagious disease model for researching and intervening in heroin epidemics. Arch Gen Psychiatry. 1972 Aug;27(2):149-55. PubMed PMID: 5042822.

6: Hughes PH, Senay EC, Parker R. The medical management of a heroin epidemic. Arch Gen Psychiatry. 1972 Nov;27(5):585-91. PubMed PMID: 5080286.

7:  Stanford, Kyle, "Underdetermination of Scientific Theory", The Stanford Encyclopedia of Philosophy (Winter 2017 Edition), Edward N. Zalta (ed.), URL = https://plato.stanford.edu/archives/win2017/entries/scientific-underdetermination/.



Monday, May 7, 2018

The Whitening of the Opioid Epidemic....





I was reading the most recent copy of the Psychiatric News (May 4, 2018) when a story jumped off the page at me.  It was called "How the Opioid Addiction Crisis Was Rendered 'White'.   I knew I had to post about it here because it contains several inaccuracies that typically occur when racial explanations are used to look into any complex phenomenon.

The article is about positions espoused by Helena Hansen, MD, PhD and in fairness it was not written by her.  There is no guarantee that she might consider these accurate depictions of her positions.  The article starts out discussing a 2015 PNAS article on mortality in white middle aged Americans (1) and what the authors termed "deaths of despair" claiming that the new opioid crisis affects these people "linked with social and economic causes: decreasing wages, disappearing jobs, and a diminishing standard of living."  In the same paragraph, the author points out that rate of increase of opioid related deaths is occurring in 55- 64 year old African Americans (see the recent respective slopes in the top 2 graphs used in the article).  For completeness, I suggest going through this data visualization and generating graphs for all of the age ranges, looking at absolute rates and the rate of increase, and comparing those generated graphs to the total deaths bar graph above it.

Dr. Hansen spells out a selective marketing strategy of opioids to white Americans - specifically selling them OxyContin as an opioid painkiller with minimal addictive properties in the 1990s.  She said that was followed up with selling white Americans buprenorphine as  a treatment for addiction.  She describes this as the "whitening" of a new class of opioids "against a backdrop of a long history in which heroin and other drugs of abuse were similarly "racialized" as the substances of choice among blacks and other minorities...."  The racializiation was accompanied with "sinister criminal imagery that ignored the socioeconomic circumstances that had always contributed to addiction in minority communities."

She suggests this racialization or whitening of the opioid epidemic was made possible by:

1.  Deliberate ethnic marketing by Big Pharma.
2.  The pharmaceutical "magic bullet" approach or buprenorphine as a solution to the opioid problem obscuring psychosocial and economic factors.
3.  A health care system that does not make psychosocial treatments equally accessible by "geography, class, or race".

She goes on to point out that the distribution of methadone versus buprenorphine has an unequal distribution with methadone being more inconvenient and distributed primarily in inner city neighborhoods.  Buprenorphine on the other hand is easier to take and is distributed primarily in the suburbs and is more easily available to the white middle class.

She brings up a familiar refrain that promoting addiction as a brain disease devoid of environmental or psychosocial context that "anyone" can get - is really code for "anyone" = "white".  She suggests that white opioid crisis has stimulated discussion of of economic revitalization for the white victims of addiction while the black victims were criminalized.  She concludes that addiction is rooted in "social problems mediated by mental illness" and therefore we need psychiatrists to address this problem.

As an addiction psychiatrist I have addressed all of these themes on this blog in the past.  I can make it as straightforward as possible.   All of the social, economic, and psychosocial explanations of addiction are highly flawed simply because the vast majority of Americans laboring under those conditions do not become addicted.  As far as I  can tell economic revitalization is political rhetoric, especially in the current circumstances where what the government will actually do to address the opioid crisis remains unclear. 

There are two critical variables for addiction.  The first is biology.  There are strong genetic components that correlate with addiction as well as some epigenetic components.  Race is not a factor.  On that same spectrum, genetics determine that some people are protected against addiction by their biologically determined reactions to addictive drugs and alcohol.  This is not speculation on my part it is a known historical fact and scientific fact.  No matter who you are or what your race is - you need this biological disposition to addiction or it probably is not going to happen.

The second variable comes down to exposure.  If there is no exposure of addiction prone individuals to the addicting drug there is no addiction.  That is where Dr. Hansen is partially right.  When Big Pharma targeted physicians to prescribe opioids for trivial pain and maintenance opioids for chronic noncancer pain that brought opioids to a much larger group of people, basically non-metropolitan whites who started to die in rural areas of opioid overdoses.  And it was much more than opioids.

The example I use in my lectures is a teenager in rural northern Minnesota in the 1970s versus today.  Let's say he knows his grandfather died of alcoholic cirrhosis and his father is an alcoholic.  What would he need to do in order to avoid being an alcoholic or addict in the 1970s versus today?  In other words if we assume his genetic make-up is the same and he inherited the family predisposition to alcohol misuse - what does he have to avoid?

In the 1970s there were basically three things: alcohol, tobacco, and cannabis.  In some areas of the country there was an amphetamine epidemic but that had not reached the northern frontiers of the US.  How about in 2018?  Today he has to avoid everything - opioids, alcohol, tobacco, cannabis, synthetic cannabinoids, amphetamine, methamphetamine, and everything he can acquire over the Internet.  We have gone from a country where rural (and white) Americans were relatively sheltered from all of these addictive compounds to where they are widespread and easily accessed.  So easy in fact that you can get many of them (opioids, amphetamines, benzodiazepines) directly from your physicians office.

I disagree with Dr. Hansen's basic theory of this opioid epidemic and how it was "whitened."  This is not a racial issue at all.  As I have been telling my students for nearly a decade now - "Until recently - why was a kid in northern Minnesota relatively protected against opioid addiction relative to a kid in the inner city?"

The answer is that kid in Minnesota - until recently - did not have to walk past any drug dealers on the way to school.

Now they do and the only relevant equation is biological predisposition + exposure = addiction.  That same simple equation is also the most compelling argument against legalization of addictive drugs because by definition it would mean a larger percentage of addictions with increasing exposure.

Men discriminate based on arbitrary definitions of race and class.

Biology does not. That is why anyone white or black can develop an addiction.



George Dawson, MD, DFAPA



Reference:

1:  Case A, Deaton C. Rising midlife morbidity and mortality, US whites.  Proceedings of the National Academy of Sciences Dec 2015, 112 (49) 15078-15083; DOI:10.1073/pnas.1518393112

2:  Moran M.  How the Opioid Addiction Crisis Was Rendered White.  Psychiatric News, May 4, 2018, pages 19 and 23.

3:  Greene, Eddie L.Thomas, Charles R. et al.  Minority Health and Disparities-Related Issues: Part I
Medical Clinics of North America 2005, Volume 89 , Issue 4 , xi - xii

4:  Greene, Eddie L.Thomas, Charles R. et al.  Minority Health and Disparities-Related Issues: Part II
Medical Clinics of North America 2005 , Volume 89 , Issue 5 , xi - xii


Graphics Credit:

1:  National Center for Health Statistics - Drug Poisoning Mortality in the United States, 1999-2016 https://www.cdc.gov/nchs/data-visualization/drug-poisoning-mortality/



Supplementary (too tedious for the post).


Dr. Hansen
Dr. Dawson
Deliberate targeting of white people by Big Pharma marketing
Influence was at the physician and institutional level.  Increased access at many levels increased exposure to all Americans. Goal of the pharmaceutical industry is to develop “blockbuster” drugs by marketing and selling to as many physicians and patients as possible.
The pharmaceutical "magic bullet" approach or buprenorphine as a solution to the opioid problem obscuring psychosocial and economic factors.
If it was marketed that way – it was a poor job considering the number of overdoses that could have been prevented since it was released in 2002.  Even today there is widespread reluctance to prescribe it and use it and large social media groups advocating to not use it or taper off it. It is prescribed without considering the race of the patient.  In healthcare systems, a focus on a medication is frequently a way to not provide necessary services for anyone.  The obvious example is closing state mental hospitals and focusing on the success of chlorpromazine. 
A health care system that does not make psychosocial treatments equally accessible by "geography, class, or race".
The problems with racial and class disparities in care have been widely known and occurred long before the current opioid epidemic (see ref 3 and 4).  Government sanctioned managed care system has been rationing mental health and addiction care for 30 years for corporate profitability.  Despite continuous discussion of the epidemic there is little evidence that the infrastructure or service for treating addiction has improved in any way. 
No broader cultural theory.
Increased cultural permissiveness for drug use as evidence by widespread legalization of cannabis and the promotion of addictive drugs as therapeutic agents can increase the likelihood of illicit use.
Distribution of methadone clinics versus Suboxone prescribers
Suboxone is clearly more convenient but access to prescribers is very limited.  Suboxone patients often have to travel as far as they would have to get to a methadone clinic and then see a provider who does not accept health insurance and charges ala carte fees for service.  A segment of Suboxone users may do better on methadone.
Medical definition of addiction as a neurobiological disease that anyone can get was invented for white people.
Clearly applies to everyone unless you believe that there are some racial characteristics to suggest that one race is more susceptible than another.  As is the case with the majority of human illnesses I don’t believe there are any susceptibilities to acquired illness based on race.
Mental illness is a product of socioeconomic circumstances and a precursor to addiction.
In genetic studies mental illness co-aggregates with addictive disorders, genetic susceptibility to one increases susceptibility to the other.