Neurodivergence And Substance Use: An Under-explored Intersection [Part 1/4]

In an essay promised at the end of our most recent Hot Topics conference last autumn, Jay Cooper takes on the hitherto neglected issue of how neurodivergence relates to drug use, and reaches back into his nineties childhood to begin sharing his own story.

There are many reasons why people use psychoactive substances. The primary one, of course, is wrapped up in that qualifying adjective: the drug or its metabolite(s) breach the blood-brain barrier and act on the user’s psyche, thence producing some desirable temporary change. For some use settings, psychotropic properties are incidental if not beside the point- viz. diners pairing wine with the courses of their meal, or Indigenous Canadians using tobacco in culturally embedded, religiously salient ways that long predate their contact with European settler colonists.

Other settings involve privileging alteration of consciousness generally over seeking out any more specific effects: consider a journal article about unsheltered people living in Naarm/Melbourne which reported subjects treating heroin and methamphetamine as “substitutable,” using one or the other based on <> availability. Their pattern of accepting an alternative pharmacologically worlds apart from drug of choice makes sense only as a desperate ritual of respite from inhumane conditions of existence on the streets.

This last example illustrates the folly of attempts to account for drug use in isolation from other factors in a person’s life. Turning to undesirable consequences, psychoactivity may be directly involved as in stimulant induced paranoia or indirectly implicated as when compulsive cravings or fear of withdrawal symptoms drive continuing use despite physical health harms (e.g. cardiotoxicity, ‘ketamine bladder’.) Moreover, significant harms like blood-borne infections are products of the using environment extrinsic to pharmacology, contingent upon access to appropriate resources.

As such, I have been pleased to see rubrics like ‘mental and behavioural health’ go mainstream, reflecting a shift away from unhelpful siloing of substance related concerns towards integrating public policy responses and service provision so as to care for the ‘whole person’. Over the past decades, attention has rightly been paid to the interaction between mental illness and (problematic) substance use i.e. “dual diagnosis”.

Also in this connexion, the sector has taken account of traumagenic experiences including childhood adversity. In the pages of DDN and at related conferences, more room exists to address non-pharmacological behaviours viewed as maladaptive responses to mental disturbances or unhealed trauma, just like drug “misuse”: problem gambling, pornography/sex “addiction”, self-injury. What has been less evident is any sustained discussion of how people living with one or more developmental variations collectively designated as neurodivergence relate to questions of substance (use).

Just as efforts to understand decision-making on drugs without sensitivity to individuals’ external lived reality are foredoomed, any honest discussion must reckon with how internal reality is no more uniform. A hermeneutic of suspicion is healthy when encountering any purported “absolute truths” on this topic. If the drug user’s usual rationale is to effect alterations in cognition, affect and/or conduct, then starting at a baseline different from the general (neurotypical) population is of inherent relevance; differentials of social power, acceptability, and access to resources which result from being neurodivergent in a society (still) far from fully inclusive accessibility further complicates the picture. I here will offer some reflections upon my own necessarily limited and subjective lived experience at this intersection, in hope of elucidating underappreciated details, and fomenting productive exploration.

When I was pre-school age, I felt a strange attraction to the local chemist: reading labels, drawing products in my sketchbook and asking the adult I was with (usually my mum) what they were for. I became well known to the staff, and was too young to grasp that my intense interests were not universal…well, I did eventually sense the relief of my relatives that I grew bored with the village Boots, no longer pleading to look around every time we walked past it regardless of need to buy anything in there. It took more than a decade’s hindsight to evaluate this as a twofold manifestation of autistic spectrum condition (ASC): hyperfocus on narrow, “grown-up” subjects which at other times included lorries, South American football and cinema advertising and the ‘limited emotional reciprocity’ that had me struggling to suss out when an interlocutor wanted to move off the subject.

On excursions beyond Merseyside, if there was a previously unexplored pharmacy in sight I was still liable to fixate on it. Aged seven, on a trip to Florida I started strutting up and down getting fidgety as Dad took a business phone call. A familiar green cross symbol down the streets had gotten my attention, but something was different: the sign identified it as a DRUG STORE. Instead of asking Mum to take me there, I asked her what was wrong with the Eckerds. “What do you mean, sausage?”, she replied affectionately. “It says there’s a drug store down the road. In the airport the signs said that if you carry drugs you can’t get into America. I started reading a leaflet one time about drugs at London Euston and you grabbed it out my hand, saying it’s bad and not for children.” Mum explained there are “good drugs” and “bad drugs”, with the good ones being legal and used to treat illness under professional supervision.

For some parents this may have been the equivalent of telling their little ones that babies come from cabbage patches delivered by storks; my mother meant every word, and I naturally believed her. It took me seven years to unlearn that lesson; it could have taken far longer. If you thought that impatient pacing around sounded a lot like hyperactivity (the repetitive movements are another autistic trait) you won’t be surprised to learn that in between those two biographical points I was diagnosed ADHD in 1999, when assessed in advance of starting full-time school. The consultant recommended methylphenidate but my parents said no, with mum later telling me she feared it would “stunt [my] growth”- while this and other contemporaneous health scares, notably the MMR-autism/bowel disease “link” which she also gave credence to, have not held up well under subsequent research her desire to safeguard me at this point was unimpeachable.