AAAS Kavli Lecture: Sarah Holt on the Making of "Addiction"

Earl Lane

Despite numerous articles and broadcasts on the horrors of the opioid crisis in the United States, filmmaker Sarah Holt was convinced there was another story to tell about the science of addiction and the national failure to aggressively pursue effective programs to tackle the epidemic.

She wanted to explore addiction as a medical condition, explaining how drugs alter brain chemistry, create memories that trigger powerful cravings and even change gene expression.

The result is "Addiction," her gripping PBS NOVA documentary that premiered on Oct. 17 and was the subject of a AAAS Kavli Science Journalism Award lecture by Holt on Oct. 22 at Arizona State University’s Walter Cronkite School of Journalism and Mass Communication.

Holt talked about the story behind the story— an intense two years of filming and editing that produced a program dealing not only with the wrenching human impact of addiction but also the brain changes that explain why it can be so difficult to control.

Filmmaker Peter Byck leads question period with Sarah Holt during her AAAS Kavli lecture.        Photo: Earl Lane

Other film treatments of the crisis were "all so negative," Holt said, "and I wanted to present a more optimistic picture that focused on solutions that can stop preventable deaths."  The experts interviewed in her documentary note that addiction is a brain disorder, not a moral failure, and treatments based on sound science are available.

"We have extremely effective medications that are lifesaving," Laura Kehoe, a primary care physician at Massachusetts General Hospital, says in the film. "This is a very treatable illness."

"People recover from addiction," says Darwin Fisher, manager of a supervised injection site in Vancouver, Canada. "Nobody is unreclaimable. The only thing you can’t recover from is death"

Speaking to an audience of about 60, many of them budding broadcast journalists, Holt told of her long, often frustrating search for subjects who would be willing to discuss their experiences with addiction. Given the stigma of the disease, she said, even those who are in recovery are often unwilling to go on camera. Several scheduled film shoots were cancelled at the last minute. But setbacks often led to new opportunities, she said.

When officials of Huntington, W. Va., wary of having their town portrayed as a focus of the opioid epidemic, backed out of planned interviews, Holt decided to pay more attention to Vancouver. There Darwin Fisher runs the first legal site in North America where people can inject illegal drugs under medical supervision. Called Insite, the program provides clean needles and supplies as well as help obtaining medically assisted treatment. The resulting segment helped Holt show how novel, sometimes controversial, approaches are decreasing overdose death rates and the spread of infectious diseases while also saving taxpayers money.

The roadblocks in West Virginia helped her film in the end, Holt said. "The cancelled shoots in Huntington lead to something better," she said. "Filmmaking is sometimes shaped by accidents, lucky accidents."

Another of those lucky accidents occurred when Holt's flight into Charleston, W. Va., was cancelled due to bad weather and she wound up driving into the state instead. She passed through McDowell County, where she found once vibrant towns ravaged by the collapse of the coal industry and the high death toll of the opioid epidemic. She soon found Jasen Edwards, a coal miner, who became addicted to opioids after losing a leg in a mining accident. He spent $21,000 in one weekend on pain pills, Holt said.

Edwards spoke unflinchingly about the impact of opioids in a state where investigators found that, over a six-year period, drug companies had shipped in 780 million addictive pain pills. As he told Holt, "West Virginia was the perfect storm." The state is dominated by one of the hardest and most dangerous jobs in the world, Edwards said. "Most of the old-timers that work in the mines work with pain. And then pain pills started flooding the community, and people that you used to know weren't the same people that they used to be. I mean, it, it ruined everything."

Holt's interviewees crossed ethnic and socioeconomic boundaries. Jonathan Winnefeld was born into an accomplished family. His father, an admiral, became Vice Chairman of the Joint Chiefs of Staff in 2011 at the same time Jonathan was using drugs to battle anxiety. His parents found a facility that offered an abstinence-based recovery program based on the 12-step model of Alcoholics Anonymous. After the Winnefelds spent hundreds of thousands of dollars for 15 months of in-patient treatment, it seemed to work. But three days after Jonathan arrived at college for his freshman year, he died of an overdose of heroin and fentanyl.

Experts in Holt's film say that abstinence-based programs can set people up to fail. They pressed for wider use of buprenorphine and methadone, drugs that curb cravings from heroin and pain pills by binding to opioid receptors in the brain. Studies suggest the drugs can cut patient deaths by about half. After one year, various studies show recovery rates ranging between 40 to 90 percent, Holt said.

In structuring "Addiction," Holt wanted to focus first on the human stories and then describe what scientists have been learning about the biology of addiction. But her executive producer urged her instead to weave in science throughout the narrative. While the restructuring was challenging, Holt said, the suggestion made for a more cogent film. As Edwards describes his descent into OxyContin addiction, for example, the film explains graphically why he had become addicted, showing how OxyContin ─ chemically similar to morphine ─ mimics the body’s natural pain relievers which bind to proteins called receptors.

Image of dopamine transmission in the brain from "Addiction."  Credit: Ekin Akalin

Opioid drugs can raise dopamine levels in the reward pathways of the brain up to ten times higher than natural rewards like food or sex, Holt notes. The pain of trying to withdraw from the drug soon leads to more use of the drug to fight the symptoms of withdrawal. As Jasen Edwards says in the film, "Withdrawals will make your bones ache."

In addition to her evening lecture, Holt also spoke to two filmmaking classes and a class of international media fellows during her day-long visit to the Cronkite School. The AAAS Kavli lecture series, now in its second year, brings winners of the distinguished journalism award to campuses for public lectures and classroom workshops.

Holt is one of the AAAS Kavli program's "laureates," journalists who have won the award three times and, under the contest rules, are no longer eligible but continue to serve as exemplars of science journalism. The fall lecture series continues with talks on Thursday, Nov. 1, at Howard University by filmmaker Llewellyn Smith and Nov. 9 at Northwestern University by freelance writer Hillary Rosner. Both are two-time winners of the award.

One of Holt's key messages during her visit to ASU was the need for young, committed journalists to continue making documentaries with a high regard for evidence and facts.

Holt, who graduated from New York University’s film school, got her start in the business editing short trailers for commercial feature films. She joined the staff at NOVA as an editor and worked her way up to producer. She encouraged the Cronkite students to get a foot in the door by doing internships wherever they can and taking editing assignments, a way to learn the details of putting a film together that will pay off throughout a career.

In some cases, an editor can "save" a film, Holt said, by addressing missed shots and gaps in reporting in the editing room. Early in her editing career, she said, she had opportunities to save others. Now she saves herself by doing most of the editing on her documentaries, occasionally with help from an assistant. Documentary films require long, demanding days of field work and late-night hours in the editing room, and Holt said she often works more hours now than at the beginning of her career. But it is worth it, she said.

"This is not a lucrative profession," she told one class, "but you meet some of the most incredible people in the world."  She said it is rewarding "to be in service to these incredible minds out there," helping to tell stories about science and its impact on society.

Holt said she was impressed by some of the projects Cronkite students are working on, with new tools and methods to tell stories and distribute them widely. In her own case, some clips from the "Addiction" documentary that did not make the final edit have done surprisingly well after being posted to Facebook. One segment received 91,000 views within the first few hours that it was online.

The bottom line in any kind of filmmaking, Holt said, is to keep it engaging. "You need to find people who are passionate, who have some sort of personal presence to engage you," she said. And don't be afraid to follow your instincts, Holt told the students. "If you find it interesting, your audience will find it interesting."


(Credit for associated homepage image: Ekin Akalin)