No one disputes that addiction is a growing problem. The rate of growth is alarming and calls for solutions are becoming more frequent and louder. These solutions are often framed under a public policy umbrella. My views on public policy have changed substantially since addiction has affected our family, but only because I’ve taken the time to research it more thoroughly. It is understandable, but unfortunate that a healthy knowledge of the subject is missing from public opinion. This is actually dangerous because we are often faced with public policy decisions made by people without adequate knowledge to make those decisions. To make matters worse, those without the knowledge who make policy are operating under common, mistaken myths on the topic.
I used to think needle exchanges and legalization or decriminalization of drug laws was a preposterous notion. Why? Because it’s counter-intuitive. After all, wouldn’t legalizing these drugs make the problem of prevention worse? It would seem so, but the evidence shows otherwise.
Needle exchanges are not to encourage drug abuse. They are simply a method to prevent the spread of disease and other IV drug use related problems. The philosophy is: If you’re going to use drugs, then do it more safely. Not providing needles will in no way stop or prevent IV drug use, so the only argument against this is that it implies public endorsement. This is an education problem. Unfortunately, public policy is dominated by political policy and we should understand that perception is more important than fact in politics.
An enormous amount of public money is spent on law enforcement, the justice system and the penal system for drug related crimes. Imagine the reduction in cost if that were eliminated. Furthermore, what good are we doing the addict or the public by punishing them with incarceration? And are our streets any safer by putting users in jail (drug traffickers is an entirely different matter)? In fairness, many court systems today offer drug courts, but those are limited to those that “qualify.” Those qualification requirements are simply a way of cherry picking those with the highest likelihood of success. While this is most likely a budgetary decision, it can’t be argued that it does any good for those excluded from it. These are among what I refer to as the “cast asides.”
Additionally, many other crimes are a direct result of drug addiction (theft, burglary, robbery, etc.). If the drugs were widely available, without permission or prescription from medical professionals, much of this problem would disappear. Overdoses could be drastically eliminated because the drugs could be provided by the pharmaceutical industry which could regulate dosages and eliminate harmful substances used to dilute (cut) the products. The drug cartels and street corner dealers would also be dramatically reduced if not eliminated. Crime and turf battles among and between the dealers might be a thing of the past. We spend $40 billion year prosecuting this war. Over 40% of arrests are for marijuana use.
But what of the argument about making these drugs more easily accessible to those previously not exposed to them? Wouldn’t this poke a hole in the prevention model? These are valid questions and of these I’m not sure. The Portugal experiment (and now policy) used decriminalization rather than legalization. In other words, there weren’t stores where people could go to buy these drugs, but personal use and possession was decriminalized. The outcome of that was staggering. Not only did addiction rates go down, but so did the frequency of overdose as well as casual or recreational use. Counter-intuitive, but true nevertheless.
Another serious issue is how the medical industry deals with substance abuse (often referred to now as substance use disorder). Consider this. If you have a heart attack and survive after a trip to the emergency room, you are typically followed up with an intensive medical regimen, including prescription drugs, physical therapy, dietary and exercise advice. You’ll also be admitted to the hospital for several days for observation and further testing such as heart catheterization,, etc. Now, what happens after a trip to the emergency room for a drug overdose? You are stablized, then sent out the door with nothing more than a warning and treated as a social outcast. If you ask for help, the best you can hope for is a verbal referral to some local rehabilitation facility which nearly always incur large costs. Not a legitimate alternative for the homeless drug addict or even that average lower or middle income family.
And the legal and medical community is also intertwined. Doctors are carefully monitored to make sure they aren’t over-prescribing pain medication. And understandably so because their licenses to practice are at stake. This process is in place by law. Granted, some physicians are in it for the business and would willingly prescribe anything to make money. These are however the minority. We simply have to consider the overall cost/benefit return. Not only that, chronic pain patients who do not abuse drugs are often treated as suspicious or even go untreated.
Finally, consider the rehabilitation industry. Yes, it is in fact an industry, and a growing one at that. While rehabilitation is obviously a necessary component, there is a problem with it today. When I learned of my daughter’s addiction problem, I was faced with getting her help and doing it quickly. I was forced to make an uneducated decision. As with anyone, I hurriedly researched using the internet. I did not have time to properly research it. She needed immediate help. So, what is the problem that exists today? Widespread, unbiased and objective information is hard to find. By far, nearly everything I researched pointed me toward a single model of recovery: a twelve step, abstinence only approach. The amount of information immediately available to me pointed in this direction. There are alternatives of which I was vaguely aware, but the availability and information on those were hard to find and very limited.
Don’t get me wrong, the twelve step model has been helpful for millions of people since its introduction in 1934 and continues to do so today. Since that time, little has changed about it. I will not criticize it because it is a viable alternative for some. The problem is that it is often presented as the only successful way to treat addiction and quite frankly, it is not.
There are a number of other models (referred to as modalities among the clinical community). The twelve step model simply does not work with everyone. In fact, some estimates suggest it works on only as much as 15% of those who try it. Regardless of the percentage, there is a massive population for whom it does not work. Of one thing I’m convinced. Like everything in life, a one-size-fits-all approach is not the best way to look at treating drug addiction.
What are some of the other models? Most of them fall under an umbrella referred to as Harm Reduction Therapy (HRT). There are many variations of this, but the principal among all of them is to promote safety first. They begin with the notion that prevention of death is of paramount importance. From there, they vary in both degree and philosophy, but they often, but not always, diverge from the classical twelve step models.
- Moderation Management. This model suggests, and there is evidence to support it, that some addicts are able to moderate their use and function in society.
- Medical Maintenance. This model suggests that addicts need not suffer immediate abstinence after detoxification. They typically rely on physician monitoring of other narcotic, addictive substances such as methadone and suboxone (in some cases, cannabis). This is typically intended to reduce or eliminate withdrawal symptoms. In some cases the addicts are slowly and methodically weaned from those drugs until they reach a point of total sobriety. Others are unable to wean off of the maintenance drugs, but are still able to function in society. Lifetime use (like diabetes patients) is a viable option for some. Some insist that total sobriety is the long term goal. Others do not.
- Pure Harm Reduction. This includes needle exchange programs, Narcan education, and counseling.
- Meetings are often stressful with attendees because they feel shame when they have failed. The very terminology itself implies that relapse equals failure.
- Relapse implies starting over at step one.
- Lifetime total abstinence appears to be an unachievable goal. Any meeting will reveal discussions by some that have failed over and over again. This does not lead to confidence for those new to the program.
- Shame and failure are not good motivators.
What is commonly misunderstood is why some people are subject to addiction and others are not. There are countless examples of people who have experienced the use (sometimes long term) of addictive substances yet did not become addicts. Studies have shown that thousands of veterans returning from Vietnam were heavy heroin users while there. Most came home and never used again. Others came home addicts. The point is that if you are disposed to addiction, you likely won’t be come one. Being disposed though isn’t necessarily biological or genetic. It could be completely psychologicial in part due to previous trauma. In the case of the Vietnam veterans, it may well have been PTSD. Some believe it may be a biological marker. Others believe it is due to other environmental factors. Some studies suggest that nearly 60% of drug addicts were victims of sexual abuse at a young age. What is not in dispute however is that a large majority of addicts suffer from some form of emotional or psychological trauma resulting in their need to mask it with drug use. Unfortunately, it works. At least long enough for some to become addicted, then the problem is compounded. This is why we often see rehabilitation services offer something called dual-diagnosis therapy. One part to deal with addiction, the other to deal with the psychological problems that brought it on in the first place.
It is not realistic or fair to expect government to pay for these services. After all, government resources are challenged at all levels. It can be argued that rehabilitation services should take a higher priority than others, but this is not likely to occur in the near future. What the government can do however is do a much better job of educating people on all alternatives. The insurance industry is the next level of hope, but we all know the challenges occurring with that at this time. It is also unrealistic to expect an insurance company to pay for services it knows to be a money loser. They are in business to provide a wide variety of health services. If they were forced to pay for the necessary services for all addicts, they simply wouldn’t have enough money in their pool to pay for other medical services for the rest of us. In this, I’m not aware of any viable solutions other than perhaps charitable endeavors. There are some, but many are religiously affiliated and nearly always follow the conventional twelve step models.
I’m still on a journey of educating myself on the problems of drug use and addiction. I expect that to be a life long endeavor. Hopefully, due to the high level of attention this problem is demanding, many of the myths surrounding rehabilitation will slowly be eroded and people who are affected by it will be able to make more informed decisions.