Everyone who has a substance use disorder, or loves, lives by, works with, or treats a person with a substance use disorder, and wants to do something about it, will not know what to do next. It’s no one’s fault. We – researchers, health care professionals, lawmakers, citizens – simply don’t know enough about what the problem is, or what solves it, to know what our next steps should be.
As Americans, I think we’re also uncertain about what constitutes a problem with substances. We don’t know, or don’t agree on, which substances, and how much of them, are okay to use. What are the criteria by which we’ll decide? Our dilemma is evident in the variety of U.S. marijuana laws. The current criterion for allowable marijuana use is where one lives.
We also don’t agree, as Americans, on how much pleasure is to be allowed and how much pain is to be tolerated. While we attach moral value to self-denial, we find ourselves fully human. Our brains are wired for pleasure and programmed to associate pain with threats to our survival. Naturally and logically, then, we want the former and don’t want the latter. What are the criteria be which we’ll decide what is enough and what is too much, for both pleasure and pain?
We also struggle with defining individual and societal control, freedom, and rights. What are the criteria by which we’ll decide when either the individual or society has gone too far?
Onto this stage, enter substance use disorder, popularly known as “addiction,” defined by the National Institute of Drug Abuse (NIDA), as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”
Science reveals to us that addiction is a brain thing. But in terms of what exactly is wrong, if anything (are we just seeing an extreme form of the brain’s ability to something or other?), and what exactly would cure or reverse what’s wrong back into what’s right, we actually aren’t sure how to define any of those terms, much less to take action on them.
As a counselor charged with providing care for people with substance use disorders, I find this imprecision daunting and dangerous. I am also a person with a substance use disorder. I am a person, not an alcoholic, addict or substance abuser. I happen to have a disorder. I need to take beneficial action on my own behalf, and describe beneficial actions my clients can take on their own behalves, all the while doing no harm. Yet, what to do – and what not to do – is ill-defined and unspecified.
Enter “evidence-based treatment.” In layperson’s terms, “evidence-based treatment” means that the treatment has been determined by research experiments to be of benefit to most people, most of the time, better than other treatments, and better than no treatment. Further, the experiments have met research criteria for design, presence of control groups, randomization, and bias-free samples, and can be repeated by other scientists doing the same experiment.
Treatment for addiction has been dominated in the U.S. for the past century by beliefs, opinions and theories. However, with publication in 2016 of Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, an attempt was made to compile a guide to effective, evidence-based treatment for addiction.
But now the plot thickens, and darkly. For a person with a substance use disorder, what would be considered the desired outcome of effective treatment?
The goal of any treatment for a person with a problematic condition would be to experience fewer symptoms, less often, over time, right? And for a problematic condition that manifests as behavior, we would aim for reducing harm towards self and others over time, right?
Ah, but for substance use disorders? By society, by lawmakers, by the criminal justice system, by child protective services, by employers, and by treatment providers, an on-demand, instantaneous cure is mandated.
Abstinence now!
For what other illness does manifestation of the illness’s symptoms result in arrest and incarceration, and deprivation of parental rights, voting rights, and driving and professional licenses? For symptoms of what other chronic illness of the body’s organs are patients denied medical care and medications, dismissed from treatment programs, and subjected to punishment as “treatment”?
The difference between abstinence from substances and evidence-based treatment for substance use disorders is not widely known or understood. This has resulted in infinite suffering for people with substance use disorders, for those who love them, and for society at large. The financial costs are in the billions of dollars and the personal, familial, and social costs are immeasurable.
For people with substance use disorders, I don’t see enlightened, compassionate care replacing mandatory abstinence any time soon. In fact, in the Philippines, they’re shooting their people with substance use disorders. My president described that leader’s efforts as a “great job.”
These are dangerous times for people with substance use disorders.
I heard an earnest, well-meaning, public health official state, in public, just a few days ago that “addicted mothers” give birth to “addicted babies.” Our leading local public health official doesn’t know the difference between addiction and dependence?! This person also mentioned an “opioid epidemic.” Really? If opioid-related deaths can give us an epidemic, tobacco-related deaths should give us an apocalypse. What we have is less a spike in opioid use via pain pills or otherwise, but more an epidemic in poisoning via contaminants in street opioids. Doesn’t misinformation from public officials endanger our citizens? Is that person someone to whom a person with substance use disorder could trust to turn for evidence-based care?
Where can a person with substance use disorder turn for evidence-based care?
I appreciate that many people have experienced spontaneous recovery without treatment. For those for whom that has not yet occurred, or may not before this illness kills them, or may be continuing to experience those “harmful consequences” despite their best efforts, to whom can we turn?
Who knows enough about what we do know, and has the humility to acknowledge what we don’t know, to help people with substance use disorders meet reasonable treatment goals for their health, and pragmatically meet society’s unreasonable, even medically contraindicated, goal of abstinence?
“I will stand up for recovery with you,” former Surgeon General Vivek Murthy tweeted on October 4, 2015.
Here’s what I wish a health care leader would stand up and say today:
We don’t yet know what directly treats the brain for addiction, except for some medications for some forms of substance use disorder. Medical care, grounded in science and not clouded in belief and theory, can be hard to come by if you have health insurance. Medical care in any form is nearly impossible to get if you don’t.
Outside of medications and medical care, we do know some indirect things that research has found to help people drink and use less, less often, over time. Abstinence can be a cruel demand, but if it’s what you want or, unjustly, what you need to keep your freedoms and rights, or to try to get them back, I will try to offer what the evidence reports may be helpful to you to try to achieve that.
You have an individual case of addiction, but our research only speaks to what’s helpful to most people most of the time. This will be a trial-and-error effort with errors along the way, even ones that may tragically result in your premature death. We may not find what’s helpful to you in the time we’ve got. If you’re in, I’m in. In spite of all the odds against us, in spite of all the dangers, I will stand up for your recovery with you.
Image: iStock
The opinions expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.
