Drug Abuse by Any Other Name
It made headlines when Michael Botticelli, the White House drug czar blamed “terms like abuser and addict” for discouraging people with drug use disorders from seeking treatment. The head of the Office of National Drug Control policy was hardly setting a trend. The words “abuse” and “abuser” no longer appear in publications and communications of the Substance Abuse and Mental Health Administration and “abuse” has been replaced by “substance use disorder” in psychiatry’s latest Diagnostic and Statistical Manual of Mental Disorders. Government and the treatment field in general seem bent on expunging language they see as contributing to the stigmatization of addiction, and they would rename the National Institute on Drug Abuse if this didn’t require action by Congress.
Stigma, it seems, has a bad name. It has—to make perhaps too fine a point—been stigmatized and unfairly so, for stigma has served for centuries as one of the most useful of social mechanisms. It is the most civil means of sanctioning behavior that threatens the community, violates community mores or norms, or is simply unattractive. This is not at all a bad thing when you consider the alternative. Without informal social controls communities turn to power to modify behavior they find sufficiently frightening, repugnant, or aberrant. We call the cops to curb the negative behaviors we cannot shame. We criminalize it, as we did with substance misuse.
Now that we are in the process of decriminalizing drug use it is no time to abandon stigma as well. If stigma is cool enough to use against smokers, why decide it’s too cruel to turn on heroin addicts? Shame works, argues psychiatrist Sally Satel in an article that answers positively the question “Can Shame Be Useful?” Although repeated drug use may indeed alter the brain, especially the regions that mediate self-control, “A vast literature,” she points out, “shows that addiction is an activity that can be altered by its foreseeable consequences.” As for the notion that drugs hold captive (or highjack) the drug user’s brain, see below.
Doubting the Disease Model
A slowly growing wave of dissent appears to be challenging the conviction put forth in the New England Journal of Medicine at the start of the year by Nora Volkow, the head of NIDA, and her co-authors. Their article celebrated increasing acceptance of addiction as “a chronic relapsing brain disease” and resulting neurobiological advances due to acceptance of the brain disease model.
In June, the neuroscientist Marc Lewis challenged the disease model in The Guardian. If addiction is a disease, he wrote, “We might wonder how the disease of addiction could be overcome as a result of willpower, changing perspective, changing environments, or emotional growth. There is evidence that each of these factors can be crucial in beating addiction, yet none of them is likely to work on cancer, pneumonia, diabetes, or malaria.” Further, Lewis reasons, “Once they recover, as most addicts eventually do, it is confusing and debilitating to be told they are chronically ill.”
Before the month ended, writer Maia Szalavitz put forth her own case in the Sunday Times that “addiction is neither a sin nor a progressive disease.” It is, she contends, a learning disorder. Addiction, she allows, “skews choice—but doesn’t completely eliminate free will.”
Moreover, belief in the disease model is nowhere near as widespread as the Volkow article suggests. A recent survey of public perceptions of drugs, drug use, and addiction, commissioned by the Rosenthal Center and conducted by the Schoen Consulting group, found three out of four Americans reject the notion that addiction is incurable. As for the hard held conviction of most brain scientists that addicts are powerless before their addiction, only 16 percent of the population strongly agrees and 44 percent flatly reject it.
Making Overdoses Safer—Not Necessarily Fewer
It could hardly have been any cuter. Adorable nine-year-old Audrey Stepp was practicing injecting her stuffed lamb with naloxone. The scene was shown on an ABC “20/20” broadcast interview with Audrey and her mother and was picked up by other evening news broadcasts. It wasn’t make-believe. Audrey was practicing how to inject her older brother Sammy who has struggled with heroin addiction for the past six years.
Naloxone is now available, without a prescription, (in nasal spray and hand-held automatic injector) at most pharmacies across the country. NIDA has just created a web section providing “how to” information about the overdose reversal medication for families like Audrey’s. According to the Institute, Naloxone is now “a front line tool used by first responders in preventing opioid overdose deaths”—a laudable goal, when overdose killed some 18 thousand users of opioid painkillers and more than 10 thousand heroin users in 2014.
But what then? What follows? As U.S. News & World Report reported on June 6th, a recent study of prescriptions filled for overdose patients during the thirty days following their hospital release found only 16.7 percent filled prescriptions for addiction treatment medication, and 22.4 percent got opioid painkillers.
While we clearly need to reduce the horrendous incidence of opioid overdose deaths, let’s not mistake a decline in fatalities as a victory over our society’s epidemic of drug misuse.