Thinking About Addiction

Nathan Gismot, April 15, 2015

Addiction is everywhere, and it can happen to anyone. It does not care about your race, class, gender, religion, age, sexual orientation, or political beliefs. All it wants is for you to have another drink and take another hit, and then another, and then again as soon as possible.

Odds are good that you or someone you know struggles with addiction. Odds are good, too, that you have an opinion about it; addiction isn’t something that tends to tread lightly in people's lives. It certainly doesn’t tread lightly in our society: Precise numbers are practically impossible to determine, but the National Council on Alcohol and Drug Dependence estimates that 1 in every 12 adults in the U.S. “suffers from alcohol abuse or dependence,” and that 48 million Americans “ages 12 and older us(e) prescription medications for nonmedical reasons.”

1 in 12. 48 million. Huge numbers, no?

For those on the outside, it can be difficult to understand how a person could ever find themselves in the throes of addiction. Many people seem to think it is the result of laziness, weakness, or some other character flaw, and consider the repeated, compulsive use of the substance or behavior “of choice” that is the hallmark of addiction as little more than a personal shortcoming.

Others emphasize the psychological origins and utility of addiction, noting that many people who are addicted suffered (and/or are suffering) some form of abuse or trauma in their lives. Viewed through that lens, drugs and alcohol can be thought to be a person’s attempt at coping. After all, none of us wants to suffer, and it is instinctive to try to avoid pain.

Still others contend that addiction is a disease, much in the same sense that cancer or diabetes are diseases. In fact, many addiction treatment providers operate under what is known alternately as the “medical” or “disease” model. The focus here is on addiction as a pathological neurochemical condition -- for which medical intervention and ongoing therapeutic maintenance are essential if the “patient” is to enjoy a successful treatment outcome.

There are any number of additional viewpoints that fall somewhere along that rough continuum, to say nothing of unique cultural or religious perspectives on the matter. Regardless of a person’s beliefs about the nature of addiction, however, treatment facilities that receive payment for services from government payors such as Medicaid are beholden to state regulations which dictate the overarching treatment philosophy those facilities must employ.

Generally speaking, states assume one of two approaches to addiction treatment and recovery: 1) the abstinence model; or 2) the harm-reduction model.

Unsurprisingly, perhaps, the goal of treatment within the abstinence model is for an addicted person to maintain complete and permanent abstinence from their drug(s) of choice. The advantage of this approach is simple: Many people with hardcore drug and/or alcohol dependence are simply unable to use the substance in question in moderation. For example, whereas most people can have an occasional drink or two and walk away without an issue, others have a drink and cannot stop drinking, sometimes with problematic -- even devastating -- social or legal results. It is perhaps intuitive, then, to see how people in the latter group are better off by simply never again having a drink, i.e., “the best way to keep yourself from having a second drink is to never have the first.”

In the harm reduction model, on the other hand, strict abstinence is not necessarily the treatment goal, though it is often the ultimate outcome. One can think of harm reduction as helping an individual through the process of incremental positive change, i.e., reducing the harmful behavior in question.

For example, a treatment provider working with an intravenous heroin user might first seek that the person switch to a safer means of use, given the extreme risks associated with IV drug use (e.g., tissue and vascular damage, exposure to fatal blood-borne pathogens). In such a case, switching to an alternate means of use would have reduced the potential for harm to the user, thus denoting a positive treatment outcome. The harm reduction work would then proceed accordingly, perhaps with introducing an opioid replacement therapy such as suboxone or methadone.

As one might suspect, there is disagreement among treatment professionals as to the superiority of the abstinence or harm-reduction model. Opinions differ within and among treatment settings, and policy-backed positions vary wildly from state to state.

For its part, the Federal Drug Administration recently caused a bit of a stir with an updated official stance on acceptable treatment outcomes for alcoholism. Namely, they stated that the attainment of a pattern of significantly reduced drinking may be an acceptable treatment outcome. That might not sound like much, but it represents a significant expansion of their previous "abstinence-only" definition of success. (The author highly recommends reading Anne M. Fletcher’s cogent and thorough article on the matter.)

Policies intended for a population of millions will always have limitations, because it is impossible to account for all the variation of circumstance and individuality within such a large group. The FDA’s updated position can be thought of as a concession to that fact, since, for some “alcoholics,” abstinence may be neither necessary nor plausible. Critics of the FDA's position will note that ongoing drinking leaves the door wide open for relapse into problematic behaviors; and they may note, too, that the FDA’s stance could give insurance companies more clout in putting pressure on treatment facilities to speed up their course of treatment, to the potential detriment of clients.

There are no easy answers to the problem of addiction, unfortunately, and some addicted people, despite all good efforts, will never find recovery and well-being. Many, however, will. Regardless of opinion or treatment approach or policy statement, one thing seems clear: The more we learn about addiction, and the more we seek to understand, the better off everyone will be.

Nate is on Twitter and Untapp'd at @nategismot