Politics and Perception in New Addiction Legislation
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With the nation in the grip of a widespread opioid epidemic, substance use problems have insinuated themselves into the political dialog in an unprecedented way. Federal, state and local governments have been proactive in responding to the epidemic by driving new initiatives around prescribing opioids and treating those with opioid addiction. But perhaps the most resounding evidence of the alarm around opioids is the fact that a decidedly inactive Congress seems likely to pass the landmark Comprehensive Addiction and Recovery Act of 2016, which has already been passed by the Senate in obviously bipartisan 94-1 fashion. But are the key elements of the legislation rooted in the assumption that addiction is a chronic disease? Addiction researcher Peter Ferentzy thinks so, and wonders if that’s a good thing…Richard Juman, PsyD
Is addiction a chronic disease? It is, at least according to the authors of the new Comprehensive Addiction and Recovery Act. In many ways, the act is progressive, supporting as it does opiate substitution for those who need it (and putting no time limits on these interventions). On this score, the act seems pragmatic rather than ideological. It suggests “a comparison of the cost of providing medication assisted treatment to the cost of incarceration or other participation in the criminal justice system.” (SEC. 302) In other ways, too, I like this act as it does stress the need for communitarian solutions (beyond the clinical). The act promotes more attention to treatment, though we might also question what kind of treatment the act means to promote (perhaps the same old ineffective, abstinence-only approach?). Here, though, we shall focus on that thorny, longstanding issue of chronic disease. Funny, but many who take issue with the theme of chronicity are also the ones who champion someone’s right to lifelong opioid maintenance. I don't mean to suggest that such persons are hypocritical. They can be on occasion, but in reality they are trying to juggle difficult—and competing—ideas and solutions:
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1. Is addiction chronic? 2. Is addiction a disease? CARA answers each of these in the affirmative, but is this viewpoint on firm footing?
The (Mainstream) Disease Conception of Addiction
In the late 1970s, Harry Levine showed how the current disease conception (the one still dominating most treatment centers and favored by AA and other grassroots organizations) emerged in the late 18th century. Levine had been foreshadowed by Mairi McCormick, who in 1969 published a study of the role played by drunkards in many 19th century English novels (McCormick, 1969). McCormick documents the rise of "gamma" alcoholics—those who, upon taking a drink, will likely continue until thoroughly drunk. Solitary, desperate and compulsive, these characters represented the new perception of the drinker. Here is what Levine had to say about the new disease conception:
In terms of external behavior, there is little to distinguish the contemporary idea of alcoholism or inebriety from the traditional colonial view of the drunkard... The main differences lie not so much in the external form as in the assumptions made about the inner experiences and condition of the drunkard. Beginning in the 19th century, terms like 'overwhelming' and 'irresistible' were used to describe the drunkard's desire for liquor. In the colonial period, however, these words were almost never used. Instead, the most commonly used words were love and affection, terms seldom used in the 19th and 20th centuries. (Levine, 1978, p. 148).
In short, Rush identified the drunkard’s condition as a disease involving loss of control, and as lifelong, given that the drunkard’s only hope was to abstain from liquor indefinitely.
Even if Rush’s proscription applied only to distilled spirits and not to wine and beer, what we see is the emergence of a solid inner identity—inviolable and impervious to outside influence (nothing can cure your disease). This was a new conception of disease, because specific disease entities were inconsistent with 18th century medicine, and a new conception of the human soul: the deviant is a deviant for life, and psychosocial issues are irrelevant because the disease, like a virus, rests inside the individual.
This conception of addiction did not evolve in a vacuum. Recall what Levine said about “inner experiences.” First, other “sins” were being transformed into medical/psychiatric issues (homosexuality, delinquency). Second, the target of such inquiries had shifted. Of special interest was no longer the act of drunkenness, but the inebriety (later to be called alcoholism) said to lie underneath. Similarly, “sodomy” had long been considered sinful and acts of sodomy were sometimes (though certainly not always) punished. Starting at this time, however, it was no longer the act of sodomy that was of serious interest but the “homosexuality” said to lie underneath the act; theft also became less interesting as such, in favor of the delinquency said to lie underneath (Foucault, 1979, 1990).
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So the new Addiction and Recovery Act, no matter how progressive in other respects, is nonetheless beholden to conceptions of disease and chronicity rooted at a specific historical juncture and that many of us are not too comfortable with (and yet can’t seem to get rid of, either).
But there was another disease conception contributing to this emerging disease model. The public health model, originally designed to target issues such as hygiene and the spread of infectious disease, was in this sense another disease conception that was eventually applied to addictions and other psycho-behavioral disorders. In terms of origin, each owed a great deal to Pasteur and the germ theory of disease. In one case we had an individualistic notion of a solid—inner—disease identity (a conception of disease that was not too respectable throughout most of the 17th and 18th centuries, and unthinkable prior to that). In another case we had a conception of germs that had to be stopped from killing us, but in this case resulting in a sociological approach to psycho-behavioral “diseases.”
Some would argue that such transpositions from biology to psychosocial realities are an illegitimate metaphorical trick, and that hence the very existence of mental and behavioral diseases is an illusion (Szasz, 1974). I tackle that matter—one that has long dogged our field—after providing some historical and conceptual foundation.
The Public Health Model
The public health model was originally focused on promoting healthy behaviors, even if it was not directed at psycho-behavioral disorders. It was in 1854 that British physician John Snow found cholera to be linked with polluted water (Vinten-Johansen, Brody, Paneth, Rachman, & Rip, 2003). Hygiene, “medical hygiene,” was one of Snow’s major concerns, and the concept evolved with a reliance on Pasteur’s germ theory of disease—a theory that, in fact, also caused efforts at imitation in 19th century psychiatry in the positing of solid, psychiatric disease entities (Dowbiggin, 1985; Rosenberg, 1979).
Psychiatrist Paul Lemkau, who founded the Mental Hygiene department at the Johns Hopkins School of Public Health, was a pioneer in the application of the public health model to psycho-behavioral disorders (note the terminology: mental hygiene). This represented a more sociological approach to mental health, and was a challenge to older conceptions rooted more in clinical experience. This was a different kind of medicalization, based as it was on epidemiology.
A question that haunts addictions to this day—should health/disease be understood as a private or a public matter, individual or social?—was coming to the fore.
As mentioned, in the late 19th century, psychiatry had tried to legitimize itself as a science through the positing specific mental ailments loosely comparable to disease constructs rooted in germ theory (Dowbiggin, 1985). With public health, a different type of medicalization emerged, one that was more inclined to view mental ailments along a continuum of harm rather than as rooted in solid and identifiable disease entities.
From the Mid-20th Century to Today
The scenario described above still reverberates to this day, with the Comprehensive Addiction and Recovery Act reflecting each approach. Section 034 is titled: “Building Communities of Recovery,” a public health approach—yet the document, as mentioned already, treats addiction as a chronic disease. We should consider the contrast. The (mainstream/AA) disease conception of addiction emphasizes an absolute need to avoid the poison in question (alcohol) and has even borrowed a bit from science through the positing of (a completely unscientific) allergy theory of alcoholism. This disease model, since then applied to other substance addictions, is well suited to sidelining harm reduction and controlled substance use solutions. Its emphasis on biology—often quite loosely, with little scientific foundation—has been very successful in its appeal. The condition is viewed as internal, firmly non-psychosocial. Conversely, the public health model has come to be associated with harm reduction. It is, in fact, an alternative disease conception well designed to challenge the mainstream disease conception.
The theme of chronicity suggests that addiction is lifelong: even after years of abstinence, one drink, one toke or one line is said to rekindle the process; according to this view, it is impossible to cut back (for more than a short while). Even in the absence of verifiable symptoms, a world of hidden, inner identities assures the addict’s permanent status as addict.
So how much truth does each of these disease conceptions contain, and what do they imply in terms of how addicts should be perceived and treated?
Is the mainstream disease model rooted in truth, in any kind of science? I’m not persuaded, despite some convincing evidence. Although the tenets (like the need for lifelong abstinence) do not always pan out, they do so often enough to receive a great deal of experiential vindication. Even if such vindication is often the product of suggestion (therapeutic or other), it certainly is not in every case. In all, to the question of whether this disease conception is true, although there does seem to be some truth in it, I would answer in the negative. The public health model suggests that addiction is more environmental, and functions along a continuum of harm. I believe that this is generally accurate, but with a caveat, since some extreme cases of addiction do not fit the mold and do indeed require lifelong abstinence. So while I believe that the psychosocial model has more explanatory power than the disease model, it can’t account for all cases of addiction.
Are psycho-behavioral ailments chronic? Not necessarily, but do consider: they are in the sense that if you have ever had the ailment in the past, you are at far higher risk than average of contracting it again. In reality, there is no such thing as absolute chronicity: even with a case of late stage cancer wherein we are sure that someone is a goner, the possibility of spontaneous remission cannot be discounted. In either case, it’s just a numbers game (though in some cases, as with the cancer, the odds are so long that we invoke “certainty”).
Let me start by observing a paradox: advocates of the mainstream disease conception, despite insisting that addiction is chronic, are also the ones more likely to object to long-term methadone maintenance. Conversely, those who insist that it is not chronic are more likely to endorse such options (albeit in a client-specific fashion). It is, in fact, hard to tell what each model implies, given that the positions people take are often rooted in ideological concerns rather than consistent applications of their respective points of view. Still, with respect to policy the PH model would definitely challenge the war on drugs, whereas the mainstream model is often used to buttress the war. Do recall, however, that the AA disease conception is not used to vindicate alcohol prohibition. Does this mean that the model could, conceivably, be bent in many directions?
Are disease conceptions benign or hostile? Well, there is something to be said for not calling addicts “sick.” Still, when moving away from sin conceptions, disease conceptions were, if nothing else, designed to be benign. Evidence for this is not hard to find: in the days of inebriety, chronic drunkenness was a disease if you were rich and a vice if you were poor. Inebriety was said to afflict persons with delicate constitutions, or those who perform intense mental labor. But the working class drunk was just a drunk. Similarly, pathological gambling first came to be identified as a disorder, a medical issue, in the wake of newly emerging legalized gambling venues: only then did a higher percentage of middle class and “respectable” individuals develop problem gambling. So long as the affliction was associated with lower class and underworld elements, it was just a vice and gamblers were unambiguously guilty.
Realistically, though, concepts can be bent in different directions: one can be hostile or sympathetic regardless of whether the target is a sick delinquent or a wretched sinner.
I believe that we need to get past silly debates about whether or not addiction is chronic. It is, to some degree and in many cases, but certainly not absolutely so. Short answer: we need conceptions of chronicity that are flexible enough to do justice to this difficult, and often baffling, condition.
As for the disease business, I don't think it really matters whether or not we use the term disease. Perhaps a bit of flexibility would be good: let each person with an addictive disorder decide if they wish to be sick. If this seems farfetched, do note that a diagnosis of an addictive disorder has long required collaboration from the client who must attest to feelings of “craving” or compulsion. In this age, we are active in the construction of “diseases” (including our own) and if this can be done across the board (addiction is a disease in all cases) then why not switch the paradigm and render it person specific? While this may seem a little silly, it is no more so than the many contradictions we are currently juggling.
In all, the Comprehensive Addiction and Recovery Act reflects many of the tensions haunting addictions today. We are moving into a different approach to dealing with addiction, but we are not quite there yet. The new act is simply consistent with the many inconsistencies we now face.
Peter Ferentzy, PhD, is an addiction scientist who has also personally struggled with substance addiction. Going by the monicker, "PhD Crackhead," Ferentzy is author of Dealing with Addiction—why the 20th Century was wrong. This and other books by him are available at Amazon and other outlets. His first novel—The Corrective—a six day journey—will be available for sale at these same outlets in May of this year.
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Ferentzy, P. & Turner, N. (2012). Morals, medicine, metaphors, and the history of the disease model of problem gambling. Journal of Gambling Issues. Issue 27, October.
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