The Center was founded to review and comment on vital drug addiction policies. For 2018, we will be examining critical policy issues related to the opioid crisis and the nature of and best practices for treating addiction. More specifically our focus will be on these issues:
Policy Issue: Addiction as Disease (Brain or Otherwise)
The prevailing orthodoxy commonly embraced by influential segments of the medical community, including psychiatric and pharmaceutical components, claims that the cause of addiction has been resolved and that addiction has been “discovered” to be a “disease of the brain.” This is the latest incarnation of an old idea that holds addiction is a purely physical problem often compared to diabetes or cancer and therefore, like those diseases, should primarily be treated with drugs.
Treatment modalities rooted in the brain disease theory are now being adopted — seemingly without question — by governments, legislators and social/health services agencies nationwide. Unfortunately, the quick-fix mentality often associated with this approach can result in programs that ignore or eliminate other factors. This raises a number of troubling questions in need of further exploration, including:
- Does the brain disease model of addiction exclude or minimize other causal or contributory factors for addiction, such as cognitive, emotional, behavioral and/or social circumstances?
- Does the brain disease model address fundamental causes or merely secondary problems caused by addiction?
- Does the science unequivocally prove that addiction has a solely physical basis?
- What is the clinical pathology for diagnosing the disease of addiction? Do any objective medical tests exist to detect or quantify the brain disease purported to underlie addiction? Because MAT proponents frequently liken addiction to diabetes, the question logically arises as to what, if any, physical tests are available to confirm it?
- What definition of “disease” is used when describing addiction as a disease? Does it differ from the definition applied to diseases with detectable and measurable pathology such as diabetes or cancer?
- What percentage of the studies cited in support of the brain disease model were funded by the pharmaceutical industry and how can the impact of that sponsorship be estimated or identified?
- How do the proponents of the disease-model theory and its related drug-centric treatment approaches explain the well-recognized placebo effect?
- Similarly, how do we explain studies that show significant numbers of people previously classified as addicted have subsequently recovered spontaneously, without medical intervention or the use of treatment drugs?
Policy Issue: Desired Addiction Treatment Outcomes
Differing opinions exist as to what the outcome should be from an addiction treatment regimen. Some maintain that a successful outcome occurs when an individual addicted to heroin or a pharmaceutical painkiller is no longer taking that drug but is instead using an opioid-based “treatment drug” — sometimes for long duration. Others argue that treatment success is only achieved when a person is able to lead a life free from drugs.
These two success definitions have ramifications that impact individuals as well as policy. For example, a published study that headlines a high percentage “success” rate might on inspection be found to define as a success a participant who has switched from heroin to methadone. While this may be an important milestone for some, it doesn’t necessarily comport with the idea of success for families who want to help a family member live drug-free.
This fundamental issue raises the following key questions:
- As a matter of public policy, what are the preferred outcomes from addiction treatment and drug rehabilitation regimens?
- Is a requirement that an addict be maintained indefinitely on a replacement treatment drug a valid or desirable outcome?
- Are there unintended (but potentially predictable) consequences for individuals who are maintained long-term on addiction treatment drugs? What studies have been done on the effects of long-term drug maintenance?
- What exactly is Medication-Assisted Treatment (MAT)? Official definitions include the use of treatment drugs coupled with support therapy. But real-world experience tends to indicate that the therapy component is commonly minimized or dropped. How prevalent is that trend? What are the liabilities of minimizing non-drug treatment components?
- Can a harm reduction approach be considered treatment? Harm reduction approaches tend to focus on the short term. Do they by themselves also produce desirable long-term outcomes for the individual? For the community and society?
- Is a drug-free life a desirable or possible outcome? What are the long-term benefits of such an outcome? In what percentage of cases is it possible?
- Who should have the power to decide what is a desirable treatment outcome and/or which treatment options should be offered and supported with public funds? Affected individuals and their families? Government? The medical/pharmaceutical industry?
- What impact do current policy trends have on treatment service providers, insurance coverages, state licensing of providers and other parts of the treatment ecosystem? What effects might these policies have in the future?
Policy Issue: Treatment Approaches Not Based on the Disease Model
Many people know an individual or a family affected by addiction. Likewise most people know of someone who has beaten addiction and gone on to live drug-free without the use of treatment drugs, medical interventions or similar disease-model solutions. This raises several questions:
- Is there evidence that supports the contention that addiction is a behavioral, emotional and/or spiritual malady? Or, minimally, that these are important non-physical factors contributing to addiction?
- Is there valid and reliable evidence that demonstrates successful results can be achieved from treatments not based on the disease model and which do not use drugs or other medical interventions? How do they compare cost-wise?
- What place should Medication-Assisted Treatment have in a treatment ecosystem that embraces many pathways to recovery?
- Are there credible personal stories of individuals becoming free from addiction using methods not derived from the disease model of addiction? If so, what are their perspectives on this issue and what, if any general lessons can we learn from them?