Wednesday, February 25, 2015

Accept the complex

There have been 2 articles talking about drug addiction that have been making the rounds lately that I feel the need to comment on.  The main thing I am seeing is that people seem desperate to compare them to one another and figure out which of them is true and which is false, as though either one can possibly reflect the full reality of drug dependency and treatment.  As is usually the case the reality is complicated.

The first article talks about how people that have strong human connections, stimulation, and purpose are less likely to become addicted to drugs.  There are good scientific reasons to believe that people who are in good psychological condition are better able to resist addiction and we know for sure that those who feel they are missing something key in their lives are more vulnerable.

When considering this though we must be clear that some people do just get addicted to things even when the rest of their lives are going perfectly.  There are huge variances in susceptibility to addiction in general as well as particular substances.  Having a great life helps but it isn't a perfect defence.

The second article is about using drugs to combat addiction.  That is, there are specific, medically tested drugs that can help people get off and stay off more dangerous drugs.  If you want to get as many addicts as possible off of heroin you really should have drugs like Suboxone as part of your arsenal.  They work wonders for many people.  One huge blockade to getting those drugs more widely prescribed and available is 12 step programs that rely on abstinence as the only cure.  We know for sure that such programs are almost completely ineffective and in fact their resistance to using drugs as part of treatment may well make them worse than nothing.

That doesn't mean that everyone who has an addiction needs Suboxone or that the only thing we need to treat people is more drugs.  Sometimes these treatments work, sometimes they don't, and there are plenty of people who get off drugs without them.

The answer to drug addiction isn't a single thing.  You don't have to believe one solution or the other.  The reality is complex and while that is difficult to grapple with compared to a simple sound byte it is undeniably true.  We can help addicts recover by trying to assist them in making deep human connections and having lives that are full of meaningful work.  People who are happy, productive, and who have a good support network are far less likely to be addicted.  We can also use medically tested drugs that help people break their addictions or keep them at bay.  Heck, we can even try both things at once as that is likely to have the best possible results.

There is no need to figure out which article is true.  Both are true and neither is complete.  In both cases you need to read them with the knowledge that they are only talking about a small part of a larger picture but they do convey something important about the bit they discuss.

The thing we really shouldn't do is rely on abstinence or incarceration as a way to combat addiction.  Neither is morally justifiable and more importantly neither works.  At all.  There are a variety of ways to help keep people from being addicted to drugs but concrete boxes and shame are not among them.


  1. Hi Sky,
    Great topic! I find your dislike of abstinence based treatments interesting, as it is, in the reading I've done in my training to be a methadone and suboxone prescriber, a viable option for a portion of the population. It certainly doesn't work for everyone, but then again, neither does suboxone and neither does methadone.
    Is it mostly the 12 Step "higher power" abstinence based programs you feel are not the way to go? Or all programs based on a theory of abstinence? In my experience the "harm reduction" approach of Methadone Maintenance Therapy (MMT) is on a continuum with eventual abstinence, and many people use MMT (or suboxone) to bridge themselves into a life of recovery, most often with abstinence as the goal. Both MMT and abstinence come with relapse, as that is a highly expected part of the disease of addiction. i think that many people think MMT doesn't come with relapse, but even when people are on their ideal dose of methadone they relapse sometimes. I am sure it is the same with psychosocial treatments.
    Interesting thoughts ... I'm so glad that MMT and Harm Reduction strategies are being more widely accepted. I've seen lives saved b/c of them.
    : )

  2. It isn't that abstinence as a concept is a bad thing. Some people just decide to stop on their own and it works. That is fantastic. However, the current standard in abstinence programs is the highly religious 12 step program that requires an awful lot of extremely problematic things of the people involved. I don't have a problem with an agnostic program that encourages people to talk about their problems and support each other; I don't know how effective it is but it doesn't bother me as long as the participants feel they get something out of it.

    Basically it is the current incarnation of programs that support abstinence and their total rejection of suboxone and its ilk that is my issue. I happily support whatever works, and we have good evidence that 12 step programs don't work any better than people just trying to kick their habits on their own. (The thing that *really* gets me is people being forced into religious programs by law enforcement. That is the worst.)

  3. The link below is to a program with a great science and history based perspective on 12 step programs. References (both scholarly and otherwise) are listed at the bottom. I recommend listening instead of reading.. but that's just me.