When we look retrospectively it’s easy to wonder, “How could this have happened?” It has little to do with how smart people have been or motives. It has more to do with how an entire culture has been trending.
What has evolved is that:
• Substance use disorders continue to be connected in thought with criminality
• An acute care system has developed to treat episodic occurrences rather than long term care
• Mutual support groups became a substitute for professional, recovery management
• We continue to create shame by using language that is based in
morality and not medicine.
Let’s take a look at each statement:
Substance use disorders (suds) are criminalized:
A person with a substance abuse disorder (sud) had it made in the United States until somewhere around 1903. Life could not have been better. No one thought about which drugs should be legal and which ones restricted. All that a person had to do
was visit their local apothecary (now more commonly known as CVS or Walgreen’s) and pick whatever they wanted off of the shelf. Laudanum, an opiate, was right there along with various concoctions containing alcohol, cocaine, and God knows what else.
Was drug use a problem way back then? Probably! However, there were no DUIs because automobiles were just on the brink of being created. There were no airplanes to fly or heavy duty tractors to plow. Problems happened at home and were kept secret.
At some point, people became concerned about opium smoking. Chinese people working on west coast railroads didn’t concern a lot of people. When young middle class Caucasian people began to imbibe, the government was forced to become concerned.
So, they passed the Pure Food and Drug Act of 1903. This legislation didn’t do much about drugs being available. It just said that they had to be labelled. No big deal, right?
Well, the really big deal happened in 1914 when Congress passed the Harrison Act. Everything changed! The day before the Harrison Act was signed in to law; suds were a medical issue that was treated in clinics around the country. The day after the Harrison Act became law, people with suds were no longer patients, they were criminals.
The clinics that had been providing maintenance medications to addicts were immediately closed. Physicians who defied the Harrison Act and continued to provide maintenance medications to patients were jailed. The day after the passage of the Harrison Act the price of drugs on the street became 50 times more expensive than it was on the day before.
Nothing linked addiction and crime more than the Harrison
• The most significant effect of the Harrison Act was that it criminalized addiction. Prior to passage there was no connection between addiction and criminality. There is today.
• “Narcotic” came to mean all illegal drugs (not just those that derive from opium).
• Heroin and marijuana were deemed to be equally as dangerous and both remain federal schedule 1 drugs today. Schedule 1 drugs are perceived to have the most abuse potential and are the most highly regulated.
• Alcohol and nicotine were left off of all of the Schedules provided by the federal government.
The Harrison Act has shaped the way people think about drugs and addiction to this day. Many people still think that all illegal drugs are “narcotics.” Behaviors related to substance use disorders became threatening. We’re fighting a “war on drugs.” Our prisons
are overflowing with people convicted of drug related crimes. The number of people in U.S. prisons is embarrassing.
To this day, even patients at the highest end treatment centers sometimes refer to them selves as “convicts.” Sometimes it’s hard to tell whether a patient is “doing treatment” or doing time” (David Mee-Lee, M.D.)
People with substance use disorders need to be responsible for the consequences of their behavior. However, recovery is not a sentence.
We developed and continue to use an acute care model to
treat a chronic disease:
Why Acute Care? As far back as anyone can go one thing has always been true of getting people with suds to treatment. This one thing was true in the early attempts of Benjamin Rush, the asylums, gold, cures, and the Minnesota models. People with suds are not
referred to treatment until their disease has reached the “severe” (DSM 5) stage. By the time this stage has been reached, a patient’s health has been compromised, a family has been devastated, and/or vocational, financial, and legal issues have broken a person’s spirit.
By the time a person with a sud has been referred to treatment, the severity of the disorder indicates that acute care is necessary. I doubt that this is going to change anytime soon.
Instead of providing long term disease management, the providers of residential care turned to Alcoholics Anonymous (AA) to support continued abstinence.
Alcoholics Anonymous (AA) is a fellowship of men and women supporting each other one day at a time. Millions of lives have been changed. Is it really based on “attraction rather than promotion?” Probably not, but we can’t really blame AA for treatment centers pointing people in their direction.
Perhaps treatment centers have done so partially because the resources for long term disease management were simply not available. All resources were for residential care. Not a lot of resources or funding left over.
Residential treatment centers have become a minor league for AA recruitment. It’s hard to walk into a residential center and miss the 12-steps and 12-traditions scrolled on the walls.
Patients are often guided through the first three to five of the twelve steps during the course of treatment. “Druggie Buggies regularly pull up to AA club houses.
There is a difference between what needs to go on in treatment and the role of AA. It needs to be respected.
More importantly, less than 50% of patients discharging from residential care engage with AA during their first year after discharge. A major portion of that 50% drop out later on. We have got to do something different.
Suds are chronic diseases that require long term disease management.
Shame and criminalization led to residential care being provided in remote locations with restricted communication (yet we tell patients, “don’t isolate”)
Traditionally, Minnesota model residential treatment programs have been located in remote areas, e.g. Center City, Minnesota. Access to phones and computers is limited. The supposed reason for isolating the patient is so that treatment will be the only thing to
focus on. That’s not the reason.
The reason is remote locations with restricted communication gives us a break from having to see or think about a person who has left a blemish on a family and on our culture. After all, don’t cancer patients also have to focus on their treatment?
The fact that it also provides a judge with a 30 day option that is less expensive than jail makes isolating an offender seem very attractive.
The shame that we create:
We think that the temperance movement is over but it’s not. The hangover lingers. We carry the shame forward by continuing to use the same language.
The lapse/relapse language within this phrase is historically rooted in morality and religion, not health and medicine…
…was linked in the public mind to lying, deceit, and low moral character–a product of sin rather than sickness (White, 2016).
“Recurrence” works much better. It is not shaming and it encourages better communication with the medical community. “Active/in remission’ works as well as does “active/inactive.”
Rather than cry out about the stigma that society imposes, we would do well to look at the stigma that we create and fix it.
Eliminating “relapse” would be a step in the right direction.
Eliminating “relapse” would be a step in the right direction. Very thorough language changes have been recommended by Dr. Michael Botticelli while he directed the Office of National Drug Control Policy (ONDCP).
The changes using “ambivalence” rather than “denial” and first person language- I have a substance use disorder as opposed to “I’m an alcoholic.”
The shame can be lifted.
So, I think that this is where we are. Question becomes “how does a system that is providing care for acute episodes evolve into one that provides lifespan recovery management?
The answer is, “very slowly.”
We have a system now that sends people to treatment without thoroughly assessing which level of care is most appropriate. If the assessment is done at a facility that only offers Intensive Outpatient Treatment, that’s where the patient winds up.
We need independent assessments that use the six ASAM dimensions to recommend an appropriate place to begin recovery.
We need to stop complaining about the “stigma” that society places on suds and start to focus on the shame that we create. Drs. Botticelli and Mee-Lee have made very powerful suggestions.
Patients with chronic diseases such as diabetes and hypertension are monitored for a lifespan. When symptoms become active, levels of care become more intense. Does this make sense?
I laid out my best attempt at laying out a model for lifespan recovery management in 2015. Dr. John Kelly and William White did so much more extensively in their book Addiction Recovery Management (2011).
Change doesn’t happen over night, although it would be nice if it did. We need to keep chipping away and eventually get to “lifespan recovery management”.
Michael Weiner has held faculty positions at the University of North
Carolina and at the Rochester Institute of Technology. He has
been a Director and Researcher for Behavioral Health of the Palm
Beaches since 1999. He provides services at Behavioral health
of the Palm Beaches and at Veritas Palm Beach. He regularly
publishes in journals and presents at conferences.