Saturday, May 25, 2013

Ethics and Addiction Treatment

Addiction Now Defined As Brain Disorder, Not Behavior Problem, LiveScience
Addiction is a chronic brain disorder and not simply a behavior problem involving alcohol, drugs, gambling or sex, experts contend in a new definition of addiction, one that is not solely related to problematic substance abuse. 
The American Society of Addiction Medicine (ASAM) just released this new definition of addiction after a four-year process involving more than 80 experts. [...]
Two decades of advancements in neuroscience convinced ASAM officials that addiction should be redefined by what's going on in the brain. For instance, research has shown that addiction affects the brain's reward circuitry, such that memories of previous experiences with food, sex, alcohol and other drugs trigger cravings and more addictive behaviors. Brain circuitry that governs impulse control and judgment is also altered in the brains of addicts, resulting in the nonsensical pursuit of "rewards," such as alcohol and other drugs. 
A long-standing debate has roiled over whether addicts have a choice over their behaviors, said Dr. Raju Hajela, former president of the Canadian Society of Addiction Medicine and chair of the ASAM committee on addiction's new definition. 
"The disease creates distortions in thinking, feelings and perceptions, which drive people to behave in ways that are not understandable to others around them," Hajela said in a statement. "Simply put, addiction is not a choice. Addictive behaviors are a manifestation of the disease, not a cause." 
Even so, Hajela pointed out, choice does play a role in getting help
"Because there is no pill which alone can cure addiction, choosing recovery over unhealthy behaviors is necessary," Hajela said. 
This "choosing recovery" is akin to people with heart disease who may not choose the underlying genetic causes of their heart problems but do need to choose to eat healthier or begin exercising, in addition to medical or surgical interventions, the researchers said.
"So, we have to stop moralizing, blaming, controlling or smirking at the person with the disease of addiction, and start creating opportunities for individuals and families to get help and providing assistance in choosing proper treatment," Miller said.

There has been a move to treat addiction as a health problem. On the surface this may seem like an improvement, but drug users may find themselves out of the frying pan and into the fire. The Livescience article I quoted from is unremarkable from other articles in the mainstream media. However I do find the choice of language telling. First we are told that addicts are not in control of their behavior, the disease robs them of the ability to make rational choices, except when they choose "recovery". So when addicts choose to enter drug treatment it is of their own volition, but when they engage in addictive behavior they are powerless. How do the addictionologists explain this rather convenient (for the addictionologist's paycheck) paradox?

Dr. Raju Hajela then compares addiction to heart disease, yet addiction is not treated like heart disease. Patients with heart disease may or may not act on their doctor's recommendation, they don't need to do anything they don't want to. If the patient does not implement lifestyle changes, the proper course is to reduce the harm of the disease. And yet with addiction, the individual is expected to cede control of much of their life to the care of the doctor. This is unethical and antithetical to the proper role of a healer.

Further Reading:

The ethics and effectiveness of coerced treatment of people who use drugs by Alex Stevens, PhD. Human Rights and Drugs, Volume 2, No. 1, 2012

Should we have bailiff and judge at weight watchers DPA Blog

Out of the frting pan and into the fire


  1. No $h!t Sherlock! 18 months later and my hypothalamic thermostat is still malfunctioning. Finally! Finally, we're getting around to the truth behind it all! Brav-phucking-O! (Sadly, I'll be dead before they get around to reforming current drug and prescribing policies and laws so, I don't think I'll derive any benefit from this.) But good on 'em!


  2. I neglected to mention my issue with the good doctor's definition of "recovery". What IS "recovery"? The complete turn around and abstinence? But what about the underlying issues that predispose us to addictive behavior? What about that very profound inner feeling of "disquiet", of dispair (not so much "depression")...that ever-present feeling of "wrongness" that just will not allow one to be truly happy or pain free...or have less pain? What about that? I believe for some, recovery does NOT mean abstinence from their drug of choice. It means an ever-present, consistent formulation delivered "as needed" by the user....perhaps for a short period of time, perhaps for the rest of their lives.


    1. I'm not a fan of the term 'recovery' because it usually means abstinence. Drug use in and of itself is often not the problem. Some people very clearly function better while on a maintenance regime.

      This is basically my view on how to best treat opiate addiction under a medical paradigm. Most addicts will terminate their addiction without any treatment, about 75%, a minority will require lifetime maintenance. Opiates themselves are non-toxic, the only risks are dependence and acute overdose. Since most will "mature out" of the addiction, they should be given regular doses of the opioid of their choice. Along with proper education about avoiding overdose (most ODs are the result of mixing drugs), there would be no more drug-related crime, less ODs, no more Hep C or HIV infections and a host of other benefits. If harm reduction was fully embraced opiate addiction could be transformed from a disaster to a minor personal condition.

      But instead we are obsessed with drug use itself. Even with methadone and suboxone the emphasis is getting off the "bad" opiates and on the "good" opioids. This is irrelevant, it doesn't matter what drug a person is using, what matters is quality of life.

    2. Ah yes......"quality of life". Don't you know: addicts get the quality of life they deserve because of their choice. (At least, according to many.)


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  4. I have issues with the whole disease and recovery model. Firstly, I thought diseases were closer to viruses (measles) or inherited conditions (Parkinson's Disease). Secondly, people with medically defined diseases get medical treatment. Drug and alcohol dependents/addicts get a stern lecture, stay in a rehab (if there is one) and apparently a life of going to NA/AA meetings. I've known people who've been helped to heal from addiction by the rehab, then 12-step model, so it's a valid choice. I've known plenty more who have relapsed many times using the same model.

    I don't know what it's like in other countries, but in Australia 12-step proponents claim every other model is a failure, so 90% of the rehab centres here make you attend NA/AA meetings. They're influential, so they shut down other methods like SMART recovery, gradual reduction of use, or anything else that helps people want to stop IF that's their choice.

    Sorry if you love 12-step, but for me it's so limiting. I've gotten off drugs through slow withdrawal (titration) and volunteering. Friends have done so through Buddhist retreats, Cognitive Behavioural Therapy, detoxing at home through a harm minimisation programme. Some still take their drug of choice once a week rather than 3 times a day. We'd all be considered failures by the 12-step industry, but they've worked for us.

    If 12-step and disease model worked for everyone, they can feel free to brag. I only did it for 9 months but basically thought "fuck youse all" after one big meeting. A very nice man "shared" that after 9 years of drug-free sobriety, he'd done a shot of heroin. He didn't like it, he didn't take too much, and didn't do it again. But he got all his pretty little keyrings confiscated, his 12-step 9th birthday revoked, and felt suicidal. Oh, and no-one but me talked to him that day even though he's been a good sponsor.

    I don't get it. I give up something, or exercise every day, for a month and I feel proud of myself. But this guy is shunned, gets into self-hate, for ONE little slip-up he didn't repeat? WTF? 12-steppers out there, please help me understand, cos I don't

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