How is addiction treated in this country? There’s no single answer. There isn’t even a standard for what makes treatment successful. Some measure years of abstinence. Some seek moderation, but don’t consider abstinence to be part of recovery. Others seek temporary reduction in use through incarceration, or simply a reduction in socially unacceptable behavior.
One reason for this is confusion about the nature of substance abuse. Science recognizes three categories: the risky user, the physically dependent person, and the addict who returns to the substance repeatedly even after being separated from it. Medicine, on the other hand, used to recognize the first two categories. But the DSM-V, the latest version, combines all substance abuse under the single label, “Substance Use Disorder.”
Another reason is the disconnect between science and medicine on the one hand, and public policy on the other. For example, the largest single “treatment” provider for drug users is the prison system. More than half a million nonviolent drug offenders are incarcerated, at a cost to the taxpayers of around $15 billion per year. While there are some drug treatment programs in some prisons, the majority of inmates do not receive drug treatment. The National Institute of Health cites public desire for retribution rather than rehabilitation as a major barrier to drug treatment in prisons.
The amount spent on incarceration pales in comparison to the $30 billion or more spent annually on treatment facilities. In 2017, over 4 million Americans received treatment in a variety of settings. Of these, 2.5 million attended a treatment facility, residential or outpatient. Others may have received help from doctors, psychologists, or Twelve Step programs. Of the treatment facilities, 53% received government funding, meaning they are prohibited from using any spiritual or religious approach, including the Twelve Steps.
A more startling statistic is that of the 20 million Americans who needed treatment in 2017, only 12% received it at a treatment facility. Another 7% received treatment at non-specialty facilities. Still, 81% of those who needed treatment didn’t get it. The most common reason, cited by 41%, was lack of insurance coverage.
Some 10% of treatment facilities provided Medication Assisted Therapy (MAT), in which physical dependence on heroin or other opiods are treated with methadone or buprenorphine– long-acting opioids that are much harder to quit after long-term use. Of these, 95% still offered methadone, while 65% offered a choice between the two substitutes. There was no indication of how many facilities used these replacements for detoxification only, and how many used ongoing maintenance. (I’ll post another time about the nightmare of “methadone maintenance.”)
So what does all this tell us? First, most Americans who need help for substance abuse don’t get it.
Second, there’s a wide variety of approaches to treatment. Some, like prison, embrace the belief that if you punish someone enough, they will somehow magically change. Others, like substitution therapy, seek to reduce the criminal and health effects of addiction, but do not seek to actually treat addiction. Still others seek to return the sufferer to “social” use. Those that do seek abstinence measure it in various ways: abstinence for the duration of the program, or at 90 days, or at a year, or at 5 years.
A study of veterans in Twelve Step programs found that 70% of those who participated for a period of months were still abstinent at 16 years. In contrast, some treatment facilities that don’t use the Steps have abstinence rates around 10% at one year.
The most successful treatment approaches, at least for those who suffer from true addiction, seek total abstinence and a changes way of living. As noted in my previous post, it’s not enough to just get someone off drugs. Addiction is a way of life, a purpose for living, and a moral framework. For treatment to be successful, these old ways of being have to be replaced with new ways of being.
To be successful, treatment does not focus on moving away from drugs, but toward a suitable new way of life.
It’s no secret that addiction is a problem in our society. It’s also no secret that, despite some advances in science, it’s not easy to treat. This is because the nature of addiction remains elusive. We can see this in the argument between those who insist it’s a disease, and those who insist it’s a choice. Some psychologists now argue that it’s both.
I don’t disagree. There are biological factors. And addicts make bad choices. I contend that, while addiction displays characteristics of both disease and choice, neither category is sufficient to explain the phenomenon.
Let me be clear that I’m referring here not to the occasional, risky user, nor to the person who becomes physically dependent on a substance but is able to abstain once separated from it. Addiction refers to those seemingly bizarre cases, now numbering in the millions, in which people return to the substance over and over, even after physical dependence has ceased.
Here’s the issue: if a person is miserable enough to want to quit, and if they have been separated from the biological need to use the substance, it makes absolutely no sense for them to return to the drug that made them miserable– unless there’s something else going on.
Enter Kent Dunnington. In his book, Addiction and Virtue: Beyond the Models of Disease and Choice, he argues that addiction is a habit in the classic sense expressed by Aristotle and Augustine. The behaviors of an addict are preconscious decisions habituated (programmed) by past reward/punishment experiences. I find flaws in Dunnington’s case for addiction as only a habit. But this introduces a third category to consider, and offers another dimension of options for understanding and treatment of addiction. The Twelve Steps, for example, can be described as a method of rehabituation.
Yet Dunnington goes further. We are habituated to our behaviors based on our view of the purpose of life. If, for example, we believe that the goal is to be wealthy, we’ll work hard and accumulate money. If it’s to seek thrills, all our efforts will point toward that goal. If it’s to follow Jesus, we’ll put our efforts into the behaviors that the Gospel describes (none of which include accumulating wealth). Indeed, James K. A. Smith argues that we can tell what we love much more reliably by what we do than by what we say we love.
Dunnington describes how addiction fills a need for transcendental experience, moral certainty, and purpose for life that are lacking in our secular society. In other words, it plays the role of a religion. Dunnington, a Christian, describes addiction as false worship. Yet he recognizes the diligence with which addicts undertake this worship, arguing that the Church could learn something about commitment from the “prophetic challenge” addicts present. Anyone who knows an addicted person can attest that we will sacrifice anything for our god, even our lives. The god may be false, but it’s the one to which we have willingly or unwillingly devoted ourselves.
If addiction is a religion adopted in response to the unsatisfying “spirituality” of secular materialism, this has implications for addiction treatment. To put it simply, the goal of treatment is not to get people off drugs– it is to replace one religion and way of life with another. This is where the disease model fails: medicine is not equipped to address the spiritual and moral nature of addiction.
Obviously, if addiction can play the role of a religion, a replacement is not limited to the Big Five: Christianity, Judaism, Islam, Buddhism, and Hinduism. For example, in the same ways that addiction serves as a religion, the Twelve Step programs do also. But, with thousands of years of practice and tradition, the established religions do have much to recommend them. I’ve found the healing power of Christ to be unique among them, but I do recognize that adherence is a choice.
From an objective perspective, my point is that it’s not enough to get a person off drugs and tell him or her to go get a job. The question that has to be answered in order for an addict to stay clean is this: “What’s the point?” Only when we can provide an answer for that question do we begin to offer hope to those mired in substance addiction.
This wasn’t going to be my next post on the subject of addiction, but the mass shootings over the weekend changed my mind. At least one of the shootings was racially motivated.
What do mass shootings and the alt-right have to do with addiction? I believe they stem from common causes, namely a national ethos that gives no meaning to life other than accumulation of wealth, and a rising wealth inequality that makes the national purpose unattainable for increasing numbers of people.
But first, let’s start with some demographics. The alt-right draws primarily from the white working class. Mass shooters come primarily from the white working class. According to Ann Case and Angus Deaton, “deaths of despair,” which include overdose, alcoholism, and suicide, are rising fastest in the white working class. To understand any of these these problems, we have to ask ourselves what’s happening in the white working class.
Case and Deaton have done significant research on this. Focusing on deaths of despair, they note that only in the white working class have deaths of despair risen in proportion to the drop in income. In this demographic group, there is a direct correlation (or, technically, an inverse correlation) between income and morbidity (death). Why this correlation does not exist in other demographic groups is an interesting question, but beyond the scope of this post. I suspect minorities, because of a history of being left out of American prosperity, are less invested in the “American Dream,” and thus less despairing as the American Dream slips away, but I have no proof of that.
Statistically, whites are more likely to sink into despair over economic factors. And economic factors have not been kind to the working class over the past few decades. This has resulted in decreased life expectancy. Since 1979, opioid overdoses among whites have increased more than twice as much as opioid overdoses among blacks, from a slightly lower rate to a rate twice as high. The suicide rate among whites is more than twice as high as any other demographic group, with the exception of Native Americans who have a higher rate.
We can speculate about the cause of this despair. Unlike other economically excluded groups, the white working class used to believe they could attain the American Dream. It’s increasingly clear that they can’t. They have lost a reason for being, or telos–the main telos put forward by our economically-motivated society.
Moreover, whites are more likely to adopt Evangelical religious beliefs. Some 76% of evangelical Protestants are white. It’s difficult to generalize about this group because there is significant diversity, but there are some typical commonalities. At an Evangelical church I once attended, the pastor was fond of saying, “Any conversation about the Gospel begins with one question: Are you sure you’re going to Heaven?” This focus on afterlife was accompanied by attention to grace to the exclusion of works. They had us memorize Ephesians 2:8-9, “For by grace you have been saved through faith, and this is not your own doing; it is the gift of God— not the result of works, so that no one may boast.” But never did I hear anyone read the next verse: “For we are what he has made us, created in Christ Jesus for good works, which God prepared beforehand to be our way of life.”
What does this have to do with morbidity? Consider a person who finds himself or herself in despair. That person looks for solace at church. The church’s answer is, “It will be better in Heaven.” Is that not incentive to hurry the process along? Add to this a persistent link to the prosperity Gospel–if God has blessed you, you will prosper–and the religious outlook for the white working class isn’t exactly stellar.
Okay, you say. Perhaps this explains the rise in deaths of despair. But what does any of this have to do with the alt-right?
I’m glad you asked. Patrick Forcher and Nour Kteilly at the University of Arkansas have compiled a psychological profile of the alt-right. In their summary, the researchers noted that alt-right supporters:
- Were more likely to be white
- Were less likely to have more than a high school education
- Were not optimistic about the current state of the economy.
These characteristics were shared by non-alt-right Trump supporters as well. Thus, the alt-right is, as expected, a subset of the white working class that has been negatively affected by the upward redistribution of wealth.
One big difference between the two was that alt-right supporters were more optimistic about the future of the economy. Their alt-right beliefs gave them hope for the future, much more so than their non-alt-right peers. This suggests that the rise of alt-right is a response to their deteriorating economic status.
This shouldn’t be a surprise. Fascism grew in Germany during the Great Depression that devastated the German economy. Forscher and Kteilly note similarities between the rise of the alt-right and the rise of the British National Party among the depressed working class.
What this does tell us is that a broad spectrum of American problems, including suicide, alcoholism, drug overdoses, alt-right activity, and, I maintain, mass shootings, are directly related to the economic decline of the white working class.
It’s not quite that simple, of course. Clearly there are factors that drive this demographic’s symptoms, especially compared with other demographic groups that are even more economically excluded. For one view of these causes, I recommend Joe Bagaent’s Deer Hunting with Jesus, which documents the decline in influence of rural America. The losses of the white working class are not just economic, they are political as well.
Liberals may not like that this formerly-privileged group is taking up more of our attention than other groups that have never been privileged. But it is historically true that those who are losing privilege are a greater threat than those who ever had it. This is an issue we need to address.
But more than that, we live in a society that values our existence in dollars. Under this philosophy, economic loss can only lead to despair. There is no other source of hope.
As a Christian, I look to the Gospel. We are not judged by how much wealth we have. The purpose of life is not to accumulate. Nor is it to survive until we die and go to Heaven. “The Kingdom of God is among you” (Luke 17:21). It is here, though it is (quite obviously) not fulfilled.
Christians have the Kingdom to offer those in despair. Are we showing it to them?
You’ve read the news. Drug use has become an epidemic and a crisis. The statistics are staggering: Since 1979, drug overdoses are up 1,460%, and opiod overdoses among whites are up 2,627%.  According to the government agency SAMHSA, some 30 million Americans over the age of 12 use illicit drugs, and 83 million more abuse alcohol.
Yet our answers to this crisis are most often misdirected: we restrict access to drugs, and we incarcerate the abusers, compounding their problems by giving them a criminal record that prevents meaningful employment. Almost half of all federal prisoners (45%) are locked up for drug offenses.
The irony is, we claim to be a capitalist nation. The law of supply and demand, we insist, will regulate the market. Yet none of our solutions addresses the basic problem: people want to escape their reality. Demand exists. But I’ll deal with that in another post. What’s important for this post is that the War on Drugs is economically ridiculous. Any economist will tell you that reducing supply does not reduce demand, it just raises the price.
The second irony is that most of those who want to quit can’t get help. According to SAMHSA’s report, 20 million Americans sought treatment in 2017. Of these, 89% did not receive it.
That’s right. Only about 1 in 9 of those who needed treatment received it.
The same report details the reason they didn’t get it. The most common reason? Lack of insurance coverage. They either didn’t have insurance, or their plan didn’t cover treatment. (And just try to find a treatment facility that will take you if you don’t have cash!)
We’ve spent over a trillion dollars of taxpayer money– $31 billion in 2017 alone– in a doomed “war” to eliminate the supply of drugs. It hasn’t worked because the laws of economics can’t be repealed. Supply will seek to meet demand. We have to eliminate demand.
Yet those trying to get off drugs can’t get help.
It costs around $30,000 per year for each person we incarcerate for drug crimes. The average prison sentence for drug possession is 3 years. For the cost of one year of incarceration, these people could instead get a 30-day inpatient rehab and 90 days outpatient rehab. Not all will be successful at kicking their addiction. But some will. And these are people who (1) won’t be buying more drugs, and (2) won’t be costing the taxpayers money for prisons and emergency medical care.
Instead, they’ll be getting jobs, contributing to society, and above all, telling others about the nightmare they survived. Recovering addicts and their stories could be the best advertisement for staying off drugs!
Isn’t that a better way to spend a trillion dollars?
For those who think such an approach is impractical, check out this evaluation of the Gloucester Initiative, in which police refer addicts seeking help to treatment instead of arresting them. According to the police chief, “It costs the program $55 per individual treatment, whereas it costs $220 to send a low-level drug user through court.” In the first year, 90% of those who sought treatment received it. The followup evaluation showed that, yes, 40% of those surveyed did return to drugs after completing the program. But do the math: 60% didn’t.
Our current national drug policy is flawed. It has been from the start. It doesn’t help, and it may actually make things worse.
But there are alternatives.
As more and more families struggle with addiction, perhaps the stigma will begin to disappear. Perhaps we can talk about addiction logically, rather than emotionally. And perhaps we can find real solutions for those who suffer.
 Statistics drawn from Jeanine M. Buchanic, et. al., “Exponential Growth of the USA overdose epidemic,” Pittsburg: University of Pittsburg, 2017, 2 (https://www.biorxiv.org/content/biorxiv/early/2017/05/09/134403.full.pdf, accessed September 22, 2018). “Drug Overdoses,” National Safety Council (https://injuryfacts.nsc.org/home-and-community/safety-topics/drugoverdoses/data-details/?gclid=EAIaIQobChMIxryIk-DO3QIVDK_ICh1c7gZVEAAYAiAAEgLHnvD_BwE, accessed September 22, 2018). Monica J. Alexander et. al., “Trends in Black and White Opioid Mortality in the United States 1979-2015,” Epidemiology 29:5, September 2018 (https://journals.lww.com/epidem/Fulltext/2018/09000/Trends_in_Black_and_White_Opioid_Mortality_in_the.16.aspx, accessed September 22, 2018).
Here are some interesting facts about the national debt.
- Today, the national debt is just over $22 trillion dollars, up from $5.8 trillion when George W. Bush took office.
- There are 83 million households in the U.S., so the national debt comes to $578,947 per household.
- Think we should all write a check? The median household wealth (the number at which half the population has more and half has less) is $78,100. That’s right: most Americans don’t have anywhere near as much as their share of the debt.
- Over that same period in which the national debt more than tripled, median household wealth went down 22%.
Here are two questions to think about:
Where is all that money going? Not into the pockets of most Americans!
Are you scared yet?
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