Presentation to the University of the Philippines
July 30, 2003
THE POLITICS AND ECONOMICS OF ADDICTION IN THE UNITED STATES
The United States of America has one of the worst track records when it comes to addiction policies of any modern industrialized country in the world. We are a great example of a model to avoid. Instead of having policies driven by research and what is in the best interests of our citizens, we have consistently let politicians establish policies that are guaranteed to fail. Our policies are driven by ultra-conservative, punitive, and foolish ideologies that are aiding in the self-destruction of our society.
This is nothing new. We have behaved in this irresponsible manner for over a century now. One of the classic examples was our effort to prohibit the consumption of alcohol---the era of Prohibition. This was a disaster! It resulted in a tremendous increase in crime before it was abolished. In fact it helped create other forms of drug addiction. “When prohibition of alcohol spread throughout the country, cola drinks laced wit cocaine…stepped in as the savior. Cocaine, in fact, was considered the remedy for addiction to other substances. Coca-Cola contained cocaine until 1903 and, not surprisingly, was an extremely popular ‘pick-me-upper.’” (van Wormer & Davis, p. 45). Our “modern” anti-drug laws have been accomplishing the same. Those policies have resulted in our incarceration of 2,000,000 Americans. (80% of people behind bars were involved with alcohol and other drugs at the time their crimes were committed according to the National Center on Addiction and Substance Abuse at Columbia University.) When you lock up an American it costs approximately $20,000 per year per inmate. A little quick math and you can see that we are spending $40 billion a year just to lock people up. (Roughly 2 trillion pesos!)
Mind you, this is just the tip of the cost iceberg. Approximately 50% of mental health clients will have problems stemming from their own or a family member’s alcoholism. Add to that the other forms of addiction and you will see that most of the mental health costs are related to our failed policies connected to various forms of addiction. What the government doesn’t address in the development of its policies is two very very important things. First, they don’t recognize that Americans have a history of quickly shifting from one drug or addiction to another. For better or worse, Americans are flexible, as long as they can find something to become addicted to. Second, as noted, we are addiction prone; which should obviously raise the question of: “Why?” Our government has stupidly concluded that the answer is that it is due to those foreigners. Following World War I our government began blaming the countries that supplied the drugs---a foolish and ineffective policy avenue that we continue to go down to this day. America’s youth don’t need cocaine to be imported from South America in order to begin a life of addiction. With alcohol to drink, cigarettes to smoke, glue to sniff, and gasoline soaked rags to snuff or breathe, they need no “evil” foreigners to provide them with anything! Our nation does nothing effective to end addiction to alcohol and tobacco and both of these substances are more destructive than all of the illegal drugs put together. Where is the wisdom behind such behavior?
Alcohol is associated with 50% of the homicides, 30% of child abuse cases, around 30% of large urban hospital admissions, 37% of the rapes, 67% of partner assaults, 40% of traffic fatalities, and 36% of all crimes for which there were convictions (as reported by the federal government). So our own government knows clearly how devastating alcohol is and still goes on focusing on a drug war with its principal target of stopping the importing of drugs into America.
In fact, instead of curbing addiction, governmental policies are clearly but incompetently designed to increase addictions! The recent (2001) movie Traffic, starring Michael Douglas as the new American drug czar who discovers his 16-year-old daughter sinking ever more deeply into addiction ends with his realization that the policies he is being asked to implement are worthless. “America’s war on drugs, (is) a war that has been driven by moral and political rhetoric but that is clearly racist and classist in practice” (van Wormer & Davis, p. 29). America has between 13 and 16 million addicted citizens in need of treatment and only about 3 million of them get help and often that help is not comprehensive enough to effectively help them. Meanwhile, 70% of the federal expenditure on drug problems is going to law enforcement instead of to treatment where it would do some good.
The cost effectiveness of substance abuse treatment pays for itself 10 times over but “only 37% of all those needing substance abuse treatment receive it, mainly due to its high cost” (van Wormer & Davis, p. 23). Our politicians decided to spend billions locking people up, billions trying without success to stop the flow of drugs into our country, when they could have spent money on treatment programs that would have effectively dealt with the problem. Fortunately, public opinion is changing. “Most Americans (69%) are in favor of treatment over jail for first- and second-time offenders” who we have been foolishly and wastefully locking up on their first offense (van Wormer & Davis, p. 29).
The national budget is burdened with war efforts and balance of payment crunches. The federal government has been paying less and less of the costs for services and the state budgets have had to take up the slack. The result is that states are now unable to meet all of the costs for effective services. So, instead of locking everyone up, government at all levels is starting to be more realistic and less fanatical in its response to addictions. One of the best alternatives that has evolved in recent years is the drug court movement. This movement began in Florida. “These new courts, which divert nonviolent drug offenders from the prison system into treatment, have proved that addicts can be returned to wok, family, and ultimately the American mainstream. Today, there are just over 700 drug courts in 50 states. Knowing that jail time awaits them if they begin abusing drugs again can offer a strong incentive to change” (van Wormer & Davis, p. 30).
However, for this type of movement to be successful, we need to ensure that the treatment they offer is the best available. So, what is the best treatment for addiction?
THE BEST TREATMENT FOR ADDICITION
In order to answer this question, you have to examine what is and has been happening not only in the United States but in other industrialized nations because the best policies are not necessarily developed in the country with the greatest addiction problems. Also, you have to be very careful to not assume that what works in one country will be effective in another. Finally, you have to define “best” in terms of what an economy can truly afford to spend. We shall explore all of these issues as we search for an answer to what is “best” treatment.
The most important lesson from Europe is one of attitude. In general their attitudes toward addictions are far more enlightened and far less politicized than American attitudes. “European ideology…is geared toward a pragmatic, public health approach that is clearly at loggerheads with American moralism and inflexibility” (van Wormer & Davis, p. 51).
They have also produced some excellent research and some outstanding treatment programs from which we all can learn. Take Norway, for example, where they accept the concept of alcoholism as a disease---a personal and family disease---and where the government provides complete funding for five weeks of inpatient treatment, including an extensive family-week program along with aftercare. The program utilizes extensive feeling work, communication emphasis, spirituality, and personal sharing like a first rate American program tends to offer. However, they also borrow from non-Western or Eastern alternatives. They use acupuncture, meditation with music, an a highly nutritious diet to help detoxify and get clients back on the road.
Research from Sweden and Denmark established that high novelty seeking and low harm avoidance (daredevil behavior) predicted early-onset alcoholism. Data from Finland indicated that aggression at age 8 predicted alcoholism in males and female children who cried easily when teased or who were anxious and shy were most apt to develop addiction problems later in their lives.
Professors van Wormer and Davis open their book entitled Addiction Treatment: A Strengths Perspective with the following statement:
“Is cutting down on drinking and drug use a realistic option for alcoholics/addicts? Or is total abstinence the only path to recovery? The moderation versus abstinence controversy is easily the most hotly contested issue in substance abuse treatment today. Each position has its strength, and each carries inherent risks. Addiction counselors who help clients merely moderate their destructive behavior run the risk of giving some of their clients false hopes and setting them up for failure. Proponents of immediate and total abstinence, on the other hand, can rest assured that they will drive away the majority of people who might otherwise come to them for help” (p. xi).
That is a tough nut to crack. Given that the large and influential self-help organization Alcoholics Anonymous is committed to total abstinence as the only “true” path and that many of their “graduates” from AA and NA styled 12 step programs are fixated on abstinence and are frequently involved in various treatment programs, anyone who suggests that another path may have value tends to get attacked. However, even if you are not an AA/NA believer, the issues are complex and the point is that you will inevitably get some who really need abstinence latching on to moderation as an excuse to avoid dealing with their problem. So, what should we do?
The harm reduction model accepts both ways of reaching out to those with addictions. “Harm reduction therapy allows for creativity in the design of treatment strategies. Total abstinence from dangerous drug use is certainly not discouraged, not is total abstinence from alcoholic beverages by those with a genetic predisposition to get ‘hooked. But starting with ‘where the client is’ rather than where we think the client should be---this is the basic principle underlying harm reduction. Placing faith in the client’s ability to make choices is a related concept” (van Wormer & Davis, p. xiv).
The reality is that if you go down the “harm reduction” road several things will inevitably occur. First, if you are an abstinence advocate, you are going to have to learn a lot of new and complicated things. This model is more sophisticated and knowledge rich than the relatively simplistic ones of AA and NA. Change is always challenging, sometimes threatening. But the rewards in this case are tremendous. Currently we are not very effectively reaching out to the millions who are addicted in the United States. Clearly we need a new and better model and the harm reduction one holds great promise for reaching millions that are unwilling to accept the total abstinence approach. Second, you are going to have to be very skilled at assessment so that you don’t encourage moderation for those who really need abstinence, and vice versa.
With the harm reduction model it is recognized that addition is not a dichotomous either/or problem. Addiction occurs along a continuum. At one end is behavior that is not destructive and at the far other end is behavior that is life threatening---and a lot of those who are addicted fall somewhere in between. Therefore, one task is to understand why people proceed along this continuum and try to move them back in the direction of less harmful behavior. Remember those European studies? For some addicts, it is the thrill of risk taking that gets them going. Therefore, in recognition of this factor, with those clients we are going to help them develop less dangerous but thrilling forms of risk taking. We are not going to say to most of them, STOP entirely taking your drug of choice. Instead we will be saying to them: “How about trying another method of getting your thrills?”
The harm reduction method of treatment relies on two basics that are inherent in all of the best forms of psychotherapy. Those basics are a strengths perspective and client empowerment. Instead of seeing the addicted person as only a person with a profound problem, we are examining him or her in terms of strengths. What strengths do they bring with them that we can effectively help them employ to build a less addictive lifestyle? The empowerment principle is based on a recognition that the client is the one that will make the decisions. Yes, they may temporarily be court ordered to undergo treatment and we may be monitoring that treatment with urine analysis to increase their motivation to abstain; however, they will at some point leave our service and be on their own. If they have not been empowered, then their potential for relapse soars at that point. The two most powerful forces against relapse in the future are strengths utilization and empowerment in the present treatment process.
Internet Based Resources
Harm Reduction Coalition www.harmreduction.org
American Council for Drug Education www.acde.org
Center for Alcohol and Addiciton Studies center.butler.brown.edu
Center for Drug Abuse REserch www.pitt.edu~cedar/navigat.htm
Drug Abuse Research Center at UCLA www.medsch.ucla.edusom/nip/DARC
Moderation Management www.moderation.org
National Institute on alcohol Abuse and Alcoholism www.niaaa.nih.gove
National Institute on Drug Abuse www.nida.nih.gov
National Institute of Mental Health www.nimyh.nih.gov
Help for smokers www.quitnet.org
Alcoholics Anonymous www.alcoholics-anonymous.org
Caine Anonymous www.ca.org
Families of Comoulsive gamblers www.gam-anon.org
Families of Drug Addicts www.narcaono.org
Gamblers Anonymous www.gamblersanonymous.org
Narcotics Anonymous www.na.org
National Organization on Fetal Alcohol Syndrome www.nofas.org
Students Agaisnt Destructive Decisions www.saddonline.com