The narrative was that addicts are manipulative and require “tough love” and heavy surveillance to fix. So-called “old school” treatment programs that developed alongside these ideas often emphasize the need for addicts to “hit rock bottom,” suffer immensely from the consequences of their drug or alcohol use and come to terms with and learn to manage their “character defects” to recover.
Present Addiction Treatment
In response to rising opioid addictions and deaths, medical and mental health professionals have rushed to develop interventions and treatment protocols to address this crisis. Presently, individuals have two primary choices when deciding how to treat their addiction: abstinence-based or harm reduction.
Abstinence-Based Treatment
The most popular type of abstinence-based treatment in the US is the Minnesota Model, a comprehensive, multi‐professional approach to treating addictions based upon the principles of Alcoholics Anonymous. The Minnesota Model, also referred to as a 12-Step based treatment, subscribes to complete abstinence from any mood-or-mind-altering substance, illicit, prescription, or otherwise, with the long-term goal of remaining abstinent for the duration of one’s life.
Although all Minnesota Model treatments are abstinence-based, not all abstinence-based treatment models are rooted in the 12-Step ideology. The Minnesota Model of treatment was popularized for introducing patients to Alcoholics Anonymous (AA) during their inpatient and outpatient treatment and utilizing continued involvement with AA as a built-in relapse prevention program.
Harm Reduction
Given the increased difficulty in treating Opioid Use Disorder (OUD), the second option that many medical and mental health providers suggest is a harm reduction approach utilizing Medication-Assisted Treatment. Harm reduction is defined explicitly as a set of practices to reduce the negative consequences of drug use rather than focusing exclusively on cessation.
Medication-assisted treatment includes the prescription of opioid narcotics to patients in combination with counseling and other social services. The harm reduction protocol has been utilized in needle exchange programs to help prevent blood-borne infections such as HIV or hepatitis C, commonly spread through sharing hypodermic needles during drug use, including among intravenous opioid users.
Medication-assisted treatment utilizes semi-synthetic opioids Methadone and Suboxone to help ease withdrawal symptoms and curb cravings to reduce opioid use while reducing the risk for overdose if abuse of opioids continues. Over the years, research supporting medication-assisted treatment has coined it the “gold standard” in OUD treatment. Yet persistent instances of abuse and prolonged, even permanent, reliance on opioid replacement medications have been cited as a significant problem with the treatment—some arguing that medication-assisted treatment is simply switching out one drug for another rather than leading to proper recovery.
The belief that medication-assisted treatment is just another way that substance users “avoid getting clean” has resulted in underfunding of these program by the government, despite research indicating favorable outcomes for OUD. This is a primary example of the morality politics of addiction treatment in the US today.
One research study from 2011 found that approximately 11-26% of individuals with OUD who receive treatment, 34% participate in MAT programs, with about a 50% retention rate after one year. Yet before 2016, less than 25% of publicly funded facilities offered medication-assisted treatment.
Medication-assisted treatment has been critiqued for its shaming practices towards individuals. Similarities to interventions utilized by the legal system, monitoring practices such as regular urine drug screening, probation-like conditions or expulsion from treatment programs following relapses, etc., have severe clinical implications for MAT patients.
Divergent Perspectives
Today, addiction treatment is highly polarized: abstinence-based philosophies, which encompass the Minnesota Model, and harm reduction, containing medication-assisted treatment, have divergent perspectives about treating addiction. While both types of treatment have developed over time to utilize a biopsychosocial model that identifies addiction as a disease influenced by many factors, the soil from which Minnesota Model and medication-assisted treatment grew is the same.
Both use practices that have been equally criticized as ineffective at best and harmful to patients at worst based on techniques that continue to be mainstream. Research on the efficacy of each type of treatment is often conflicting, and few quality comparative studies exist. The morality and “one-size-fits-all” mentality remain at the core of addiction treatment in the US, and has been argued as “a critical part of why addiction treatment fares so poorly in contrast to general medicine.”
Summary
History demonstrates that the use of mood-altering substances has been a part of human culture since it began. However, a permanently “drug-free” human society has yet to be seen. Although addiction is a problem that has plagued 10-20% of the population for centuries, the overall success rates of addiction treatment have not improved substantially in the last 50 years, despite significant advancements in essentially all other areas of medicine.
In a notable 40-year longitudinal study completed in the early 1990s, researchers found men with problematic alcohol use showed comparable improvement in their drinking regardless of whether they participated in formal treatment or not.
Another study concluded that the cost of alcohol treatment was inversely related to the amount of evidence for their effectiveness. Addiction treatment in the US seems frozen in time, mainly due to early misconceptions about addiction reflecting personal moral failure or lack of willpower and calculated racist associations between addiction, crime, and immorality that persist in the US policy and popular culture today.
Learn more from the Substance Abuse and Mental Health Services Administration if you or someone you know is struggling with substance use.
