health care reform

Placing Addiction
in Historical Perspective

Health care reform and the limits of abstinence policies


Vol. 13 No. 1
Fall 2010

Return to Contents


The Well Being
Health care reform examined around the university

Health Care Reform
Key provisions from the Accountable Care Act

The Patient Protection and Affordable Care Act
Opportunity and uncertainty for academic health centers

"Among the most immediate challenges we face . . . is our communication efforts with the American public: we need to keep everyone informed about what the new law does and doesn't do, and how it will work for them."

"I'm a great believer that what medicine does best is to think about multiple causes for complex outcomes. And much of what I"ve heard over the last couple of years both in the medical science, sadly, and also in the political realm is exactly the opposite."

Ahead of the Curve
Challenging conventions with predictive health

Broadening our Lenses
Ethical reflections on health care reform

Thomas Jefferson: No Happiness Without Health

Cost Control and Health Care Reform
Defusing a fiscal time bomb

The Affordable Care Act
Will the bill improve coordination of care in the U.S.?

Health Reform Law and its Impact on Physical Therapists
Value across the spectrum of care

Placing Addiction in Historical Perspective
Health care reform and the limits of abstinence policies

Further Reading

Endnotes

Although methadone has been used to treat addiction since the 1940s, it was most widely deployed in the 1960s and 1970s in response to increased drug use among white, middle class youth. This new class of user appeared to challenge the historically embedded notion that addicts had irredeemable character defects, and it briefly enabled more permissive approaches to addiction. Methadone maintenance emerged with the free clinic movement and the idea that health care is an inalienable right, irrevocable despite drug use.

According to historian Carolyn Acker, however, such utopian notions would not persist in the following decades. Nancy Reagan’s Just Say No campaign would make a sharp distinction between abstinence and any use at all of illicit substances. A similar agenda was behind the “zero-tolerance” drug policy of the George H. W. Bush Administration. The Clinton Administration would also fail to fund syringe exchange.

Addiction policy decisions tend to reflect long-standing public attitudes about the identity of addicts. That is, most policy supports addiction management by the criminal justice system. While the promise of the new health care reform bill recalls the free clinic era as it aims to diminish inequities in health care access, the bill has not changed most of the assumptions about addicts and addiction. Despite overwhelming medical evidence that addiction is a disorder rather than a choice, addicts by and large are more likely to become stigmatized than treated.

These ongoing policies of criminalization have their roots in a history of attitudes and punitive practices. For instance, the earliest federal addiction intervention, the 1914 Harrison Narcotic Act, attempted to limit public access to narcotics by regulating the prescribing practices of physicians. Several historians date the Harrison Act as the beginning of associations between criminal behavior and addiction. Before then, doctors frequently administered opiates for a range of common ailments, such as menstrual cramps and back pain. Later, the act would authorize the Treasury Department to begin prosecuting physicians who were identified as prescribing opiates improperly. As addictive drugs and physicians were separated, patients who had encountered these substances as medicine were forced to turn to more expensive and unsavory means of obtaining their supply. As Acker argues, as it banned legal access to drugs, the Harrison Narcotic Act created the criminal behavior that became necessary to obtain them. In Creating the American Junkie (2002) she argues that little has changed about national drug policy since 1914.

The study of addiction in historical perspective uncovers the contingent nature of not only social policy, but also scientific research agendas aimed at elucidating the causes of addiction. Across time, various etiological hypotheses—psychopathology, degeneracy, addictive personality, altered brain chemistry—have held out little hope for a cure and have provided ammunition for those advocating a punitive policy response to addiction. More recently, however, a consensus has arisen around the claims popularized initially by Alan Leshner, director of the National Institute for Drug Abuse from 1994 to 2001, who argued in a 2001 publication titled Addiction is a Brain Disease that prolonged substance use turned on “a switch in the brain” that permanently transformed brain mechanisms, The result, Leshner argued, was to make interventions aimed at reversing addictions extremely difficult. According to the brain disease model, addicts require medical treatment rather than stigmatization and legal penalties, especially incarceration.

While also eschewing the criminalization of addiction, historians have attempted to place the brain disease paradigm in a wider context by providing evidence that calls into question the effectiveness of negative incentives and criminalization. They remind us that the science of each era has attempted to identify the mechanisms behind the observed behaviors of addiction. Not surprisingly, these attempts reflect the dominant scientific paradigm of each era. And there is plentiful evidence that organic triggers for and biological effects from substance dependence interact with cultural and social forces. Addiction historian and psychiatrist Griffith Edwards, former chairman of the UK’s National Addiction Center, offers a more useful definition of addiction arising from a broader look at centuries of observations: addictions are not “brain diseases,” he suggests, but are actually syndromes of dependence with multiple triggers and pathways, ranging from the cultural to the organic.

Edwards’ distinction between syndrome and disease has important implications for illicit substance use. Measles, polio, and Huntington’s are diseases—a tentative diagnosis based on signs and symptoms is confirmed or rejected through a laboratory test indicating a pathogen or genetic mutation. In contrast, the cause of a syndrome—such as schizophrenia, Tourette syndrome, or affective disorders (depressions)—remains unknown. The diagnosis of syndromes depends on possible combinations of signs and symptoms displayed by an individual within a certain time period. This list of signs and symptoms is tentative, and disagreement often surfaces over which signs and symptoms are crucial to authorize a diagnosis. As a result, identification of a syndrome often varies over time and by geographic location.

Recognizing the many and varied routes to substance dependence syndrome, researchers and clinicians have begun to craft a variety of interventions and policies that consider a spectrum of cultural and biological triggers. Further, there is growing evidence that substance dependence alters brain reward mechanisms, such as brain architecture and neurochemistry, sometimes permanently, as proposed by neuroscientists Nestler and Malenka in 2004. This alteration seems to occur even when the addiction, such as gambling, is not attached to a substance—thus raising a question about the labeling of certain non-substance behaviors as addictions.

Addiction involves attempts to alter consciousness—a fact of human life, historians have shown, since time immemorial. As Edwards reminds us in his 2004 book, Matters of Substance: Drugs and Why Everyone’s a User, for much of human history, including our own era, most mind-altering substances initially have been consumed to self-medicate for a variety of ills, including major and minor psychiatric disorders. That self-medication plays an important role in persistent substance use and abuse, despite awareness of potential harm, provides further support for questioning the effectiveness of abstinence policies. Neuroscience has shown that what we label “addiction” might be understood as a possible consequence of an attempted biological adaptation to social factors. Thus, all addictions are syndromes of dependence, informed and “enabled” by an interaction of culture and biology.

Health policy reform that adequately addresses the multi-faceted problem of addiction would include expanded access to mental health services and programs that offer methadone treatment and syringe exchange, and perhaps even fund research into safer alternatives for the delivery of nicotine. The promise of universal health care is utopian in the best sense, but we should also remember Carolyn Acker’s observation that “criminalizing addiction created a chasm that many drug users fear to cross to seek medical care.” A historical perspective reminds policy makers that abstinence policies have failed because they neglect the historical evidence that humans in all societies and cultures have relied and continue to rely on substances to alter their consciousness. Addictive behaviors, rather than diminishing, have increased. In the face of persistent human drives to alter consciousness and markets that cater to these, abstinence appears to be unattainable. Once we acknowledge this, federal reform policies may be able to deliver their promised effect.