Capital Commentary is the weekly current-affairs publication of CPJ, written to encourage the pursuit of public justice.
A Just Response to Drug Addiction
Michelle Crotwell Kirtley
The numbers are staggering. According to the Centers for Disease Control (CDC), the number of deaths due to heroin overdose nearly quadrupled between 2002 and 2013. Heroin use has doubled among females, among non-Hispanic Whites, and among 18 to 25-year-olds of all races. These increases are seen across every income bracket. Part of a larger substance abuse epidemic—nine in ten heroin users also use at least one other drug—the heroin epidemic is closely correlated with the abuse of prescription pain killers. More than 40 percent of heroin users also use opioid prescription drugs, and for a majority of heroin users, addiction to prescription pain killers preceded their heroin abuse.
The issue has even taken center stage at key points in the presidential primaries. Senator Ted Cruz’s sister tragically died of a drug overdose, which he blames in part on Mexican drug cartels’ easy access to the US market. In early January, GOP candidates participated in a forum on drug abuse in New Hampshire, a state that has seen heroin overdose deaths double in only two years. Former Secretary of State Hillary Clinton hosted a town hall exclusively focused on substance abuse. And for good reason. In one poll, 25 percent of New Hampshire residents cited drug abuse as the most important problem facing the state—surpassing even concerns about jobs and the economy.
Harm Reduction Policies
In response to this epidemic, some policymakers, focusing on the risks of overdose or contracting blood-borne diseases such as HIV or Hepatitis C through needle-sharing, have called for the expansion of harm reduction services for drug users. Harm reduction is philosophically rooted in the idea that the choice to use drugs is morally neutral, and that society is obligated—for the common good and out of compassion for the drug user—to mitigate potential harms from drug use wherever possible. Some harm reduction advocates also promote drug legalization, but not all do. The harm reduction label encompasses a range of services, including needle exchange programs and safe injection facilities, where addicts inject drugs under the supervision of medical personnel prepared to intervene in the event of overdose. Billionaire George Soros has given millions to support harm reduction programs around the world.
Although proponents often cite the ability of harm reduction programs to engage clients previously hidden from the range of social services available to them, studies of existing needle exchange programs and safe injection facilities have shown only a modest rate of treatment referral at best. Needle exchange programs may have an impact on the spread of HIV and Hepatitis C, but they, like safe injection facilities, involve government in the promotion of activities it has deemed illegal. As limited resources are carefully allocated, public money should fund programs designed to make addicts whole—not merely keep them alive. In this, harm reduction strategies are insufficient. In certain crisis areas, limited and targeted use of needle exchange programs may help curb the spread of HIV and Hepatitis C, which are both deadly and costly to treat. But these programs must be part of a comprehensive prevention and treatment strategy that seeks to use contacts with those drug users to bring them into treatment and recovery.
Although often motivated by good, compassionate intentions, harm reduction—in refusing to call drug abuse “wrong”— risks relegating drug users to a life of addiction. When isolated from concerted efforts to draw addicts into treatment and recovery, needle exchange programs and safe injection facilities, although they may communicate a level of care for the drug user, fail to adequately uphold human dignity because they offer no vision or hope of a better life. Drug addiction is not an alternative lifestyle. It is a disease of body and mind that God longs to heal and redeem. A high view of human dignity and the goal of human flourishing require that we help our neighbors rise above something as enslaving and debilitating as drug addiction.
A Better Understanding of Addiction
New research suggests that addiction is more than a moral problem. Modern brain imaging techniques, along with other advances in neurochemistry and genetics, have exposed a physiological basis for addiction, particularly opioid addiction, such that most of the medical establishment has definitively labeled drug addiction a medical disease. Some leading addiction researchers see diabetes as a useful analogy for addiction both in the complex interplay of physiological and environmental factors that cause the disease and in the need for life-long medical and behavioral management.
Affirming the medical component of addiction does not require wholesale support of the harm reduction philosophy, nor does it mean that we must condone or excuse sinful and destructive behavior. Scripture tells us that every aspect of creation has been marred by the Fall, which resulted in both sin and physical disease and death. Attempts to simplistically categorize public health problems as moral or medical, or to distinguish physiological or psychological conditions reflect the West’s age-old dependence on classical dualism rather than the holistic anthropology we see reflected in scripture.
Modern neuroscience increasingly affirms the complex interplay between mind and body. Viewing addiction as a multifaceted problem helps to inform best practices in treatment and to shape public policy. Much like the response to diabetes, a just response to drug addiction must attend to the multifaceted nature of the disease.
Many experts now believe that a combination of counseling and medication, called medication-assisted treatment (MAT), is the best treatment for opioid addiction. But for years, methadone and newer substitution treatments such as suboxone have been viewed as merely substituting one dependency for another. Some treatment programs will not accept users who are on methodone or suboxone, and many programs refuse to use these medications as part of their treatment paradigm.
Neither drug is a cure, but suboxone, a partial heroin analogue, satisfies an addict’s cravings—what users call “the sickness”—without triggering the euphoria that accompanies heroin use. In essence, suboxone buys time for long-term psychosocial healing, not merely by keeping the addict from overdosing, but by quieting the intense desire for a high that drives so much of an addict’s destructive behavior. Because suboxone is an opioid drug in its own right, it can be abused. The government tightly controls its distribution, requiring special licenses for prescribing physicians and limiting the number of patients each physician can treat. The side effects are significant, and withdrawal must be carefully monitored. Many heroin addicts require long-term therapy with suboxone while they receive intensive counseling for the psychological component of the disease.
Embracing MAT does not require embracing harm reduction philosophies. MAT can be applied as part of a comprehensive recovery program that honors human dignity by giving addicts a vision for a better life along with the evidence-based physical and psychological tools necessary to achieve that vision. Integrating the latest medical and scientific research with what we know to be true about human nature and the possibilities of real and lasting change allows us to better steward the resources we have at our disposal towards policies that will offer the addicts the best chance of recovery and a safer, more just society for everyone. With this framework in view, certain policy implications emerge.
Developing Just Policies and Practices
Since many drug users unfortunately encounter the criminal justice system before ever getting treatment, efforts to couple drug enforcement with treatment and rehabilitation need to be strengthened. Most states have implemented drug courts as an alternative to traditional drug enforcement paradigms. Instead of being tried and sentenced for drug-related offenses, eligible individuals are instead sent to treatment programs under the close supervision of the justice system for a minimum of one year.
According to a report from the Government Accountability Office, court-mandated treatment in programs such as these appears to reduce recidivism. Another comprehensive study of drug courts found reductions in both recidivism and drug use at 6- and 18- month evaluations compared to other drug enforcement and treatment programs. Programs such as these reflect values at the heart of the Christian emphasis on restorative justice: a sober assessment of the reality of human nature and the very real consequences of sin (and, therefore, the need for accountability) coupled with a belief in the possibility of restoration.
Some have criticized the drug courts for partnering with treatment programs using unproven methodologies. As one journalist noted, “a reforming justice system is feeding addicts into an unreformed treatment system, one that still carries vestiges of inhumane practices — and prejudices — from more than half a century ago.” While leaving room for faith-based organizations to implement treatment protocols consistent with their deeply held convictions, state and federal governments should insist on measures of effectiveness in the treatment programs used as part of the drug court program.
Too many addicts cycle through treatment facilities of varying quality only to relapse days after being released. Medical schools, which have been slow to include training in addiction as part of their programs, must revamp their curricula to include broader and more detailed training in addiction therapy. Psychologists and treatment workers need better, addiction-specific training. A 2012 report from the National Center on Addiction and Substance Abuse at Columbia University found that a majority of front-line treatment counselors do not even have a bachelor’s degree. Policymakers at all levels should consider mechanisms that set standards for and certify treatment professionals to ensure that addicts are receiving the best possible care.
To encourage state and locally funded treatment programs to adopt MAT and other evidence-based treatment strategies, the federal government should condition subsidies for these programs on the use of proven treatment protocols. Federal and state grants should be given for non-profits who design innovative and effective treatment paradigms, and best practices should be aggregated and disseminated.
Despite several decades of treatment history, there has been strikingly little research into what really works and how treatment paradigms should be adjusted based on the substances or combination of substances involved or the co-presenting mental health conditions. The Clinical Trial Network established by the National Institute on Drug Abuse is a good starting point. More longitudinal studies are needed to follow patients in the months and years following treatment. More research is also needed in the best ways to wean opioid addicts from suboxone and encourage full, long-term recovery.
Access to Care
Connecting drug users with available, affordable treatment remains a significant challenge. The federal government estimates that in 2011, of the over 20 million people across the United States who needed treatment for alcohol or drug abuse, only 11 percent were actually admitted into a treatment facility. There are an estimated 14,500 private and public treatment programs around the country, but private treatment programs, particularly those with the best record of success, can be expensive and have long waiting lists.
The Affordable Care Act (ACA) has improved access to rehabilitation services through several key provisions. The law mandates that all insurance plans cover substance abuse treatment without any lifetime coverage limits, and a pre-existing substance abuse diagnosis cannot be used to deny coverage. The law also requires that mental health and substance abuse services be covered the same way—with the same deductibles, co-pays, treatment limits, and care management requirements—as medical or surgical services. And children can stay on their parents insurance until age 26. For drug addicts with private insurance, these provisions enable access to treatment that might otherwise have been cost prohibitive. As health care policy is debated in the next election, these mental and substance abuse parity provisions should be maintained.
For those who make below 400 percent of the poverty line, and are thus ineligible for ACA insurance subsidies, Medicaid offers some coverage for substance abuse treatment if the patients meet the eligibility requirements of their states. The nature of the coverage varies widely from state to state, and thousands of users live in states in which they are not eligible for Medicaid. For these individuals, unless they enter treatment through a drug court mandate, publicly funded or charitable treatment programs are their only option.
As the ACA has expanded coverage for mental health and substance abuse services, demand for inpatient treatment has skyrocketed, resulting in long waiting lists for care even at publicly funded facilities. This critically undermines efforts to reach people who need treatment. As the CEO of Louisiana’s largest treatment facility told the National Review, “we know… that when a person has a problem with addiction and they have that moment, that break in the wall of denial — if they can access treatment at that point, then they’re more likely to engage in the treatment process and to be more serious about it. The other thing we know is that the longer we keep people in treatment, the longer they’re going to stay clean and sober.”
A Christian Response
With the critical need for more high quality treatment facilities, we should consider supporting or even starting such a ministry in our local communities. Because of the extensive regulations accompanying opioid pain killers and heroin substitution therapies, most free and charitable health clinics simply do not prescribe these and other Schedule II drugs. Ministries specifically devoted to drug rehabilitation should partner with the network of clinics, community health centers, and hospitals that serve as the health safety net for vulnerable populations. Christians should seek to operate facilities that honor the dignity of their patients—regardless of their income level—with a safe, clean environment in which to embark on the hard and difficult journey towards recovery.
We must follow the example of Jesus in caring deeply for our neighbors who are trapped by drug addiction. Behind each of the sobering statistics is a person of infinite worth, made in the image of God, with grieving loved ones, broken families, and deep societal wounds left behind. We must avoid the temptation to moralize in the face of an obvious need for mercy and justice and instead advocate for policies that encourage wholeness and opportunities for restoration and redemption.
Questions for Reflection:
- Throughout Scripture we are called to pair mercy and justice in the example of Jesus who was full of grace and truth. Yet in reality we tend to more naturally display one or the other. When thinking about heroin addiction, what is your natural response? How does thinking of heroin addiction as a medical (not merely moral) problem reflect both mercy and justice? How does attending to the psychological side of addiction reflect both mercy and justice?
- How does a complex problem such as heroin addiction highlight the need for various institutions (government, non-profits, churches, medical facilities) to work together in their respective roles for public justice? Where might you help institutions you are involved fulfill their responsibilities in the area of addiction?
- How are the varying Christian responses to heroin addiction affected by underlying attitudes about the relationship between faith and science?
- Michelle Crotwell Kirtley is the Bioethics & Public Policy Associate at the Center for Bioethics & Human Dignity and a former health and science policy advisor on Capitol Hill. She is also a Trustee of the Center for Public Justice and a 2003 alumnae of the Center’s Civitas program in faith and public affairs.
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Capital Commentary is a weekly current-affairs publication of the Center for Public Justice. Published since 1996, it is written to encourage the pursuit of justice. Commentaries do not necessarily represent an official position of the Center for Public Justice but are intended to help advance discussion. Articles, with attribution, may be republished according to our publishing guidelines.”