The solution to the opioid crisis remains elusive. The evidence speaks for itself; opioid addiction is a legitimate public health crisis and the death toll continues to rise. Why have increased funding, political attention and evidence-based FDA approved drugs available for treatment failed to produce favorable outcomes? The explanation is rarely discussed on the record because of sensitive social connotations and risk of “stigmatizing” the patient.
So instead, we dance around the truth that addiction, unlike any other public health concern, creates antisocial behavior. This is not a moral judgment, but simply a fact inherent to addiction. Addiction must not be dismissed as simply a moral failure. A genetic component exists. Research suggests that neuroplasticity within cortical pathways reduces the addict’s ability to make good choices. But it would be Pollyanna to ignore that bad choices become routine and create pain for others.
Is addiction a disease? This is debatable. Even critics of the disease model acknowledge that addiction’s genetic component, profound changes in neurobiology, and evidence-based FDA approved drugs available for treatment lend credibility to the disease model. But active addiction, unlike any other disease, creates antisocial behavioral patterns. It is here that the disease model shows weakness. Though some argue that the disease of addiction “hijacks the brain,” the actively addicted person consistently and repeatedly makes bad choices.
Let’s take accurate stock of the addict’s behavior; many calculated decisions are made. The individual must go somewhere to get the drug, typically an unsafe setting inhabited by career criminals. It is a beguiling and time-consuming endeavor. First, however, money must be obtained. Sometimes the addict takes hard-earned money out of a paycheck. Sometimes the addict steals, connives, or engages in unspeakable acts for money. Once obtained, the money is given to a drug dealer. In all cases, it is demoralizing.
The time required to maintain active addiction means important obligations and responsibilities go unfulfilled. And the actively addicted person masters a dubious art of saying things that have a certain plausibility but their words are, in fact, totally untrue. How often does the addict engage in the above behavior? Every day. For years, sometimes decades.
Because addiction is a public health concern it is treated largely by health care professionals. Many doctors that treat addiction have a poor understanding of the behavioral dysfunction described above. Doctors, in general, are used to patients being worthy of trust and saying true things. But the patient new to treatment is recently removed from active addiction and therefore unaccustomed to concepts of truth and trust. A doctor treating a patient in early recovery is often unprepared for the challenges presented by a patient with such profound behavioral dysfunction. Success in recovery requires truth and accountability. Addiction Medicine is an important medical specialty. Let’s take off the kid gloves.
Timothy Gammons, DO