The Evolution of Harm Reduction in America: How the disease theory stopped progress

The American Dream: We can bypass human consciousness, lived experience and intentionality so as to cure addiction medically.

Alcohol: Colonial America to Mary Pendery

Antiquity through American Colonial Period. Psychoactive substances were not identified as special objects capable of creating addiction. It was therefore not thought to be a special event when people quit or cut back their consumption of coca, cannabis, opiates, tobacco — any more that if they did so with a favorite food, a love relationship, or any other habit — with whatever difficulties those choices presented. Harm reduction was a standard part of people’s consciousness and array of behavioral options.

Post-Colonial Period. Alcohol was a ubiquitous beverage consumed at all community places and events throughout the American colonies. But the period after independence through roughly 1830 saw the emergence of drinking at Western and urban salons among all-male groups without family and community constraints present. Alcohol came to be seen as a pervasive social problem in America in this period, leading to the rise of the Temperance Movement and its goal of eliminating alcohol consumption in the United States

The Temperance Movement. For roughly a hundred-year period — 1830 to 1930 — the dominant conception of alcohol in Protestant America became that of an uncontrollable substance that inevitably led people to become permanent drunkards. The only preventive measure or remedy was total and utter abstemiousness. Although people were aware of individuals who had drinking problems throughout history, it was in nineteenth-century America that the concept of loss of control and progressive substance addiction was first laid out in the case of alcohol.

The Medical Addiction Concept. In a way that is simply incomprehensible in contemporary America, in nineteenth century America, while alcohol was widely considered inevitably to create dependence, Americans consumed opiates indiscriminately and without compunction.  Opiates were widely used by people from all social classes and of all ages (babies and children were regularly given laudanum — a tincture of opium — for teething and stomach aches). At the end of the nineteenth century, especially after the isolation of heroin from morphine, when medicine was for the first time becoming institutionalized, the medical concept that opiates created what we now know as the addiction syndrome was presented as a medical truism.

Along with the medical concept of addiction, opioids in the form of heroin came to be seen as a drug used by social deviants, immigrants, and minorities. Building on this new scientific conception, any use of opioids outside of medical treatment (as well as of drugs irrationally associated with opioids — namely cocaine and marijuana) became illegal and was reviled as morally degenerate. Harm reduction (meaning controlled use) of these substances was ruled out as a possibility in mainstream America.

The End of Temperance—>Dominance of AA. The ill-conceived policy of banning alcohol consumption — a substance used widely in upper social circles, by immigrant groups (especially Catholics and Jews) and even by pockets of rural Protestants (as in moonshine liquor) — was doomed to fail. When National Prohibition was repealed in 1933, a gap was created that AA surged to fill. AA’s organizing principle modified the temperance one that all alcohol use was addictive into the idea that alcoholism was a “progressive” disease afflicting a special, identifiable population of “alcoholics” for whom lifelong abstinence was the only antidote.

Abstinence, the Only Therapy for Alcoholism.  AA’s model grew rapidly in the ashes of temperance to become the dominant twentieth century conception of alcohol addiction in America. Alcoholism was (and still is) almost universally conceived to be a permanent, irreversible individual trait. In the therapeutic arena, America became fixated on abstinence as the only solution for alcoholism. Any claims otherwise were attacked with temperance-like moralism and vituperation.

The Epidemiology of Drinking Problems. The 1970s ushered in two social scientific movements: large scale epidemiological surveys and behavioral conditioning. In 1970, Don Cahalan published the first national survey of problem drinkers. He and his colleagues at Berkeley’s Alcohol Research Group (ARG) eschewed the label “alcoholism” since they found little trace of the progressive loss-of-control drinking on which AA focused. (Perhaps 1 in 100 American men displayed that syndrome.) Instead, they found people with a diverse set of drinking problems that depended largely on their cultural, social and religious backgrounds and, most immediately, on whom they drank with. Instead of progression, these problems shifted and often disappeared within relatively short time frames.

The Rand Report on Alcoholism. Independently of the Berkeley group, the National institute on Alcohol Abuse and Alcoholism (NIAAA) commissioned the respected Rand Corporation to study outcomes at NIAAA funded alcoholism treatment centers around the US. The Rand results, published in 1976, provoked a furor.  In the first place, their subject population wasn’t a randomly selected group of American men, but rather men diagnosed with and treated for alcoholism.  And, yet, the Rand results bore a strong resemblance to the Berkeley group’s. Despite the Rand subjects’ severe alcohol problems, the researchers found a sizable minority reduced their drinking in the 18 months following treatment to achieve nonproblematic drinking.

The Second Rand Report. The National Council on Alcoholism, a private confederation of AA disease advocates, first tried to get Rand to jettison the report, then convened a press conference on the day the report was released to decry and to deny its results. The researchers’ response was to carefully respond to the NCA criticism in a subsequent four-year follow-up study by stiffening their definition of non-problem drinking. Although this somewhat reduced that category of drinkers, the overall view of the malleability of alcoholism and the possibility of what today would be termed harm reduction persisted.

The Sobells’ Controlled Drinking Experiment. In the early 1970s, before the Rand Reports appeared, two behavioral psychologists, Mark and Linda Sobell, utilizing behavioral techniques, taught controlled drinking (CD) skills to alcoholics being treated in a California VA hospital. They then compared outcomes over one-and two-year periods for the CD group with a similarly composed group who received standard abstinence-only treatment at the hospital.  Although both groups reported relapses, the CD group had significantly fewer, and less explosive, drinking days. In other words, the Sobells identified harm reduction in the 1970s.

The Pendery et al. Sobells Assault in Science. In 1982, the prestigious journal Science published a study by a group led by Mary Pendery (who worked at the VA hospital where the Sobells conducted their research) of what purported to be a follow-up study of the Sobells’ research. Only in a bizarre deviation from anything remotely scientific, Pendery et al. only examined the CD, and not the abstinence, group. Thus, from its conception, it was impossible for the Science study to refute the Sobells’ results. Instead, it reported negative events among CD subjects. The study was widely reported nationally, including on 60 Minutes, where Harry Reasoner was filmed in front of the grave of a CD subject. (More abstinence-only subjects had died in the same period.)

The Death of CD Therapy. The organized opposition to the Rand Reports and the Sobells’ research are an early version of the denial of science and reality that characterize modern political discourse. In the aftermath of the Pendery et al. fiasco, it became highly risky — perhaps even creating legal liability — to practice CD therapy with people considered to be alcoholic. Thus even prominent CD practitioners and advocates (such as Bill Miller) insisted that CD therapy was only appropriate for “problem drinkers.” And what could be done for people who were certifiably alcoholic — like subjects in the Sobells’ study and the Rand Reports? Even when idealized criteria for controlled drinking weren’t realized, was there no value in teaching skills for reducing explosive relapses?

Drugs: Needle Exchanges to MOUD

The Switch to Drug Harm Reduction. In fact, the concept of harm reduction in alcoholism was laid to rest for the next decades. In its place, HR was redirected towards drug use, specifically injectable drugs, meaning generally heroin, primarily in terms of needle exchanges. Begun informally in the 1970s, and more systematically in the 1980s, just as the Sobells-Pendery and Rand disputes were gutting controlled drinking, government sanctioned needle programs were inaugurated in the Netherlands, UK, and Australia. They then spread worldwide due to the AIDS epidemic.

The US Experience Around Needle Exchange. Nothing indicates America’s temperance tradition, moralistic rejection of substance use and users, and permanent public health paralysis than its long tortured history with clean syringe programs.  While from the 1999s on every major American medical and public health organization (the AMA, CDC, etc.) endorsed the safety and life-saving benefits of such programs, virtually alone among Western nations, the US never fully endorsed and systematically funded the provision of clean syringes. It still hasn’t. This permanent ambivalence is captured in Wikipedia:

In the United States, a ban on federal funding for needle exchange programs began in 1988, when republican North Carolina Senator Jesse Helms led Congress to enact a prohibition on the use of federal funds to encourage drug abuse. The ban was briefly lifted in 2009, reinstated in 2010, and partially lifted again in 2015. Currently, federal funds can still not be used for the purchase of needles and syringes or other injecting paraphernalia by needle exchange programs, though they can be used for training and other program support in the case of a declared public health emergency.

What?

This paralysis has been embodied by the opposition to clean syringe programs of America’s dominant AA and abstinence establishment, as expressed by Ethan Nadelmann in a 2013 interview with Will Godfrey:

Godfrey: You’ve criticized America’s “pig-headedness” against harm reduction approaches that work elsewhere. Has the relative dominance of the abstinence-based 12-step movement in the US been part of the reason that harm reduction has been less welcome here?

Nadelmann: I don’t have a simple answer. We were one of the only countries in the western world to prohibit alcohol. That attitude, the abstinence-only approach, preceded AA. Our instinctive reliance on criminalization is not inherent to AA. . . .Where the 12-step thing has the most to own up to is its role in impeding harm reduction interventions to stem the spread of HIV/AIDS. Why was it that Australia and England and the Netherlands were able to stop the spread, and keep the number for injecting drug users under 5-10%, and the US was not? It’s that notion—that abstinence is the only permissible approach, that we are not going to “enable” a junkie by giving him a clean needle. There has to be a kind of owning up to that role in hundreds of thousands of people dying unnecessarily.

The Disease Theory and Harm Reduction.  It is critical to note that this regressive, punitive, moralistic approach to substances is not limited to Jesse Helms and conservatives. Prohibition was a progressive initiative in the US. Progressives have been leaders in the 12-step “thing” (per Nadelmann) as underlain by the disease concept expressed as: “We must abandon moralistic approaches to substance use and realize that addiction is a disease.” (AA, of course, is as moralistic as a public institution can be.)

In formulating drug use and addiction in disease terms, however, progressives have preserved essential elements of America’s temperance, anti-substance use, platform. In this viewpoint, substance use is at its heart a negative experience that must be avoided while compulsive usage patterns (addiction) are beyond people’s control and require external (spiritual and medical) interventions. In this framework, the first public assault on AA as ineffectual balderdash was presented to progressives circa 2015 (in The Atlantic, which is like other progressive organs befuddled by the swirling waters of addiction and its own values). But the critique was couched entirely in the context that a chemical treatment that reduced a person’s alcohol consumption (naltrexone) was viable in replacing AA. This comprises a vision of alcoholism and treatment equally as delusional as AA’s.

Medication-Assisted Addiction Treatment. Medications used in dealing with opioids are of two types: agonists, which duplicate the effects of opioids, and antagonists, which block them. The three primary such medications are buprenorphine, methadone, and naltrexone. (The use of these drugs is distinct from naloxone, commercially sold as Narcan, an antagonist which is used in emergencies to reverse the effects of opioids.) Buprenorphine and especially methadone are agonists, and naltrexone an antagonist. Suboxone combines buprenorphine with naloxone.

Not satisfied with the term “assisting,” prominent influencers in the field like Maia Szalavitz upped the ante in renaming use of such medications “medications for (treating) opioid use disorder” — MOUD.

The Effectiveness of MOUD. A series of studies with populations administered methadone and buprenorphine has found that those receiving these agonists survive better and are less likely to relapse while receiving the medications. Their use (and Narcan’s) is now widespread, although also spotty (for example, in rural areas). Nonetheless, large treatment chains advertise on billboards and administer buprenorphine and Suboxone around the US.

As use of MOUD (and Narcan) have grown, we might expect drug deaths to decrease. In fact they have continued to rise precipitously.  What accounts for this paradox? Simply that most people on MOUD cease taking them in a relatively short period. Not only are they no longer receiving the benefits measured in controlled studies; they may be more likely to relapse because they have been taught to discount their own behavioral self-control. Even when buprenorphine cessation is therapeutically planned, relapse rates are high, along with drug deaths. This phenomenon is particularly pronounced for socially disadvantaged, less educated Americans, when it is labeled “deaths of despair.”

In this context of reported success in combating opioid addiction and easier and wider availability and greater acceptance of buprenorphine, the accessing and retention of MOUD by patients remains shockingly low and is currently decreasing.

Initiation of buprenorphine in hospitals in the United States has plateaued since 2018, with low retention rates of less than 25%, based on data from more than 3 million individuals who began buprenorphine between January 2016 and October 2022.

“Our study shows that buprenorphine initiation rates have been flat since the end of 2018 and that rates of 180-day retention in buprenorphine therapy have remained low throughout 2016-2022,” Chua told Medscape. “Neither of these findings are particularly surprising [why not?], but they are disappointing,” he said. “There were a lot of policy and clinical efforts to maintain and expand access to buprenorphine during the COVID-19 pandemic, such as allowing buprenorphine to be prescribed via telehealth without an in-person visit and eliminating training requirements for the waiver that previously was required to prescribe buprenorphine. [Why go through this rigmarole if its dismal results were unsurprising?] The fact that buprenorphine initiation and retention did not rise after these efforts were implemented suggests that they were insufficient to meet the rising need for this medication,” he said.

But American public health seems to be selling something that people aren’t buying — however life saving it can be. And this low level of accessing and continuing MOUD is most pronounced for those most likely to die due to drug use — minorities and the disadvantaged:

Medication Treatment for Addiction Is Shorter for Black and Hispanic Patients, Study Finds: The analysis of 15 years of prescription data showed that the racial disparities are widening. (2022)

The rallying cry among harm reduction advocates (HRAs) is that MOUD is vastly under-prescribed. If these medications were adequately utilized, then surely addiction and death rates would decline, they believe. When people aren’t adopting what public health reckons to be best practices, there are two alternatives: enlightened persuasion, and coercion.  Many reformers and HRAs are critical about the degree of coercion entailed in routing people into ineffectual 12-step programs. But similar coercion is now appearing throughout the progressive drug and mental illness biosphere.

The Harm Reduction Rush to MOUD. From its beginnings, the drug policy reform movement yolked itself to MAT in the form of methadone. The process was reciprocal. The most prominent methadone advocates and providers (e.g., Bob Newman, Ernie Drucker) presented it as a medication to deal with a disease. Newman, Drucker and other reformers conceived the disease model as the opposite of viewing addictive drug use as a socially conditioned choice. This stance appealed to them even though, as progressives, they believed poverty and degraded social conditions caused addiction.

Drug policy reformers have never been able to extricate themselves from this paradox. Thus Ethan Nadelmann, the foremost drug policy reformer in America from 1995 to 2015, endorses an experiential model of addiction as a response to emotional pain along with inequality as a wellspring for addiction.  Based on these beliefs, Nadelmann attacks the National Institute on Drug Abuse led by Nora Volkow for giving these factors short shrift.

And, yet, Nadelmann agrees with Volkow that MOUD is the essential solution to the decades-long crisis of escalating drug deaths. There are no longer essential differences between HRAs and advocates of the disease theory like Volkow in their proposals to stem the opioid epidemic.

American Beliefs About Addiction. All societies view their conceptions of reality as the only possible explanations of the universe. The US is a particularly prone to this cultural “exceptionalism.” Specifically, Americans as a group believe their moods and maladies are biologically created and are best treated medically.

Despite its complete failure to stem negative outcomes, up to and including death, Americans are committed to the disease theory of addiction. According to Wikipedia (accessed July 2023):

Drug addiction, which belongs to the class of substance-related disorders, is a chronic and relapsing brain disorder that features drug seeking and drug abuse, despite their harmful effects. This form of addiction changes brain circuitry such that the brain’s reward system is compromised, causing functional consequences for stress management and self-control. Damage to the functions of the organs involved can persist throughout a lifetime and cause death if untreated. Substances involved with drug addiction include alcohol, nicotine, marijuana, opioids, cocaine, amphetamines, and even foods with high fat and sugar content. Addictions can begin experimentally in social contexts and can arise from the use of prescribed medications or a variety of other measures. (My emphasis)

This self-assured assertion of the sources, nature, and treatment of addiction is built into the character of Americans. It is opposed by one that comprehends that drug addiction, like alcoholism, is multifactorial and not biologically determined, follows the usual stages of human development, involves intentionality and personal values, and is generally self-ameliorating. This view is presented by Wikipedia as the Life Process Model of Addiction (LPM). LPM is consistent with the realities of harm reduction: that people may use drugs of all sorts casually or in a controlled manner, and they usually decrease use and increase control over time.

In rejecting the LPM, the supposedly radical policy called harm reduction has been co-opted by the disease theory of drug use and addiction. In the drug policy universe reform and harm reduction advocates hold to the same central beliefs as the disease model. Instead of believing that people can gain control over substance use and its consequences, they insist that when users develop problems they can only control or quit drug use with drug treatments.

Harm reduction advocates thus share the American dream that we can bypass human consciousness, lived experience and intentionality and cure addiction medically. But we can’t, and only fail to adopt effective common sense policies by believing that we can.

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Stanton’s memoir: A Scientific Life on the Edge: My lonely quest to change how we see addiction

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