Public Policy, Treatment

The public policy landscape surrounding treatment for substance use disorders within the United States has been shifting continuously for more than 150 years as countervailing scientific, religious, moralistic, and political forces wax and wane. Throughout our nation's history, public perceptions and policy have reflected profound ambivalence regarding substance use disorders. This ambivalence occurs at many levels and cannot simply be reduced to a question of whether addictive orders are a disease and should be treated as such or whether they are simply a form of moral depravity, hedonism, or selfishness.

Within the various groups that are party to the national policy dialogue, ambivalence is also prevalent. Some advocates of science-based approaches to addictions treatment sometimes still exhibit ambivalence regarding the use of medications for the treatment of addictive disorders or the adoption of harm-reduction approaches despite robust scientific evidence of their clinical efficacy. The popular conception of addictions treatment as a 28-day [Page 736]residential treatment program with a graduation ceremony—a still common approach—reflects an acute care or cure approach. As William White (a prominent recovery advocate) and others have pointed out, while Americans have long declared addictions chronic, relapsing disorders, Americans still tend to treat them as though they were acute conditions amenable to a time-delimited intervention. Even the paradigm that researchers and policymakers typically adopt when measuring treatment outcomes reflects this paradigm: evaluating treatment effectiveness through pre- and postmeasures. As researchers such as Tom McLellan have pointed out, treatments for other chronic disorders are typically measured during treatment. It is assumed that cessation of treatment for a chronic disorder (e.g., discontinuation of a drug to treat hypertension) will result in relapse. Yet, substance use disorders, while being labeled chronic relapsing disorders, are treated in a manner more akin to physical trauma or acute illness. Ambivalence about treatment and skepticism about its effectiveness have emerged, in part, because of the frequency of posttreatment relapse. Yet relapse is what one would predict even when the best possible approaches are applied.

The stigma associated with addictive disorders may be one factor supporting the continued use of such approaches. To the extent that a disorder can be cured rather than managed and to the extent that treatment can be time-delimited, the individual and society can view addiction as an episode that one can put in the past. This provides a mechanism for disassociating oneself and one's family, community, and the larger society from the issue. The Big Book of Alcoholics Anonymous responds to the tendency to see alcoholism as a transitory condition that can be cured. It characterizes the thought that an alcoholic can someday regain control of his or her drinking as an illusion and compares the likelihood of regaining the ability to drink in moderation once one has become a true alcoholic to that of regrowing severed legs.

There are also those that believe that substance problems are neither diseases nor reflections of moral shortcomings. Among those who argue this position are psychotherapist Stanton Peele, physician Thomas Szasz, and psychologist Jeffrey A. Schaler. Peele specifically argues that the disease concept's position that addictions are necessarily progressive conditions is a reflection of the moralistic perspective once reflected in the Temperance Movement rather than a scientifically based and pragmatic view.

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