Responses to Stanton Peele's article, "The results for drug reform goals of shifting from interdiction/punishment to treatment," PsychNews International, 1(6), 1996.

I. Response from Mark Reisinger, Belgian Methadone Advocate

When I read your article I felt it did not fit with my experience of heroin addiction as a MD (using methadone and buprenorphine among other medications), as a psychotherapist, as a social anthropologist and also as a friend of some heroin users and addicts.

So I wasn't too surprised that you write mostly about alcohol. In this field, I follow you largely, but I don't think you have ground to extend your conclusions to heroin.

As a matter of fact your incursions in the heroin addiction field are not too convincing:

Of all the men addicted in Vietnam [defined as prolonged heavy use and severe withdrawal symptoms lasting more than two days], only 12% have relapsed to addiction at any time since their return. . . . Of those men who were addicted in the first year back, half were treated and half were not. . . . Of those treated, 47 percent were addicted in the second period; of those not treated, 17 percent were addicted...

Don't forget that the duration of the enrolment in Vietnam was not very long. I think the GIs were staying something like 10 months in Vietnam. So even if they became immediately addicted on their arrival (which is unprobable), they didn't have time to develop a severe habit. In the US, a lot of them went back in the middle of the country where heroin was not available. So it is not surprising if 88% had no relapse.

I don't deny that the environment is an essential co-factor of addiction to heroin, nicotine, coffee, thee or anything. I don't need to deny it to emphasize the importance of treatment. An efficient treatment like methadone is important precisely because you can't have much influence on your environment.

The fact that 47% of treated soldiers were addicted "in the second period" (?) and only 17% of those not treated, probably reflects the fact that the treated ones had a worst habit or a worst environment.

Perhaps an even more surprising finding than the high proportion of men who recovered from addiction after Vietnam was the number who went back to heroin without becoming readdicted . . . . Half of the men who had been addicted in Vietnam used heroin on their return home, but only one-eighth became readdicted to heroin. Even when heroin was used frequently..., only one-half became readdicted."

This proposition is vague. How long and how often did they use heroin on their return home? How "frequently" did use heroin those who did not become readdicted? What was the environmental difference between those who became readdicted and the others?

Even with a legal substance, treatment will be more often coercive when treatment rolls expand, because this is the major way in which new slots must be filled. People simply don't recommend themselves for treatment in sufficient numbers to fill expanded drug slots. Indeed, today in the U.S. drug treatment is already largely coercive, indicating that more treatment slots can only be filled by forcing people into them.

This view is tautologic and limited to the US experience (+ all the countries which imitates it). Since drug treatment is only offered in a coercitive context (daily attendance,urinalysis, compulsory counseling, etc.) addicted people are not too happy to fill "slots". But it is perfectly possible to treat heroin addicts as normal patients. Then you can observe that at least 60% of them are ready to enter methadone treatment (as in Amsterdam). An additional 20% are probably ready to receive heroin treatment (as the Swiss experiment seems to indicate). In my country (Belgium) we expanded methadone treatment 15 fold in 5 years and many patients are still asking for treatment because it is performed in a humane way (prescriptions by GPs, delivery in pharmacies, take-home dosages, few urinalysis, no compulsory counseling, etc. - please see my article "Methadone as a normal medicine" on HabitSmart Web Site:http://www.cts.com:80/~habtsmrt/

II. Stanton's Response to Reisinger

Reisinger noted Stanton wrote in the original article:

Even with a legal substance, treatment will be more often coercive when treatment rolls expand, because this is the major way in which new slots must be filled. People simply don't recommend themselves for treatment in sufficient numbers to fill expanded drug slots. Indeed, today in the U.S. drug treatment is already largely coercive, indicating that more treatment slots can only be filled by forcing people into them.

Reisinger responded:

This view is tautologic and limited to the US experience (+ all the countries which imitates it). Since drug treatment is only offered in a coercitive context (daily attendance,urinalysis, compulsory counseling, etc.) addicted people are not too happy to fill "slots".

Stanton's response:

My comments are very much directed to the American situation — and to "all the countries which imitate it." In the US, as I indicate, broadening treatment immediately "12-stepizes" it, because this is the American model of treatment based on the private alcoholism treatment industry, which is pervasive and massive here. Expanding treatment in the drug arena has the paradoxical effect of pushing out the more diverse (and effective) treatment methods already practiced in drug treatment, even though the data show no general effectiveness for the 12-step approach (and AA and the private treatments predicated on it).

When I spoke about the above matters at the Lindesmith Center in the US, methadone providers dejectedly commented on the extent to which recovering addicts and the 12-step model pervade their programs — this already-entrenched trend will accelerate with time and expanding treatment. Moreover, you hit it on the head when you refer to countries which imitate the US. Those are quite numerous — the US is a leading exporter of addiction approaches, even though we can point to nothing to show that we are successful in dealing with drug and alcohol abuse other than the gobs of money we spend, the large numbers of patients we recruit, and the growing number of people we induce to claim that they are out of control of their substance use.

You describe a European system in which drug treatment is integrated into the national health care system (for which we have no parallel), where treatment is non-stigmatized (for example, people do not have to "admit" that they are inherent, lifetime addicts), and where people select a treatment they desire because they believe it can help them. To the extent that you operate in such a system — thank God! The US does not. But, be careful, or else you will find your system tilting towards ours, just like your countrymen drink Coca-Cola and watch Hollywood films.

Reisinger further noted about the original article:

You further commented on the data by Robins et al. (1980) representing a three-year follow-up of Vietnam Veterans addicted in Asia in which only 12% became readdicted in the States. Among those readdicted in the first year, half were treated and half not: 47% of these readdicted in period 1 who were treated continued to be addicted in period 2, compared with only 17% of those readdicted in period 1 who were not treated.

to which Marc responded:

The fact that 47% of treated soldiers were addicted "in the second period" (?) and only 17% of those not treated, probably reflects the fact that the treated ones had a worst habit or a worst environment.

Stanton's response:

You are correct, Robins et al. reported those who received treatment had more severe addictions in period 1 (the first year back; period two was years 2 & 3 covered in the study). Please keep in mind, however, that — in order to qualify for the study — the soldiers had to have engaged in prolonged heavy use and to have undergone severe withdrawal lasting at least two days. So everyone involved was an addict, and would certainly be welcomed into treatment in the US (where several studies have found it fairly common for "addicts" in treatment centers to have hardly any or no narcotics in their systems, but to nonetheless report dependence and withdrawal).

Reisinger further quoted the original article, which in turn quote Robins et al. (1980):

Perhaps an even more surprising finding than the high proportion of men who recovered from addiction after Vietnam was the number who went back to heroin without becoming readdicted . . . . Half of the men who had been addicted in Vietnam used heroin on their return home, but only one-eighth became readdicted to heroin. Even when heroin was used frequently..., only one-half became readdicted."

Reisinger commented:

This proposition is vague. How long and how often did they use heroin on their return home ? How "frequently" did use heroin those who did not become readdicted ? What was the environmental difference between those who became readdicted and the others ?

Stanton responded:

In order to assess predictors of addiction of veterans who used narcotics again on their return home, Robins et al. looked at 35 different variables including early drug history, demographic characteristics, intelligence test scores, psychiatric treatment, whether men got off heroin through treatment or on their own, length of drug use in Vietnam, whether they injected or not, prior drinking problems, drug use by friends, etc. without finding any that differentiated those who became readdicted from those who did not.

Although in this instance and others, your arguments are with Robins et al. about their research and reporting of data, I think you will be reassured to note that Robins and her chief collaborator, John Helzer, subsequently reversed directions, although only with alcohol and as far as I know not with heroin. Helzer, Robins et al. (1985) examined alcoholics treated in an inner-city hospital and reported in the New England Journal of Medicine in 1985 that hardly any (1.6%) resumed moderate drinking. Helzer and Robins' results with alcoholics — unlike the three-quarters of the returned Vietnam addicts who used narcotics again without becoming readdicted — seem to be in keeping with your ideas that once an addict always an addict, ideas which are widespread and generally accepted in the US.

Helzer, Robins et al. (1985) focussed on this absence of resumption of moderate drinking in their title, abstract, and results. However, some might consider it more noteworthy that, of the alcoholics in the study who were actually treated in an alcoholism ward that only 7 percent survived and were adjudged in remission at from 5 to 8 years following treatment! Here's what I think happened: Helzer and Robins felt they could get away with such iconoclasms as resumption of moderate heroin use by returned addicts, but they saw they could not buck the alcoholism juggernaut (not that they want to) and reversed their finding with regards to drinking.

In order to come up with findings with alcohol that contradict their results with heroin, Helzer and Robins changed their definition of resumption of use so that occasional drinking was not counted as moderate consumption, and by changing their definition of relapse to alcoholism by defining several instances of intoxication as relapse even in the absence of rehospitalization and without reports by subjects themselves or collaterals of reappearance of dependence symptoms.

In the US, at least, researchers must practice this kind of — if not intellectual dishonesty — then at least political prudence because of the supremacy of the coercive alcoholism treatment industry that we are now replicating in the case of drugs. At some point, Robins and Helzer can go back and revise their earlier results on heroin to bring them in line with the treatment precepts they explicitly rejected then of (a) the need for treatment and (b) the need for abstinence in achieving remission in addiction.

References:

Helzer, J.E., Robins, L.N., Taylor, J.R., Carey, K., Miller, R.H., Combes-Orme, T., and Farmer, A. (1985). The extent of long-term moderate drinking among alcoholics discharged from medical and psychiatric treatment facilities. New England Journal of Medicine, 312, 1678-1682.

Robins, L. N., Helzer, J. E., Hesselbrock, M., and Wish, E. (1980). Vietnam veterans three years after Vietnam: How our study changed our view of heroin. In L. Brill and C. Winick (Eds.), The Yearbook of Substance Use and Abuse (Vol. 2, pp. 213-230). New York: Human Sciences Press.

III. Comment from Vincent Dole, Developer of Methadone Treatment

Dear Marc...Fully agree with your response to the s.peele article. Who is he and what is his experience in treatment? Does he see no difference between making treatment attractive and making it coercive? I'm glad that you are in the field.

IV. Stanton's Response to Dole

I just wanted to reassure you that I am nobody, and that you can safely disregard my views. After all, how has it hurt you to do so in the 20 years since I published "Love and Addiction"?

V. Comment from Bob Newman, American Methadone Advocate

I've followed the internet correspondence between you and Marc Reisinger with interest. I suspect there's a lot more concurrence than one might think and the apparent differences reflect that one is looking at different parts of the elephant.

Two key points (partially covered already in your correspondence): first, the American approach to addiction treatment is bizarre, irrational and unprecedented. We view the "problem" exclusively from the societal standpoint and respond to it according to what is believed or purported to be in the society's interests - the addicts be damned. Treatment providers under these game-rules are compelled to comply and the "programs" are perverse when compared to any other medical treatments. It's an extraordinary testimony to the desperation and motivation of a very large segment of the narcotic addict population that they seek and accept treatment under these conditions. But the reality is that in America, today, it's that or nothing, and it would be presumptuous to argue for abandoning today's services if there is absolutely nothing to take their place. Instead one must advocate for the relatively "normal" medical approach that prevails in many other countries, in which the medical establishment as a whole treats addiction like other chronic diseases, and utilize methadone like every other medication. The fact that it can be done elsewhere should be a lesson in America - though the situation is far from ideal even in countries that do allow general practitioners to be involved (eg Germany). And as you point out, the pervasive American dogma threatens the viability of the more rational approaches that today are tolerated in other countries.

The second point regards the challenge to the notion that addiction is a life-long problem and the inevitable consequence of once becoming dependent on heroin, it's a question of definition. Addiction treatment providers see a self-selected segment of the heroin using population - those who believe they have a problem that they need help in overcoming. That problem is not today's dependence on narcotics - that's readily resolved with a host of techniques - including simply locking someone up in a closet for a week. The "problem" - the condition that prompts heroin users to seek help - is REMAINING abstinent once abstinence is achieved. The "illness" is the extremely high likelihood of relapsing to heroin use; heroin users who can limit their use or who can abstain without difficulty don't have this illness and do not seek treatment. Those who are unable to remain abstinent (and want to!) seek help, and treatment providers' view of the heroin using population and the "problem" is based exclusively on this latter group. It is similar with regard to alcohol use: most folks drink, and many drink a lot; those who consider themselves to be on a self-destructive downward spiral and know from experience they can't stop or significantly reduce their alcohol intake on their own seek help, and the experience with this group supports the widespread view of AA that no one is ever "cured" of alcoholism and that drinking in moderation is impossible. The rest of the drinkers (and I'm not including those who are considered to be "in denial"), however, who never feel the need to go to AA or other care providers, are not viewed and do not view themselves as having an illness. They do not pose a challenge to the assumptions (whether correct or not) that stem from the experience with those seeking help.

Bottom line : as with all other medical regimens, treatment of drug use should be limited to those who believe they need it and who want it - and it should be available with no more constraints than apply to the care provided by clinicians for any other condition. One must not impose treatment on folks who do not want it or feel they need it; one must also not deny treatment to those who seek.

VI. Stanton's Answer to Bob Newman

Thanks for your mail. Always glad to hear from you. I respond slightly differently to the two points you raise:

1. Although we attack addiction from a societal perspective, we define it in individual terms — i.e., an internal disease state of the individual;
2. I'm not so clear as you that there are "real" addicts who cannot reduce use or quite on their own, and it is these who seek — and need — treatment. After all, that's what the Vietnam data state, which many people in methadone don't seem to be able to come to grips with. The soldiers were real addicts in Vietnam; Stateside, they could quit or use moderately because the situation did not require them to be addicted.

Where I think we have good agreement is (a) that treatment be inviting and not coercive; (b) that it offer life support in addition to medical treatment, (c) that people not be required to pay religious/political/economic obeisance in order to get help in dealing with addiction (such as labeling themselves as out of control or powerless), (d) that in regarding it as medical treatment we deliver it with the same dispassion and supportivenes as all medical treatment is supposed to offer.

VII. Marc Reisinger Wrote a Nice Letter to Stanton

Dear Stanton

Thanks for posting our discussion on your website. My last comments came late. Is it still possible to add them (as well as the present comments)? They may be useful to clarify things, since you tend to present us (Bob Newman and I) as thinking that there are "real" addicts. I can't find this expression under his pen. He speaks about an "extremely high likelihood of relapsing to heroin use", which is a behavioral definition of addiction, as you recommend yourself I believe. When you oppose to "real addicts" people who can reduce use or quit "on their own", don't you fall in a definition of addiction in individual terms ? The fact that people can quit "on their own" depends largely of the product and the environment (cf. the first image on your site).

I must add that the Vietnam data certainly don't state that addicts can "reduce use or quit heroin on their own". They only state that 88% of people addicted to heroin for an average 6 months can stop heroin after a massive change of environment (from Vietnam to USA, from army to normal life), plus a change of psychological state (from war to peace), plus treatments, plus a probable change in the quality of heroin. You will admit that these conditions are far from from the usual heroin addicts. I also have to add that the idea that addicts can quit on their own, based on this interpretation of Vietnam data, has been widely used by opponents to methadone treatment in France and elsewhere to promote drug-free treatments. The multidimentional aspect of the problem completely dissapeared behind a psychological interpretation of the phenomenon. That is why I think that this restatement is important.

VIII. Stanton Replied in Kind

Dear Marc:

My interpretations of addiction should never be used to support the idea that, if we address the underlying psychological (or medical) basis of addiction that we can, through treatment of any kind, eliminate addiction. Rather, these impressions simply support moralistic do-nothing (or do-what-I-say) interventions that are intrusive and ineffective. Nothing you do or say could possibly be as bad as this approach, which dominates in the U.S. I welcome methadone treatment in general, and more especially because I see it practiced with people needing help in conjunction with counseling and life support that offers them the chance ot make real changes in their lives, which is what therapy must always ultimately accomplish. God bless you and Bob Newman and others like you for your work! If any kooky people in France maintain otherwise, please direct them to me, and I will straighten them out.

IX. The Substance of Reisinger's Further Reply

About the American treatment system

You wrote :

You describe a European system in which drug treatment is integrated into the national health care system (for which we have no parallel), where treatment is non-stigmatized (for example, people do not have to "admit" that they are inherent, lifetime addicts), and where people select a treatment they desire because they believe it can help them. To the extent that you operate in such a system — thank God! The US does not. But, be careful, or else you will find your system tilting towards ours, just like your countrymen drink Coca-Cola and watch Hollywood films.

I respond :

I AM careful and that is why I take care in replying to you. There is obviously "imperialist" pressure to adopt the American way of treating addiction. I remember the nasty comments from a man who supposedly designed the current US methadone system 25 years ago and who is still influential, about progresses in the European methadone delivery system : "I don't see what is so new there !" Then, forced to recognize the quantitative and qualitative changes of MMT in Europe he added inconsistently: "Well, this is still very new."

Fortunately, I also see signs of a change in the US. When I first presented a poster about MT in general practice at the AMTA Conference in 1992, the only comment I heard - in the middle of a general disinterest - was : "This is prehistory!" Today it seems that I will be invited to speak in a workshop on GP's methadone prescription at the next AMTA Conference in April 1997. A recent survey on Medical Methadone Maintenance also found widespread approval for methadone prescription in physicians' offices (See Addiction Treatment Forum on http://www.atforum.com).

About heroin use and addiction

You think that I think that "once an addict always an addict", but I don't think so. Let me clarify my position.

I see 3 steps in heroin addiction

A/ Heroin use:

Heroin use is pleasant. You don't need to be crazy or stupid to try and appreciate it. Usually you just need a few friends who share some dope and tell you : "Don't ever try this !" (By the way this is a current advertisement for Bailey's liquor in France).

You can use heroin for months or years without becoming dependent if you are careful and not depressed. If you are not careful, you will use it too often and one day you will wake up sick (without even knowing you are in withdrawal). If you are depressed you will tend to take heroin everyday, since it is a good antidepressant and you will become dependent. This is a reason why we can assume that many heroin users in Vietnam became dependent.

B/ Heroin addiction

Once you take heroin everyday, you begin to suffer from a DOUBLE dependence. A NEUROPHYSIOLOGICAL dependence which manifests itself by withdrawal symptoms. After disappearance of those symptoms, many people become readdicted to heroin when they go back to the environment where they used heroin. This is the ENVIRONMENTAL side of dependence ("habits"), which reinforces the first one.

The "illness" as defined by Bob NEWMAN as "the extremely high likelihood of relapsing to heroin use" is a combination of neurophysiological and environmental dependence. So this is not an illness in the strict sense of an "organic affection", but it doesn't mean it doesn't need to be treated. Doctors treat a lot of problems which are not illnesses: alcoholism, depression, insomnia...A treatment is simply something that helps.

An important point is that the closer to the beginning of dependence IN A GIVEN ENVIRONMENT you treat, the best results you get. The reason is that when the environmental dependence is not very strong, physical withdrawal is sufficient to treat (physical) dependence. This is probably the reason why 88% of US heroin addicts in Vietnam were not addicted after 3 years in the US. The importance of the environmental factor is shown by the fact that 50% of the Vietnam's addicts completely stopped heroin after their arrival in the US. On the contrary 75% of those who used heroin after their return home were still addicted after one year.

C/ Treatment

Heroin addiction is a "double dependence". Hence there is a double way to treat it. One way of treatment is giving a "substitute environment". This can be a residential treatment, but it can also be performed "informally" by moving away from the environment in which you got used to heroin. The other way of treatment is a "substitute drug" (methadone).

Most Vietnam Veterans who were treated probably received a substitute drug. They felt the necessity of a formal treatment. The others probably realized they could quit heroin with a simple withdrawal and some distance with the environment where they used dope. This explains the paradoxical observation that more treated Veterans continued to be addicted than those who were not treated. As a matter of fact, you already confirmed that those who received treatment had a more severe addiction. The alternative explanation - that treatments would aggravate the problem - is also invalidated by the fact that, as you quoted, the fact that "men got off heroin through treatment or on their own did not differentiate those who became readdicted from those who did not".

By the way the fact that "in order to assess predictors of addiction of veterans who used narcotics again on their return home, Robins et al. looked at 35 different variables including early drug history, demographic characteristics, intelligence test scores, psychiatric treatment, whether men got off heroin through treatment or on their own, length of drug use in Vietnam, whether they injected or not, prior drinking problems, drug use by friends, etc. without finding any that differentiated those who became readdicted from those who did not", does not mean that there is no such predictor. It just means that they did not find it, and that they should look closer. In my model I would look for change of residence, important life events and availability of heroin.

Conclusion

My reaction to your article was based on your assumption that an expansion of treatment "would seem to be counter to critical drug policy reform goals", based on the fact that "there is no evidence that substance abuse treatment reduces overall substance abuse rates". If this is true for the treatment of alcohool problems, it cannot be said for the treatment of heroin addiction - even in the US. Dole, Newman and so many authors have shown the efficiency of methadone treatment. The difference between alcooholism and heroin addiction is that there is a medicine which works rather well for the latter condition - even in the worst ideological conditions.

This is why it would be intersting that your negative critic of the abstinence-oriented treatments would become a positive critic of the rigid methadone maintenance treatment (vs less rigid treatments). I think that treatments, in the sense of "taking care" of people, must be expanded.

Finally I want to challenge a common idea that there would be two groups of heroin users, one for which heroin use is problematic and one for which it will never be the case. Bob NEWMAN wrote that "heroin users who can limit their use or who can abstain without difficulty don't have this illness and do not seek treatment. Those who are unable to remain abstinent (and want to!) seek help, and treatment providers' view of the heroin using population and the "problem" is based exclusively on this latter group". Based on my observation of heroin users in a more open setting than in the US, I consider that the difference between those "who can abstain without difficulty", and those who "are unable to remain abstinent" is mainly a matter of time. The proportion of problematic users is rising in a given population of heroin users. There is a global trend to use heroin more frequently, which brings people closer to dependence. Moreover, depressing life events (like death, separation, etc., which are almost unavoidable), make very often people jump from heroin use to addiction.

X. Stanton's Final Reply to Marc Reisinger

You (and Bob Newman) express a number of beliefs and draw a number of distinctions about addiction that are wrong. Indeed, much of my web site and my work is devoted to attacking these beliefs and distinctions (see, for example, my book The Meaning of Addiction, and "Addiction as a cultural concept" and "Introduction" at The Stanton Peele Addiction Website, www.frw.uva.nl/cedro/peele/):

1. There is neurophysiological addiction and psychological (environmental) addiction. People often speak about the need to overcome categories that separate mind and body, and then retreat to this distinction whenever challenged. This distinction is misused and inappropriate when applied to addiction. There may be people whose addiction is so resilient that it transcends one environment and they are addicted in different settings. But the addiction is the same: a reliance on an experience (whether pharmacologically engendered or not) to negotiate their existence.

Some evidence we all know: Hospital patients, often taking narcotics for extended periods of time, almost never become addicted. The persistent neurophysiological operation of the substance does not induce them to be addicted. They do not become wedded to the narcosis experience, do not seek to extend it, and quit without notable discomfort.

You claim that the heroin (narcotic) addiction process begins with the user who experiences initial heroin use as pleasurable. But hospital patients generally find narcosis uncomfortable. When offered the opportunity to self-regulate analgesics, they decrease their dosage more rapidly than do their physicians. Thus, we return to the question of why some people find pain relief an inviting experience from the start, a very fundamental question, which is at heart more existential (and situational) than neurophysiological.

2. (Bob Newman) Those heroin users who seeks treatment are different (i.e., are real addicts) than those who don't seek treatment. Prove it! In some cases the addicts who seek treatment have more severe problems than those who do not, but in many cases they don't. Repeatedly, in the U.S., we encounter in drug treatment heroin users with hardly any heroin in their systems, while we know of many seriously addicted heroin users who quit without treatment (see my book, The Meaning of Addiction, and Dan Waldorf's articles in the 1981 and 1983 (of which he was editor) issues of the Journal of Drug Issues, as well as Patrick Biernacki's Pathways from Heroin Addiction).

However, I do believe both that addicts differ from nonaddicted heroin users and that addicts who seek treatment differ from those who do not. The differences are complicated but include differences in outlook (i.e., people who welcome pain relief versus those who do not; people who seek external solutions for their problems) as well as environmental ones. I thus agree with you that, although Robins et al. did not find distinctions between those who became readdicted stateside and those who did not, that psychological and background differences are involved.

Meanwhile, your numbers are wrong: of soldiers addicted in Vietnam who used heroin again stateside, not 75% but 25% became readdicted; even among those former addicts who used heroin regularly stateside, only half became readdicted. You must learn these data, since they are so significant. It is true that the radical shift in environment, including the release from pain and danger as well as that many could not easily find and associate with fellow heroin users, is a significant component in who became readdicted. But these social and environmental factors in fact strongly undercut the idea that addiction is a special disease requiring treatment. It instead suggests finding new opportunities and associations for people in order to overcome heroin lifestyles and addiction.

Finally, let me describe a virulent addiction which people say is harder to quit than alcohol and cocaine and as hard to quit as heroin, that many millions of American have nonetheless quit, that nine-tenths have done so without treatment, and that practically none of them have radically shifted their environments in order to quit — nicotine addiction. Such addicts do have alternate values and meaning in their lives that enable them to quit. Your model of addiction must reflect this (see at my web site "How people's values determine whether they become and remain addicts").

3. (Marc Reisinger) Any user who takes narcotics at a high enough dosage for long enough will become addicted. Addiction is more than regular heavy use. Hospital patients do not become addicted, even after months of powerful, regular narcotics infusions, because they do not think of themselves as addicts, because their lives are otherwise motivated, because to be a heroin addict is outside the scope of their outlooks and lifestyles. Please read Life with Heroin (by Hanson et al., NIDA researchers of all things!), Irving Lukoff's work in New York, etc., which describe inner city heroin users who control their use of heroin for decades.

4. While alcohol problems have not declined in the U.S., drug problems (particularly addiction) have, due to enhanced treatment. Drug abuse treaters point to studies in which treated addicts fare better than untreated. But alcohol abuse/alcoholism therapists point to the same kinds of data. Two other kinds of studies and statistics paint a very different picture (as I show in my original article). Going to community populations, and asking of those who have been alcohol/drug dependent which have been to treatment, does not find the treated fare better. Likewise, large scale epidemiologic studies do not find intensive use/dependence symptomatology reported in general populations to be declining long term — rather it is rising! We have a massive treatment industry, and a population to be treated that never goes away. It is a happy marriage.

Think now about cocaine (as I describe in my original article). Community studies all depict long-term users who sometimes go overboard, but who regularly recover without treatment. These data may change as we expose more of these people to treatment (as we are doing in the U.S.). But what is the long-term consequence? Will we have fewer cocaine addicts? Does the treatment apparatus become self-justifying and self-perpetuating? Does treatment expand beyond the addict who might be considered the appropriate recipient to the larger class which may function well without treatment? How does it affect our culture to think about drug use in terms of loss-of-control requiring treatment? In the U.S., as my article shows, we do not significantly dent the hard core addict population (in fact we pay less attention to them) while recruiting many more "casual addicts" to the fold, increasing both self-reported dependence and treatment for it.

5. Methadone is a valued treatment component. I respect the work of Marc Reisinger and Bob Newman because they take on the hard cases, they display personal courage in confronting entrenched social and medical resistance to these problem populations, and they seek to go beyond standard categories of thinking about addiction and therapy. In doing so, however, they reify the notion of the inbred or acquired physiology of addiction, they lose sight of addicts who do not enter their treatment rolls, and they fail to decipher larger cultural trends in addiction and treatment which misuse their notions for popular consumption and broader marketing of treatment.

Here are my ideas about addiction treatment: (a) addiction will always be more of an existential than a medical problem, (b) treatment must allow people to form new connections to work and to people to change their situations, (c) treatment should not convince people of the permanence of their affliction or their powerlessness to change it, (d) treatment should respect the preferences, beliefs, and values of the individual drug users as the best way to overcome resistance to change, (e) treatment writ large in the society develops additional characteristics not intended by concerned therapists but which has seriously modified our modern vision of the world and of what it means to be human.