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The SMAC Manifesto

The SMAC Manifesto

1. Addiction is a disease. Yes, addiction is a disease. To be precise on this controversial question, it is an acquired, chronic mental illness, amenable to treatment and subject to remission and relapse (with sad frequency). There are close parallels with the eating disorders of bulimia and anorexia nervosa in particular. Those who dispute the disease label might well argue that other compulsions, depression, bipolar disorder and the like aren't diseases, either. To avoid interminable and mostly pointless debates, SMAC embraces both "disease" and "disorder" to refer to addiction.

As with essentially all chronic diseases, the condition is not limited in effect to any single organ system or mental function. Addressing any chronic disease entails individual, social, cultural, political, economic, spiritual, and psychological dimensions that go well beyond the usual understanding of the term "medical."

Thus, acknowledging the disease (or disorder) nature of addiction is not the same as endorsing the "disease model," the "medical model," or the "chronic disease model." However, SMAC embraces aspects of these perspectives, as well as the "public health model." Addiction must be understood as a complex biopsychosocial phenomenon. This understanding is not in conflict with modern medical thought about chronic disease, but is integral to it.

This disease is most succinctly described as a dysfunctional pattern of behavior around substance use. When the behavior ceases, the disease can be said to be in remission. Substance use that is not demonstrably problematic is not addiction. When an individual experiences a relapse, it is the disease that relapses. Relapse is not a simple choice of the afflicted, it is a manifestation of a disease.

Addiction is not physical dependence. The term "chemical dependence" to mean addiction is misleading terminology and should be abandoned. Physical dependence refers to measurable withdrawal effects from sudden cessation (or reduction of dose) of a substance that has activity in the central nervous system (brain). Physical dependence is a common, but not universal, phenomenon in addiction. Notably, physical dependence develops during long-standing treatment with a range of medications that are clearly not addictive, including many blood pressure medications and virtually all seizure medications. Sudden cessation of such medications can be lethal, but the physical dependence is in no way an indication of addiction.

Conversely, addiction can be present with no objectively-measurable evidence of physical dependence. Stimulants in particular (nicotine, cocaine, amphetamines, others) produce no objectively-measurable withdrawal symptoms (by ordinary measures of blood pressure or heart rate, for example), but are the most addictive substances known.  Thus, the oft-cited distinction between "physical" and "psychological" addiction is a false one.  Addiction is simply a dysfunctional pattern of behavior around substance use.  This behavior can be viewed as being driven by cravings (or compulsion, urges, appetite or similar words)--but these cannot be measured objectively.  For useful purposes, we must focus on behavior patterns.

Some substances (and routes of administration) are more addictive than others. It is utterly misleading (though perhaps technically true) to say "an addict can become addicted to any substance."  We simply don't find Tylenol or tofu addicts anywhere.  Thus, judicious use of medication is perfectly appropriate for people in recovery from addiction.

Alcohol is a drug; alcoholism is addiction to alcohol. Alcoholism is addressed differently from other addictions in our society for historical, cultural, and political reasons, not because of any particualr difference in biology or in the nature of the disease.

Addiction is not related to "dependent personality disorder." Also, there is simply no such thing as an "addictive personality."  Careful research demonstrates no typical personality traits pre-existing the development of addiction.

Addiction is not primarily a moral issue, though there are typically moral aspects to individual cases.  Active addiction is a state of personal desperation.  The "immoral" behavior frequently observed is a manifestation of desperation, not moral decay. This is a description and explanation of errant behavior, not an excuse. All persons hold responsibility for their own voluntary actions.

As a disease, sufferers have a right to the same sorts of considerations and support from society that sufferers of other chronic diseases enjoy. This is appropriately defined in Federal laws such as the Americans With Disabilities Act (ADA) and Fair Housing Act, in which those in recovery from addiction are recognized as having a disabling condition, with specific rights to reasonable accommodations. SMAC supports efforts to provide universal healthcare access and to establish parity in healthcare between physical and mental conditions.

2. "War on Drugs." This is awful and deceptive terminology. SMAC does not urge "surrender" in this "war." There is no real war here, but a problem with social, clinical, economic, and political dimensions. A rational response to this problem isn't a "war." A rational response must be as multi-faceted as the problem being addressed.

In general, "War on Drugs" means a criminal justice response to the problems of substance misuse and addiction. This approach was a monumental disaster for alcohol during Prohibition, and the approach is not working any better for dealing with other addictive substances today. The disasters are the same: widespread disregard and disrespect for the rule of law, lucrative funding for organized crime and official corruption, political instability across national borders, and devastation of basic civil liberties.

In legal and political terms, a rational response to addictive substances should more closely resemble what society does with alcohol, rifles, explosives, and toxic chemicals. That is, use of dangerous material needs to be carefully regulated, controlled, monitored and taxed in ways that do not turn millions of ordinary citizens into criminals.

It is inappropriate for society to incarcerate individuals for simple possession of addictive substances. Movements such as Drug Court are a step in the right direction of diverting individuals out of criminal justice pathways and into treatment. Coerced treatment is recognized as having outcomes comparable to more purely voluntary treatment.

However, legal coercion is not a good thing in itself, and is an inappropriate tool for addressing a clinical problem when the "crime" is simple possession or use of an addictive substance. Society should not discourage use of addictive substances by making the symptoms of a disease into crimes. Mandatory minimum sentences in such cases only compound the damaging absurdity.

Note that for treatment to be a realistic alternative to criminal justice penalties under currently-existing laws, treatment must be readily available. Society has an opportunity to spend its limited resources more wisely by shifting funding from prisons into treatment programs. SMAC strongly supports making treatment available on demand, and seeks elimination of incarceration as punishment for simple possession. SMAC acts to help bring sufferers into clinical care.

3. Pain sufferers. Essentially all addictive substances have some valid, appropriate uses, most prominently, pain relief.  Unfortunately, society's paranoia about the substances rather than their misuse has caught many innocent souls in the crossfire of the War on Drugs.  Many, many individuals suffering chronic pain cannot get access to effective treatment for their conditions.  People who have a legitimate need to use an addictive substance should not have undue obstacles placed between them and access to the medications. Use of narcotics to treat pain does NOT commonly result in addiction, even under chronic administration (except when the patient has a prior history of addiction).  Thus, SMAC is opposed to measures that have the effect of discouraging physicians from treating pain.  SMAC supports responsible efforts to allow appropriate individuals access to therapeutic cannabis.

4. Ethical standards in treatment.
Treatment for addiction in the US has had a sad history of abuses, toxic ideology, cult-like groups, disrespectful "confrontation" techniques, and disregard for evidence-based practices. Ethical standards that hold sway in the treatment of essentially all other diseases have been widely disregarded in addiction treatment. Enormous strides have been made to bring addiction treatment into the modern era, but more efforts are required to bring the field fully into the fold of professional, clinical standards of ethics.

In particular, respect for client autonomy is as vital here as in the clinical care of sufferers of any other disease. Paternalistic approaches to sufferers of addiction are no more appropriate here than in other fields of clinical or medical practice. Sudden terminations of care without compelling justification are client abandonment and are unethical. SMAC insists on adherence to the ethical standards as recognized in the treatment of other health conditions.

5. Twelve-step fellowships. Millions have found recovery through the fellowships of Alcoholics Anonymous, Narcotics Anonymous and the like. Peer support may be the most generally powerful tool for most sufferers seeking recovery. The Big Book of AA has a lot to recommend it, overall. However, the Fellowships sometimes become reservoirs of wrong information, and unhelpful attitudes and practices. The Midtown Group is an example in the Montgomery County area where cult-like dynamics have hijacked a potentially helpful movement.

There are, in fact, a range of different groups and fellowships which sufferers of addiction find helpful. It is simply untrue to claim that "AA is the only thing that works" or "AA works better than any other approach." Good research generally suggests a helpful effect of AA participation across whole populations, but individual responses are not always positive. Other types of support groups and approaches to treatment often show comparable or even superior results, compared to 12-step facilitation or "Minnesota Model" approaches. Required participation in 12-step fellowships in particular by government-supported treatment programs is unconstitutional, inappropriate, unethical, and a violation of the founding principles of the fellowships themselves.

6. Methadone, buprenorphine, other medications for addiction, and "abstinence." When a pattern of dysfunctional, addictive behavior is the problem at hand, abstaining from addictive behavior is a logical, inevitable goal of interventions. However, abstinence from addictive behavior is not the same as abstinence from all addictive medications, and certainly doesn't imply avoidance of non-addictive medications.

Medications, including methadone, can be essential to the recovery of many individuals who have descended into addiction. A need for medication can often be life-long. This is no more a failure for the individual or a treatment system than when a diabetic is on life-long insulin. Nor should there be any greater stigma. The decision to start or continue with prescribed medication is a matter between patient and prescribing physician. It is not appropriate for individual treatment decisions to become a political football, as often happens with methadone treatment. All approaches with solid evidence of benefit should be made available whenever feasible.

Occasionally, a person with a history of addiction may need to be on a potentially addictive medication. This is sometimes perfectly appropriate. A heroin addict in recovery may need to be on post-operative narcotics. An alcoholic in recovery may need to be on a form of amphetamine for attention-deficit disorder. A recovering cocaine addict may need a benzodiazepine for periodic panic attacks. None of these are necessarily inappropriate, and treatment with such agents must be a matter between patient and prescribing physician. Third parties (especially non-medical treatment programs and judges) must not insert themselves into this relationship or these decisions except in accordance with recognized standards of professional ethics.

7. Harm reduction.
SMAC supports harm reduction efforts. Convincing research has demonstrated benefit to needle-exchange programs, safe injection room availability, and many other measures under this rubric. Most opposition to such efforts seems to be based on moralistic attitudes and narrow ideology, rather than evidence. Virtually no widely advocated harm reduction efforts demonstrate any tendency to promote additive use, and commonly demonstrate benefit in encouraging entry into treatment as well as substantial benefits for social costs and burdens.

8. "Dual-Diagnosis." SMAC recognizes that addiction and other mental disorders commonly co-exist, commonly exacerbate each other, and commonly require simultaneous effective treatment to produce favorable outcomes. High percentages of persons suffering from addiction have undiagnosed mental illness, and high percentages of persons under treatment for mental illness have undiagnosed substance use disorders. Awareness of these often-intertwining problems must be built into any rational treatment system.

9. Prevention. Addiction is a devastating condition, and prevention of the disorder is obviously good. It is important to recognize, however, that most dollars that have ever been spent on prevention efforts around alcohol and other drugs have been wasted. DARE and virtually every media campaign ever conducted have been consistently shown, whenever subjected to careful measurement, to be either ineffective or even counter-productive. Most classroom or school curriculum initiatives have been disappointments as well.

To be sure, there are indeed effective prevention programs, and SAMHSA's Center for Substance Abuse Prevention maintains a database of evidence-based, effective programs. SMAC supports wider implementation of effective, evidence-based prevention programs.

Recognizing that dollars wasted on ineffective programs are unavailable for funding evidence-based programs, SMAC opposes funding for programs with no clear evidence of effectiveness.

Addiction does not develop in a vacuum. Many of the most powerful prevention efforts don't look much like addiction-prevention programs. Head Start, access to quality schools and health care, and treatment of mental health problems are among the most effective prevention efforts. Treatment of attention-deficit disorder appears to be notably useful, even though treatment commonly includes use of potentially addictive medication. Rational, effective responses to the problem of addiction in society are often not at all obvious. SMAC supports creative, effective, evidence-based prevention efforts.

© 2008, SMAC, Ltd
The Substance Misuse and Addiction Coalition, Ltd.
A Maryland nonprofit, 501(c)(3) pending

Content licensed under Creative Commons 3.0 by SMAC, Ltd. May be freely distributed, with attribution.

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