From Badness to Sickness:
The Medicalization of Addiction
Drugs & Society
Instructor: Sarah Whetstone
medicalization
• The process by which human problems come to be defined
and treated as medical issues
– Issues as individual pathologies
– Physiological causes
– Biomedical interventions
• Human life seen on a sickness-wellness continuum
• Stages
– Conceptual: medical vocabulary used to define a problem
– Institutional: medical personnel become gatekeepers for
knowledge and resources
– Interactional: physicians treat patients’ issues as medical
problems
medicalization as a continuum
minimal
medicalization
partial
medicalization
full
medicalization
spouse abuse
opiate addiction
death
sexual addiction
PMS
childbirth
obesity
cancer
gambling addiction
• More stigma
• Criminalization
• Emphasis on moral responsibility
• Less stigma
• In the realm of professional medicine
• Illness considered beyond patient’s control
Disease Model of Addiction
• Alcoholism as disease- mid 1800s
• Addiction as disease- late 1800s
• Early notions were differently applied
• Elements:
• Chronic – remission is possible, never “cured”
• Relapsing
• Progressive
• Fatal if left untreated
• Loss of control
• Preoccupation
• Intense craving
• Continued use despite negative consequences
Contemporary Addiction Science: The
NIDA Perspective
– Who will have an addiction problem?
• Estimates that about 10% of the population will develop an
addiction
– Three notions of “brain disease”:
• Genetic predisposition
• Brain “plasticity” or chemical re-wiring
• Psychology of cognitive-behavioral conditioning: Action of
dopamine in pleasure-reward circuitry is fundamentally changed
with repeated drug use: dopamine depletion
– Despite advances, mechanisms are still not very
understood
Decreased Dopamine Transporters in a
Methamphetamine Abuser
Methamphetamine abusers have significant reductions in dopamine
transporters. Source: Am J Psychiatry 158:377–382, 2001.
Medicalization of Addiction: Group
Discussion
1. What does Reinarman mean that addiction is a “discourse” that is
“accomplished?” Who were the moral entrepreneurs who sought to transform
addiction into a medical problem instead of a criminal one? Give an example of
addiction as historical accomplishment, political accomplishment, and
interactional accomplishment.
2. Characterize the major forms of treatment discussed in readings from the past two
weeks: Alcoholics Anonymous, residential therapeutic communities, and
methadone maintenance therapy. How does each program define the problem of
addiction, and what does each program see as the best route to recovery?
3. Summarize Fox’s main argument about the treatment models she studies. What
does Fox mean that there are “hidden arguments in scientific claims?” What
assumptions are made about alcoholics in AA v. heroin addicts in methadone
therapy?
Types of Abstinence-Based Drug Treatment
• Chemical Detoxification
• Drug-Free Outpatient/Inpatient Rehabilitation
• Self-Help Groups (Alcoholics Anonymous, Narcotics Anonymous,
etc.)
• Residential Therapeutic Communities
• Court-mandated programming
• Methadone Maintenance
– Begins to challenge abstinence-based perspective
Interventions
Harm Reduction/Needle Exchange
Detox
Vaccines
Therapeutic communities
Opiate maintenance
Mainstream Psychology
Drug Court
Alcoholics Anonymous/ 12 Steps
Medical therapies
Lifestyle changes
MEDICAL
ADDICTION IS A
BIOCHEMICALLY
ROOTED DISEASE
MORAL
ADDICTION IS A
PROBLEM OF THE
“WHOLE PERSON”
Program Philosophy
How People Start Outpatient Treatment
Where are People Going to
Treatment?
“Hidden Arguments” of AA v
MMT
• AA – global fellowship founded by Bill
Wilson and Dr. Bob Smith in 1935
• Methadone Maintenance Therapy – Methadone
first applied to therapeutic program by
Dole & Nyswander in the 1970s
• Hidden argument about class in each
treatment paradigm:
– Methadone patients needs supervision, while
alcoholics in AA can “treat themselves”
– Self control and willpower are “middle class
values”
Drug Courts: Social Context
• 1989 - Miami-Dade County, Florida
• Now over 2,300 drug courts nationwide
• Criminal Justice Policy Foundation: In 2004, 25% of
people in rehab facilities were referred from court,
prison, probation, or other diversion programs.
• Social factors leading to drug court movement:
– Prison overcrowding, budget crises
– Renewed interest in rehabilitation, research showing link between addiction
and crime
– More power for judiciary after mandatory minimum guidelines
– A bipartisan project: Addressing drug war issues, but still not “soft” on crime
– Cost effective
Addiction & Criminality
• Estimated costs of drug-related crime to society in 2012: $107
billion
• Total cost of drug war to date: over $1 trillion (Drug Policy
Alliance)
• In 2011, about half of the federal prison population was there
for a drug offence.
• In 2004, almost 1.5 million arrestees are at risk of drug abuse
or dependence (Urban Institute).
• 53% of people in state prison were estimated to have a drug
problem, and only 15% were receiving treatment.
The Drugs-Crime Connection
Psychopharmacological
model: substance use
incites short term
aggression or violence
Systemic model: crime
is intrinsic to
involvement with illicit
drug trade
Economically
compulsive model: drug
users engage in
economic crime to
support habit
“Subculture” model:
crime and drug use
coincide and flourish as
a response to structural
constraints
Drug Court Basics
• Drug defendants are “sentenced” to treatment
instead of traditional criminal justice response
• Deferred prosecution v. post-adjudication
models
• Eligibility: established history of substance
abuse problems, non-violence offences
• Three shared characteristics:
– Coerced treatment with maximum judicial power
– Heavy level of surveillance and long term rehab
– Strict reward-punishment system in a therapeutic
community setting
How do drug courts work?
For a minimum term of one year, participants are:
• provided with intensive treatment and other services they require to get
and stay clean and sober;
• held accountable by the Drug Court judge for meeting their obligations to
the court, society, themselves and their families;
• regularly and randomly tested for drug use;
• required to appear in court frequently so that the judge may review their
progress; and
• rewarded for doing well or sanctioned when they do not live up to their
obligations.
Source: National Association of Drug Court Professionals
Drug Court Eligibility in Hennepin County:
Targeting the “High Risk- High Need”
• High Risk
– Under age 24
– Started using drugs at or under
age 13
– First criminal conviction at or
under age 15
– Unstable living arrangements or
periods of homelessness
– Unemployed
– Prior failure in rehab
– Failures to appear in court
– “Deviant peer associations”
• High Need
– Physical addiction to drugs or
alcohol
• Withdrawal syndrome
• Binge use and loss of control
• Cravings or compulsion
– Major mental illness
– Chronic substance-abuse related
health problems
Drug Court Readings: Discussion
Questions
1) What does it mean that something is “partially medicalized?”
Why does addiction reflect this, according to Tiger?
2) Why are drug courts concerned with more than just the
offender’s sobriety? Draw specific examples from both the
Kaye and Tiger articles of how treatment targeted other
goals.
3) What do you think of the idea, posed by Kaye, that the courtmandated rehab is a “mini-prison?” Do you think the tactics
described in his article are effective?
4) Do you agree with drug court advocates’ claims that “force is
the best medicine?” Make a list of both supporting
arguments and critiques of the drug court, pulled from the
readings due today.
Perspectives on Drug Court
PROS:
- Reduction in drug use/recovery
from addiction
- Coerced treatment gets better
results
- Recidivism (decreased re-arrest or
reconviction)
- Cost savings
- Restored lives and reunited
families
- Productive citizens
- “Tough love” approach more
compassionate than prison
- Addresses roots of crime, for some
drug-involved offenders
- Provides social supports
1
2
3
4
5
6
7
8
9
CONS:
10
- Net-widening
- Increased sentence length or
11
severity
- Suspends due process, violates
12
basic rights
- Racial disparities – African
13
Americans disadvantaged in
selection process and in treatment
success
- Focuses on individual rather than
social solutions for addiction
14
- A medical framework silences
social factors like role of racial bias
in mass incarceration
(depoliticization)
15
Methadone Maintenance Therapy
• Late 1960s – Jerome Jaffe established experimental
methadone program
• Methadone first applied to a therapeutic program by Dole &
Nyswander in the early 1970s
• 1972- Nixon supported expansion of methadone programs
nationwide
• Crime rates fell, sometimes dramatically
• Deaths from heroin overdoses decreased
• 2/3 of Nixon’s original drug war budget went toward addiction
treatment
• Funding for treatment abandoned for “tough on crime”
approach to drugs in 1980s and 1990s
Dole & Nyswander’s Research
• Methadone patients stopped engaging in crime, “anti social”
behaviors ceased
• Psychogenic theory V disease theory
• Their argument: The consequences or symptoms of addiction might be
anti-social behaviors, but the cause is a metabolic response to drug craving
and withdrawal.
• Medical cause requires medical cure
• Suboxone – contemporary version
• Measure of success in MMT
• Not abstinence-based
• Meeting markers of social functioning and quality of life
• Changes notion of what constitutes treatment
• What is the end goal of recovery?
From Heroin
to
Methadonia