We should stop punishing addicted people for being addicted

Earlier this month, a BBC news magazine report explored a new, controversial drug law in Australia’s Northern Territory targeting alcohol problems among aboriginal people. In short, the new law entails that problem drinkers can be forced into treatment. Drinkers who go on to escape from rehab three times face a jail sentence. This will cost around $95m (US) over three years. The measure is presented in the article as an initiative that originates (at least partly) from the aboriginal community themselves, who are fed up with the effects of alcohol, in particular alcohol- related violence. Aboriginal people in the Alice Springs area are 31 times more likely to die from alcohol-related causes than other Australians.

So, as the article wonders, is forced rehab a solution for Australia’s aboriginal problem drinkers?

It is interesting to contrast the argument for forced rehab as a way to keep people alive with another article that appeared in The Conversation this month, “Addiction Can’t Always be Cured, So Let’s Focus on Quality of Life”. If ongoing problem drinking is caused by people failing to seek treatment, rather than by a lack of instant effective treatment for addiction, than the forced treatment and the criminalization of drop-outs sounds like an effective measure. But what if there is no easy cure available for addiction? According to the article, addictions last, on average, for 27 years. (Researchers Emmelkamp and Vedel estimate that recovery takes about an average of 8 years ), usually with several relapses during that period.) The above cited article from The Conversation contrasts two approaches to treatment, one which seeks to treat addiction the way we would a broken leg, and the other, the recovery movement, which acknowledges that recovery takes a long time and entails more than just to stop using drugs or alcohol. Many users have stated that the quitting is not the hardest aspect of recovery, but rather the staying clean. The recovery movement doesn’t focus on getting clean, but on quality of life. This is more than just harm reduction or the prevention of diseases related to addiction, but rather a focus on creating a positive identity and meaningful social relationships.

An interesting study in this context is the so called ‘rat park experiment’. This experiment showed that rats who lived in large cages where they could socially interact with each other, and where they had toys to keep them occupied, reacted totally different to the possibility of administering themselves with heroin than rats who lived alone in small cages. Where the latter administered themselves with heroin, sometimes even until they died, the rats in the larger cages (even when they were brought up in the smaller cages) showed less interest in the water containing heroin and preferred the plain water, even when the heroin water was sweetened on top of it.

So, regardless of the strong emphasis on evidence based treatment in addiction, many treatments are not really effective, especially not in long term, and the chance of relapse is especially high if people return to their old environment. Forced treatment, with its punitive connotation is probably less likely to be effective (one doctor estimates the success rate of forced treatment to be less than 10% once they return to the community ) than a more environmental approach that focuses on the quality of life of aboriginal people. The quality of life of aboriginal people in the Northern Territory is on average very low.

In the article on forced treatment of aboriginal people, the kind of treatment they are forced to undergo is not specified.

There is however, one promising treatment that focuses both on getting clean and on enhancing someone’s quality of life, the so called “contingency management”. The basis of this treatment is that people get a reward for every clean urine sample they provide. The first reward they receive is rather small, but the longer they continuously provide clean samples, the larger the reward gets. The rewards are either money, or vouchers, for example to go to the cinema or zoo for 2 people, or a family. In that way the vouchers reinforce social relationships and quality of life.

This treatment is proven effective, yet public and political support for this treatment is very low. People feel that it is wrong to reward people for doing the right thing when they were doing wrong in the first place. The lay vision is that treatment of addiction should be in line with contemplating your sins rather than helping people to create a ‘rat park like’ environment. The strong emphasis on the blurring of treatment with criminal offences reflects this attitude. But is this attitude correct even when the source of addiction lies in large part in social disadvantage?

The 95 million dollars over 3 years set aside for forced rehab could also be used to provide people with an incentive to stay clean and at the same time improve their living condition by using the money like a kind of micro finance. We should stop punishing people for addiction, without proclaiming a ‘right to rot’. It would be very interesting to see the results of applying contingency management as (forced) treatment for this disadvantaged group in Australia, to see if people manage to use the money to improve the quality of their lives in a way they perceive to be meaningful.

 

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10 Responses to We should stop punishing addicted people for being addicted

  • Nicholas Shackel says:

    I agree that we should stop punishing people for addiction, but the reason is precisely that they do have a right to rot and our infringement of that right is immoral. So even if forced rehabilitation actually worked it still wouldn’t be right. Worse yet, the assumption that for all addicts the only better life is not to be addicted is almost certainly false. If we didn’t impose enormous costs on addicts (by taxes on alchohol, using doctors and chemists to impose arbitrary procurement costs and by making other sourcing of drugs illegal) their lives would be much better, and for some might even be their best life. After all, people take drugs for the perfectly good reason that it is pleasurable. So the issue is not only a right to rot, but a right to lead your own life.

    That being said, I quite agree that if you do think that addiction is a disease requiring treatment then instrumental rationality requires taking the most effective means, which in this case may well be rewarding addicts. Unfortunately public policy is almost never instrumentally rational and that must make one wonder whether the stated goals really matter at all: politicians just do whatever makes them look good and the consequence can go hang.

    The question of whether it can be right to reward a wrong-doer if that is effective in stopping the wrong-doing is subtle, but my suggestion would be that the more you find rewarding addicts a persuasive thing to do the less you actually thing what they are doing is wrong. Indeed, the fundamental problem here is that people think addiction is either immoral or irrational but it is not immoral and it need not be irrational.

    • Anthony Drinkwater says:

      I agree largely with what you and Anke say, Dr Shackel : helping and encouraging people is going to be more effective than punishment and penalisation which is often counter-productive.
      But your “right to lead one’s own life” is, I fear, simplistic. Alcoholics, and other addicts, have partners and children who can suffer terribly from the addiction. No man (or at least very few of us) is/are an island.
      It’s not a question of wrong-doing per se – but it can be immoral in its consequences on other people’s lives.

      • Anke Snoek says:

        Thanks Anthony for the point you made. The demand for forced treatment came mostly from the family members of the affected people, and alcohol dependent people often suffer most about the hurt they are causing their families and the social isolation they experience. For most people the right to lead one’s own life is highly interwoven with their relations to other people and their relational autonomy.

      • Nicholas Shackel says:

        Yes, but then the wrong is what they do, not the addiction. The others are not suffering terribly from the addiction but from what the addict does, for which the addict is responsible and should be held responsible.

    • Anke Snoek says:

      Thanks for your comment! I am quite skeptical about the idea that an addicted life can be a good life. Although it can be true for the happy few I think we must be especially critical of the notion of the ‘good addicted life’ in disadvantages groups. Although it can be the best option in the few options people have, than still I think it is more moral to offer people alternative options than to respect their rights to rot. Although I agree with you that it is not entirely moral to force this upon people, and people still should have a choice in if they want treatment and what kind of treatment they would prefer.

      • Nicholas Shackel says:

        Yes, we should immediately offer people the alternative option they would have if we stopped actively making their lives worse by taxing alcohol, using doctors and chemists to impose arbitrary procurement costs and outlawing drugs. That is the sense in which addicts are disadvantaged and we could get rid of it tomorrow. Your claim that there is something more moral than this to be done is wishful thinking: we have decades of evidence that such attempts do not work.

        • Nicholas Shackel says:

          PS: In my remark about wishful thinking I was assuming that by ‘something more moral than this to be done’ you meant something other than offering voluntary treatment for addiction. But if that was all you meant, well, we were already in agreement over that.

    • Claudia says:

      Nicholas & Anthony, I believe that you are quite rightly following the baselines of Learning Theory, where one learns through direct reinforcement. By placing rewards, this is seen as positive reinforcement, where something (vouchers for the cinema or the zoo), which is a much much better solution long term wise than punishment, where Bandura himself, the conduct of this whole theory, found that did not last long and proved ineffective.
      So in summary, positive reinforcement by adding positive things to a person’s life, helps them to learn much better than punishment itself, under Learning Theory (Bandura)

      Just out of curiosity, what exactly do you mean by the fact that addiction can be not immoral? How can one justify that being addicted to substances largely frowned upon society (alcohol and drugs) as not immoral?

      Thanks!

      • Nicholas Shackel says:

        “How can one justify that being addicted to substances largely frowned upon society (alcohol and drugs) as not immoral?”
        First of all, I don’t have to. The burden of proof lies on the person who claims it is immoral. Absent such a proof the presumption is that it is not immoral. Secondly, being a substance frowned on by society proves nothing about whether being an addict is immoral. Insofar as society frowns upon alcohol and drugs it is wrong to do so. People who drink and take drugs are not stupid: they do if for the perfectly good reasons that these are means to pleasurable and interesting experiences.

  • Anke Snoek says:

    Nicholas, thanks for your comment. Although I agree with you that substance use is not immoral, I think it is for another reason, and this reason is exactly that at a certain point during the course of substance use, substances are not taken for the perfectly valid reasons they were taken before, but either because of physical habituation or because people think that it is one of the few options they have left in life. Different research in neuroscience and economics have shown that the role of reasoning and pleasure significantly changes during the course of use. http://www.ncbi.nlm.nih.gov/pubmed/24093020

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