Saturday, April 07, 2007

Free From Bondage

Through this Holy Week, "All Things Considered" on NPR has been running a series on The Forgotten War on Drugs. (I'm not sure that there's any intentional correlation with Holy Week. That's just an easy way to tag it in my calendar.) Thursday's report included this:

Peter Reuter, a longtime drug policy researcher at the University of Maryland, says studies show that treatment — even "not very good" treatment — is cost effective.

"Just getting people to cut down from using heroin three times a day to just twice a week, which is what you get while people are in treatment, will cut down on their criminality a lot," he says. "That reduction in crime has huge value, and the cost of providing treatment — particularly not very good treatment — isn't very high. Locking people up is very expensive."


So, putting addicts into addiction treatment is cheaper than the paying for the incremental costs for public safety personnel if the same addicts are out on the street. Whatever benefits treatment may have for the individual addict, treatment makes the rest of us safer and so costs us less money.

So why, then, have we spent more money - so much more money! - on law enforcement and corrections, than on treatment? The NPR report speaks of two possible reasons. The first is that there is so much of enforcement that is measurable, guantifiable: so many arrests made, so many pounds or kilos or tons siezed, valued in so many dollars. It is honestly hard to quantify some measures of treatment, and can appear distressing: how many patients post treatment are still clean at one month or one year or five years. Those numbers, those percentages go down, because some patients - perhaps most patients - relapse, and those declining values can look depressing, even disturbing. Indeed, the one number that is easily measured is how many dollars go into treatment; and like other healthcare costs, that number goes up without any increase in actual treatment.

The second reason suggested is that enforcement is sexy in a way that treatment isn't. We have seen on TV and in movies of the dramatic struggles and the dramatic successes of law enforcement. Sure, most of the stories are fiction; but the literary form is so compelling that news and documentary pieces take on the same "plot."

Enforcement is "sexy," too, to politicians and enforcers because it can drive acquisitions. All the "cool tools" - the planes and helicopters and radar systems and fast boats - have more than one possible application. Today's drug enforcement tool might be used tomorrow for homeland security or defense. This can excite people in enforcement (and the military), people who develop and build the equipment, and the elected officials whose districts are affected. A new fast chase boat can be a whole lot more exciting than new hospital rooms, even at the same price (and, no, I don't know for certain that they are the same price; but I know these toys aren't cheap).

Still, I fear there is another reason that politicians favor enforcement over treatment, and it's a moral one: it's easier to feel superior to addicts as criminals (and the criminals who maintain them), than for addicts as patients. It is easier for "us" to distinquish ourselves from "them" if "they" have bad morals than if "they" have a treatable disease.

I have seen that commonly when speaking with folks about the disease concept of addiction. Considering addiction as a disease can make a number of things easier. One can present clear symptoms, both physical and behavioral, and a predictable course for the disease. One can present treatment, and can discuss the affectiveness of various interventions, both medical and behavioral. Whether one wants to see it as demonstrated science, or as very good analogy, the concept has its strengths.

Many, however, still resist the disease concept, and most come down to the same point: "It lets the addict off the hook!" And they have a (limited) point. If addiction is a disease, the responsibility of the addict is limited: the addict didn't choose to be addicted. And, responsibility for some behavior is limited: the disease of addiction is at least in part psychological, and we don't hold fully responsible those with other psychological impairments.

At the same time, the disease concept does leave the addict responsible in many ways. The addict is certainly responsible for the first use, and for every use of the addictive substance until control is lost. No one becomes addicted without choosing to use. At some point the addict becomes responsible for living with the disease. That isn't really that hard a concept. Diabetes, high blood pressure, and allergic disorders require some responsibility on the part of the sufferer. Bad choices can cause illness, deterioration, and death. The addict in recovery is also responsible for living with the illness, for demonstrating healthy behaviors and maintaining the health support system that keeps the addict clean and sober. The addict is also legally responsible for crimes committed, and morally and emotionally responsible for harm done in family and other relationships. So, while the addict using is in some ways limited in responsibility, the addict prior to use or in recovery certainly isn't "off the hook."

The disease concept has another advantage: it reduces shame if the addict suffers a disease. For those concerned about responsibility, that’s not an advantage. After all, shame is the appropriate response, isn’t it, for moral failing? However, shame also brings about hiding and secrets. It encourages the addict to hide the problem; and that discourages the addict from seeking help. However help may be available – treatment, 12-step programs, therapy – the addict will not seek or accept it if it he or she is ashamed; any more than we are likely to address our own sins and shortcomings if we are ashamed. If we are guilty for what we have done, we may seek to correct and redress. If we are ashamed – convinced we are not worthy of forgiveness, of correction – we will simply hide. To think the addict somehow different is to think the addict less than human.

But those who favor enforcement over treatment cling to that fear of letting the addict off the hook, and call for accountability – and prison. They don’t do that only for drug crimes. Look at the growth in the number of prisons, and the number of inmates in them, in the past generation; and then think of how many of those incarcerated have been nonviolent drug offenders – users found holding, rather than dealing. We might well have saved some money putting those folks into treatment, even long term treatment. Instead, to “hold them accountable,” we have them in prison.

But, after all, it is hard to feel ourselves superior to folks who have a life-changing, even life-threatening disease than to folks who are morally weak. Sometimes, it is easier to fear less our own inhumanity if we can find someone we can point to as less than human.

Tomorrow we will give praise and thanks for all that God has done, and especially what God has done in Christ, to set us free from sin and death – from our own vices, our own inhumanities. Let us remember those whose lives, whose sins, know real bondage in addiction. Let us remember them, praying for their liberation in this world even as we give thanks for our liberation, and theirs with us, in the next. And, let us remember them when politicians want more money for “the war on drugs.” Perhaps its time to bring those victims home, to treat their wounds, and not simply to lock them away. We will be part of offering them new hope and new lives. And, who knows? We might improve our safety and save some money along the way.

2 comments:

bls said...

I can understand the idea that the "disease concept" might be construed as "letting people off the hook" for what ought to be considered a moral failing.

The problem, though, is that so many of the people I've known in recovery were abused dreadfully - both physically and emotionally, and sometimes sexually - as children. You just can't claim that people like this are flouting societal norms and ought to straighten up and fly right; what they are doing is self-medicating in order to survive long enough to get some help.

So many people are just plain damaged, and thus the notion of "moral failing" just can't apply. I really think many people don't appreciate how difficult it is to deal with the world under the burden of that sort of background. This is why, also, recovery often takes such a long time and involves numerous relapses; people have to start from scratch in rebuilding their own psyches. It's really very difficult.

Marshall said...

bls, I agree with you; but it's still a hard concept. First, we're heavily acculturated to a "bootstraps" mentality, and often feel threatened by the thought that anything might be out of our control. So, encountering someone who is certainly out of control is frightening to some folks.

The same issue, sadly, can be applied to abuse victims. How often have we heard the question of why an abused spouse stays with the abuser?

Some of us fear for ourselves losing that sense of rationality, and so fear what seems to us irrational. But in all these cases, we're not talking about folks who are really irrational, so much as limited in perspective. Within the world as they see it, their behavior is logical. It's their premises that the rest of us would question. What you note, and I would affirm, is that it isn't that easy to reset the premises. It isn't that easy to help another person find a new vision of himself or herself. Even a more positive self-image can feel like a threat to what self-image the victim has maintained in the face of fears and struggles and bondage.