15
Treatment for Addictions: effectiveness and moral aspects in the coercive treatment v. voluntary treatment debate.
Student: Peter Timusk, B.Math, fourth year legal studies student.
Course: LAWS4306B Fall 2004, Criminal Law Issues: Drugs, Users and the State.
Professor: Dawn Moore, B.A.Hons. M.A. Ph.D. (ABD), assistant professor of legal studies, Carleton University Department of Law.
Date Due: 04-11-30
Date Submitted: 04-11-30
Introduction
“It is possible to overcome the desire to use drugs with the help of the Twelve Step program of Narcotics Anonymous and the fellowship of recovering addicts. ”1
While this expresses a hope for recovery from drug addiction, there is a debate as to whether treatment, and therefore recovery from addictions, should be voluntary or imposed. The difference between voluntary treatment and imposed treatment is critical in the legal field of drug control. This is a debate in the criminal law and a debate between civil liberties and parentalistic views and ultimately a debate about state control of public health. This paper will look at this debate and examine drug policy scholars who conclude that successful treatment needs to have both voluntary and coerced aspects.
We will look in this paper at at the work of George E. Vaillant who has questioned both ends of the spectrum from forced treatment to voluntary treatment and examine his suggestions and observations as to what works.2 We will also look at moral aspects of self help groups and hospital treatment programs. These will be considered here to be the more voluntary forms of treatment and we will regard these as 'soft' treatment. Some reference will be made to 'hard' treatment meaning lengthy jail sentences and more coerced treatment.
We will also look at the idea of addictions as a 'disease' and examine the work of drug policy scholars who question this definition. The placing of addictions into the disease category has many consequences; for instance it may mean that the addict is not responsible for her behaviour. Also the 'how' and 'what' of treatment depend both practically and philosophically on how we define addictions. The idea of a disease being an involuntary condition of the body will be contrasted with the idea of addictions being a voluntary activity that we can recover from without formal treatment. From a moral perspective, how we view addiction is significant both in the law and in our views of health and the body.
Let us start with a well known definition of addiction. For a person to be addicted according to the World Health Organization(WHO) they must fit this definition:
“addiction, drug or alcohol Repeated use of a psychoactive substance or substances, to the extent that the user (referred to as an addict) is periodically or chronically intoxicated, shows a compulsion to take the preferred substance (or substances), has great difficulty in voluntarily ceasing or modifying substance use, and exhibits determination to obtain psychoactive substances by almost any means.”3
Addiction might best be seen as a disease as the WHO look at addiction. This is how the 'soft' side, i.e. the voluntary treatment side view addiction. But there is a difference between how the medical or professional treatment providers and the self help groups view addiction. Both of these communities see addictions as a disease but the medical community view addictions more as a brain disease,4 whereas some groups such as Alcoholics Anonymous or Narcotics Anonymous see addictions as a spiritual disease,5 as well as, a medical condition.6
But the law and some scholars of addictions do not see it this way. In Canadian law, possession of 'drugs of abuse' is a crime. Certainly someone who is addicted to illegal substances must possess these substances to use them; so if possession is a crime, then addiction must be seen to be a crime. And if addictions and drug abuse are crimes then the treatment for these is a matter for courts, and corrections officials.
Stanton Peele argues in his book the Diseasing of America that the disease label should not be applied to alcoholism or other addictions.7 He feels that the use of the disease label is really problematic.8 On the other hand, some scholars have examined addictions as a chronic relapsing disease or as a brain disease and concluded addictions are not diseases, and that addictions and recovery are voluntary activities.
Canadian law and drugs.
People have been given some rights of control over their own bodies. The abortion debate in R. v. Morgentaler brings this into focus.9 In Morgentaler the courts found that a women has a right to control her own body. Other cases concerning medical consent also bring into focus the rights to control one's body and health even if one is disabled.10 Medical treatments generally require the patients informed consent. But the drug law apparatus says we cannot do what we want with our bodies. By legally restricting drug use we are controlling health and our right to take drugs. It can be argued that the drug laws take away our rights to control our bodies, or limit this right in a parentalistic way; on the other hand, so can treatment especially when it is coerced treatment.
The idea of coerced treatment is a key idea in treating the criminal addict. Coerced treatment is discussed by Anida Chiodo in the context of the drug courts, which offer a form of voluntary but coerced treatment.11 Chiodo explains the debate in terms of drug courts. In a drug court a criminal addict can choose treatment but this choice is coerced because the alternative is jail time. Where Chiodo sees a civil liberties problem, other scholars conclude that successful treatment cannot be totally coerced nor totally voluntary; instead there must a be the proper balance between these motivators.12 In a sense, both views agree that choosing treatment, when the alternative is hard time in jail may be a blend of voluntary but coerced treatment. In some sense, groups such as Narcotics Anonymous are a form of coerced treatment, although these self help groups or mutual help groups,13 are based on voluntary membership often at no cost or fee.14
Addictions treatment solutions
In the book Drug Addiction and Drug Policy: The Struggle to Control Dependence,15 treatment and other aspects of drug policy are examined from a demographic and experimental perspective.16 In particular, two authors examine longitudinal surveys to assess the effectiveness of 'treatment claims'. In one chapter by George, E. Valliant, titled If Addiction is Involuntary, How can Punishment Help?,17 Valliant concludes that neither 'soft' hospital programs, or 'hard' prison programs work.18 He suggests, that parole with strict employment conditions has been the best way to get someone away from drugs and away from drug using associates and keep that someone off drugs for an extended time.19 Valliant finds that this middle way using voluntary but coerced structured treatment to be the reason that a group of New York heroin addicts he studied in the middle 20th century over came their addictions.20 He analyzes the effects of both hospital programs and jail sentences on these men in the study group, and is also able to examine in the study, when they were in prison, when they were in hospitals, when they were employed, and when they were paroled.21 From this he concludes that by restoring order through supervised abstinence and supervised employment, both provided by the parole process, these men over came their addictions.22 Returning the addict to a structured existence includes such things as helping the addict maintain employment. Employment is key as this “...can reflect competence, social utility, and self esteem.”, says Valliant.23
Valliant's opening arguments about what has failed in drug law,24 lead him to discuss the nature of coerced treatment. He compares addiction with suicide and truancy problems that he claims we have gotten right, the balance of coercion v. civil liberties;25 and are similar parentalistic aspects of the law.26 He goes on to argue that restoring the social fabric is the broader health goal these men needed to stop using heroin.27 He does note that parole has changed since the 1950's and 1960's and that parole may have lost its effectiveness because of changes in quality and intensity .28
Another author in this book, Drug Addiction and Drug Policy, Gene M. Heyman, in the chapter Is Addiction a Chronic, Relapsing Disease?,29 attacks the claims of medical clinicians who assert a certain pessimistic view of recovery.30 Heyman uses large surveys of addicts empirically to compare these with clinical surveys. Hospital treatment programs in the clinical survey show high rates of relapse and this produces the pessimistic claims.31 Heyman also notes that this pessimism maybe a rhetorical tool for clinician, to use to help a patient recover from addictions.32 In comparison, Heyman, also examines, these other large surveys outside of the hospital treatment population, to show that, in fact, most addicts beat their addiction. He points to a well know study of returning Vietnam soldiers who were addicted to heroin and also larger survey data that gathered information about addictions and recovery. These studies showed that many addicts recover from addictions. Heyman says that the claims by the clinicians are wrong generally about addictions, but may be true for those treated in hospitals.33 This pessimism is unique to hospital treatment programs and seems not to occur in the larger populations of addicts in these other surveys.34 Heyman is careful to critique the use the these large surveys. He mentions factors like interviews for these surveys being done by lay persons not psychiatrists,35 the fact that drug use is illegal, so under reporting could occur,36 but successfully deals with these limitations.37 Heyman concludes in agreement with Valliant and Satel “that addiction is a voluntary behaviour” and that is really the environment, in terms of structured social fabric, that helps someone quit using drugs.38 In fact, Heyman comes to conclude that drug use and recovery is a voluntary activity, not an involuntary condition like a physical illness or disease.39 Further, Heyman's analysis of these large surveys show that addiction is not really a chronic relapsing disease. Because cessation of drug use can be brought about by rewards and punishments, addiction is not involuntary. But the problem he notes is that the harm from drug use is typically a long term effect and that short term effects of drug use are beneficial to the addict. Thus time horizons need to shift in the addict for recovery to happen.40
Stanton Peele also argues along a voluntary/non-disease v. involuntary/real disease dimension to say that addiction is not a disease. He argues that quiting drugs simply means we stop using them.41 Thus if we stop using we are not diseased. This is not the case for a disease like cancer or diabetes. We cannot choose with these real diseases to become non-diseased. Cancer or heart disease recovery is not voluntary to the same extent that addictions are. Like Heyman, Peele views this same real disease v. behavioral disease as proof that addictions are not a disease.42
Another drug policy scholar, Sally L. Satel also looks at this real disease debate by examining the current trend to see addictions as a brain disease.43 This is significant because if addictions are a brain disease, the addict is suffering involuntarily and thus criminal responsibility is not a given. Also if addictions are involuntary then this philosophical position effects how we view treatment and could effect how treatment is delivered. Satel in her chapter, Is Drug Addiction a Brain Disease? in Drug Addiction and Drug Policy, concludes that the addiction as 'brain disease' model, detracts from criminal justice solutions to addiction.44 Satel says we can gain a lot by restoring accountability and self control to addicts.45 The brain disease model takes away this dignity of self control. All of the scholars examined in this paper conclude that addictions, while serious problems are voluntary activities. Thus we can voluntarily choose recovery from addictions.
Addiction treatment as a moral enterprise
While programs like Narcotics Anonymous are voluntary treatment programs, courts often order people to attend these treatment groups and other forms of treatment.46 Although these self help groups may be voluntary, there is imposition of morals at some of these groups.47 We will now also examine this moral aspect of treatment.
Existing recommendations on what works in treatment are a prescription of what we 'should' do. Thus finding what works is also a moral prescription. It is this moral prescription that influences treatment so that treatment becomes not a medical procedure, but a moral procedure.
In the book What's Wrong with Addiction?48, Helen Keane questions and compares morals in the discourses of the medical community and the self help community.49 She questions the labeling of addictions as bad and certainly the law labels addictions as bad. In fact, for many addictions the law finds the use of the drug and thus the addiction a crime. Keane also says that there is very little admission of addictions as pleasurable and good in modern self help discourse.50
It would seem that admission of the facts concerning drugs should be equal and truth seeking. That is, both sides of a moral argument should be given to admission of the facts. So that while some may be allowed to say for instance, that smoking is harmful to the health, others must be allowed to say that smoking is fun, cool, and pleasurable. But the post-modern world is directed by the 'moral right' and seems to be not seeking the truth, but instead weighted to quick impulsive judgments of wrongful behavior. In other words, the 'new moral reality' seems to favour moral panics as drug law formation has in the past.51 It is argued by Keanes and Michael Dorn,52 a geographer of disabilities, amongst others that the medical model of addiction is a moral enterprise. Moral improvement is also the method of treatment of the anonymous self help movement groups such as Narcotics Anonymous. This allows the law to prescribe morals by prescribing drug treatment for criminal addicts. These morals are not a 'take it or leave it' affair. The whole benefit of anonymous groups is to provide social fabric to the addict by improving their standing in society. This imposition of Christian morals and personal productivity is the only way the addict is told that they can voluntarily recover from addictions. So while on the hard side there is perhaps a growing voluntary component to the treatment enterprise, on the soft side there is also a bifurcation between voluntary and coerced treament. Even drug courts are imposing a moral value in treatment programs where the addict is required to be honest about drug use.
Peele takes issue with legislation in the USA requiring treament,53 and court ordered Alcoholics Anonymous attendence.54 Peele was writing in 1989 and at that time Peele took issue with George Valliant. Valliant was strongly for Alcoholics Anonymous treatment. Valliant's more recent position appears to be modifided to include a legal coercement view. Although Valliant now sees Alcoholics Anonymous as a coerced form of treatment as well, he does not agree with Peele that there is anything morally wrong with this.
It is worth while to close this discussion of morals in self help groups with a qualification. Not all self help groups have a spiritual dimension.55 The tendency is to examine only the big groups like Alcoholics Anonymous or Narcotics Anonymous,56 and both of these groups have a spiritual, although perhaps secular program of recovery.57 But other groups helping with addictions may not involve spiritual recovery. So the assertion that self help groups impose morals is not true in all cases. From the same source, Keith Humphreys' global study of self help groups for addicts,58 he notes studies that show Alcoholics Anonymous may have only a slight effect on reducing crime rates.59
Summary
The questions of addictions as voluntary or involuntary has been been briefly examined in this paper with a general view that addictions should be considered voluntary, behavioural phenomena. Also we have examined treatment and scholars who suggest that treatment should be coerced but should also be voluntary. Lastly, we have briefly examined self help groups as a voluntary alternative for treatment, but that in many cases these groups are prescribing morals on the addict and this makes these groups also a coercion.
Conclusion
The positions of scholars in drug policy are significant in drug law. Certainly we should know that addictions are not diseases but may not be easy to cope with, both in legal terms and in terms of staying drug free. Legal drugs are everywhere in our society; as well as, the legal drugs, illegal drugs have been popular and widely available to many people in Canada. It should be the case, that treatment for addictions be well researched, and that treatment should be highly available both in our public health system and in our legal corrections system. It should also be the case that treatment should be effective and that if someone voluntarily chooses to quit illegal drug use, this choice should be supported by our legal authorities and by our society at large. The continuing academic study of drug policy will only help in this regard.
It is fine to say that drug use is voluntary, but this does not mean treatment need only be voluntary. Although ideally we would hope an addict would choose to enter recovery, in some cases we may need to forceably help the addict. It should be obvious too, that forcing treatment means we are in effect forcing a moral view on the addict. If we can accept this then we are a happy with the status quo. Bu if we want to have more liberties, we must find a balance of coerced and voluntary treatment that does not require an imposition of morals. This is a challenge we must all take up to improve the lives of the criminal addict; and thus reduce the criminal harms and health effects of addiction.
Bibliography
Chiodo, Anida. “Sentencing Drug-Addicted Offenders and the Toronto Drug Court” (2002) 45 Crim. L.Q. 53.
Cohen, Stanley. Folk Devils and Moral Panics, 3rd ed. (London: Routledge, 2002).
Dorn, Michael. L. The moral topography of intemperance in Butler, Ruth and Parr, Hester. eds., Mind and Body Spaces: Geographies of Illness, Impairment and Disability (London: Routledge, 1999) at 46-69.
Giffen, P.J., Endicott, Shirley & Lambert, Sylvia. Panic and Indifference: The Politics of Canada's Drug Laws (Ottawa, Ont.: Canadian Centre on Substance Abuse, 1991).
Heyman, Gene M. Is Addiction a Chronic, Relapsing Disease? in Heyman, Philip B. & Brwonsberger, William N., eds., Drug Addiction and Drug Policy: The Struggle to Control Dependence (Cambridge, Mass.: Harvard, 2001) at 81-117.
Heyman, Philip B. & Brwonsberger, William N. eds., Drug Addiction and Drug Policy: The Struggle to Control Dependence (Cambridge, Mass.: Harvard, 2001).
Humphreys, Keith. Circles of Recovery: Self Help Orgnizations for Addictions (Cambridge, UK: Cambridge, 2004).
Keane, Helen. Smoking, Addiction, and the Making of Time in Brodie, Janet Farrel & Redfiled, Marc. eds., High Anxieties: Cultural Studies in Addiction (Berkeley, Cal.: University of California Press, 2002).
Keane, Helen. Whats Wrong with Addiction? (New York: New York University Press, 2002).
Leukefeld, Carl G. Tims Frank & Farabee, David. eds., Treatment of Drug Offenders: Policy and Issues (New York: Springer, 2002).
Narcotics Anonymous, For the Newcomer (NP: Narcotics Anonymous World Services, Inc.1983) on-line <http://www.na.org/ips/eng/IP16.htm> (cited October 29, 2004).
Peele, Stanton. The Diseasing of America: Addiction Treatment Out of Control (Lexington, Mass.: Lexington, 1989).
Sally L. Satel, Is Drug Addiction a Brain Disease? in Heyman, Philip B. & Brwonsberger, William N., eds., Drug Addiction and Drug Policy: The Struggle to Control Dependence (Cambridge, Mass.: Harvard, 2001) at 118-143.
Valliant, George, E. If Addiction is Involuntary, How can Punishment Help? in Heyman, Philip B. & Brwonsberger, William N., eds., Drug Addiction and Drug Policy: The Struggle to Control Dependence (Cambridge, Mass.: Harvard, 2001) at 144-167.
World Health Organization, Web Site, <http://www.who.int/substance_abuse/en/> (Cited September, 30, 2004).
1Narcotics Anonymous, For the Newcomer (NP: Narcotics Anonymous World Services, Inc.
1983) on-line <http://www.na.org/ips/eng/IP16.htm> (cited October 29, 2004).
2George, E. Valliant, If Addiction is Involuntary, How can Punishment Help? in Heyman, Philip B. & Brwonsberger, William N., eds. Drug Addiction and Drug Policy: The Struggle to Control Dependence (Cambridge, Mass.: Harvard, 2001) at 144-167.
3World Health Organization, Web site <http://www.who.int/substance_abuse/terminology/who_lexicon/en/> (Cited September 30, 2004) at “addiction”.
4Sally L. Satel, Is Drug Addiction a Brain Disease? in Heyman, Philip B. & Brwonsberger, William N., eds. Drug Addiction and Drug Policy: The Struggle to Control Dependence (Cambridge, Mass.: Harvard, 2001) at 118. See also infra note 13 at 38.
5Ibid. at 121.
6Ibid.
7Stanton Peele, The Diseasing of America: Treatment Out of Control (Lexington, Mass.: Lexington, 1989) at 3.
8Ibid. at 26-29.
9Morgentaler v. The Queen (1988), 44 D.L.R. (4th) 385.
10Re Eve (1986), 31 D.L.R. (4th) 1 (S.C.C.).
11Anida Chiodo, “Sentencing Drug-Addicted Offenders and the Toronto Drug Court” (2002) 45 Crim. L.Q. 53 at 80-84.
12Supra note 2 at 145.
13Keith Humphreys, Circles of Recovery: Self Help Orgnizations for Addictions (Cambridge, UK: Cambridge, 2004) at 13.
14Ibid. at 16.
15Philip B. Heyman, & William N. Brownsberger, eds. Drug Addiction and Drug Policy: The Struggle to Control Dependence (Cambridge, Mass.: Harvard, 2001).
16Ibid. at 3-17.
17Supra note 2.
18Ibid. at 146.
19Ibid. at 154.
20Ibid. at 151.
21Ibid. at 151-157.
22Ibid. at 160.
23Ibid. at 155.
24Ibid. at 145.
25Ibid. at 144.
26Ibid.
27Ibid 152-155.
28Ibid. at 157.
29Gene M. Heyman, Is Addiction a Chronic, Relapsing Disease? in Heyman, Philip B. & Brwonsberger, William N., eds. Drug Addiction and Drug Policy: The Struggle to Control Dependence (Cambridge, Mass.: Harvard, 2001) at 81-117.
30Ibid. at 83-84.
31Ibid.
32Ibid. at 84.
33Ibid. at 95-99.
34Ibid. at 95.
35Ibid. at 110.
36Ibid. at 110-111.
37Ibid.
38Heyman, Philip B. & Brwonsberger, William N. eds., Drug Addiction and Drug Policy: The Struggle to Control Dependence (Cambridge, Mass.: Harvard, 2001). at 8.
39Supra note 29 at 107.
40Ibid. at 103.
41Supra note 7at 6.
42Ibid. c. 2.
43Supra note 4.
44Ibid. at 140.
45Ibid. at 140-141.
46Supra note 7 at 221.
47 Ibid. at 44.
48Helen Keane, Whats Wrong with Addiction? (New York: New York University Press, 2002).
49 Ibid. at 70.
50 Ibid. at 84.
51P.J. Giffen, Shirley Endicott, & Sylvia Lambert,. Panic and Indifference: The Politics of Canada's Drug Laws (Ottawa, Ont.: Canadian Centre on Substance Abuse, 1991) c. 2. See also Stanley Cohen, Folk Devils and Moral Panics, 3rd ed. (London: Routledge, 2002) at xiii.
52 Michael L.Dorn, The moral topography of intemperance in Ruth Butler and Hester Parr, eds. Mind and Body Spaces: Geographies of Illness, Impairment and Disability (London: Routledge, 1999) at 47.
53Supra note 7 at 227-229.
54Ibid. at 221.
55Supra note 13 at 18.
56Ibid. at 11.
57Ibid. at 18.
58Supra note 13.
59Ibid. at 125.