The inspiration for this post was reading one of The Economist’s Letters to the Editor in response to the magazine’s article, America's Syringe Exchanges Might Be Killing Drug Users. First, a passage from the original article:

“Needle exchanges opened across America and Europe. For years no one detected the feared rise in substance abuse. That was before the opioid crisis plagued America and economists started looking into the trade-offs. A new study by Analisa Packham published in the Journal of Public Economics uncovers an uncomfortable truth: this particular harm-reduction tool does lots of harm. Ms Packham compares how drug users fared in counties that opened syringe exchanges between 2008 and 2016 with those in counties that did not. Before the clinics opened, upticks in HIV diagnoses or overdoses in one set of counties were mirrored in the other. Once a syringe exchange came to town, outcomes diverged. Rates of HIV fell by 15% in counties with the new programme. But deaths soared. On average syringe-exchange programmes led to a 22% spike in opioid-related mortality.”.

Now, an excerpt from the letter:

“Your article, based on a single new study in a rapidly changing drug-use environment, did not reflect the wealth of research…the world needs to move away from failed, punitive, stigmatising approaches towards a human-rights, community-led approach, rooted in decades of experience and evidence.”

Which got me thinking: why would Packham's research findings lead to a punitive and stigmatising approach to drug abuse? A few thoughts...

A punitive approach to drug abuse uses the experience and threat of punishment to change the behavior of drug abusers. Punishment is supposed to act as a disincentive to bad behavior, but that only works if the person being punished has some control over their behavior. If they can’t help it, then punishment is cruel and ineffective. If they can help it but continue misbehaving anyway, then punishment might persuade them to change their ways. And the ability to change behavior in response to the experience or threat of punishment means one is, at least to some degree, responsible for one’s actions. The same goes for the ability to change behavior in response to incentives. In other words, if carrots and sticks change the behavior, then the person has at least some control over the behavior, which is another way of saying: if one is able to engage in goal-directed behavior (e.g. approach carrot, avoid stick), one is responsible to some degree for one’s actions and the outcomes of those actions.

That’s where “stigma” comes in. According to the World Health Organization (WHO), “stigma in the context of health is the negative association between a person or group of people who share certain characteristics and a specific disease, including mental illness”. Many in the rehab, medical and research community consider drug addiction a mental illness as well. For example, the National Institute on Drug Abuse (NIDA) classifies drug addiction as a mental illness and describes it as a brain disease. Per NIDA:

“Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control. Those changes may last a long time after a person has stopped taking drugs. Addiction is a lot like other diseases, such as heart disease … impairment in self-control is the hallmark of addiction.”

To many advocates of this view, drug addiction = brain disease = impaired self-control = not responsible/not to blame for one’s behavior or life outcomes. And per the voluminous literature on stigma, a common stigmatizing stereotype associated with mental health disorders such as drug addiction is that people are responsible for their condition. This explains the onslaught of criticism directed at Anne Packham’s research, which suggests that drug abusers change their behavior in response to perceived risk: decreasing drug use if only dirty needles are available and increasing drug use when needles are clean. That sounds like self-control to me.

The disease model of chronic drug abuse and addiction does not go uncontested, however. Just Google “rational addiction theory” (eg, Blondel, S., Y. Lohéac, et al., 2007), “decision-making and drug abuse” (eg, Cabedo-Peris et al, 2022), or “Free Will and the Brain Disease Model of Addiction” (Racine et al, 2017). There’s also plenty of research on the use of incentives, such as money, to motivate drug addicts to change their habitual behaviors (Silverman et al, 2019).

Of course, impaired self-control is not the same as absence of self-control. And abundant self-control doesn’t mean one can overcome any barrier to a happy and productive life. As they say, it’s complicated.

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References:

Blondel, S., Y. Lohéac, et al. (2007). "Rationality and drug use: An experimental approach." Journal of Health Economics 26(3): 643-658.  https://doi.org/10.1016/j.jhealeco.2006.11.001

Cabedo-Peris J, González-Sala F, Merino-Soto C, Pablo JÁC, Toledano-Toledano F. Decision Making in Addictive Behaviors Based on Prospect Theory: A Systematic Review. Healthcare. 2022; 10(9):1659. https://doi.org/10.3390/healthcare10091659

Fox AB, Earnshaw VA, Taverna EC, Vogt D. Conceptualizing and Measuring Mental Illness Stigma: The Mental Illness Stigma Framework and Critical Review of Measures. Stigma Health. 2018 Nov;3(4):348-376. . doi: 10.1037/sah0000104. Epub 2017 Sep 21.

Racine E, Sattler S, Escande A. Free Will and the Brain Disease Model of Addiction: The Not So Seductive Allure of Neuroscience and Its Modest Impact on the Attribution of Free Will to People with an Addiction. Front Psychol. 2017 Nov 1;8:1850. doi: 10.3389/fpsyg.2017.01850

Silverman, K., Holtyn, A.F. & Toegel, F. The Utility of Operant Conditioning to Address Poverty and Drug Addiction. Perspect Behav Sci 42, 525–546 (2019). https://doi.org/10.1007/s40614-019-00203-4