Drug Addiction and Treatment for the 21st Century

What makes the drug debate seemingly never-ending, and what impact does this have on the drug-dependent individual? First it is necessary to understand what actually constitutes and drives this debate. Vehement opposition displayed by certain authorities to individual ideologies may actually be a preventative factor in finding a workable solution. To make sense of this apparent contradiction, we need to examine possible motivations for preventing a solution. Indeed there may be advantages in avoiding a solution. If so, who stands to benefit and at whose expense?

The Australian drug debate, for example, is focused on two major opposing philosophies; zero-tolerance policy which advocates abstinence from heroin achievable by treatment with the opioid antagonist drug naltrexone, and liberal drug policy operating via a harm minimisation strategy which supports maintaining the addiction illness using substitution drugs such as methadone in place of heroin.

As with many debates, we focus on polarised views instead of making an effort to find the common ground. For example, one could examine how the positive attributes of each treatment alternative could be harnessed to form a collaborative solution. In practice, although Australia has a zero-tolerance national drug policy, it appears to favour the harm minimisation approach in adopting the methadone treatment program as its 'gold standard' (O'Connor 2005). This could be viewed as somewhat of a fence-sitting strategy, however this position also provides the potential for future cooperation between factions.

While a liberal drug policy seeks to prevent illicit profiteering by heroin traffickers, it does not seek to prevent legalised profiteering by pharmaceutical companies who manufacture and market this heroin substitute (methadone), or by those who make a living from prescribing it, and in so doing taking advantage of addicts in their already weakened state. Keeping patients addicted to a substance seems to have certain economic advantages for corporations and bureaucracy that influence ideology in our society and successfully warp our perception of reality by their creation of 'common sense' arguments.

We have been culturally conditioned to perceive a heroin addict as a 'deviant' from normal society and then we make value judgements that assign them a negative identity in order to create a separation between them and us (Cohen 1990; Einstein 1981). However those of us in mainstream society may well have been unwittingly manipulated into serving the needs of bureaucracy and corporations. These dominant influences in our capitalist society may have led us to draw incorrect and under-informed conclusions.

Antonio Gramsci discussed the term 'hegemony' as the struggle of the minority ruling class to impose its ideology on the majority. The dominant minority responds to resistance from the subordinate majority by introducing constructions that are perceived as 'common sense' (Gramsci, cited in Fiske 1990). For example, drug addicts engage in criminal behaviour to support their habit, are manipulative, incurable and must be controlled for the common good. Oral methadone therapy is a means of gaining that control by supplying legal heroin to addicts thereby reducing criminal activity to meet the cost of illicit heroin. Furthermore it reduces injecting and so limits the spread of HIV/AIDS and hepatitis, and addicts may function in a near normal manner within mainstream society. Problem solved. It's 'common sense'.

This acts as a mechanism to deflect the truth that drug addicts are often from disadvantaged social groups as positioned by the dominant culture. In the words of Tammy Anderson (1995), "the value systems underlying drug addiction are in line with the dominant culture, not outside it. The ideology of the dominant culture influences rates of addiction while simultaneously condemning their existence, a cultural contradiction."

The attitude we adopt toward the subject of drug addiction comes from the Marxist theory that we allow ideology to create a "false consciousness", a false understanding of the way drug addiction illness is managed. For example, we gloss over the fact that treating heroin addicts with opiates-based therapies such as methadone is actually confining them within their addiction. We package them into this program and then attach a label that identifies them as abnormal which they in turn incorporate into their own identity.

It is often their struggle with social identity that motivates individuals toward a drug subculture. Then once a drug user becomes part of a drug subculture, their drug use typically increases with their identification with that subculture (Anderson 1994; 1995). Furthermore, there are other associated identity changes evident with the different stages of drug addiction and recovery (Biernacki 1986; Waldorf et al. 1983). Identity problem is a clear theme throughout initiation and recovery from drug addiction according to more recent studies (McIntosh & McKeganey 2001; McCoy et al. 2005) recognising that this needs to be given strong consideration by staff trained in identity issues during treatment and recovery.

Manipulation is another theme observed throughout this research on issues relating to drug dependency and treatment. It exists from the high levels of the dominant culture to the individuals within the marginalised drug subculture. Yet it is often a term that mainstream society employs in its definition of the drug addict (Levine & Stephens 1971). Interestingly, members of mainstream society don't see their own roles as manipulators, and where they do show awareness it is explained away as a necessary mechanism to keep the order in society. It is self-preservation and preservation of the reality that serves their interests. It's marketed as 'common sense'.

Conversely the manipulation exhibited by drug addicted individuals may be considered a normal response to their devalued and powerless states of existence (Bowers 2003) in a way similar to that described for prisoners (Cohen & Taylor 1972). Bowers explains that it may be more effective to attempt to understand the basis for the behaviour, rather than dehumanising the individual further and contributing to their problems relating to identity and self worth.

Those of us who are given choices in life have no problem believing in democracy. The majority of the population would, by definition, belong to the mainstream, and choices are offered to those who conform to the rules of politics and academia. It is the marginalized and the dehumanised that, according to the mainstream, cause difficult problems in our society. Yet, by marginalising and dehumanising them, we are at the same time preventing them from integrating and reforming in accordance with our ideology. How can we overcome this apparent contradiction?

Althusser suggested that we need to recognize that our relationship to the 'real' world may be imaginary. "Ideology is a 'representation' of the imaginary relationship of individuals to their real conditions of existence." By extrapolation, we could ask ourselves whether our current accepted methods of treating drug addiction are based on imagined or omitted truths.

One truth about opiates addiction that is often overlooked according to addiction medicine specialist Dr George O'Neil is that the opiate receptors on brain cells become damaged by frequent exposure to heroin. Overcoming the physiological addiction then becomes a problem of how to repair the damaged receptors and restore the chemical balance in the brain. The opioid antagonist naltrexone is well known for, not only its anti-addiction properties, but also its capability to repair the damaged receptors. Methadone by contrast has no receptor repair function.

Preliminary research data shows that 50% of patients who receive a naltrexone implant remain clean from opiates for 5 years (G O'Neil 2008, pers comm., 20 March). No such evidence exists for any other treatment in the world, including methadone. Furthermore, the same 5 year study also indicates that 85% of patients previously on a methadone program do not go back to using heroin or methadone after receiving naltrexone implants.

It seems incomprehensible that, while our drug policy is developed within a medico-health framework, our complete knowledge of medical science is not taken into consideration when making or updating this policy. Worse, could there be advantages for certain powers among the dominant culture in refusing to view positively and initiate moves to incorporate and fund improved technology?

One prison doctor argues that "bureaucracy of drug addiction needs drug addicts far more than drug addicts need the bureaucracy of drug addiction." He maintains that the idea of drug addiction as an illness is propaganda and serves the interests of the drug user wishing to continue using and being able to put the blame and responsibility elsewhere, and also bureaucracy wishing to continue in employment "preferably forever and at higher rates of pay" (Dalrymple 2007).

Promoting a harm minimisation strategy, while simultaneously discrediting naltrexone use (Linteris et al. 2008; Wodak et al. 2008), would certainly suit bureaucracy wishing to continue in employment. This premeditated prejudice and conscientious manipulation of academic, medical and political opinion is perpetrated with flagrant disregard for the recovery and personal rights of those suffering from opiates dependency (Drug Free Australia 2008; S Reece 2008, pers comm., 23 February).

How can this situation be changed? Stuart Hall explains his idea of changing the predominant influence (Hall, cited in Katz 1997). "Hegemony is not a formation that incorporates everybody. It entails quite a different conception of how social forces and movements, in their diversity, can be articulated into strategic alliances. To construct a new cultural order, you need not to reflect on an already-formed collective will, but to fashion a new one, to inaugurate a new historical project."

It should be possible to gradually move all patients from the methadone program to the naltrexone program once they are stabilised. The 85% success rate with naltrexone for individuals already stabilised on methadone indicates that together these two separate programs provides a strong strategy that benefits everybody. In such a collaborative effort one can contain and manage drug dependency in the first instance then offer an effective way to overcome the physiological addiction, potentially ending the debate. Inauguration of a new historical project; that's common sense.

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