Globally, opioids accounted for 55 percent of drug-related deaths in 2010 (Wakeman & Rich, 2018) and in the United States 116 people die from opioid overdoses every day (Seth, Scholl, Rudd, & Bacon, 2018). In a single year the death rate from heroin alone increased by 21 percent, and deaths due to synthetic opioids (e.g., tramadol and fentanyl) increased by 100 percent between 2015 and 2016 (Seth et al., 2018; Rudd, Seth, David, & Scholl, 2016). As of 2017, the acting US Health and Human Services (HHS) Secretary, Eric D. Hargan, publicly announced that America is in the midst of a nationwide public health emergency due to the opioid crisis (HHS, 2017). Recent research has identified that the general public is more likely to agree that those who abuse substances should be punished, rather than treated (Meurk, Carter, Patridge, Lucke, & Hall, 2014), which aligns with public statements made by President Trump and recent policy changes made by the US Department of Justice (Office of the Attorney General, 2017, 2018a, 2018b). The general public maintains the opinion that punishment is more appropriate than treatment for those who abuse opiates, even when they are exposed to education on the biological development of addiction (Meurk et al., 2014; Ricardo, Henderson, & Christensen, 2018).
Conversely, the general public appears to support legalization of drug use as it relates to recreational and medical marijuana consumption. This is reflected by the influx of states voting to legalize both medicinal and recreational marijuana use, or decriminalization at the very least. This distinction may be a result of the public’s perception that marijuana is less harmful and by implication that it may not have the same addictive properties as opioids. This line of thinking may perpetuate the belief that addictive processes may work differently for marijuana than opioids. With these potential contradictions existing in the public discourse around substance use, it is not necessarily surprising that research indicates educating individuals on the biological aspects of the development of addiction does not influence the likelihood that they provide less punitive responses on hypothetical sentencing tasks (Ricardo et al., 2018). In fact, individuals appear to maintain stigma towards those with substance use disorders (SUDs) regardless of understanding and endorsing the idea that biology plays a significant role in the development of addiction (Ricardo et al., 2018). If such education does not influence participants’ judgments, it may likewise be ineffective at increasing public support for substance use policy changes, such as harm reduction and alternatives to incarceration for opioid addiction.
In treatment, public policy, and the justice system, there are two prevalent perspectives on drug and alcohol addiction: the brain disease model of addiction (BDMA) and the moral weakness model (Blum, Roman, & Bennett, 1989; Lawrence, Rasinski, Yoon, & Curlin, 2013; Heather, 2017). The BDMA is rooted in scientific literature that chronic drug use leads to neurological changes in the brain at the molecular, cellular, functional, and structural levels. This research has suggested that such changes are not immediately reversible and affect multiple aspects of individuals’ abilities (or lack thereof) to return to sober lifestyles. In contrast, the moral weakness model focuses on the personal characteristics of individuals, attributing their drug use to poor decision making and lack of moral structure, leading them into a degenerative lifestyle of addiction. Proponents of this model often refer to people’s decision to first use the drug, believing they are entirely at fault for engaging in use of the illicit substance, believing that continued drug use is a conscious and moral choice, regardless of the physical dependence that may follow social or recreational use. From this point of view, addicted individuals are solely responsible for having developed their addiction as well as for ultimately abstaining from drug use. This model posits that individuals with SUDs continue to use drugs because they are unmotivated to change (Kloss & Lisman, 2003). Irrespective, endorsement of the BDMA and the moral weakness models are not mutually exclusive; acceptance of a particular model does not necessarily predict a shift in perspective on the development of addiction (Meurk et al., 2014; Ricardo et al., 2018).
In 1997, Alan Leshner, the director of the National Institute of Drug Addiction (NIDA) at the time, firmly and publicly affixed the official stance of the NIDA on drug addiction as a brain disease. In his seminal article published in the same year, Leshner argued that over twenty years of research had supported the assertion that the brain plays a significant factor during the transition of recreational drug use to addiction. He explained that such research unequivocally points to the need for policy reform with respect to reducing stigma around treatment and improving access to treatment for those in need. Presently, both the NIDA and the American Society of Addiction Medicine (ASAM) support Leshner’s perspective and define drug and alcohol addiction as a chronic, relapsing disease of the brain (ASAM, 2011; NIDA, 2018). However, opponents of the BDMA hold the perspective that the model negates the responsibility of people to change or take accountability for their behaviors, and subsequently leads them to become more fatalistic about their own sense of agency (Bell et al., 2014; Meurk et al., 2014). This conceptually implies that individuals with SUDs tend to engage in learned helplessness and may no longer strive to obtain complete sobriety, as they do not believe they can ever be completely cured of their addiction (Bell et al., 2014). An additional concern from this perspective is that the BDMA normalizes the notion that individuals with SUDs have no self-control and must be coerced into treatment, especially when engaged in the criminal justice system (Caplan, 2008; Szott, 2015).
Nora Volkow, the current director of the NIDA, and Alan Leshner have both argued that use of the BDMA in explaining the development of addiction may produce beneficial changes to social policy regarding how individuals with SUDs are treated, both within and outside of the criminal justice system (Leshner, 1997; Volkow & Li, 2004). These anticipated changes included a reduction in stigma, increased funding for both research and treatment of addiction, and increased public acceptance of addiction as a medical disease—together they would likely result in a favored perspective that addiction should be treated through medical services rather than punished in the criminal justice system (Bell et al., 2014; Hall & Carter, 2013; Meurk et al., 2014). To this end, both the NIDA and the National Institute of Alcohol Abuse and Alcoholism (NIAAA) have made it a priority to fund studies that investigate questions regarding substance use from the perspective of the BDMA (Hall, Carter, & Barnett, 2017). In an effort to disseminate this research and support the BDMA, these same institutes have conducted “well-funded, high-public-profile education and advocacy efforts in favour [sic] of the BDMA over the past twenty years” (Hall et al., 2017, p. 104), even in the face of considerable dissent (Heim, 2014; Lewis, 2017).
Among practitioners, there is a considerable division in support for the BDMA. For instance, Lawrence and colleagues (2013) demonstrated that the moral weakness model of addiction tends to persist in both psychiatrists and primary care physicians, with a combined 11 percent believing that moral failings play a significant role in the development of addiction. In 2003, Kloss and Lisman found a moderate to high endorsement of the disease model by mental health clinicians, while simultaneously finding high rates of blame attribution (i.e., the responsibility for causing their problem) toward mentally ill and/or chemically-addicted patients. Interestingly, although understanding and agreement with the BDMA does not predict a reduction in stigmatizing beliefs among practitioners, Bell and colleagues (2014) found that most practitioners use the BDMA as a partial explanation for addiction when discussing the topic with their clients.
Attempts to intervene and reduce stigma during the academic learning phase of graduate medical programs were likewise found to be largely unsuccessful (Crapanzano, Vath, & Fisher, 2014). In a multipart educational intervention, physician assistant graduate students learned about basic neurobiological factors that contribute to the development and maintenance of addiction, among other didactics and learning modules. When assessed following the intervention, participants reported improved attitudes toward heroin users; however, results exhibited small effect sizes and attitudes remained negative overall. The investigators noted that, in addition to students’ continued struggle to accept a biological basis for addiction, their greatest disappointment was that “half of the students continued to express stigmatizing beliefs with factual errors” (Crapanzano et al., 2014). These findings are consistent with research conducted by Meurk and colleagues (2013) that endorsement of the BDMA does not automatically translate to the empathic treatment of individuals with SUDs; rather, many professionals continue to attribute people’s SUDs to moral failings and personal choices. In his 2017 article, Nick Heather deemed this disparity between endorsement and empathy as “lip service” to the BDMA, which has been demonstrated by both helping professionals and the general public (Meurk et al., 2014).
Importantly, prior research has identified that stigma towards those with mental illnesses is associated with decreased public support for government-funded SUD treatment, at the same time being positively associated with increased support for punitive policies (Kennedy-Hendricks et al., 2017). Taken together, these findings suggest an interrelation between medical and mental health practitioners’ attitudes toward SUDs can negatively impact funding and access to treatment. This relationship appears to occur despite education, understanding, and endorsement of the BDMA within the medical and mental health professional fields. As noted previously, endorsement of the BDMA does not necessarily predict a perspective change regarding the development of addiction or what should be done to treat it. Where we might arguably expect to see lower stigmatizing beliefs, we see a demonstration of the persistence of the moral weakness model while simultaneously agreeing and incorporating the BDMA into their own understanding and practice.
What positive impacts on social policy have been produced by this decades-long institutional effort to shift the dominant perspective on addiction from moralistic to medical? Through the Affordable Care Act, “insurers are required to treat SUDs in the same way they would any other chronic disease” (Botticelli, 2014; Volkow & Koob, 2015). Similarly, the NIDA released its Principles of Drug Abuse Treatment for Criminal Justice Populations, for which the first principle states, “drug addiction is a brain disease that effects behavior” (Fletcher, Chandler, & OSPC, 2014, p. 1). This has been reflected by criminal justice systems that offer alternatives to incarceration, such as inpatient substance abuse treatment (Heather, 2017). However, this policy change comes with its own subset of ethical dilemmas. For instance, does mandated treatment as an alternative to incarceration increase the likelihood of coercive treatment by making the alternative (incarceration) noxious enough that individuals, given the choice, are unlikely to turn it down? An article by Caplan (2008), a bioethicist, encourages mandatory treatment as a means of “reemergence of true autonomy” (p. 1920) for those with SUDs, as he believes they “do not have the full capacity to be self-determining or autonomous” prior to receiving treatment (p. 1919).
Similar to the issue of violated autonomy and coercive treatment, proponents of the BDMA may have either had no influence or paradoxically increased stigma associated with substance abuse, rather than reduce it. Specifically, prior research has indicated that when a biological explanation is used to describe patients’ mental health conditions, clinicians are significantly less empathetic towards them as compared to when a psychosocial explanation is provided (Lebowitz & Ahn, 2014). The general public tends to regard those with biologically based behavioral abnormalities as dangerous, which may lead to avoidance and isolation of those with such abnormalities (Heather, 2017). Importantly, recent research has indicated that when potential jurors are given a brief education on the BDMA before assigning a sentence length to defendants on trial for drug-related crimes, they assign nearly identical sentences to those who did not receive such information (Ricardo et al., 2018). This same study identified that although individuals are significantly more likely to endorse the BDMA after brief education, this does not have a positive impact on their empathetic response when faced with the opportunity to incorporate the BDMA into their decision-making. This disparity speaks to a possible lip service (Heather, 2017) of endorsement of the BDMA, as well as the lack of positive impact the BDMA appears to have on criminal justice policy. Similarly, Meurk and colleagues (2014) noted that although endorsement of the BDMA predicted lower support for imprisonment of average, non-justice-involved individuals with heroin use, the effect size was small, and the results were only marginally significant (i.e., the p value for the study was not smaller than the widely-used .05 criterion).
A possible option regarding access to treatment for those in the criminal justice system includes opioid agonist therapy (i.e., methadone or buprenorphine), as the risk of drug overdose death is increased by 129 times following release from prison (Binswanger et al., 2007). Prison-based opioid agonist therapy initiation can result in a 75 percent reduction in all-cause mortality and an 85 percent reduction in deaths by overdose in the first month after release (Marsden et al., 2017). Yet, in the US there are few such opioid agonist therapy programs available in correctional facilities (Wakeman & Rich, 2018). For the general public within the US, 30 million people live in counties without a single prescriber of medications for addiction treatment (Wakeman & Rich, 2018). A large factor contributing to the lack of access to such care is likely due to the small proportion (less than 4 percent) of licensed physicians within the US who are waivered to prescribe buprenorphine (Wakeman & Rich, 2018). To complicate matters, although proponents of the BDMA were generally successful regarding insurance coverage for substance use treatment, private and public insurers continue to apply arbitrary dosing and duration restrictions to opioid agonist therapies (Wakeman & Rich, 2018). As of 2016, methadone was the least-covered medication by Medicaid for treatment of opioid use disorders, while in all but one state buprenorphine was only covered through Medicaid if prior authorization was obtained (Grogan et al., 2016). Recent federal legislation has been implemented to combat these challenges by expanding coverage and resources directed toward opioid abuse nationwide (SUPPORT for Patients and Communities Act, 2018). Although these efforts may produce significant benefits for those with opioid and other SUDs, the specific effects on relapse and prevention rates remain to be seen.
Stigma towards those with mental illness has been associated with decreased support for insurance parity, a policy designed to eliminate discriminatory insurance coverage of mental health and SUD treatment benefits (McGinty, Pescosolido, Kennedy-Hendricks, & Barry, 2018). Although education on the BDMA has yielded higher rates of agreement, it has not decreased stigma towards those that use substances, suggesting that the BDMA likely does not produce any positive impact on support for the treatment of SUDs through a medical framework (Meurk et al., 2014; Ricardo et al., 2018).
Promises made regarding the development of new pharmacological interventions to treat substance abuse (beyond the agents already available such as buprenorphine and naltrexone) have not been realized. More precisely, only modest advancements have been made on this front for a host of reasons, including reluctance by pharmaceutical companies due to doubts regarding their profitability (Hall, Carter, & Forlini, 2015; Volkow & Li, 2004). For instance, although previously discussed opioid agonists are an option for medical intervention for opiate use, their—specifically methadone’s—development occurred some decades prior to the widespread dissemination of the BDMA (Hall et al., 2015).
For decades, proponents of the BDMA have asserted that should perspectives on the development of addiction shift from a moral model to a medical one, the effects would be unparalleled (Hall & Carter, 2013; Leshner, 1997; Volkow & Li, 2004). In some respects, developments have been positive. For example, we see progress in the requirement that insurance coverage consider addiction to be the same as any other brain disease (Botticelli, 2014), and treatment within the criminal justice system reflecting the perspective that addiction is a brain disease (Fletcher, Chandler, & OSPC, 2014). However, as of 2004, 80 to 85 percent of prisoners that could benefit from substance abuse treatment are not receiving it (Mumola & Karberg, 2004), suggesting that there is much left to be desired regarding interventions for those in the criminal justice system. For inmates and probationers who are given the opportunity to engage in substance abuse treatment, mandated participation may reflect the assumption that the model encourages coercive treatment, as argued by BDMA critics. In addition, for those that are not in traditional talk-therapy- and/or psychoeducation-based programs, the medical field has only made modest progress in the treatment of SUDs through pharmacological interventions (Hall et al., 2015), some of which are hotly debated (e.g., the use of Narcan for opioid overdoses), and with access to others being exceptionally scarce. Most importantly, recent research has identified a disparity between acceptance of the BDMA and empathic responses towards those with SUDs by both the general public and by helping and/or criminal justice professionals (Meurk et al., 2014; Ricardo et al., 2018). There also appears to be weak support that use of the BDMA leads to a reduction in stigmatization (Heather, 2017; Lebowitz & Ahn, 2014; Meurk et al., 2014), which presents an additional area of concern. In fact, the opposite appears to be true such that a biological explanation associated with the BDMA paradoxically increases stigma. Therefore, wider acceptance of the BDMA has led to some progress with respect to how those with SUDs are perceived, but the progress has not been uniform.
At a time when the nation is considered to be in the midst of an opioid crisis, it is imperative that we find ways to address this health emergency with both proactive and reactive sociopolitical policies. Where the BDMA appears to have the least positive impact is on the general public’s treatment of those with SUDs, which is arguably the most important area for intervention as public support drives public policy (Goot, 2005). The ultimate question is this: if the BDMA is not garnering the necessary support from the general public to affect sociopolitical policy change via empathic response in conjunction with an understanding of the biological basis of addiction, what do we do now? How do we shift our perspectives, explanations, and understandings of substance abuse such that we can disseminate the necessary information to unify both the general public and our goals around treatment and the reduction of addiction? There is likely no single or best answer to these questions; instead, they are meant to promote positive discourse with members of the public regarding the implications of the field’s predominant model (i.e., the BDMA) for conceptualizing SUDs. There is little question regarding scientific support for the biological basis of addiction, but there is room for discussion regarding its effects on public policy and treatment.
Mia M. Ricardo, MA, is a clinical psychology doctoral candidate at Sam Houston State University in Huntsville, Texas. Her research focuses on sociopolitical policy on substance use, public support for harm reduction initiatives, and forensic evaluations. Clinically, Ricardo is training to become a general practitioner with a specialization in forensic issues, including evaluations of competency to stand trial and mental status at the time of the alleged offense. She intends to pursue licensure and board certification in forensic psychology following graduation.
Craig Henderson, PhD, is professor of psychology at Sam Houston State University and a licensed psychologist in the State of Texas. Dr. Henderson’s research interests concern the health behaviors of adolescents and emerging adults. He is chair of the SHSU clinical psychology program diversity committee and is committed to improving the diversity of the field of psychology.
Maxwell R. Christensen, MA, is a clinical psychology doctoral student at Sam Houston State University in Huntsville, Texas. His research interests include juvenile justice issues, substance use, and decision-making among young adults. Clinically, Christensen is training to become a general practitioner with an interest in psychological assessment and treatment of internalizing psychopathology. He plans to pursue licensure and an academic career following graduation.