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Manus haec inimica tyrannis.

Tuesday, April 17, 2012

Opium Dens as Public Policy

After all, it worked so well for the Victorians, right?
The Spectacled Avenger is not in the habit of recycling his blog posts, and he has only done so once before. However, he is about to do so again. Now, as then, his purpose is not merely to fill empty space; he has not run out of time or inspiration to write something new. Rather, he wishes to direct attention to an issue that has become pertinent again.

Back on May 3, 2011 I wrote about Insite (“Insights from Insite”). Insite is a safe injection site in Vancouver’s drug-blighted Downtown East Side. Therein I took what was — and remains — an unpopular position on publicly-sanctioned shooting galleries. I realize that mine is very much the minority view on the subject, at least if the mainstream media is any indication. I counseled caution, arguing that even if we accept the dubious claims about Insite’s immediate efficacy, in the long-term the program, and others like it, may end up doing more harm than good. I am returning to this issue because of a recent recommendation that three sites be set up in Toronto and two in Ottawa. That represents quite an acceleration of the program. Thus, with the possibility of shooting galleries popping up like mushrooms all over the country, I will once more advocate a “go-slow” approach.

I wrote what I did in the belief that the current Canadian government (which, incidentally, I despise with a rare passion) had done a lousy job of articulating its opposition to Insite. Since this is possibly the only issue on which the government and I are in agreement (although for different reasons), I thought I would attempt to make a more coherent case. In short, there are respectable arguments against Insite; one needn’t be opposed to it out of a reactionary conservatism or some instinctive hatred of junkies.

In any case, I still stand by my arguments in that post. These are:

1.     Even if you agree that Insite keeps junkies (relatively) disease free and “healthy”, the empirical evidence about the further claim that it brings more junkies into treatment programs is unproven and likely false, if for no other reason than that the limited availability of treatment programs remains unchanged, meaning that it is mathematically impossible for more addicts to be entering treatment programs, because there are not more treatment spaces available for them to enter than there were before, and those programs were already operating at capacity. In fact, it’s likely that fewer addicts are entering treatment, because since the 1990s the available spaces in Canada for them has been declining, at least according to the few figures I’ve seen.

2.     Insite and programs like it are predicated on the disease model of addiction, which I believe to be mistaken, internally incoherent, empirically unverified, and demonstrably unhelpful in treating addiction — as the poor success rates and abominable relapse statistics bear out.

3.     The disease model and treatment programs based on it view the addict as a patient, when it is his activity rather than passivity that is the core of his problem and also the core of his problem's solution. In this sense, if addiction is a disease, it is what was once upon a time referred to as a “moral disease”.

4.     If addiction is a moral disease in the above sense, then in the long run we can expect a program like Insite to do more harm than good, through the inconsistent moral messages it gives to addicts, and through its removal of motivational incentives to quit using and their replacement with incentives to continue using. However, note that this too is an empirical claim, and one that can only be tested in a longer time frame, which is another reason for avoiding rapid proliferation of safe injection sites.

To these arguments, I only wish to add the following two considerations: First, I urge those of you who profess to be so enthusiastic about the sites to ask yourselves whether you would be comfortable with having one situated next door to your home. If you are not comfortable with it, then you are probably a hypocrite. If you are enthusiastic about them being located in poor or drug-infested neighbourhoods only, then my reply is that the poor are no less entitled to live in decent neighbourhoods than the rest of us.

Second, I am sympathetic to the notion that if it is wrong for me to do something, then it is generally wrong for the government to do it on my behalf — barring a few obvious exceptions. Similarly, if my conscience tells me that a certain action is wrong, then it is probably wrong for me to pay the government to do it on my behalf. I believe that it would be wrong for me to open my home as a safe shooting gallery for junkies. No improvement is made in the moral status of this belief if I were to instead offer money to the government to open a safe shooting gallery somewhere on my behalf.

People like me, who believe it would be wrong to open our own shooting galleries, resent being put in the situation of being forced to pay for such shooting galleries through our taxes. And calling such shooting galleries “safe injection sites” changes nothing in this regard. By all means, let us use that money to create more spaces in treatment programs, if it can be demonstrated that this would improve the situation of addicts. But don’t expect me to cheerfully hand over money to create a comfy space for them to continue to shoot up in.

Without more ado, here is my earlier post…

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Insights from Insite

For someone like me, who is of mildly conservative leanings, the application of public policy can be visualized as the dropping of a stone into a calm pond. Much like ripples, public policy has social effects that radiate outwards from the centre of social action. The most proximate effects are the ones that tend to get noticed, these being more pronounced and closer to the point of impact. The concentric circles further out are less pronounced and eventually fade away into imperceptibility.

However, while those inner ripples are fewer in number, the outer ones are more numerous and widespread. Thus, like ripples, the greater overall effects of a policy might just be those that we least take notice of. Herein lies the task of the conservative social policy analyst. Where others might be tempted to focus only on proximate effects, she must look to the long-term and often indirect effects, to that which is hidden. She must do this not out of a reflexive impulse to pooh-pooh any measure that smells like change. Rather, she must do it out of a desire to urge us to slow down, just a bit, and to consider for a moment whether we may not be creating unintended consequences through the best-laid plans of mice and men.

For some time now, there has been a social experiment going on in Vancouver’s drug-blighted Downtown East Side. It is called Insite, a program that provides a safe injection site for junkies to shoot up in. The main aim of Insite is to cut down on the rate of drug-related deaths by users. A recently-released study indicates that, by this standard, the program is a clear success. There is now talk of expanding the program to various other cities.

However, the current federal government here in Canada has always hated the idea of Insite and has bent over backwards to try to get it eliminated, to no avail so far. They don’t like the idea of coddling a group of citizens they consider to be little better than criminals, and they have gone to some lengths to provide their own counter-evidence purporting to show that Insite is actually a failure.

The government is on firmer ground when it appeals to an economic justice argument, for the fact is, Insite technically subsidizes junkies to shoot up, using funds presumably provided by taxpayers. If a convincing case can be made that taxpayers don’t want to subsidize junkies, then this to me represents a compelling case not to do so. On the other hand, if the program works, and if taxpayers can be convinced that it’s worthwhile, then, Insite is economically defensible. And if Insite relied only on charitable donations rather than tax funds, then no economic injustice would be committed. But I have a gut feeling that the current government would still hate and oppose the program in either case, so their aversion to it really has little to do with economic justice as such

I loathe the current federal government, so it pains me to find myself in ― qualified ― agreement with them. I have grave reservations about Insite. However, my reservations are not based on the federal government’s preconception that addicts are ipso facto criminals rather than persons. Thus, in what follows I will address their problems as if they were upright citizens deserving of just as much respect as you or me, albeit they happen to be citizens with a very serious health problem.

Also, my grave reservations about Insite are not based on any skepticism about the validity of the study indicating Insite’s success. I am willing to grant that the available studies are correct: Insite has been successful in its stated goal of reducing drug-related deaths in Vancouver’s Downtown East Side.

However, the successes focused on in these studies are what I was referring to above as the inner ripples of policy, its immediate or proximate effects. But what about the outer ripples, the ones that are harder to see or to measure? I heard an interview on the radio last week with a senior administrator of the program (unfortunately I didn’t catch his name). He stated that the goal of Insite was to “keep addicts disease-free until they are ready to make the decision to seek treatment for their addictions” (I’m necessarily paraphrasing here, but pretty accurately, I think).

The evidence indicates they have indeed been kept (more) disease free. This I won’t dispute. But it begs a larger question: What warrant do we have to assume that untreated addicts reliably make the decision to seek treatment? Evidence here varies, but most of what I’ve seen is not encouraging. That is one of the unseen ripples of the policy.

We can also follow the ripples a little further out. For example, what warrant do we have to assume that untreated addicts reliably make the decision to seek treatment when they receive services that enable them to continue using drugs relatively safely? If Insite facilitates addicts’ safe drug use, might it not be the case that a very strong incentive to quit ― the high probability of disease or overdose ― has been removed? This question was screaming to be answered in the interview, but neither interviewer nor interviewee seemed much interested in addressing it. On the interviewer’s part I imagine this was motivated by an implicit desire to display his social liberal credentials to a mostly like-minded CBC audience.

Defenders of Insite have argued that the availability of information and professional consultation available at Insite will help guide users to treatment options. Perhaps this is the case, but again, it is an empirical claim for which we want evidence. The report touting Insite’s success simply tells us that addicts using it are more likely to remain disease-free. It is (tellingly?) silent about how many of them end up seeking treatment. Until we have information on this, the claim that addicts who avail themselves of Insite’s services are more likely to seek treatment remains an unproven hypothesis, not a fact.

There is further reason to doubt this claim’s validity: most professionals in the “addiction services industry” (I don’t really know what else to call it) will tell you that there is a shortage of spaces available in treatment facilities. There are too few spots to service current demand, let alone an increase in demand.  Logically, this means that it would be impossible to treat more patients given current resources. So Insite cannot be leading more addicts to treatment, because the treatment isn’t there for them to be led to.

Obviously this is not an argument against Insite’s claim to efficacy in bringing addicts closer to treatment. If anything, it’s an argument for an increase in resources devoted to addiction treatment. Again, however, we must consider the policy ripples a little further out. Might it be the case that the increased access to addiction treatment information is at least somewhat ― if not entirely ― offset by the convenient and comfortable drug injection environment offered by Insite? At the very least, we must admit that mixed messages are being sent here: “We’d like you to consider getting treatment for your addiction. Here’s a brochure. And here’s a clean needle and a comfy room to shoot up in.” A junkie could be forgiven for taking away from this the message that his addiction is not so bad for him after all, and that treatment is not imperative.

Much of one’s attitude toward programs like Insite will depend on the views one has about the nature of addiction itself. Addiction is a puzzling phenomenon. Once upon a time, it was simply viewed as a matter of lack of willpower, and was thus regarded as a moral problem, a moral failing. We could call this the “moral disease” view of addiction. It has to a large extent fallen out of favour among researchers (along with many other things that employ the term “moral”). Speaking very broadly, the moral disease view has largely been replaced by either of two currently popular models of addiction. Fortunately, my reservations about Insite are unaffected by whichever of these views one happens to hold.

The Disease Model

Probably the most widely accepted and fashionable paradigm for understanding addiction is the disease view, which treats it as if it were a medical condition on all fours with, say, diabetes or cancer. Of course, there is a large psychological component to this particular disease which differentiates it from purely physical conditions, but for treatment purposes, addiction on this model is seen as a medical condition, a psycho-physical sickness beyond the control of its victim. This is the operational viewpoint of most Twelve Step programs.

From what little I know about the history of addiction treatment (and it’s probably more than the average person, for personal reasons I don’t wish to expand on here), the disease model was developed in the treatment of alcoholics in the early 20th century for at least two reasons. One was that clinicians noted that chronic alcoholism had a more or less definite disease pathology, a natural progression or history of symptoms, when left untreated. Another was the hope that by seeing alcoholism as a medical condition, people would be less judgmental of alcoholics, and alcoholics would be more willing to seek treatment once the stigma of their condition was removed. In other words, it was specifically hoped that the disease model would replace the old moral disease view with its accompanying social stigma.

Both of these were valid points to some extent. Chronic and very acute alcoholism does have a fairly well-defined physical pathology. And probably more problem drinkers have ended up seeking treatment than they otherwise would have once the social stigma attached to the “disease” was mitigated.

On the other hand, not all problem drinkers fit a disease profile that was originally developed with the most advanced late-stage alcoholics in mind. It was a one-size-fits-all model that has not proved very helpful in understanding the “disease”, if disease it be. And although more people sought treatment, the treatment programs based upon this disease model have been notable only for their abysmal success rates. Alcoholics Anonymous has been around since 1939. It does not track its success rate in treating alcoholics. You’d think they would want to. But there is probably a good reason why they don’t. Others have done the studies on their behalf, and the general consensus is that Alcoholics Anonymous is a failure at keeping people sober. There are far more failures than successes, and even among the “successes”, relapse rates are sky high. If alcoholism is a disease, and if A.A. is the “cure”, then as a doctor, I’d consider taking my chances by prescribing a placebo to my alcoholic patients.

Long-time members of A.A. will counter by saying that the organization is not supposed to “keep people sober”. Alcoholics are supposed to keep themselves sober; the responsibility for recovery always lies with the alcoholic herself. But doesn’t this seem in tension with the notion that addiction is a disease for which its sufferer is not responsible? A.A. members will also tell you that failure or relapse happens because an alcoholic can’t be treated unless he “is ready” to recover, or has hit bottom and decided to give up the drink. But again, this seems in tension with the disease model’s stress upon the notion that alcoholism is not a function of the alcoholic’s lack of willpower.

Sooner or later it seems, every treatment scheme predicated on the disease model runs up against this tension. The disease model may be better at luring the addict into treatment, but at bottom, the treatments themselves end up stressing willpower and the addict’s own inner resources for recovery. Alcoholics Anonymous is no exception. As a matter of fact, their entire program of recovery can be viewed as a conscious attempt to instill in the alcoholic a transformational revolution of character, the beneficial moral effects of which will hopefully mimic those of intense religious conversion. It is no coincidence that Bill Wilson, co-founder of A.A., was greatly influenced by William James’ The Varieties of Religious Experience. It is important to stress that such an approach works on the internal resources of the alcoholic’s own moral agency, which seems rather at odds with the disease model of addiction. After all, we don’t cure cancer or diabetes by relying on the character or willpower of the patient.

In a true disease model, the patient is just that ― a patient. But addiction treatment almost always ends up (as it must, I believe) treating the patient as an agent. Perhaps the success of such programs might be improved if they were to be honest about this from the beginning. Maybe we must fess up and admit that kicking addiction is a matter of willpower after all (helped along, of course, by a certain degree of moral support from others). Obviously, putting it this way grossly oversimplifies the phenomenon of addiction. But then again, so does the disease model.

The Rational Choice Model

The other school of thought ― the rational choice model ― is less popular than the disease model, at least among clinicians. The rational choice model has been adopted mainly by behavioural economists because it fits well with the observed behaviour of addicts. In a nutshell, this model views the addict as a rational consumer, in almost all respects the same as you or me.

Generally speaking, when the price of a good increases, consumption of that good tends to fall. The rate of decrease of demand will vary from one good to another, and from one agent to another, but the general trend is obvious. The addict’s consumption of drugs is, in principle, no different. If you lower the price of cocaine or heroin, addicts will tend to increase their consumption of them, and some people will begin to consume these drugs who otherwise might not have.

The fact that the addict is addicted to the drug simply means that his demand for the drug is inelastic relative to other goods. If the price of heroin goes up, before he considers cutting down his consumption, the junkie will instead often forego food or rent. This seems like an irrational consumption choice, but if each of us were to systematically examine our own consumption choices, we would often find similar though perhaps less harmful patterns. I once knew someone “addicted” to electronic gadgets; he absolutely had to have the latest thing, spending well beyond his slender means, even if paying for it meant that he didn’t know how he would make his rent or pay off his ridiculous credit card bill. My wife might say that my penchant for book collecting meets this description. There just happens to be no self-help group akin to Alcoholics Anonymous that I know of for my particular form of consumption aberration (if there were, I’m sure my wife would have left a brochure on my pillow by now).

The rational choice model views the addict as making choices about consumption, based on what they believe will best satisfy their overall preferences. To the third party observer, these choices can seem downright irrational, but to the person making the choice it seems perfectly rational: they have a (very strong) desire for a drug, which gives them pleasure or ― what amounts to much the same thing ― relieves their pain. Any approach to treating the addict should treat them as rational persons making choices based on a preference set and an information set. Such an approach would work on improving their decision-making by modifying their preferences and providing them with information. Inevitably, there will also be situational and environmental factors standing in the way of better decision-making, things such as easy availability of the drug, hanging out with the wrong crowd, etc.

The point is, rather than approaching the addict as a powerless patient whose addiction is an external force majeur that strikes him through no fault of his own (the disease model), the rational choice model treats the addict as an empowered, decision-making agent, responsible for his own conduct. He ought to be praised for his good choices, especially when, as in the case of addiction, good choices are difficult choices. And he ought to be held responsible for his bad ones. The prevailing view that addiction seizes and controls the addict, as well-intentioned as it might be, is probably misguided. It is one part of an overall tendency to “medicalize” conduct that is moral in nature. I will illustrate this medicalization of moral conduct with an anecdote from an essay by Theodore Dalrymple.

Dalrymple was a prison psychiatrist. He was interviewing an inmate who was in prison for viciously beating up his girlfriend badly enough to put her in the hospital. This was not unusual behaviour for this particular inmate. Dalrymple asked him why he beat up his girlfriend. He replied to the effect that he had difficulty controlling his anger and she had made him really angry. Not really his fault, you see. The general gist of his answer was that he was in prison due to a problem largely beyond his control ― he had “anger management issues”, to use the parlance of our times. He simply couldn’t help beating his girlfriend to a bloody pulp. Dalrymple then asked him how it was that since he had been in prison he had managed to be well-behaved, with no outbursts of anger or violence. He replied that the guards didn’t let prisoners get away with that kind of bullshit in prison.

The prisoner had ascribed his violent behaviour to a quasi-disease model of anger, which he probably picked up by osmosis from the liberal claptrap he was hearing around him. Working from within the disease model, the prisoner’s subsequent good conduct behind bars makes no sense. But working from the rational choice model, it makes perfect sense. He was able to modify his behaviour in the presence of a strong incentive, namely getting the proverbial tar beaten out of him by a prison guard. Research on addiction done by behavioural economists bears this phenomenon out.

This has obvious implications for programs like Insite. When we ask ourselves what motivation Insite offers addicts to quit, we mostly come up empty-handed. Again, yes there are brochures and addiction counselors, but there are also the clean needles and the safe and comfy shooting galleries that cancel these out. The rational choice model predicts a poor long-term treatment prognosis for users of Insite. I hope someone will do the research to test this hypothesis. It represents one of those outlying ripples of this particular social policy, one of those rare ones that is, in principle, empirically measurable. And the test should probably happen before the program is expanded, not afterward. That is how conservative policy analysis should work.

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