People Enjoy Using Drugs
Have you heard? Maybe not, especially if you work in abstinence-based substance use treatment. In a September post about the false distinction between recreational and therapeutic drug use, I said I'd come back to the topic of pleasure.
I've found it's pretty taboo in community treatment to acknowledge that people enjoy using drugs (including alcohol). Back in my days of agency staff meetings, if I said I didn't think a certain patient wanted to quit, this was considered a contemptuous judgment rather than a clinical observation. Even if the patient had explicitly told me they didn't want to quit, that was never supposed to be taken at face value. To show care and respect for a patient was synonymous with an abiding faith that deep down, they wanted to be sober (part of what I call the pity discourse--see below if you missed it).
Rosalie Genova
This is ridiculous. It's like ignoring the proverbial "elephant in the room" when most everyone first came to the room specifically for the elephant! If treatment providers can't acknowledge that people enjoy using drugs, how can we expect them to be honest with us? What does it mean to weigh the costs of continued use if we refuse to recognize its benefits?
Here are some particular blind spots in treatment that stem from ignoring pleasure:
- Expecting people on opioid replacement medications to give up street opioids. These medications prevent withdrawal and may protect against overdose. At a standard dose for someone with established tolerance, they probably won't cause a high. So if someone wants that high, they will still go and get it. I have had patients who kept their prescribed Suboxone on hand just for days when they could not get the street drugs they would ideally prefer. We should understand opioid maintenance more along these lines: a safety support for people who may or may not be getting high as well.
- Assuming people can experience comparable pleasure without drug use. We hear a lot about dopamine and how neurologic changes from long-term, heavy substance use can make it more difficult to achieve pleasure. I do not doubt this. But some people describe an innate inability to feel good, with drugs bringing the first pleasurable experiences of their lifetime. In other words, lack of natural joy led to their substance use, rather than the other way around. I glimpse the disability model of addiction in this idea: drugs as an aid to access pleasure that is available without drugs to everyone else. But it's not reflected in policy; the Americans with Disabilities Act covers addiction treatment and recovery, but not ongoing use. It would take a radical reorientation even to establish that everyone is entitled to pleasure, let alone to trust and accommodate the drug users who say they can't get it any other way.
From the very first drug experience to the deepest throes of addiction, we also need to think about external, systemic barriers to pleasure. In Addiction: A Disorder of Choice, psychiatrist Gene Heyman shows how appealing but "nonaddicting" alternative activities are a major factor when people voluntarily moderate or end their substance use. People's choices about how much, for how long, or at what cost they will keep using, are strongly influenced by what other options are accessible to them at a given time.
And just about all of these alternative pleasures involve access to resources. Money is one, but also think about: necessary materials, safe and accessible space, and time away from responsibilities. A lot of people have access to drugs but not to the resources necessary for nonaddicting alternatives. I suspect this is one reason poverty predicts poorer outcomes from treatment. We can foster motivation to change, and even find alternative sources of community or identity. But for a person with no other source of pleasure, it is not surprising if drugs remain indispensable.
PS: For those wondering if I would ever finally become a Medicaid provider, October 23 brought magical news! Sober cheers to Maine for paying for our people's care.
