Credit: Paul S.

For people interested in substance use, Dr. Jonathon Erlen has built a cave of wonders. Erlen is a history of medicine librarian at the University of Pittsburgh, and one of his projects is an ongoing bibliography of dissertations related to drugs.

To his knowledge, he is the only person in the world maintaining this sort of bibliography. One of the things that makes it fun, said Erlen, is that substance use intersects with so many fields.

“It’s an intellectual challenge because there is no rhyme or reason to where you’ll find the scholarship,” he said. “There’s health, there’s history, there’s social problems. There are dissertations talking about new drugs that come out, regional drug trade issues, drug use and HIV, drugs from the perspective of women’s studies, drugs and their relationship to religion or the lack thereof…”

Dissertations, said Erlen, can be considered “gray literature,” since they have not had the benefit of peer review. As such, many dissertations would never see the light of day, if not for his bibliography.

Erlen is quick to point out that he’s not an expert on substance use. As a librarian, his role is to seek, compile, and offer access to information. However, his decade-long work on the dissertation bibliography has given him an unusually broad perspective on drug-related issues.

For example, when I said that Americans seem increasingly to agree that we can’t arrest our way out of this problem, Erlen responded that this dialogue has been repeating itself for a hundred years.

Treat Versus Punish is Nothing New

john erlen

Dr. Jonathon Erlen

“There has been an ongoing dichotomy between treatment and punishment,” Erlen said. “Historically, we vacillate. And it’s very difficult for people to come down in the middle. They’re either really into punishment or really into treatment.”

What has the “punish” side of the debate sounded like? Well, there has been the rhetoric (“Public enemy number one in the United States is drug abuse,” – Richard M. Nixon), but more importantly, there’s been a century of public policy. Since the passage of the Harrison Narcotics Act in 1914, United States drug policy has almost always come down on the side of punishment as the solution to social problems caused by substance use and addiction.

Before the Harrison Act in 1914, opiates and cocaine were legal to buy, sell, and use. In fact, they were often recommended by doctors. The Harrison Act didn’t outlaw these drugs altogether, but made it illegal to possess cocaine or opiates that were not prescribed by a physician. People who had been obtaining and using these drugs freely were suddenly criminals.

And over time, they were considered much more dangerous criminals, since penalties for drug use got much stiffer. According to historian William White, “When the Harrison Tax Act was passed, the maximum possible penalty for violation of the Act was five years in prison. In less than fifty years, penalties had risen to include the option of life imprisonment and the death penalty.”

Three decades later, the War on Drugs (declared in the 1970s, peaked in the 1980s) introduced mandatory minimums and three-strikes policies, which dramatically increased the number of drug users serving long prison sentences.

All the while, the “treatment” camp voiced very familiar ideas, pointing out that criminalizing drug users is counterproductive and that addiction is a health issue. Treat, don’t punish, they said.

1938 – It’s not feasible to put everyone with an opiate addiction in prison, argued Henry Smith Williams. Let’s put every person who’s addicted to opiates under medical supervision and prescribe them the drugs they need.

1947 –  The enormous effort that goes into punishing drug users is useless and expensive, said Alfred Lindesmith. It’s also cruel to people with addiction. Addiction shouldn’t be the domain of policemen, but of medical professionals.

1956 – Law enforcement shouldn’t be making decisions about how to deal with addicted people, said Lawrence Kolb. Qualified physicians should be making these decisions. People with opiate addictions should be offered maintenance medications.

These arguments aren’t too different than the ones we hear today. But despite the fact that “treat, don’t punish” messages have been around pretty much since drugs were criminalized, public policy has reflected the opposite view.

This is still the case. In 2016, the Surgeon General recommended that we “implement criminal justice reforms to transition to a less punitive and more health-focused approach,” but that same year, we actually spent more money on domestic law enforcement related to drug use than we did in 2008. To be fair, spending on treatment also increased over the same period, but the shift in funding priorities was quite slow and small, considering the Obama Administration’s emphasis on “treating addiction as a public health problem.” The Trump Administration gives all indications of reversing that shift.

Why has it been so difficult for the “treat don’t punish” concept to get in a foot in the door?

Erlen pointed to an obvious issue.

But What Is Good Treatment?

“The problem that you keep running into,” Erlen continued, “Is what is good treatment? That’s what makes treatment a hard sell.”

Addressing the question of “what is good treatment” is an essential ingredient in the treat versus punish debate and, all too often, it’s ignored. Part of the reason this question is ignored is because effective addiction treatment is not well-understood.

“If there was a nice simple way to do it, we would probably do it,” said Erlen.

Despite the fact that treating addiction is not simple, we know that some approaches to addiction treatment are more effective than others. For a one-stop synopsis of what “good treatment” looks like, we suggest a review of the VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders, which was updated in 2015. It uses a rigorous methodology to assess research evidence about effective addiction treatment.

Although the VA/DOD Guideline isn’t the only source of information about good treatment, it’s a great place to start.

Get Off the Merry-Go-Round

As Erlen points out, the “treat versus punish” merry-go-round has been spinning for an awfully long time. Let’s step off.

We know addiction is a health condition and that treatment is more cost-effective (and compassionate) than punishment. But what we should really be talking about is good treatment. The longer we ignore that (complex) part of the conversation, the longer our drug policies will default to “punishment”—because at least we know what that looks like.

 

Recommended Resources

For information about the history of drug policy, see: Jonathan Erlen’s bibliography collectionPoints Blog, which regularly posts updates from Dr. Erlen; and The SALIS Collection

For information about good treatment and good public policy, see: The Surgeon General’s landmark report on Substance Use and Health (2016);  The American College of Physicians Position Paper on the Prevention and Treatment of Substance Use Disorders (2017); and the VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders (2015)