24 Nov Addiction: Treating Patients Or Punishing Criminals?
As with all complex and controversial problems, addiction is often looked at in black and white terms. One camp would have you believe that addicts are nothing but weak-willed junkies and criminals. The other asserts that addiction is an anti-social disorder caused by a set of bio-psycho-social factors.
Treating addiction as a disease or disorder is a common medical practice in many countries across the world today. Treating addiction as a criminal act is equally common. This is because drug addiction and criminality are often co-related. First, let’s look at addiction as a medical phenomenon.
Not all people who heavily use drugs (including alcohol) are addicts. Today, about 10% of the South African population have addiction problems. I am interested with the habitual and compulsive drug user. Their brain is fundamentally altered by the habitual use of drugs. The brain’s reward system is essential for survival. It governs our impulses for food, procreation and self-defence — in a phrase, self-preservation. Excessive drug use alters the reward system in the brain because various drugs deliver between twice and ten times as much pleasure as food or sex can. Eventually, addiction rewires the reward system in the brain to confuse the next hit with the basic survival instincts the brain’s pleasure system is designed to encourage.
Some people are more susceptible to this change because of genetic factors in addiction. Yet, addicts are responsible for starting themselves on the path. Most people will stop using or cut back long before their reward system starts to be re-wired, but many have overriding genetic factors working against them. In other words, when people talk about addiction being a genetic disease, it is a disease of choice. Some people are predisposed to choosing high-reward behavior and drugs provide plenty reward for the brain. For the addict, self-destruction becomes indistinguishable from self-preservation.
Genetic predisposition is not sufficient for the condition though. Nurture and environmental factors play a major role in addiction. Trauma, neglect and an inability to form normal relationships (often caused by correlating mental illnesses) can lead to addiction. Humans are hardwired for connection and substances provide that connection never learnt in socialisation. Hence, early experience plays a vital role in addiction. Trauma, for example, can change the way the brain functions. Addictive behaviour and substance addiction can become a solution for soothing the psyche. Self-medication after trauma is a primer for addiction. Hence, violent and impoverished communities that suffer from high rates of trauma and abuse struggle with addiction. Often addicts in these communities turn to crime to feed their habit (more so than so-called ‘middle-class’ junkies, who often have a socio-economic net to fall into).
‘Nurture and environmental factors play a major role in addiction.’
It’s a complicated situation and there are a myriad of factors involved in addiction. Yet, we often approach it only as a criminal problem. The correlation between crime and addiction is often due to possession and using offences. However, even in the case of petty-crime there is still good reason to review the way we treat addicts. Treating addiction as a medical problem rather than a criminal problem could be key to reducing the problem of addiction as well as that of drug-related crime.
Twelve percent of the prison population are incarcerated for drug-related crimes. An American study shows that treatment reduces recidivism and further crime. In some cases it is a socio-economically better alternative to imprisonment in the first place. Incarceration for a year costs nearly R120 000, which is the equivalent of one month in an in-patient addiction facility, followed by eight or nine in a halfway house. Aside from the financial cost, the psycho-social cost of imprisonment is higher for addicts and the community because they are more likely to re-offend if they continue using.
Introducing non-violent addicts into a violent prison population can worsen not only their addiction, but radicalise their behaviours. No treatment is a magic bullet for the problem. But it makes more sense to provide treatment and prevent both radicalisation and recidivism in the prison population, than to simply incur the socio-economic costs of incarceration, repeat offences and untreated addiction.
Yet, it’s extremely hard to think of addiction as both a criminal and medical problem. People want crimes to be punished in the hopes that they will prevent further offence. Yet, those who return to prison range from 24% to 95% in different studies. In other words, imprisonment is not a disincentive to commit crimes, in a significant number of cases. If addicts continue in their addiction it increases their chance of re-offence and return. Even if they don’t and continue they remain destructive, in most cases. The practicality of treatment is preferable to imprisonment as a first choice.
Some reject medicalisation of addiction for moral reasons. They think treatment encourages addicts to avoid responsibility for their actions. They might cynically cite the case of Tiger Woods who claims his serial infidelity was caused by his sex addiction (a far more controversial diagnosis than drug addiction). But the medical route need not absolve addicts from responsibility. It merely changes the way addicts take responsibility. They become responsible for their treatment and their crime. Hence, it is a pragmatic approach to preventing further criminal activity. Addiction-related crime should only be punished when treatment fails, not before.
In addition, successful treatment creates vital resources for working with other addicts and improving the community. Successful imprisonment potentially radicalises non-violent offenders, does little if anything to prevent addiction and sees half of all offenders return. In many ways, untreated and imprisoned addicts are a lost resource.
There are 12-Step groups such as Narcotics Anonymous that take volunteer members into hospitals, institutions and prisons to help other addicts. Some religious groups offer help and use addicts to help others suffering from addiction. These are simple examples of the myriad of ways addicts become useful in helping addiction treatment. Even some of the worst offenders offer experience that can prevent others from making the same mistakes.
Not all drug-related offences should receive treatment instead of imprisonment. But non-violent offenders convicted of use, petty-crime and possession are prime candidates to start with. The economic costs of treatment are comparable to imprisonment, but the potential benefits far outweigh that of jail time. Hence, medicalisation is better than criminalisation.
It is a lot easier to sympathise with a diabetic and his insulin needles than a loaded junkie. Self-destructive, anti-social and criminal behaviour often result in knee-jerk reactions against treating addicts. However, given the chance to take responsibility for their treatment an addict can escape the deadly cycle of mental and physical imprisonment, instead of providing fuel for the cycle. Decriminalising addiction through treatment programmes is a good start, but stronger legal measures may prove more beneficial.
Portugal decriminalised possession and use in 2001, causing use and the concomitant health problems to plummet by 2012. The fears of a spike in drug use never materialised. Overall use (of people ages 15-64, the most vulnerable group) dropped by 15%. Drug-induced death dropped by 60%. HIV infection among injecting users dropped by 30%. Imprisonment dropped for obvious reasons but, more importantly, it became easier for addicts to seek medical help, which they did. Their drug policy was not the only cause of these changes, but it played a significant role in reducing the problem.
Portugal’s decriminalisation approach was bolstered by medical and social aid programmes. Integrating addicts into communities proved a key to success. Here in South Africa, we do not have the funds for widespread welfare programmes for addicts. But, if we have enough money to imprison addicts, then we certainly have enough money to treat them. And in turn, we have a better chance to reduce the harm caused by addiction and to treat the core problem — not just hide its symptoms.