Addiction is a chronic disease. It has a ‘lifestyle’ factors, i.e. it relies on apparently voluntary choices by its victim for its perpetuation. One can argue about how ‘voluntary’ those choices really are during different phases of the diseases. For example, people appear to have greater control over their unhealthy lifestyle choices during sustained abstinence than during early recovery. That lifestyle component is not, however, a bug unique to addiction – it is a feature of most chronic diseases. Yet, our resistance to harm reduction approaches is particular to addiction.
According to the American Diabetes Association 23 million Americans have diagnosed diabetes. Another 7 million have undiagnosed diabetes (based on screening data). An additional 84 million Americans have prediabetes of whom just over 9 million are aware that they have prediabetes. About 95% of diabetes and prediabetes is secondary to obesity. About half of all US adults have diabetes or prediabetes according to a 2015 JAMA study.
According to the CDC, about two-thirds of American adults and about one-third of American children are overweight or obese. Being overweight or obese increases risk of diabetes, abnormal lipid profile, high blood pressure, heart disease, stroke, gall bladder disease, sleep apnea, osteoarthritis, pain, depression, anxiety and some cancers (endometrial, breast, colon, kidney, gallbladder and liver). Researchers tell us that even 5% reduction in weight can lead to improvement in various consequences of overweight and obesity. We know from studies that increasing and sustaining moderate levels of daily physical activity is protective against heart disease, type 2 diabetes, obesity, depression, joint problems and certain types of cancers.
Yet, no one treating patients with cancer insists that they will not be prescribed chemotherapy until they lose weight. No one tells patients with high cholesterol, diabetes or high blood pressure, “I am sorry, I don’t believe in treating your condition with medications. Losing weight will fix it.” No clinician in their right mind withholds medications or cardiac rehabilitation from an obese person who has had a heart attack. Instead we treat all such patients with every intervention in the clinical toolkit. We tell them to modify their diet and physical activity levels, and encourage them to do what they can on those two fronts. Harm reduction, defined as “any positive change,” is the norm in the clinical care of all diseases with strong lifestyle components. Except addiction.
Day in and day out, people with opioid addiction hear from their counselors, therapists, physicians, family members and community supports that medication treatment is not the solution to their addiction. That the only solution is abstinence. That being on medication for addiction means one is not committed to ‘true recovery.’
Even though many people end up needing wheelchairs, walkers and other assistive devices because of consequences of diabetes and obesity, we don’t go around arguing against making those devices available so that people will be motivated to lose weight. We don’t say we won’t provide medical care to people who get injuries from risky sports that they are involved in. When it comes to physical health problems we really don’t take this approach to care. We don’t even say that seat belts encourage people to drive fast.
Yet, such arguments about ‘moral hazard’ are commonplace when it comes to addiction. Meanwhile moral hazard concerns are ever-present in discussions about safe and supervised injection sites, about needle exchange program and about access to methadone or Suboxone® maintenance. We don’t want to give naloxone even to people who have had multiple overdoses — what if encourages them to use more. Evidence from study after study fails to convince us that harm reduction for addiction reduces suffering and saves lives just as it does for other chronic diseases.
It’s high time that we get off our hypocritical high horse regarding the moral hazard of harm reduction in addiction and treat this chronic disease the same way we treat all other chronic diseases. We must give up all our qualms about using all available tools in our toolbox to treat addiction. Just as we do with other diseases, let’s encourage and support those with the addiction to do what they can to modify lifestyle factors that contribute to their illness and suffering.
