Defining Substance Use Disorder and Addiction Remission

**Part 4 of Safe Supply Saves Lives: a look beyond the deadly war on drugs, a 7-part series.**

Twelve Step Programs reverberate the line from AA’s 1975 Living Sober handbook that addiction “is an incurable, progressive, fatal disease”¹ treated only by ongoing spiritual transformation and abstaining from all mind-altering substances (except caffeine and nicotine). In stating a theory of addiction as a disease, participants are often swayed towards believing the Twelve Steps are up with contemporary scientific and medical research.

Indeed, healthcare institutions in the United States broadly tow a similar enough theory, with the National Institute on Drug Abuse stating, “Like other chronic diseases such as heart disease or asthma, treatment for drug addiction usually isn’t a cure.”² NIDA director AI Leshner came out with the landmark editorial “Addiction is a brain disease, and it matters” in 1997.³ The US government wasn’t unanimous in this approach; just a year earlier Congress had eliminated addiction as a Social Security benefit-qualifying disability.⁴

Martin Sheen presents at an anti-Proposition 36 news conference hosted by Crime Victims United in Sacramento, Friday, Oct. 20, 2000 (Mercury News)

The dominance of the disease model of addiction has been successful at introducing the public to treating Substance Use Disorder as a question of health rather than moral failure that should be punished, which is a very positive development. Even in the 90s and early 2000s, liberals such as West Wing President Martin Sheen and the Clinton administration’s drug czar campaigned against California Proposition 36, which diverts defendants towards forced treatment for their first two drug possession charges.⁵ Incensed that relapse wouldn’t result in immediate incarceration the way it previously had in drug courts, Sheen believed that ‘tough love’ sentencing fosters recovery. Sheen cited his son Charlie’s court-ordered treatment following an overdose as his motivation, despite Charlie never facing incarceration. California voters passed this landmark reform anyway and quickly proved cost savings to the nation.

In the United States, the disease-centric model creates a false dichotomy. “If addiction is not a lifelong disease, it must be a choice. “Anyone who doubts the equivalence of cancer and addiction is judging the ethical character of substance users and opens the room for further drug war criminalization – right? This debate is unheard of and irrelevant in much of the world; the health agency websites defining addiction for the United Kingdom,⁶ Canada,⁷ and Ireland⁸ do not include the word disease, instead essentially explaining the diagnostic concepts behind Substance Use Disorder.

The DSM-V definition of Substance Use Disorder has 11 criteria that can be categorized as involving risky use, impaired self-control, physical dependence, and undesired social outcomes. Severity is assessed by counting the criteria a patient currently meets: 2-3 is mild, 4-5 is moderate, and 6+ is severe.

1. Taking the substance in larger amounts or for longer than you’re meant to
2. Wanting to cut down or stop using the substance but not managing to
3. Spending a lot of time getting, using, or recovering from use of the substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home, or school because of substance use
6. Continuing to use, even when it causes problems in relationships
7. Giving up important social, occupational, or recreational activities because of substance use
8. Using substances again and again, even when it puts you in danger
9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance
10. Needing more of the substance to get the effect you want (tolerance)
11. Development of withdrawal symptoms, which can be relieved by taking more of the substance

The DSM-V criteria, while accepting Substance Use Disorder as a psychiatric condition, does not necessitate addiction as an incurable disease, and is not incompatible with other theories of Substance Use Disorder, such as psychosocial and environmental models. Each individual may range in and out of meeting different SUD criteria throughout their life. If harm reduction tactics are effective at achieving recovery from meeting clinical SUD criteria, abstinence does not need to be the central focus for all patients.

Data on Substance Use and SUD Recovery

The NESARC-III is the best available data on substance use in the United States, having surveyed a representative sample of the US population with over 36,000 participants from 2012-2013. In an analysis of NESARC-III data, McCabe (2018) identified that 25.4% of the US population has at one time (onset more than a year ago) met two or more DSM-V diagnostic criteria for a Substance Use Disorder (including alcohol).⁹ Of them, 38.1% experience persistent or recurrent SUD, 14.2% report abstinence, and 47.7% continue to use the substance to a non-disordered degree (asymptomatic use).

The study finds that only 27% of people who have had a SUD have engaged in formal treatment of any kind. While the population who received treatment are more likely to be sober, the majority of people in sober recovery, 55.3%, received no treatment, and people who received treatment are slightly more likely to have persistent SUD than those who did not. 83% of people who asymptomatically use did not receive treatment. This indicates that many people can and do recover from a SUD without formal treatment, whether through sobriety or moderation. More than improving the odds of recovery, treatment appears to reduce the likelihood someone will use in moderation, which is in line with the “all or nothing” approach that many Twelve Step programs can instill.

In SAMSHA’s 2020 National Survey on Drug Use and Health, the prevalence of meeting SUD criteria quickly peaks at ages 21-25, then declines steadily with age.¹⁰ Quite different from cancer or heart disease, the average course of SUD is remission, not progression. That is if people with a SUD are afforded the means to stay alive during their use.

Safe supply prescriber Dr. John Marks of the Halton Drug Dependency Clinic in Liverpool, England relayed this observation in his 1995 interview with 60 Minutes:¹¹

[60 minutes] But doesn’t Dr. Marks try to cure people?

“Cure people? No, nobody can. Regardless of whether you stick them in prison, put them in mental hospitals and give them electric shocks – we’ve done it, give them a social worker and pat them on the head. Doesn’t matter what you do. 5% random, one in twenty per year, get off spontaneously. Compound interest-ed up, that reaches about 50% – 50/50 after 10 years. They seem to mature out of addiction regardless of any intervention in the interim.
But you can keep them alive, and healthy, and legal, during that 10 years, if you so wish to.”

[60 minutes] By giving them drugs?

“It doesn’t get them off drugs, it doesn’t prolong their addiction either. But it stops them offending, it keeps them healthy, and it keeps them alive.”

Analyzing NESARC-II 2001-2002 participants who have had a prescription drug use disorder (including prescribed stimulant, opioid, sedative, and tranquilizer medications), Blanco et al (2012) find that greater than 96% of PDUD cases remit, with half experiencing remission at 4-5 years since onset.¹² This data is notably from before the crackdown on opioid prescribing, and long before fentanyl pressed as Oxycodone flooded the illicit market. In a bygone era of abundant prescriptions, the vast majority of prescription drug SUD patients recovered over time, with or without formal treatment. This data would likely look quite different in 2022, when prescription dependent patients, disordered or not, are forced to a deadly street supply.

The treatment center industry¹³ and government bodies¹⁴ frequently cite that “only 1 in 10 addicts get the treatment they need” as evidence for a dramatic expansion of their services. This figure also comes from SAMSHA’s annual National Survey on Drug Use and Health, which defines “needing treatment” as anyone who meets two or more SUD criteria and individuals who went to treatment without meeting SUD criteria, such as those forced by drug courts for possession.¹⁵

In the 2020 survey, 5.2% of adults meet Cannabis Use Disorder, 2.3% have another illicit SUD, and 11% of people have an Alcohol Use Disorder. 11.8% of adults have used cannabis in the past month, indicating that just under half of current cannabis users meet the criteria for a SUD – compared to 22% of alcohol users and 67% of other illicit substance users. By conflating clinical criteria for even mild SUD with “needing treatment,” SAMSHA indicates that 2/3rds of people needing illicit SUD treatment are cannabis users.

This is not to downplay that many cannabis users experience dependence and social, emotional, or economic harm and may benefit from some form of treatment. However, we’re having this conversation because treatment is promoted as the catchall solution to 108,000 drug overdose deaths a year. The risk profile of cannabis is inherently quite different from other illicit drugs, largely thanks to the availability of safe supply. In the late 2000s, volatile synthetic products (‘Spice’ and ‘K2’) flooded the market, designed to evade drug laws and sell something that looks like weed at convenience stores. As cannabis legalization swept North America, these troubling products disappeared, as reflected in Google Search trends, while non-psychoactive CBD products became very popular as home remedies thanks to the labeling regulations. When a safe supply of cannabis is enabled, users trend towards less potent and risky products. Grasping at the straws of urgently proliferating treatment becomes a lower priority for society.

Google Trends comparing K2, Spice, recreational marijuana, and CBD products as search terms.¹⁶

Continue reading in: What is Drug Treatment? Science-Resistant Industry and Courts vs. Clinical Best Practices

References

1
“4. Remembering That Alcoholism Is an Incurable, Progressive, Fatal Disease.” In Living Sober, 2019 ed., 7. New York: Alcoholics Anonymous World Services, Inc., 1975. https://www.aa.org/sites/default/files/2021-10/b-7_livingsober_1-17.pdf.
2
National Institute on Drug Abuse. “Drugs, Brains, and Behavior: The Science of Addiction Treatment and Recovery.” National Institute on Drug Abuse, July 2020. https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery.
3
Leshner, Alan I. “Addiction Is a Brain Disease, and It Matters.” Science 278, no. 5335 (1997): 45–47. https://www.jstor.org/stable/2894496.
4
Davies, Paul S. “The Effect of Welfare Reform on SSA’s Disability Programs: Design of Policy Evaluation and Early Evidence.” Social Security Bulletin 63, no. 1 (2000): 9. https://www.ssa.gov/policy/docs/ssb/v63n1/v63n1p3.pdf.
5
Kaplan, Tracey. “Proposition 36: Voters Overwhelmingly Ease Three Strikes Law.” The Mercury News, November 6, 2012. https://www.mercurynews.com/2012/11/06/proposition-36-voters-overwhelmingly-ease-three-strikes-law/.
6
nhs.uk. “Addiction: What Is It?,” January 18, 2022. https://www.nhs.uk/live-well/addiction-support/addiction-what-is-it/.
7
Canada, Health. “About Substance Use.” Education and awareness, September 30, 2014. https://www.canada.ca/en/health-canada/services/substance-use/about-problematic-substance-use.html.
8
“Our Approach – Soilse.” Health Service Executive. Accessed December 5, 2022. https://www.hse.ie/eng/services/list/5/addiction/soilse/our-approach.html.
9
McCabe, Sean Esteban, Brady T. West, Stephen Strobbe, and Carol J. Boyd. “Persistence/Recurrence and Remission from DSM-5 Substance Use Disorders in the United States: Substance-Specific and Substance-Aggregated Correlates.” Journal of Substance Abuse Treatment 93 (October 2018): 38–48. https://doi.org/10.1016/j.jsat.2018.07.012.
10
“Table 5.2B – Substance Use Disorder in Past Year: Among People Aged 12 or Older; by Detailed Age Category, Percentages, 2019 and 2020. 2020 National Survey on Drug Use and Health.” SAMHSA & CBHSQ, October 26, 2021. https://www.samhsa.gov/data/sites/default/files/reports/rpt35323/NSDUHDetailedTabs2020v25/NSDUHDetailedTabs2020v25/NSDUHDetTabsSect5pe2020.htm#tab5-2a.
11
Legal Heroin for Addicts in Liverpool. 60 Minutes (US). Liverpool, UK, 1995. https://www.youtube.com/watch?v=Zy_86iVhmkQ.
12
Blanco, Carlos, Roberto Secades-Villa, Olaya García-Rodríguez, Marta Labrador-Mendez, Shuai Wang, and Robert P. Schwartz. “Probability and Predictors of Remission from Life-Time Prescription Drug Use Disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions.” Journal of Psychiatric Research 47, no. 1 (January 1, 2013): 42–49. https://doi.org/10.1016/j.jpsychires.2012.08.019.
13
Northpoint Idaho. “Solving the Mystery: Why Only 1 in 10 People Facing Addiction Get Help,” October 25, 2017. https://www.northpointrecovery.com/blog/solving-mystery-1-10-people-facing-addiction-get-help/.
14
Surgeon General’s Report on Alcohol, Drugs, and Health. “Key Findings: Early Intervention, Treatment, and Management of Substance Use Disorders.” Accessed November 20, 2022. https://addiction.surgeongeneral.gov/key-findings/early-intervention.
15
SAMHSA and CBHSQ. “Needed and Received Treatment or Perceived Need for Treatment and Made Effort to Get Treatment, and Reasons for Not Receiving Treatment – Results from the 2020 National Survey on Drug Use and Health: Detailed Tables,” October 26, 2021. https://www.samhsa.gov/data/sites/default/files/reports/rpt35323/NSDUHDetailedTabs2020v25/NSDUHDetailedTabs2020v25/NSDUHDetailedTabsTOC2020.htm#toc.
16
Google Trend. As states legalized cannabis, the harmful substitutes disappeared and CBD grew. “Google Trends.” Accessed November 19, 2022. https://trends.google.com/trends/explore?date=all&geo=US&q=k2%20drug,spice%20drug,recreational%20marijuana,cbd%20products.