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Abstract
The paper explores the varied implications of cure, healing, and recovery and considers why recovery is often the preferred characterization in relation to a medicalized drug dependency. The positive as well as the negative dimensions of recovery are noted; the ethical challenges of the primarily processual associations of recovery are investigated; and some policy implications are indicated.
Notes
1 The category of “drugs” is somewhat amorphous and socially contested, and in fact I use it here not simply to refer to those psychoactive substances commonly referred to as drugs but also as a dummy for other dependencies (associated with, say, gambling and eating) from which people often seek recovery.
2 Not all philosophers are so unselfconscious. An illuminating discussion can be found in M. B. CitationFoster (1957).
3 There is a large literature that focuses on the conceptualization of disease and concepts that are related to it and whether they should be construed functionally, normatively, statistically, or in some other way, and although that debate has important implications for how we categorize drug dependence and characterize that categorization, I shall not pursue those issues here.
4 This may not always be true of a person's social status, which can be permanently affected by the preexisting condition.
5 In addition, of course, it is somewhat more natural to speak of an “organ” being healed and of a disease being cured. Nevertheless, healing is more frequently associated with a “residue” than a cure.
6 The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.
7 Of course, cure and healing may be out of our reach for other reasons, such as the availability of and accessibility to resources. “Availability” and “accessibility” may be a function of micro and macro social, political, and catastrophic “big events,” and economic, religious, and geographical factors. Overcoming such factors may sometimes have to await major social change.
8 In the case of methadone or buprenorphine, used as medicines, the recovery is effected by the substitution of a substance that is deemed less toxic for one that is deemed more toxic. Whether, minus a level playing field, this judgment about relative toxicities is justified is another matter.
9 Although groups such as AA officially reject particular explanatory accounts of alcoholism (cf. the Tenth Tradition), seeing it as an “illness” rather than as a “disease” or “moral failure,” some of its early contributors, particularly Dr. William Silkworth, viewed alcoholism as an “allergy” that one would not grow out of. It is not, however, part of what we understand by an allergy that one cannot grow out of it. Chronicity may not be “curable” but, to the extent that one can grow out of it, need not be permanent. See Kurtz (2002).
10 Without wishing to downplay the physiological and psychic effects that drug dependencies may have, we should not forget the extent to which the burdensomeness of drug use may be socially exacerbated through prohibitions, social opprobrium, and so forth. Just as disease is, to some extent, a social construct (and not a simple reflection of “scientific” functionality) so too is recovery. Independently of their impact on human systems, we may make the use of certain substances burdensome to those who use them.
11 Either way, it might be claimed, we problematically mystify and empower them, whereas the emphasis ought to be on our own empowerment.
12 We should not leave unnoted the economic burdens that might be associated with substitution treatments, such as buprenorphine, and the ethical dimensions of deciding whether to use it or methadone.
13 Ironically, it was emphysema that was largely responsible for the death of Bill Wilson, AA's cofounder. See CitationCheever (2004).
14 This “opioid agonist replacement therapy” substitutes for heroin an alternative opiate that is claimed to have less disruptive euphoric, sedative, and analgesic effects, thus enabling a person to engage more effectively in everyday activities. In addition, because it is said to be less addictive, it is said to enable a person to be more effectively weaned off drug (opiate) dependency. Whether these claims are factually correct or significantly infused with social and political agendas is another matter. Methadone too has become a “street drug.” The relatively recent vocabulary of “methadone maintenance” may suggest that it is an interim therapeutic measure, like being maintained on a respirator until one is able to breathe by oneself. See, for example, some of the treatment options discussed in Terry and Pellens (1928). However, for some advocates of methadone maintenance the analogy has been to insulin maintenance for those people living with diabetes, and who do not anticipate being weaned off it. We might wonder about the legitimacy of the latter analogy.
15 A question: how does this differ from the case of the person whose deficiency requires dependence on drugs that are so costly that they allow for nothing much more than survival? In the latter case we might argue that it is the drug itself that is the source of the “economic disenablement,” whereas in the former case, the economically disenablement is generated by something external to the drug for which the drug provides an antidote. But this won't quite do, because the drug is usually economically disenabling only because it has been prohibited with the consequence that the economic costs of obtaining it have been multiplied. Otherwise access would be more like access to cigarettes—expensive, perhaps, but not usually so economically disenabling as to be crippling.
16 Libertarians often tend to associate (most of) the burdensomeness of the so-called problem drugs to the restrictions we place on accessing them. See CitationSzasz (1996).
17 Whatever one thinks about the language of “addiction,” it is always problematic to turn an adjectival characterization of a person into a noun that now becomes the predominant focus—such as “homosexual,” “criminal,” “ex-felon,” or “Jew.” It is not merely the refocusing from part to whole, however; the substantival forms often tap into deeply ingrained social stereotypes/prejudices which are then communicated and experienced as dehumanizing.
18 I find the data unclear. Apart from anything else, it is unclear whether the groups are interchangeable. A significant number of those who responded well to a methadone treatment program may not have responded well to a twelve-step program and vice versa.
19 The focus on abstinence is sometimes used discriminatorily. In US disability law, a diagnosed “alcoholic” does not have to be abstinent in order to qualify for publicly funded vocational rehabilitation programs whereas those who suffer from illicit substance use disorders do. See Magura and Staines (2004).
20 For a perceptive critique, see CitationMarshall (1975).
21 Strictly speaking, a chronic condition simply persists over a significant period of time, but in medical contexts it tends to carry the added implication that it cannot be cured (only alleviated). We should be careful, however, not to harden what is at best a contingent distinction (acute/chronic) into an absolute one, especially given the tendency for derogatory socializations such as “once an addict/alcoholic, always an addict/alcoholic”.
22 The concepts of vulnerability, predisposition, and susceptibility are hardly perspicuous, and their various dimensions—physiological, social, and psychological—need to be articulated and evaluated.
23 Given that dependency is partly a function of social setting and not simply of physiological (or genetic) predisposition, it is not unreasonable to think that changes in personal skills and social situations might enable people who have experienced periods of dependency on drugs to use them in moderation. I say this without questioning the general practical wisdom of 12-step living.
24 There is, of course, then the further issue of transferring such knowledge into actual programs—partly an economic and political problem, partly a reflection of the social communication gaps among researchers, policy makers, and practitioners.
25 The reference to “certain other factors” might countenance (future) possibilities such as genetic manipulation or other forms of counteraction that would eliminate the predisposition.
26 Perhaps we should think here not of certain drugs as, per se, “recreational” but less tendentiously of “recreational drug use,” that accommodates a wider range of substances (albeit under certain conditions).
27 I am of course leaving out of the equation certain social policies that serve to exacerbate the human problems. Nevertheless, I am assuming that even with different policies these dependencies would often be disruptive of socially satisfying relations.
28 However, we should not disregard the limited but real helping community that sometimes develops among drug users. A small number of harm reduction based needle exchange programs in the USA, the UK, and Australia have recently begun to train active-injecting drug users in the use of naloxone—which is given to them in packages with syringes—as immediate first aid for someone having an opiate overdose. As a result, lives have been saved.
29 “Rational addiction” theorists have argued that, because individuals do not voluntarily take actions that they expect will make them worse off, they do not cede but express autonomy in continuing to use drugs. See CitationVuchinich and Heather (2003). But this apriori view of what constitutes rational behavior is probably better suited to the presumptions of economic theory than people as we encounter them.
30 The US. Supreme Court notwithstanding (United States v. Oakland Cannabis Buyers' Cooperative et al., 532 U.S. 483 [2001]), it is unconscionable that our exaggerated social response to marijuana should flow over into our policies regarding its medical use.
31 I am grateful to Stanley Einstein and Alexandre Laudet for provocative comments on a draft of this essay. Like all good editors, not only have they prompted better answers but also more questions than those for which I have answers. Andrew Long provided valuable research assistance.