The surgeon general’s new report, Facing Addiction, is chock full of statistics intended to startle people into action. One in seven Americans will experience a problem with alcohol or other drug misuse in their lifetimes, and some 20 million have current substance use disorders. But with 78 people dying from overdose every day, only 10% of people with addictions ever receive any sort of help towards recovery.



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“For far too long, too many in our country have viewed addiction as a moral failing,” writes Surgeon General Vivek Murthy in his introduction. “We must help everyone see that addiction is not a character flaw – it is a chronic illness.”

Murthy hopes to spur revolutionary change the way his predecessor Luke Terry did, with his 1964 report on smoking that galvanized Americans into confronting the clear link between cigarettes and lung cancer. But with Facing Addiction, he hasn’t produced a report that is radical enough to do so.

Unfortunately, while it calls for welcome initiatives on many fronts – such as expanding access to harm reduction programs, including needle exchange and distribution of the opioid overdose antidote naloxone – it doesn’t go nearly far enough.

For example, while calling for “less punitive” treatment and more drug court programs, the report doesn’t recognize that we don’t treat other diseases with punishment or criminalization. While correctly noting that TV-style, in-your-face interventions and confrontational addiction treatment are not helpful, it doesn’t reckon with the fact that they are common.

And while demanding increased access to treatment supported by scientific evidence, it makes no attempt to address the contradictions inherent in labeling addiction a disease while the vast majority of treatment programs work to get patients to accept the prayer and surrender to a higher power involved in the 12 steps.

Avoidance of these issues has led to a report that is vague, which interferes with its usefulness.

This is most glaring for those concerned about opioid addiction. For instance, one of the “key points” emphasized in the report is “well-supported scientific evidence shows that treatment for substance use disorders – including inpatient, residential, and outpatient – are cost-effective compared with no treatment”. This will be used by expensive rehabs to justify insurance coverage.

But this is not true for residential and outpatient treatment for opioid addiction that doesn’t include ongoing use of maintenance medications such as methadone and buprenorphine, which is the majority of residential care. In fact, a study of the entire UK treatment system showed that people with opioid addiction who underwent residential or other types of treatment without maintenance medication had twice the death rate of those who stayed on meds.

Another problem that results from vagueness in the report is its use of the term “medication assisted treatment” (MAT) to refer to all three medications currently approved for the treatment of opioid addiction. The report states: “MAT is a highly effective treatment option for individuals with alcohol and opioid use disorders. Studies have repeatedly demonstrated the efficacy of MAT at reducing illicit drug use and overdose deaths improving retention in treatment and reducing HIV transmission.”

This, however, is true of only two of the medications, methadone and buprenorphine. There is no data suggesting that that the third, naltrexone, reduces overdose death rates (the oral or implanted forms were associated with an eight times greater risk of death in Australian research compared to deaths following methadone; there’s not enough research to know if the injectable long-acting version could have similar problems). Only long-term use of methadone or buprenorphine is linked with saving lives; this data should have been highlighted and these medications advocated as superior care.

Finally, the report doesn’t address the problems associated with a tactic called “12 step facilitation” (TSF), which is used in one form or another by at least 80% of all American treatment programs. This involves, as the report describes, promoting “acceptance” that abstinence is the only solution, pushing “surrender” to a “higher power” and urging “active involvement in a 12 step program”.

The report cites evidence showing that in the treatment of alcoholism, this approach is as effective as less problematic and more systematic treatments such as cognitive-behavioral therapy and motivational enhancement therapy. But what it doesn’t explain is why a treatment that has been ruled to be religious in every relevant court case should be used when there are good alternatives. And it doesn’t note that there is little evidence supporting it for opioid treatment particularly.

It’s highly unlikely that the public will be convinced that addiction is really a disease when the main treatment for it continues to involve admitting immoral behavior and making amends for it. And since you can attend 12-step groups for free in nearly every city around the world, I remain baffled as to why reports like this don’t call for the removal of 12-step content from paid professional care, even if only to avoid redundancy and save money.

This is not to say that 12-step programs aren’t helpful as support groups for some. I’m merely suggesting that a report calling for improvement of addiction treatment cannot sidestep the reality that they are not professional care and should never have been sold as such.

If addiction is to be seen as a disease like any other, it can’t be criminalized, and it can’t be the only part of medicine where being made to surrender to a higher power is legitimate therapy. Any report that doesn’t confront the contradictions in the way we moralize addiction while claiming to want to medicalize it, cannot produce the radical changes that Murthy – and everyone else concerned with addiction – knows are necessary.