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What Happened to Rehabilitation?

Marcel Gemme By Marcel Gemme | Last Updated: 19 September 2023
  • What You'll Learn

A new “solution” to substance abuse

Brace yourselves for the future of heroin addiction treatment. It’s not a new miracle drug, or form of behavioral therapy. It’s HAT, or Heroin Assisted Treatment, and it’s exactly what it sounds like. Giving people heroin to get them off…well, never mind. It’s just giving people heroin.

Shocked? Don’t be. Switzerland has been doing it for years. It began as a semi-political, public safety response to resident’s complaints of open drug activity. It was a bad look, and people wanted it gone. A then radical approach was adopted, where a medically supervised clinic was set up for heroin addicts to come and receive and inject pharmaceutical-grade heroin. And with the purpose of cleaning up the streets, it worked. Less open drug use, obviously. Less crime, too, as people didn’t have to resort to it to obtain drugs.

The industry standard

Today, the medical field is highly in favor of Medically Assisted Treatment, or MAT, which consists of placing people on strong opioid medications in lieu of the illicit narcotics they were abusing. The American Society of Addiction Medicine, or ASAM, has taken the stance of backing the gold standard and only recognized form of valid treatment for opiates. They have also denounced abstinence-based models that encourage clients to be free of all mind-altering chemicals. ASAM suggests that abstinence models are both risky and negligent.

Studies on the subject of both HAT and MAT prove to be quite fascinating. If you research it, you’ll be surprised to find a fair amount of positive studies indicating the effectiveness of this approach. At first glance, they paint a compelling picture of reduction of drug use, relapse, addiction related crime, and health risks. But it’s only when you read the studies that you understand the degree to which they are misleading. It’s all in the language.

What is treatment?

The primary misnomer is that these are both referred to as treatment. The drug rehabilitation field has long used the term “treatment” to refer to methods of getting people off drugs and restoring them to a former capacity. One would expect any treatment to handle the source problem, rather than the consequence. For instance, cancer has well-known treatments like chemotherapy and radiation. People suffering from cancer often have consequential symptoms, such as pain. Medications are issued to mitigate this pain. Yet, no one would consider pain medications as the “treatment” for cancer. It’s quite clear that HAT and MAT are harm reduction measures intended to lessen the consequences of addiction. This logically disqualifies them as being forms of treatment.

Secondly, misleading nomenclature is found when referring to the success of these studies. Boasting higher rates of “retention” to traditional forms of treatment isn’t hard to imagine when you consider that the participants are being given free heroin. Of course, they keep coming back. Similarly, claims of reduced rates of relapse are almost ridiculous when considering that you can’t relapse onto something you’re already doing. But these are scientific claims referred to as factual evidence showing the effectiveness of HAT. Perhaps the only logical aspect of this approach which emerges is that HAT is effective as another harm reduction measure. Harm-reduction is an umbrella term for measures aimed not at solving the root problem, but rather mitigating the fallout. When viewed simply as such, MAT and HAT have their place and saves lives. But we must be very careful to not confuse harm reduction with addiction treatment.

The shifting of goals recovery

This shift toward HAT is likely due to the fact that overdose has become so prevalent, and the medications given in MAT do decrease overdose rates significantly. But the goal of treatment in America has clearly changed. It’s now about keeping people from dying rather than recovery.

We cannot ignore the fact that many people do achieve full recovery from opioid addiction and are effectively rehabilitated. Rehabilitation is defined as a return to a normal condition. In terms of substance dependence, this would look like someone who was no longer addicted to drugs. Closing the door on the possibility of this as the goal of substance abuse treatment seems illogical. People who strive for more than substitution medications should be able to get help, too.

Many may argue that if abstinence models were effective, we wouldn’t have this problem on our hands. After all, the treatment industry has been notably lacking in oversight and uniformity. But it’s also been lacking in research and quality assurance. Why is it that models based on pharmaceutical medications garner fast research and publication, yet the traditional treatment methods have languished in the “unproven” category for decades? Some might argue that rather than dumping all new efforts and funding into medications and legal heroin, we could improve abstinence-based models so that they are more effective.

What would you do?

It’s easy to compartmentalize the opioid addicted population, but if this were a family member or close friend, one may feel very different about the subject. I guess the question we all have to ask ourselves is whether we’d want someone we knew and loved to achieve true rehabilitation or resign to injecting legal heroin for the indefinite future. Further, would we treat our own children the way that HAT is proposing, by giving them drugs and a place to use them? Of course, we’d do almost anything to save their life. But it’s hard to ignore that most families dealing with addiction answer no to the above. After all, there are other options. For now.

Future implications

Ultimately, recovery as a goal shouldn’t be abandoned. Do we really want more people shackled to their prescriptions? Recovery can restore people to the place they were before their lives took a sharp turn, and that’s ultimately what the person who’s struggling with substance dependence wants. Money and effort spent in this direction would inevitably save our nation much more than it costs. MAT and HAT bring with them a continuation of the need for healthcare, often for the rest of one’s life. The financial implications of this are questionable and favor pharmaceutical companies more than they do our society. Things like this cannot be ignored when we truly examine the bigger picture of where we want to go as a nation.

Efforts are underway right now to make HAT a thing in the United States. This will require a lot of political and legislative involvement, and undoubtedly the misleading studies and statistics will be leaned on by proponents of the movement. Luckily, there are a few, sensible arguments being made that if employed, HAT be an absolute last resort for select patients who show no response to the myriad of other forms of actual treatment. It’s essentially a white flag. We give up. You’re going to use heroin, so we might as well make it safer.

More research and more choice

Not surprisingly, much more study has been done on the effectiveness of HAT than its risks. Beyond the sentiment of not wanting heroin dispensaries in our neighborhoods, we need more information on how implementing HAT could impact the future. Not only may it affect how we view drug use, it could supersede abstinence as a desirable alternative. Let’s fully understand what we’re getting into before jumping headfirst.

People should have options to fit their goals. Just as the person who chooses MAT or HAT shouldn’t be stigmatized for their choice, neither should the individuals choose abstinence-based recovery. Furthermore, let’s not forget the tragedies, like the over-prescribing of Oxycontin, when it comes to medication-based solutions being relied on as fact. If we blindly follow the “science on our side” approaches of healthcare without questioning them, we’ve learned little from our recent teacher, hindsight.




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Marcel Gemme has been helping people struggling with addiction for over 19 years. He first started as an intake counselor for a drug rehabilitation center in 2000. During his 5 years as an intake counselor, he helped many addicts get the treatment they needed. He also dealt with the families and friends of those people; he saw first-hand how much strain addiction puts on a family and how it can tear relationships apart. With drug and alcohol problems constantly on the rise in the United States and Canada, he decided to use the Internet as a way to educate and help many more people in both those countries. This was 15 years ago. Since then, Marcel has built two of the largest websites in the U.S. and Canada which reach and help millions of people each year. He is an author and a leader in the field of drug and alcohol addiction. His main focus is threefold: education, prevention and rehabilitation. To this day, he still strives to be at the forefront of technology in order to help more and more people. He is a Licensed Drug and Alcohol Treatment Specialist graduate with Honours of Stratford Career Institute. Marcel has also received a certificate from Harvard for completing a course entitled The Opioid Crisis in America and a certificate from The University of Adelaide for completing a course entitled AddictionX: Managing Addiction: A Framework for Succesful Treatment.