UNCONTROLLED SUBSTANCE USE IS A NATIONAL EPIDEMIC: WHERE HAVE DECADES AND BILLIONS SPENT ON MEDICAL MODEL RESEARCH AND APPROACHES GOTTEN US?
By Clark Miller
Published August 2, 2018
Updated April 4, 2021
Measured by public health outcomes, trends, and related research and data, medical industry control of healthcare resources to treat compulsive substance use, or “addiction”, has been a lethal failure – providing instead of effective treatments and gains, a continually worsening national substance use epidemic diverting public funding away from therapy treatments established for decades as effective, but not implemented in traditional, medically-managed “rehab” and addiction treatment programs.
While the Opioid Crisis commands headlines nearly daily, many more Americans are trapped in equally lethal, broader, and worsening epidemics including substance abuse, child and adult obesity, and diabetes. Implementing effective prevention and treatment approaches will require fundamental change in healthcare, because the public health crises emerged from current treatment models, the opioid crisis for example caused by the predictable and avoidable costs of treating an entirely non-medical problem with medical fixes – opioids for common chronic pain.
Maybe most disturbing, and unrecognized, is a looming diabetes epidemic fueled by a substance use epidemic in kids – in kids – runaway childhood obesity driven by compulsive overuse of food, driven by stress, or “emotional eating”, constituting a substance use problem like any other, but in kids and fueling worsening obesity and diabetes epidemics.
This wasn’t supposed to happen –
Not with persistent promises of help to a public increasingly trapped in opioid and addiction epidemics, promises for decades by top medical experts of “medical treatments” for substance use just around the corner: as in this 2007 addiction documentary featuring assurances from top U.S. medical and healthcare authorities – promised some 15 years, billions in public health funding, and multiple worsening lethal epidemics ago.
As we will see, those false promises that have never materialized – despite decades and $billions of public funds entrusted to those experts – will never provide a cure, or help at all, because just as with the Opioid Crisis and its increasing cost in deaths and illness, the made-up, invalidated fabrication of these entirely non-medical problems as medical conditions, “diseases”, is what has caused the epidemics, instead resulting in public health epidemics that were predictable all along.
Who knew? We did, all along, or should have,
because it’s obvious, because with any level of critical examination, exposure to critical thought and critical discourse, the fabrication that compulsive use of mood altering substances is a medical condition, “disease of the brain”, or remotely resembles a medical condition, makes no sense at all, never did, just as the lethal error of prescribing opioid pain medications for common chronic pain was always indicated as ineffective, unsafe and never supported by any type of evidence
Let’s take a look
Behavioral health and substance use treatment are typically in programs and settings overseen by a medical organization and/or a medical director. More universally, treatment for substance use disorders across a broad range of settings is guided by the Medical Model of “addiction” or “Disease Model”, more currently “Hijacked Brain” model.
Under the medical model, and typically oversight by medical directors or staff, and in the context of claims of continuing advances in brain science and related understanding of addiction, the universally provided treatment as usual (TAU) – consisting of the same components across treatment settings including outpatient and residential “rehab” –
1) has not changed over past decades,
2) is established by decades of research to predict at best no benefit, more likely harm, and has no research base supporting effectiveness as treatment.
“What we simply need is a a nice bulldozer, so that we could level the entire industry and start from scratch . . . There’s no such thing as an evidence-based rehab. That’s because no matter what you do, the concept of rehab is flawed and unsupported by evidence.”
– Dr. Mark Willenbring, former director of treatment and recovery research at the National Institute of Alcohol Abuse and Alcoholism (NIAAA)
Despite decades of biomedical research and $billions diverted to that research:
There is no identified disease model etiology, has never been
The “Hijacked Brain” model is invalidated independently by multiple lines of evidence
No medical treatments are supported by research as effective
A national substance use epidemic continues to steadily worsen over time – that and related evidence a focus of this post
The medical model asserts that “addiction” is a medical condition, a “chronic, relapsing disease”, a “disease of the brain” And (You just can’t make this stuff up) :
The dominant, near universal, medically-overseen “treatment model” are the 60-year-old prescriptions of a religious subculture – for a “disease of the brain” – those prescriptions established as countertherapeutic by decades of research.
At encouraged or forced meetings of that religious subculture, addictive use of the most lethal and addictive substance known is normalized and socially reinforced
Continued participation in those religious subculture meetings is encouraged and facilitated almost universally in medically-overseen treatment programs
One way to evaluate the validity and effectiveness of decades of control of substance use funding and treatment by the Medical Industry and the Medical Model, with hundreds of $Billions diverted to medical model treatments, grants, and research is to ask – How has That Helped?
Or – Compared to other medical conditions and public health threats, have decades of research and billions spent on research led to at least some gains in medical treatment outcomes ?
As clearly evidenced by any cursory outline of course of problem substance use incidence and costs over past decades for –
“Substantial increases in alcohol use, high-risk drinking, and DSM-IV alcohol use disorder . . . for the total US population and, with few exceptions, across sociodemographic subgroups” (JAMA Psychiatry. 2017;74(9):911-923).
Those results in problem alcohol use trends, as reported in the Journal of the American Medical Association (JAMA), are congruent with and strengthened by concurrent “increases in alcohol-related increases in cirrhosis and in hypertension as well as leveling off of previous decreases in cardiovascular and stroke-related deaths”.
As summarized in this report:
“Increases in alcohol use, high-risk drinking, and DSM-IV AUD in the US population and among subgroups, especially women, older adults, racial/ethnic minorities, and the socioeconomically disadvantaged, constitute a public health crisis. Taken together, these findings portend increases in many chronic comorbidities in which alcohol use has a substantial role.”
Evidence and trends point to increases in problem use of nicotine, especially by youth. Any apparent decrease in use of tobacco by youth is being offset by increasing use of electronic cigarettes, “e-cigarettes”, by “vaping”, with signs of vaping leading to long-term increases in use of tobacco by smoking, by youth.
Endorsement in the Journal of the American Medical Association (JAMA) of a plan to encourage vaping as harm reduction cited a small downward shift in vaping by youth over just one year- 2016. But as described in new reports in the online news source Vox, more recent data point to booming use of e-cigarettes among youth, that use increasing likelihood of young people starting to smoke (tobacco) cigarettes. Additional takeaways from the 2018 report on e-cigarette use by the National Academies of Sciences, Engineering, and Medicine include:
long term health effects are not known
the evidence is not clear as to whether use of e-cigarettes actually reduces tobacco use
If anything, it appears that problem nicotine use and its consequences, and possibly tobacco use long-term, is worsening among youth as related to 1) booming use of vaping; 2) vaping increasing risk of tobacco use; and 3) the direct links among childhood obesity epidemic and childhood and adult diabetes epidemic fueled partly by nicotine use – nicotine effects that occur whether administered through smoked tobacco or by vaping.
No evidence-supported gains related to medical treatments appear from review of the evidence over the past decades for alcohol or nicotine use, instead signs pointing to worsening problem. Downward trends in administration of nicotine by smoking of tobacco (of cigarettes) is generally attributed to public health education campaigns, medical “treatments” in any case without evidence of effectiveness.
What about overall status and trends for public health and all substance use problems? There’s the Opioid Crisis – described as a public health crisis in its own right, without doubt contributing to an overall worsening of problem substance use on a national public health level; generated by the inappropriate application of the Medical Model to an entirely non-medical condition, against all lines of evidence; a medical industry-generated public health crisis responded to with . . . a medical fix that is not supported as working by research evidence.
What about meth?
Google “methamphetamine” for the predictable results.
“Increases in alcohol use, high-risk drinking, and DSM-IV AUD in the US population and among subgroups, especially women, older adults, racial/ethnic minorities, and the socioeconomically disadvantaged, constitute a public health crisis.”
But it’s the Hidden Addiction
that will overwhelm all others combined as measured by illness, deaths, public health costs, and contribution to a continually worsening national substance use epidemic – and in providing evidence for the lethal failure resulting from control of substance use understanding and treatment over past decades by the Medical Industry and Medical Model.
Considering the key features that describe a substance use disorder –
behaviors involved in use
primacy of and understanding of underlying distress or discomfort as driving the compulsive behavior
neurobiology – how the brain is involved
the psychology related to urges and associations
and types of associated emotional states and social distress
– compulsive use of the substance food leading to obesity and harmful health effects effects is not different from compulsive use of other mood-altering substances, recognized for some time, for example here:
Below are the diagnostic criteria for substance use disorder, from the DSM 5, or Diagnostic and Statistical Manual of the American Psychiatric Association – the criteria used to diagnose any substance use disorder from heroin to methamphetamine. In clinical interview, patients meeting a minimum of 2 of the criteria are diagnosed with the disorder, in this case Food Use Disorder, falling under the DSM 5 category of “Other Substance-Related Disorders”.
A substance use disorder is assigned a level of severity according to number of criteria met: 2 – 3 = LOW 4 – 5 = MODERATE 6+ = SEVERE.
For Food Use Disorder, there is lack of clarity about the potential for tolerance and the experience of withdrawal symptoms, due to lack of research and barriers to recognition as an included, named disorder – barriers unrelated to the evident nature of compulsive, maladaptive use of food as a substance use disorder like any other, instead understandable on other grounds, cultural and institutional.
The DSM 5 criteria:
1 The substance is often taken in larger amounts or over a longer period than was intended.
2 There is a persistent desire or unsuccessful effort to cut down or control use of the substance.
3 A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
4 Craving, or a strong desire or urge to use the substance.
5 Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.
6 Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.
7 Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
8 Recurrent use of the substance in situations in which it is physically hazardous.
9 Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10 Tolerance, as defined by either of the following:
- A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
- A markedly diminished effect with continued use of the same amount of the substance.
11 Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for that substance (as specified in the DSM- 5 for each substance).
- The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.
Healthcare professionals and nonprofessionals will recognize that for adults, adolescents, and children commonly encountered and struggling with obesity or overweight, many or most of the criteria for a substance (food) use disorder will be met, indicating diagnosis of Food Use Disorder.
But Food Use Disorder, a clearly valid DSM 5 diagnosis under published criteria, is never, that I have observed, (apart from in my own assessments) diagnosed. Why not? – more about that in an upcoming post.
“Stress eating” is established in children and adults
Jääskeläinen et a l. Stress-related eating, obesity and associated behavioural traits in adolescents: a prospective population-based cohort study. BMC Public Health 2014, 14:321 http://www.biomedcentral.com/1471-2458/14/321
Sominsky L, Spencer SJ. Eating behavior and stress: a pathway to obesity. Frontiers in Psychology. 2014;5:434. doi:10.3389/fpsyg.2014.00434.
Haines et al. International Journal of Behavioral Nutrition and Physical Activity (2016) 13:68 DOI 10.1186/s12966-016-0393-7
Critically, the social and healthcare costs of Food Use Disorder are and will increasingly eclipse and overwhelm systems, social resources, and effects of all other substance use disorders combined – more so the longer it remains hidden, denied – for the obvious reasons that don’t require links to research: the consequences of an obesity epidemic for a range of serious health risks and illnesses, including as a primary risk factor for diabetes, now predicted to become the greatest healthcare epidemic ever.
What’s that about, anyway?
In the greatest nation in the history of the world?
In separate posts we’ll examine and dismantle additional lines of evidence related to the fabricated model of problem substance use (“addiction”), as somehow a medical condition, chronic disease, or disease of the brain, including:
Does the phenomenon of “addiction” fit with our conception of “disease”
Is there an identified disease (biological) etiology, pathology?
Are there alternative conceptualizations supported by evidence that are incongruent with a medical condition model?
Is the epidemiology of substance use congruent with a chronic disease or medical condition course?
Are medical model explanations logically congruent?
Are predictions for causes, patterns and course of relapse based on the “hijacked brain” model supported by the evidence?
So far in this post we’ve established that –
A runaway national substance use problem is not just worsening, but is a recognized crisis and epidemic that:
Impacts children as well as adults
Will increasingly overwhelm public health care resources
Has not benefited from or been moderated by $ billions and decades of research under a never-evidenced, fabricated “medical model”, nor by treatment as usual (TAU) that is not treatment at all, nor by “addiction medicine”
But what about those medical treatments for substance use problems, promised for decades? Aren’t they just around the corner?
How can those promises and claims square with runaway substance use epidemics?
For Alcohol –
Current research does not support medications as effective treatment. One recent review of current results is headlined:
For Tobacco –
The most current evidence points to no benefit from longstanding nicotine replacement therapy (NRT), despite continued standard use by medical professionals for smoking cessation.
Other medications commonly used for smoking cessation (like bupropion and varenicline) have very small long-term benefit (less than 20% at one year) and clinical trials often include supportive counseling – which factor had the effect?
Importantly, a body of research establishes that urges per se to use substances, specifically tobacco, do not predict return to problem use (“relapse”), instead other factors do (e.g. Herd, Borland and Hyland, 2009, cited). The assumed (and invalidated) effectiveness of medications and NRT for quitting tobacco use is based on the assumption – false – that urges to smoke are a primary trigger and cause of relapse.
Worse, provision of NRT and other medication-based interventions to patients trying to stop smoking, with no or clinically insignificant benefit, is associated with additional harm due to reinforcement of patient belief in the invalidated disease model of “addiction” (NRT provided by medical providers in medical settings and perceived as a medical treatment for addiction), because research establishes belief in the fictional disease model as a primary predictor of relapse.
Effects for positive outcomes with NRT have always been small for example “number needed to treat” NNT to provide one positive outcome, in this study NNT = 29 = 97% failure rate:
Newer research and meta-analysis point to no tobacco cessation benefit (no difference in cessation rates compared to no treatment) from NRT:
Herd, N., Borland, R. and Hyland, A. (2009), Predictors of smoking relapse by duration of abstinence: findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 104: 2088–2099
For opioids –
Healthcare industries responsible for the opioid crisis have rushed to claim effectiveness for Medication-Assisted Treatment (MAT) with Suboxone, a medical fix for a lethal epidemic caused by the unsupportable medicalization of a non-medical problem, popular media tagging along without critical examination of claims and evidence that, on examination, does not support MAT as an effective response to the opioid crisis.
But evidence for the universally accepted medical fix for the medically-generated opioid crisis, Medication-Assisted Treatment, is at best inconclusive, with multiple studies pointing to treatment failure and MAT as a currently unvalidated approach.
The lethal false promise of medical treatments for substance use is invalidated by the evidence and lack of evidence over decades of wasted research funding, but does not depend directly on clinical trial research, is independently debunked by common sense reasoning:
– If there were effective medical treatments, there would be supporting bodies of replicated randomized controlled trials (RCT), generated over past decades and $billions allocated to research. Then apologists for the fabricated chronic disease model could point to and cite these bodies of research, rather than continuing to promise cures “just around the corner”. For medical conditions with medical treatments that do provide benefit – for example diabetes and AIDS – there are such bodies of research, congruent with real, established benefit for the conditions.
– Health problems that are not medical conditions at all and don’t seem like medical conditions, do not have medical treatments.
– The logic: if there are such medical treatments, the result of decades and $billions of public funds diverted to medical research, then why is there no evidence for gains in treatment success, instead clear evidence of worsening epidemics?
– Individuals and families with loved ones trapped in life-threatening substance use problems are generally desperate for help, for change
Are the effective medical treatments simply too expensive for those in need to obtain? – no evidence for that
Are insurance providers refusing to reimburse for the effective medications? – no evidence for that either
Are there any barriers to distribution of the effective medications, despite overwhelming need by Americans trapped and dying in opioid and substance use epidemics? – no indication of that either
Are the effective medical treatments still “just around the corner”,
but requiring additional billions in public health care funds? The costs are growing.