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We need to keep expanding the conversation

Understanding substance-use disorder as a disease removes the stigma of drug dependency by framing it as an individual’s medical and psychological journey. But that silences the roles of poverty and other social and economic factors that affect the opioid epidemic.

Anna Mullany is a doctoral candidate in public health at the University of Massachusetts, Amherst

Brattleboro

At the Opiate Public Forum on June 20 at the Brattleboro Central Fire Station, Dr. Kate McGraw opened by calling the current rise in opiate-related overdoses and deaths in Windham County a “health crisis” — echoing the “public health crisis” discourse taking place on a national level.

Dr. McGraw’s words were followed by many throughout the evening voicing that addiction is a “disease” — again, in line with the national conversation happening around the issue.

This wording and “disease model” approach to addiction serves two purposes: 1) it challenges the stigmatizing rhetoric of addiction as a personal moral failing, and 2) aids in the movement to decriminalize possession of illicit drugs. (Why would you arrest someone that has an illness?)

If we are to call the fact that Vermonters are suffering from opiate-related deaths and overdoses a “health crisis” — which I am in agreement with — then it matters how we define “health” when we search for solutions.

That definition will influence the approach of treatment and remedies. The disease model, or what is also known as the “chronic-illness care model,” is seemingly a fitting descriptor to a “health crisis.” However, the disease model is lodged in a narrow definition of health that focuses on individual pathology.

Consequently, this most commonly translates into individual remedies, often medicated — and those remedies may or may not work.

For instance, only 10 percent of people living with what is called “opiate use disorder” (OUD) access medicated-assisted therapies such as methadone or suboxone, and retention is low.

There is no doubt that people dying of overdoses need remedies — in this immediate moment, we need available Narcan and training, more treatment centers, clean needle exchange, and a push for a safe injection site.

More than 120 such sites operate in Australia, Canada, and Europe, some dating back to the 1980s. These sites have proven to reduce the spread of HIV and hepatitis, reduce overdose deaths, and move more people into sustained recovery, according to the Drug Policy Alliance.

When it comes to the longer struggle of how to address addiction, it is essential to expand our definition of health.

Health is not limited to biological manifestations but related to the larger scope of people’s living conditions and environments — like clean water, nutritious food, and safe, sanitary housing.

To think and speak of addiction as a brain disease (which current research challenges) silences the social determinants and histories that lead certain individuals to addiction and overdose.

* * *

This idea of examining the social-economic conditions that produce ill health is nothing new, yet is often omitted.

In 1948, the World Health Organization put forth a definition of health: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”

When we understand health as larger than just the “absence of disease,” we are forced to look at the structural factors that either support it or cause suffering.

The addiction piece then becomes one strand of a larger conversation of what constitutes a healthy society. According to neuroscientist Dr. Carl Hart, research shows that although drug use crosses class, and anyone, regardless of demographics can become addicted, the overall pattern of those dying from opiate-related overdoses and struggling with the definition of addiction in the Diagnostic and Statistical Manual of Mental Disorders, are among those living in poverty.

It was no coincidence that June 20th’s forum had a representative from Groundworks Shelter as one of the panelists. And rightly so — the addiction conversation should also be the housing conversation.

* * *

We need to keep expanding the conversation to really uncover the institutions in our lives that create brutal social conditions (as well as untreated chronic pain) that can sometimes lead to the kind of suffering that is solved by escaping pain through the use of drugs.

We must look carefully at where the burden of addiction and overdose deaths predominantly lie and ask if the dominant question is about addiction or if it is about poverty.

The assumed model of disease and chronicity — although intended to be helpful in steering away from individual blame and stigmatization — needs to be questioned, as it only prescribes individual-based interventions mostly centered around “fixing” the brain.

When we see addiction as one consequence of a sick society — then we are more apt to start questioning the political economic structures of society that create poor health.

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Originally published in The Commons issue #517 (Wednesday, July 3, 2019). This story appeared on page E1.

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