Non-abstinence based addiction treatment can unite us around restoring agency
Escaping the caustic drug war debates through better medications for substance use disorder.
Karam and I spoke to Dr. Jeffrey Singer a couple weeks ago about CASPR’s research on the promise of GLP-1s for addiction. He was eager to hear about the emerging evidence and then wrote a great op-ed for RealClearHealth on the subject, GLP-1 Agonists: A New Hope for Substance Use Disorders?
Dr. Singer is a surgeon and a senior fellow at the CATO institute and has testified before Congress on substance use disorder policy. As you might guess from his CATO position, he is a committed libertarian and believes that all drugs, including opioids and stimulants, should be legalized. I don’t agree that this is a good idea! (But it’s hard to say with too much confidence that it would be worse than the decades of drug war disaster that we’ve lived through.)
What’s surprising is that Dr. Singer and I can be pretty far apart on a fundamental policy question like legalizing opioids while agreeing on nearly everything else related to harm reduction and treatment. Beneath a lot of the policy debates around addiction, I think there’s a widely shared core desire for people to be free and in control of their own health.
Drug policy fights mask a shared desire for freedom
The current ideological rigidity of drug policy debates often break down like this:
Libertarians believe that adults should be free to use any drug because they have a fundamental right to make any decision with their own body.
Left-wing decriminalization and harm reduction advocates don’t have many libertarian friends, but they agree that no one should be locked up for drugs and that we should not stigmatize anyone for choosing to use drugs.
Centrists are wary of drug use, worried about the massive deaths and burden of disease, and are looking for any workable solution that can help people escape the trap of addiction and keep communities safe.
Right-wing conservatives believe drug use is a swirl of moral and criminal decay and want to lock away people who bring dangerous substances into their community or use substances that are illegal. But even the most morally-oriented conservative viewpoints are welcoming of non-opioid medications that can help people get free and reduce the customer base for drug dealers.
What unites all these different American beliefs? A desire for people to be free! Free from danger, free from craving, and free to live their lives as they choose. Medications for addiction that don’t require abstinence have the potential to unite people across the political spectrum.
Medicine that restores agency
Nearly every American across the political spectrum deeply believes in freedom and personal agency. Addiction strips people of agency and criminalization strips them of freedom.
In cities across the country, we are stuck in debates about whether it is more humane to force people into treatment or let them stay on the street with extreme risk for trauma and death. Both options are agonizing even to people who strongly believe one is better than the other. Neither is freedom.
Medicine that can restore agency to people, without burdening them with stigma, without requiring rigid compliance, and without substituting their dependence, will be universally loved, by patients, their families, and policymakers across the political spectrum. The endless debates of drug war vs legalization and paternalism vs harm reduction will vanish if people have medication that lets them easily end a drug dependence by choice. There’s no scientific or medical barrier to creating and offering medicines like these for everyone who wants them, we just have to put enough focus and resources on that goal.
Addiction medication development is severely underfunded. So far, the best hope we have for addiction treatment, GLP-1RAs, came out of diabetes research and we are still struggling to do large scale addiction studies even after these drugs have been FDA approved for several other conditions with much smaller patient populations.
Effective medication for opioid and alcohol addiction that works with or without abstinence helps maximize human freedom and agency, and is much, much more appealing to someone who has a substance dependence but is on the fence about whether to accept treatment.
As Dr. Singer writes:
Second, many addiction specialists oppose abstinence-only treatment for substance use disorder. They argue that patients may view themselves as hopeless failures if they “fall off the wagon” and resume heavy substance use. Reports show that 12-step abstinence programs have only a 5 to 10 percent success rate. Some addiction researchers note that most people eventually outgrow their addictions without treatment and argue that treatment should focus on harm reduction and moderation management. GLP-1s are compatible with this approach. They reduce cravings and increase satiety without generating abstinence.
Finally, if the evidence shows that GLP-1s are effective for treating substance use disorder, imagine how they could help people concerned about their substance use manage it privately and avoid stigmatization. Health care consumers already use telehealth to purchase GLP-1s through retailers employing licensed practitioners in their states. It’s easy to envision people using telehealth in the privacy of their homes to access GLP-1s to moderate or quit using a substance. This could prevent many people from progressing to more severe forms of substance use disorder and their associated harms.
It's too soon to tell if GLP-1 agonists will become a new tool for treating substance use disorders. Researchers have only recently begun to explore this issue in depth. A new organization, the Center for Addiction Science, Policy, and Research, tracks and aggregates the evidence on its Substack site. Let’s hope the evidence fulfills the drug’s promise.
What are the next steps?
Effective medicine for addiction that people are excited to take is the path out of this crisis. It’s the path that can unite us around our shared beliefs in agency and freedom.
We should be pursuing studies of all sizes and scopes on GLP-1s for addiction treatment.
We should be dramatically increasing funding for NIDA to help develop the next generation of addiction medications.
And we should be pressuring and incentivizing pharma to step up and solve a crisis they helped create.