Addiction Science Advocacy: Mobilizing Political Support to Influence Public Policy

This paper proposes a new conceptualization of addiction work that makes public policy advocacy central to prevention, treatment, and recovery. The term “addiction science advocacy” is offered as a way to conceptualize what is needed in the addiction field to translate scientific findings into public policy and thereby reduce the harmful consequences of drug problems. Although there are a plethora of evidence based strategies to reduce and prevent harmful consequences associated with drug problems, interventions and their beneficial effects are often neglected, misunderstood, mischaracterized, and underutilized due to destructive social and political influences.

This paper suggests that addiction practitioners, researchers, and educators have historically developed professional identities that are too narrow to effectively counteract forces that are destructive to a science based approach to addiction (e.g., moralization and criminalization). Addiction science advocacy rejects the contention that treatment and prevention should be politically neutral because that neutrality is increasingly used by others to ignore, dilute, and redefine important findings. There is therefore an urgent need for development of broader professional identities that emphasize influence of public policy as an integral component of one's work. This paper proposes strategies for addiction professionals to influence policies at national and local community levels.

WAR ON DRUGS IN AMERICA

Since the beginning of the “war on drugs” in the early 1970's the primary response to illicit drug use in the U.S. has been criminalization. However, there is little evidence that incarceration of drug users reduces substance use and the costs of incarcerating them has soared over the past three decades (Grattet, et. al., 2009; Perreruti & Walsh, 2008). The policy of incarceration of drug offenders has resulted in the U.S. imprisoning more of its population than any other industrialized country (Walmsley, 2006). At the conclusion of 2005 one in every one hundred thirty-six adults in the U.S. was incarcerated in criminal justice institutions (Pew Charitable Trusts, 2009). When individuals on probation and parole are added, the proportion is a striking one in every thirty-two.

There is a mountain of evidence documenting harms associated with the policy of incarceration. Incarcerated offenders become isolated from their families and communities, lose their jobs, and in some jurisdictions lose their housing (Perreruti & Walsh, 2008; Petersilia, 2003). Public policy research has shown treatment of offenders with drug problems is cost effective, while incarceration is not (Perreruti & Walsh, 2008).

POLITICS OF HARM REDUCTION

Harm reduction is a significant public policy alternative to incarceration of drug users that emerged largely in Europe during the 1980's (Cook, et a., 2010). Rather than prohibiting substance use via the threat of incarceration, harm reduction focused on changing the circumstances of drug use to minimize destructive consequences. Examples include needle exchange programs, increasing access to medical services, and controlled drinking. Over the past three decades there has been a growing body research supporting a variety of health and economic benefits resulting from harm reduction policies (Rhodes & Hedrich, 2010).

Despite substantial scientific evidence supporting harm reduction, there continues to be significant resistance to it. In the U.S. the label “soft on drugs” has been applied to elected officials who support alternatives to incarceration and it has resulted in substantial political harm to them. Counterproductive public policy is also manifest in resistance to community programs that assist individuals with drug problems. Needle exchange programs, which have been shown to reduce HIV risk while not increasing drug use, continue to be illegal in many states in the U.S. The federal government prohibits funding of needle exchange programs, but funds other programs that have little or no empirical support, Drug Abuse Resistance Education (DARE) being a prime example (Kubi, 2012). At the local level, efforts have been made to pass laws discouraging residential recovery homes in communities (Sober Living Network, 2013) despite data showing well operated houses are effective in helping individuals overcome problems with drug use and are perceived t0 be good neighbors (Polcin, et al., 2010; 2012).

FEAR VERSUS SCIENCE AS THE BASIS FOR PUBLIC POLICY

How is it possible that the primary response to the problem of drug abuse in the U.S. continues to be criminalization given the extensive data over many years showing the health and economic benefits of prevention, treatment and harm reduction? Part of the answer may be that emotional fear about addiction and related problems (e.g., crime) dominate media portrayals about drug use as well as policy discussions. In contrast, research findings, especially in the absence of strong advocacy, are experienced as academic (i.e., without much emotional charge). The fear perspective was crystalized in the U.S. by the term “war and drugs,” which was initiated by President Nixon in the early 1970's. Addiction was conceptualized as a frightening external threat that needed to be removed from our communities. Subsequent presidents, particularly President Reagan, continued use of this terminology and enhanced a military response against drug suppliers. Mandatory minimum sentences for drug convictions initiated during the Reagan years resulted in a flood of inmates to jails and prisons. The consequences of this “tough on drugs” policy continue to be felt in the U.S. today.

The failure of the fear perspective over the past several decades has not been completely lost on the U.S. public. A poll by Angus Reid Public Opinion (Gwynne, 2011) indicted only 9% of the American public believes we are winning the war on drugs, yet 64% believe the country has a serious drug problem. A poll in California revealed over 75% supported alternatives to incarceration for nonviolent offenders (Tulchin Research, 2012).

These changing views beg the question of why there is a continuing policy of incarceration in response to drug problems and why there continue to be policies that hinder development of evidence based services in communities. Part of the problem may be that the addiction field has not presented or marketed a strong, coherent alternative. Presentation of scientific findings in academic journals is clearly not sufficient to impact public policy and the limited efforts we have made to disseminate findings to the public have not had a large impact. Fear among the public is easily responded to by politicians but research findings are not.

It is striking that many addiction and related professionals (e.g., mental health) do not know that the U.S. National Institute on Drug Abuse (2012) has concluded that for every one dollar spent on addiction treatment the public saves between seven and fifteen dollars. This speaks to the poor job we have done disseminating important research findings even within our own field, let alone among the general public. Without a clear alternative that is consistently and coherently communicated we continue a failed criminal justice response to the problems caused by drug use and addiction.

TEACHING ADVOCACY IN TRAINING PROGRAMS

Training of professionals who work in the addiction field (e.g., drug counselors, psychologists, social workers, nurses, and physicians) has typically focused on teaching technical skills related to prevention, treatment and recovery. Historically, the goal has been to maintain some degree of neutrality on political issues because it enables a “broad tent” approach that invites many different types of individuals to join the profession and receive its services. If national, state, and local government officials were responsive to scientific findings as a basis for public policy, this approach might be appropriate. However, what has transpired over the past several decades is public policy driven by fear and special interests (e.g., the prison industry and conservative groups) that are not consistent with a public health perspective. The passivity of addiction professionals in terms of influencing state, local and national policy has invited these other groups to have stronger influences that are counterproductive to public health.

New models of training for addiction professionals are needed that emphasize the importance of personal and professional advocacy. Training should emphasize personal aspects of supporting the addiction and recovery field (e.g., voting for candidates supportive of a public health perspective of addiction), but also avenues for professional influence. Involvement in advocacy activities of professional organizations supporting addiction research and treatment is important. Perhaps the strongest advocacy efforts in the U.S. are those by American Public Health Association, which involve solicitation of members to support public health by calling legislators, signing petitions, and contributing to lobbying efforts. Although endorsement of specific parties or candidates is legally prohibited for nonprofit organizations, APHA identifies voting records of politicians in terms of their level of support for issues of relevant to public health. These are strategies that could be practiced at the local community level to identify policymakers who do and do not support the priorities of addiction professionals and their clients.

Although important, it is no longer is sufficient to report scientific findings in professional journals. For the field to have adequate influence students must learn how to communicate to wider audiences of varied stakeholder groups, including the general public, consumers of services, family and friends of those with addiction problems, and others stakeholders impacted by addiction. Dissemination of new programs and research findings in colloquial forums is essential. Professional training should prepare students to frame addiction information so that it maximizes its impact on various stakeholder groups.

ROLE OF CITIZENSHIP FOR RECOVERING PERSONS

In addition to the aforementioned strategies there may be ways to simultaneously facilitate recovery for addicted persons and increase support for addiction related policy. A critical part of recovery for most persons with drug problems is engaging in the process of “giving back.” Particularly common in 12-step groups such as Alcoholics and Narcotics Anonymous, giving back means individuals who have benefited from their involvement in a program or activity have a responsibility to help others benefit. White et al (2010) has used the term “citizenship” to describe this type of participation in various communities, including treatment programs, recovery groups, neighborhoods, and religious organizations. Of particular importance here is active participation in larger political processes that can support the alternatives to incarceration.

There are good reasons for emphasizing citizenship as part of recovery. First, it is thought to benefit the helper as well as the person receiving help (Kaskutas, et al., 2007). Second, it builds cohesion within recovery programs as well as in the larger recovery field. Citizenship among the large number of recovering persons in the U.S could have an enormous influence on issues vital to recovery, such as availability of treatment, housing and other services for persons with drug problems. We challenge treatment and prevention practitioners, researchers, educators, allied professionals, and the recovery community as a whole to begin development of citizenship as a central component of recovery.