A Brief Commentary on the Ethics of Substance Use Diagnosis and Treatment
Few disorders in the DSM-5-TR are more stigmatized, inaccurately diagnosed, and ineffectively treated than substance use disorders. Pervasive bias and misinformed notions about substance use are largely a result of the cultural norms of the past century. One hundred years ago the United States was knee-deep in the failed alcohol prohibition experiment, and frustration with the public’s conspicuous flouting of the 18th amendment led to the government’s decision to make alcohol more poisonous. The state-sanctioned mass-poisoning of citizens who chose to imbibe and disobey alcohol prohibition draws uncomfortable parallels to current drug prohibition policies and their resulting fallout in fentanyl-related deaths.
Drug prohibition is steeped in a century of scare tactics and racist motives. For example, first commissioner of the Federal Bureau of Narcotics Harry J. Anslinger said, “Marijuana is the most violence-causing drug in the history of mankind.” Former Nixon aide John Ehrlichman said, “by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.” The fear-based, racist drug propaganda of the 20th century is the culture from which mainstream theories and treatment approaches for substance use problems emerged. While many of the drug myths of the past century are being dispelled, the field of clinical psychology is slow to integrate updated knowledge.
Despite the integration of knowledge that many people overcome addictive problems influencing changes in the DSM-5 and DSM-5-TR editions (e.g. the exclusion of the term addiction from the diagnostic lexicon and the acknowledgment that alcohol use disorder is often erroneously viewed as an intractable condition), clinicians continue to engage in diagnostic procedures and treatment recommendations that could be considered unethical in light of current evidence. It is not uncommon for people to receive substance use disorder diagnoses simply for admitting past use of an illegal substance, even though such an admission is not consistent with any of the DSM-5-TR diagnostic criteria. It is also not uncommon for clinicians to make blanket recommendations to abstinence-only mutual-aid groups when other, evidence-based approaches may be a more appropriate fit for their clients. It is important to note that the majority of addiction treatment options in the U.S. are not evidence-based.
The fact that frequency of use, quantity of use, and the ingestion of an illegal substance are not part of the DSM-5-TR diagnostic criteria cannot be underemphasized. Simply ingesting psychoactive compounds, legal or illegal, even daily and sometimes to the point of intoxication, do not by themselves constitute a diagnosis of a substance use disorder. The reality is that most people experiment with psychoactive compounds and only a small minority of them ever struggle with addictive problems. Additionally, many people who overcome addictive problems do so by establishing a self-regulated pattern of use rather than by pursuing total abstinence. Psychologists are ethically obligated by standard 2.04 to select methods and provide professional opinions and services based on current scientific and professional psychological knowledge. It is no longer consistent with the knowledge base of scientific and professional psychology to recommend total abstinence to everyone experiencing substance problems, or to diagnose people with substance use disorders simply for admitting to the ingestion of psychoactive compounds on a regular basis.
The war on drugs and its subsequent drug policies may very well be looked back upon as among the most egregious human rights violations in modern times. Countless lives and families have been ruined because one family member, most often a man from a marginalized community, is locked in a cage for disobeying the unjust laws that stem from the war on drugs. The ethics code demands that psychologists break the law when not doing so would violate an individual’s basic human rights (standard 1.02), representing APA’s long-standing commitment to the value of civil disobedience in catalyzing positive social change. Misdiagnosing people with the stigmatizing labels associated with addictive problems and indiscriminately referring people to abstinence-only approaches perpetuates the misinformed notions that all substance use reflects pathology and that the only way to overcome addictive problems is total abstinence. The field of psychology has a long history of promoting harmful positions (e.g. advocating eugenics, diagnosing homosexuality as a mental disorder, etc.), and only supporting important social movements in response to overwhelming public pressure. Assuming a role of leadership in advocating for the eradication of unjust drug policies and demanding accurate diagnostic practices and individualized treatment recommendations based on current evidence is an ethical obligation for our field and all who work within it.