Sorting through science and belief on Martha’s Vineyard


There has been a lot of focus on addiction in general, and the opioid crisis in particular, on Martha’s Vineyard recently. The discussion on social media and in local venues is passionate, and sheds welcome light on an issue that has been in the shadows too long.

The discussion covers three questions: Is addiction a health condition (disease) or bad behavior? Is getting help for this condition a matter of willpower and readiness, or access to the (health) systems that treat the condition? What works to treat the condition, and what do we need on the Island?

The Island discussion is a blend of personal experience and the growing science that supports understanding of the nature of addiction and its treatment. The reality is that the nature and treatment of many health conditions, especially those of bio-social-environmental origin, are variable, not one-size-fits-all. One’s personal experience with addiction is a frame of reference for others, but not a template that all can or should follow.

It is disappointing that we are still questioning whether addiction is a bad behavior. The American Medical Association recognized addiction as a disease by the 1960s, and there is ample science to support this understanding. Is choice involved? Yes, absolutely. It is one factor, as it is for those with asthma, diabetes, and hypertension who consume large sugary drinks and salt-filled meals, and have activity-absent lifestyles. Addiction is not a sympathy-evoking disease, but that doesn’t make it a moral condition.

Why don’t those who are addicted get help? First, the essence of the disease is to “get more,” to extend the feeling that temporarily blocks the pain, gives the boost, or brings the peace. But no one has to hit bottom before help is possible. There is ample research that demonstrates that screening, brief intervention, and referral to treatment (SBIRT), conducted by trained personnel in primary care and emergency department settings, is effective at both reducing substance use and identifying the need for treatment. Research also supports patients seeking treatment because of the leverage of the threat of job loss, loss of family, or loss of freedom through the justice system. Finally, most seek treatment voluntarily because, as one resident commented, “they are sick and tired of being sick and tired.”

The good news is that both federal and state law require health insurance plans, including Medicaid and private insurances, to cover substance-use disorders, and not to apply limits of time, quantity of interventions, or medical reviews to addiction treatment that are different from those used for general medical care.

Where and how does one start the journey to recovery? Fortunately, there are three major paths that lead to recovery from substance-use disorders, and each path contains variations.

Many people with substance-use disorders stop on their own — natural recovery — through a variety of personal and social supports. There is little research on this path.

Many more people manage their addiction through self-help groups such as Alcoholics Anonymous and Narcotics Anonymous, or other fellowships. Self-help works, for those who it works for. Self-help does not claim to be treatment, but it does maintain sobriety, and enables a healthy life for those who maintain the fellowship.

Last, there are a variety of research-supported counseling approaches and medications provided in both bed-based and outpatient settings that successfully treat substance-use disorders. There is strong evidence to support the use of these counseling techniques: motivational enhancement, cognitive behavioral therapy, and contingency management. There are also strong evidence and medical standards that support the use of medications, most prominently methadone, buprenorphine, and naltrexone, which either block, taper, or neutralize alcohol or opiates. What is called rehab is often mainly housing and group therapy unless it uses proven practices that meet medical standards.

Medical treatment for substance-use disorders begins after detoxification with a medically stable patient. Medical detoxification (stability) requires a three- to five-day process. Treatment plans do not stop at the end of a magic number of days, but include the ongoing monitoring of results and adjustment of interventions just as one expects with diabetes or hypertension.

There are many examples (especially this political season) of passion and loud voices overshadowing the information that research and science provide. But I have more faith in research and science to provide answers and solutions than a single personal experience.

Let’s channel the energy of the discussion, and use the best research and science to understand and resolve the gaps in what we need on this Island to prevent and treat substance-use disorders (primarily medication-assisted treatment and intensive residential care). Debating the equivalent of whether the earth is still flat or the temperature is not rising doesn’t work.

Victor Capoccia is an Island resident who works with local and national organizations to improve access to and quality of health care, especially for treatment of substance-use disorders.