There were two related and important developments in addiction medicine this week. Walter Ling has a paper in the Journal of the American Medical Association showing that a buprenorphine implant is effective at reducing drug craving and use in opioid addicted patients, and the FDA has approved an extended-release formulation of naltrexone for the treatment of opioid addiction. In both cases, the usual challenge of oral medication â€“ namely that one needs to decide each morning whether or not to take it â€“ is surmounted by a single decision made in advance that keeps the medication present in the body for a month or so.
A minority of people reacts to the existence of these medications by expressing a well-meaning but fuzzy-headed concern that they are inherently “coercive”, for example they might be used to give a opioid dependent person who is leaving prison an injection that will constrain his drug use after he goes into the community. This makes sense only if one assumes that a person who is scrambling to score and shoot heroin several times a day is at the maximum of his or her freedom. Note also that the risk of death to opioid addicted men leaving prison is as high as 1 in 200 in the first fortnight in some places (e.g., Scotland) and death does tend to crimp oneâ€™s liberty.
More importantly, it also overlooks how many people, addicted or not, want the power to coerce their future selves. Thomas de Quincey, in one of the many revisions of his spellbinding Confessions of an English Opium Eater, tells the story of how Samuel Coleridge hired a working class assistant to tie him into a chair to stop him from using opium. Coleridge warns the assistant that once in the chair for a few hours, he will begin shouting abuse and saying he didnâ€™t mean what he was saying back then, and he should be untied right away. This captures a basic human dilemma, we fear the urges of our future selves and want to confine them while our present self is at peak capacity. Hence we do not buy the double-chocolate-fat-enriched-salt-loaded pretzels at the store because we worry that in a day or a week or a month we will be tired or stressed enough to eat them.
Anyone who has ever met a person in early recovery from addiction who is desperately afraid of relapsing in a day, or a week, or a month, or on a special occasion (e.g., getting drunk at their child’s wedding) will understand how warmly greeted extended release medications will be by many addicted people and their families. That’s why the development of these medications represents an expansion rather than a restriction of human freedom.