Robert F. Kennedy Jr. and I share the experience of recovering from heroin addiction. Like me, he started the process at a residential rehabilitation facility in the 1980s and participated in a 12-step program based on Alcoholics Anonymous, which promotes abstinence from substances. Unlike me, however, he seems to have remained wedded to this treatment model, despite evidence that it fails many people with drug addictions. This could do enormous harm if he is confirmed as secretary of health and human services.
H.H.S. oversees the National Institutes of Health, the world’s largest source of funding for addiction research, and the Substance Abuse and Mental Health Services Administration, which provides billions in funding to states for drug treatment. It also leads the Food and Drug Administration, which regulates medications, and the Centers for Disease Control and Prevention, which tracks overdoses.
Addiction care has made agonizingly slow but meaningful progress since the 1980s, shifting from a one-size-fits-all model of total abstinence toward a data-backed approach that can include addiction medications and is tailored to people’s needs and preferences. This could be reversed if such therapies are no longer prioritized by the government.
Mr. Kennedy has said very little about highly effective addiction medications, like methadone and buprenorphine, despite the fact that these are the gold standard for opioid addiction treatment. And he has repeatedly expressed opposition to other psychiatric medications, a view that could be particularly harmful.
Mr. Kennedy’s vision for the future looks like the past. He has proposed building a network of organic farms where people with addictions would labor in the fields and be “reparented” (potentially referring to an approach where the therapist and other patients serve as a surrogate family). Presumably they would also attend 12-step groups — as Mr. Kennedy still does and has repeatedly supported. Psychiatric drugs would almost certainly not be used: The farms would also be places for people to go to get off of antidepressants or A.D.H.D. medications, which may mean no anti-addiction medication, either. People would stay for as long as three or four years, eating healthy diets. Phones and other screens would be banned.
Mr. Kennedy also favors involuntary treatment. At the premiere of a documentary he made as a presidential candidate, he said that the government must use “tough love” and incarcerate people with addiction if they refuse treatment more than two or three times.
Nearly every element of this approach has serious problems — and most of it has been tried previously and failed. According to a leading expert on addiction research, Dr. Nora Volkow, who heads the N.I.H.’s drug addiction institute, using threats of incarceration to mandate treatment is not supported by data.
Then there’s 12-step rehab, which is based on A.A.’s concepts of addiction from 1935. Although many people find this abstinence-based treatment helpful, millions of others do not, and so it should only be used voluntarily. Nonetheless, since at least the 1980s, a majority of American rehabs have required that patients accept the 12-step method.
Mr. Kennedy’s views on other approaches to addiction, like harm reduction, which focuses on reducing the dangers of drug use rather than requiring abstinence, are murky at best. He has said he supports “all the different forms of treatment” and would be open to making supervised drug consumption sites part of his drug plan. But in October he posted on X: “To end the opioid crisis we need common sense solutions not ‘harm reduction.’”
In contrast, he actively promotes abstinence-only rehab, which often includes resistance or outright opposition to medication use. Narcotics Anonymous, the 12-step program for people addicted to heroin, views people who take prescribed addiction medications like methadone or buprenorphine to treat the disorder as not “clean” from drugs, even though these medications have enabled many people to turn their lives around.
Research has repeatedly demonstrated that use of either medication cuts the risk of overdose death by half or more — while abstinence treatment does not. One study suggested that abstinence-only treatment could worsen the odds of dying of overdose, compared with no treatment. In the study, medication was associated with a 65 percent reduction in overdose death risk compared to those receiving no treatment — while abstinence-based rehab was linked to a 42 percent increase in mortality and detox programs were linked to a 27 percent mortality increase.
Treatment reform in recent years has focused on increasing acceptance of medication. With opioid addiction driving the worst overdose death crisis in history, now is not the time to backtrack. At least 40 percent of rehabs still reject the use methadone and buprenorphine.
Historically, many programs also used the abstinence concept to ban the use of psychiatric medications, even those with no addiction potential. But since research now shows that around half of people with addiction have mental illnesses, which can drive relapse if left untreated, this has also improved. Successfully medicating common conditions like depression and A.D.H.D. can increase the odds of kicking addictions.
My own story illustrates this. When I became profoundly depressed several years into abstinence, antidepressants revolutionized my recovery. For the first time, I was able to feel comfortable socially, without the harms of addictive drugs. Years of meetings and therapy couldn’t match the way these pills helped me to finally feel connected to friends and family members.
Mr. Kennedy, however, seems to think I need a work farm to end my Prozac “addiction.” He has even spoken out against Ozempic and similar drugs, which have recently shown promise in reducing substance misuse and overdose risk.
Mr. Kennedy’s opposition to medication comes from a well-founded skepticism of the pharmaceutical industry. Perhaps he doesn’t know, however, that the research into methadone, buprenorphine and other psychiatric drugs during addiction treatment was overwhelmingly funded by the N.I.H., not industry. (This is largely because drug companies have historically been reluctant to develop drugs for addicted people).
Moreover, rejecting all psychiatric medications because of a failure to distinguish between unhealthy addiction and therapeutic dependence is dangerous. Addiction involves compulsive behavior despite harm, while dependence on appropriately prescribed medications reduces compulsion and improves health. When the benefits outweigh the risks, these drugs can be what stands between a life of productivity and connectedness and a return to dysfunction or even death.
The overdose crisis highlights the urgent need to bring compassionate, evidence-based care to addiction treatment. The farm system Mr. Kennedy has advocated may sound idyllic, but it would recapitulate a troubled history. One of the world’s first residential programs for heroin addiction, founded in the 1930s by the U.S. government, was known as the “narcotics farm,” because an important aspect of treatment at the Kentucky site was farm work. Although humane by comparison to prison, the center was not effective and conducted some research that is now considered unethical.
America’s history of tough-love residential rehab is marked by horrifying institutional abuse, neglect and exploitation, which is inevitable when vulnerable populations are stigmatized, isolated and unable to expose maltreatment. Only recently have these harms been widely recognized, driving a shift away from residential care whenever possible. The last thing we need is someone to bring us back to the 1930s.
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