Arthur Krieger

Safer supply is a medical form of harm reduction in which a patient is prescribed a drug to which they are addicted. Despite ample high-quality evidence that it is a safe and effective last-line treatment for severe, treatment-refractory substance use disorders, safer supply is not widely used or advocated. We assume that this is partly due to ethical concerns and argue that safer supply is ethical by both general moral standards and the professional ethical standards of healthcare. Recent defenses of various harm reduction interventions argue that they are permissible regardless of the moral quality of the drug use they facilitate. We critique those defenses and argue that safer supply is permissible by general moral standards because the medical drug use it supports is not immoral. Furthermore, safer supply does not run afoul of biomedical ethics because it is not maleficent, unhealthful, or nonconsensual. As an evidence-supported and ethically permissible practice, safer supply merits wider use and advocacy.

The distinction between first- and second-order ability in the philosophy of action enables new clarity in the discussion of behavioral control in addiction. Addiction involves automated patterns of thought and behavior that undermine the first-order ability to reliably abstain. However, addicts retain a second-order ability to reliably abstain if they remain able to learn the “epistemic prerequisites” of reliable abstinence, including addiction-specific metacognitive skills and cue-avoidance strategies. The second-order ability to reliably abstain depends to a significant extent on socio-economic situation and access to the right social resources. This “Epistemic Prerequisites Model” supports the view that addiction is a compulsion, and suggests that moral responsibility in addiction depends on factors relating to both orders of ability.

In their replies to “The Epistemic Prerequisites of Reliable Abstinence in Addiction,” Federico Burdman and Zoey Lavallee identify substantive considerations that call the plausibility of my Epistemic Prerequisites Model (EPM) into question. Burdman argues that how I talk about the ability to φ “reliably” is problematic, and that it makes more sense to focus on the scalarity of ability and self-control at the level of individual behaviors. I clarify the notion of reliability operative in EPM and argue that we ought to center how an addict’s control over individual behaviors varies with environmental factors, which has important implications for extended autonomy. Lavallee argues that my emphasis on automaticity overlooks important ways in which behavioral control is compromised in addiction, and whether they break the EPM framework. If the phenomena Lavallee indicates do in fact compromise behavioral control, they may be compatible with EPM; and if they are not, the model will require revision, but its core claims will remain intact.

The medical and public health communities are divided around the use of benzodiazepine (“benzo”) pharmacotherapy for anxiety disorders. Recent years have seen increased attention to benzo overprescription and its risks, leading to a pervasive emphasis on deprescribing. Some have resisted this trend, arguing that the balance of evidence supports the safety and efficacy of benzo pharmacotherapy for both short-term and long-term treatment of anxiety disorders. Given that rising rates of anxiety disorders and benzo misuse are both serious public health concerns, there is an urgent need for comprehensive evidence-based best practices for the prescription of benzos for anxiety. At present, however, major scientific gaps make it impossible to formulate such guidance. Most concerning is the lack of research into as-needed and intermittent prescription and use, which are both what benzos are best suited for, and likely, how they are most commonly administered. Further research into the safety and efficacy of both long-term daily and intermittent, as-needed benzo prescription and use are badly needed. But a roundly “anti-benzo” sentiment may be causing problematic underprescription of benzos, particularly when superior alternatives like cognitive-behavioral therapy are not widely available.

Withdrawal involves emotional pain that motivates much addictive behavior. In this paper, I argue that the emotional pain of withdrawal compels much addictive behavior. Researchers have noticed this possibility but it is widely underappreciated. Among philosophers, only Hanna Pickard has discussed emotional compulsion in addiction, and the emotional aspect of withdrawal has been almost completely neglected. Accounts of emotional compulsion in the philosophical literature (from Tappolet, Elster, and Furrow) probably do not capture how the distress of withdrawal compels, so I propose a more suitable account of “pathodoxastic” compulsion in addiction. On this account, the emotional pain of withdrawal compels when it undermines the ability to believe that one can continue to endure it, and therefore the ability to intend abstinence.

Is addiction a behavioral pattern, or the underlying cause of a behavioral pattern? Both views are found in prominent accounts of addiction, but theorists generally do not notice that they are taking a controversial position, let alone justify it. A third possibility is that addiction consists in both addictive behavior and its causes, though this view is less obviously present in the literature. I argue that two important considerations favor the "cause view" over the "behavior" and "hybrid" views. The first is that we want to be able to explain addictive behavior with reference to addiction. The second is that addiction seems to persist long after addictive behavior has ceased. Only the cause view can easily accommodate both data points.