By Ernest Drucker
Winter 2003-04, Vol 7 No 2
When I was asked to write on the future of drug treatment, I was told there would also be a complementary piece on the future of psychiatry. These days, it’s hard to talk about one without mentioning the other. The popular and graphic term “drug crazed” is evidence of their conjunction and of the widespread confusion about their relationship to one another. The notion of dual diagnosis used by professionals is not very helpful. It dodges the question of etiology and its therapeutic (and policy) implications.
Does the use of illegal drugs make us crazy? Are people who use illegal drugs crazy to do so? Is this a knot worth untying? It is true that many “crazy” people (some of them psychiatric patients) do use a lot of drugs? In New York City, most psychiatric emergencies involve the misuse of drugs or alcohol; and many heavy drug users have a concurrent psychiatric diagnosis. So popular confusion is understandable. But mental health professionals should know better. Despite much imprecision in the use of the term “addiction,” there is no great diagnostic confusion about its symptoms. Like the judge once said about pornography, we know addiction when we see it.
And these days we can literally see it. Modern brain imaging techniques confirm what we have known from addicts for some time – that their drug problems, while not “in their heads” in the psychological sense, are quite real in their brains. The same things may be (or should be) said of the major psychiatric diagnoses. I think DSM-IV-R does a pretty good job.
But another confusion clouds the future of addiction treatment. That confusion lies not in our diagnosis of addiction, but in our profession’s intentions – what do we think should be done about the problem of drugs, and to whom are we held accountable?
Improving the precision and timeliness of diagnosis and the efficacy of addiction treatment will not be driven by the white coats. While important treatments using new medications may some day emerge from imaging and genetic studies, we are still awaiting that long promised “vaccine” for cocaine. And I’m not sure we need new addiction technology. With a correct diagnosis and appropriate care, addiction treatment already has better long-term outcomes than cancer, diabetes or congenital heart disease. As addiction researchers George Vaillant and Norman Zinberg taught us, the natural history of most drug use seems to favor control – with reduced levels or discontinuation of use the norm as the years go by.
But although addiction treatment has a better prognosis than many other chronic medical or psychiatric conditions, clinical and scientific ignorance, therapeutic nihilism and medical malpractice are still the norm in most of the world. While the particulars of treatment compliance for other chronic diseases vary, no one suggests that refractory diabetics should be incarcerated “for their own good.” Yet addiction most often ends up in the criminal justice system. The prisons are the first and last response to addiction, and in many cases, the only response readily available to all drug users. But prisons are institutions that convert a treatable problem into a complex social disaster and a clinician’s nightmare.
More importantly, treatment policy and practice have only the most tenuous relation to scientific evidence. Despite the mass of evidence on the efficacy of methadone in treating opiate addiction, methadone is still treated as a pariah drug in many parts of the world. Entire nations (e.g., Russia and India) forbid its use, and in the United States, where methadone was first used for addiction treatment, eight states still outlaw it. Elsewhere in the United States where methadone is medically approved, its clinical application is so irrational or downright mean-spirited and punitive that despite its proven efficacy, many have grown to hate it. Indeed, much of the allure of the newly approved use of buprenorphine is that it is not methadone.
The most powerful determinant of future drug treatment will be reforming many of the ideas behind it: the basic concepts for understanding why people use drugs, why some have difficulty controlling use and how we may help users achieve their goals in using drugs, the help they most urgently seek again and again from addiction professionals.For much of the world, drug use and addiction are still shrouded in a medieval cloak of moral disapproval. And many national policies are still punitive and unforgiving of professionals who are too accepting of drug use. Basic non-judgmental harm reduction ideas, almost universally seen as supportive by drug users, their families and human rights advocates, are rejected by many authorities as “sending the wrong message” and as “enabling” by hardliners. And ”drug legalization” is used as an accusation akin to treason.
With the pervasive easy access to potent drugs of all sorts growing daily, and given poor access to treatment, we have managed to turn treatable addiction into a public health Frankenstein equivalent to AIDS. So when we talk about the future of addiction treatment, we need to understand its history and take it seriously. The future of drug treatment depends on the fate of the medieval idea that drug use is a moral lapse and addiction a form of possession to be purged from its “victims.” Neither brain research nor the discovery of potent new medications will mean much until we deal with these ideas and eliminate the errant policies they perpetuate.