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Medicalization
of Drug Abuse Control
By: Tod. H. Mikuriya, M.D
first published: in Addiction and Treatment, presumable during the mid-70's.
SUMMARY
Reinstating the medical approach to drug abuse prevention and control is preferable
to current counterproductive coercive violent moralistic drug policy. Rewriting
laws to permit physicians to prescribe controlled substances to addicts denied
them since the early 1920s would reinvolve physicians in treating substance
abuse and dependence.
No physicians, however, would want people coming for the prescribing of drugs
for non-therapeutic purposes. Therefore, another distribution system is needed.
Voluntary Drug Users Cooperatives would create a new category of drug user
who is medically supervised but self-prescribing. From participating pharmacies
the users obtain their drugs of choice. Presenting an identification card and
paying a transaction fee providing funding and information for the program.
Price structure would be determined by the abuse potential with less concentrated
substances less expensive and more concentrated more costly.
Entry to the program would be at the age of majority after passing written
and physical tests that would demonstrate knowledge of risks and side effects
of drugs, responsibilities, and consequences for misuse.
Monies collected from transaction fees would pay for treatment and prevention
of misuse as well as monitoring local use patterns for refinement of policy.
MEDICALIZATION OF DRUG ABUSE CONTROL
In the heat of the first national attack of Prohibition, the "American
Disease," opiates and cocaine were also criminalized. Five years before
alcohol was outlawed The Harrison Narcotic Act was passed. Regulation of commerce
of addicting drug was carried far beyond its original intent by zealous prohibition
and treasury officials. Narcotics police, their successors, took over the control
of prescribing these drugs, which they retain to this day.
The definition of the addict as a criminal instead of being ill dictates how
society responds. Moral defect: enforcement/corrections. Health problem: health
institutions.
Current ascendance of the moral model over the medical model not only impedes
treatment but also has helped to create the current crisis in drug policy.
Criminalization versus medicalization creates both the underground market and
the "forbidden fruit" allure of the illicit drugs. The users obtain
their supplies through antisocial or dissocial networking which encourages
further involvement. The oppositional definition of these commodities creates
the demographic characteristics of the users: young and male.
Since the early 1920s the health professions have largely been excluded from
treating opiate and cocaine dependence. Notwithstanding the Linder Supreme
Court decision in 1925 to the contrary, specific prohibition continues against
a physician furnishing or prescribing substances to maintain opiate or cocaine
addicts habits in the course of "good faith" practice of medicine.
Except for detoxification within the confines of a hospital or jail, no narcotics
can be given.
In the late 1960s Dole and Nyswander overcame opposition form the narcotics
enforcement establishment to set up methadone maintenance clinics. It was based
upon the assumption that addiction is an illness needing pharmacologic intervention
to modify antisocial behavior.
Methandine, a long acting orally effective narcotic is dispensed on a daily
basis to outpatients at a dose level sufficient to "blockade" the
effects of heroin, a short acting narcotic.
Today methadone maintenance is an accepted therapeutic modality that is available
under tightly regulated clinic programs with the goal of withdrawing the addict
after a behavioral stabilization has been effected. Recently, the system has
come under attack from the Drug Enforcement Administration because of alleged
selling or trading of methadone for other drugs like cocaine.
The use of "symptomatic detoxification" utilizing alpha-blocker blood
pressure drugs like clonidine or inderal and benzodiazepines to suppress the
same of the heroin withdrawal symptoms has gained contemporary ascendance.
It has been my clinical observation that was developed in the Lexington and
Fort Worth federal hospitals in the 1940s.
Notwithstanding, because of the escalating controls and paperwork required
by the Drug Enforcement Administration, it is rare to find a hospital that
is able to comply with the complex and detained requirements for using methadone
detoxification. The excessive control of controlled substances significantly
adds to substance abusers pose additional difficulties for the treating physician.
PERMIT PHYSICIANS TO TREAT ADDICTS ONCE AGAIN
To bring medicine back to involvement with issues of drug dependence, the criminalizing
policies need revision to make the treatment of addicts a medical matter.
Redefine an addict as ill rather than criminal in functional terms.
Rescind the doctrine of prohibiting physicians from maintaining opiate and
cocaine addicts. Transfer control of treatment protocols and standards from
the Department of Justice to the Surgeon General's Office. Mandate development
of maintenance or drug hygiene standards with participation of organized medicine.
Rufus King, who once proposed this idea, should oversee setting up a joint
American Medical Association and American Bar Association committee to draft
legislation to revise laws to optimize freedom to appropriately treat substance
abuse, safeguard patient's rights, and protect the public health.
Most physicians and clinics would probably not be enthusiastic about dispensing
drugs to users for non-therapeutic purposes. There is also the possibility
of temptations for profit to encourage excessive consumption or overlook abuse.
VOLUNTARY DRUG USERS' COOPERATIVES
A new category of legal non-therapeutic users of controlled substances should
be created making available all drugs listed in the Controlled Substances
Act of 1970 and amendments for actual controlled use.
Success of the program is based on the assumption that the rate of morbidity
to use will be acceptably low in an informed group of users.
Reacting to some adversity a chronic user will increase his/her dose, which
causes psychosocial dysfunction, health problems, or financial crisis that
motivate seeking of treatment.
Upon entering a detoxification program the addict forswears the habit vowing
to stay "clean" from now on. The rare addict will truthfully admit
to the treatment goal of reducing a habit to manageable levels.
Even with success in completing detoxification and maintaining a period of
abstinence, drug dependence is a chronic relapsing illness.
The mission of VDUC is to control, treat, and prevent drug abuse in a flexible
and appropriate fashion. The dispensing of controlled substances through participating
pharmacies to registered users is included.
Price structure based upon abuse/use ratio of a substance would encourage the
use of less or dangerous products. A harmfulness tax is an idea that has been
recently proposed by Grinspoon.
The VDUC would be somewhat more controlled than differential toxicity tax rates
because written and physical tests would be required for entry into a pharmacy-based
program using credit card identification.
Another VDUC goal is to institutionalize connections between cost/benefit or
actual facts with social policy and the marketplace. These connections only
dimly exist for alcohol and tobacco industries and their users. Unlike these
hazardous substances, drugs sold through VDUC would not be granted exemption
form product liability laws.
Transaction fees and all taxes would be earmarked to support the administration
of the cooperative and contracting community treatment providers for users
needing services.
DIFFERENT FROM THE BRITISH "SYSTEM"
The old British "system" was to encourage distribution and sales
to both India and China of opiates and cannabis. The Indian Hemp Drugs Commission
in 1896 recommended regulation of that drug through a moderate rate of taxation
with no capital involvement with the trade. With opiates the British policy
was to sell as much to China in their "concessions" would permit
until the Boxer rebellion and other local resistance helped end the British
opium trade.
During the 18th and 19th centuries opiate addicts were known in England and
obtained their supplies at the chemist. Opiate dependence was looked upon as
a vice more the province of the upper classes and the intelligentsia. In the
Victorian imperial worldview it was seen as the curse of the Oriental morally
inferior addict who inhabited the opium trade.
World opinion perhaps influenced by the temperance/prohibition movement, which
was suppressing the use of alcohol and other drugs, finally ended this exploitive
policy. In Britain their addicts became more closely restricted.
The contemporary British "system" derives form their national health
service that is represented by local health councils, which manage medical
resources. The availability of physicians who are addiction specialists and
priorities of local councils determines whether the addict will obtain appropriate
treatment.
The rapid increase of heroin addicts and small numbers of addiction specialists
has overwhelmed that system. The illicit free market filled the drug needs
of the users the National Health Service could not meet. Substance abuse treatment
services in Great Britain are just as fragmented as that in the United States
but with differences in dynamics of control, economics, and influences of special
interest groups. Both are ill equipped and overwhelmed by the impact of problems
connected with substance abuse.
An example of malpractice was described by addicts under treatment at the 1987
University of London conference of the Drug Policy Foundation. Two methamphetamine
addicts were switched to methadone (a long acting opiate) maintenance because
the policy was for all addicts to receive this treatment.
Unlike prescriptive medical clinic models the proposed Voluntary Drug Users
Cooperative is not vulnerable to over-subscription. Since the scheme is transaction
fee supported, the larger the number of users, the more money is available
for treatment, prevention, and education.
Since there would be no intervention unless there was evidence of dysfunction,
costs would be lower than a clinic or physician visit type of maintenance program.
This lower level of control and services for problem-free users would support
a spectrum of services for those suffering drug-related illness or dysfunction.
More importantly, the program would provide an ongoing source of data on which
to refine policies that would optimize use/morbidity rates.
ELIGIBILITY
The age of majority would permit the taking of a written test on drug effects,
side effects as well as the conditions of the VDUC program including consequences
of misuse or violation of conditions. Passing of these tests would constitute
informed consent.
An entry medical evaluation including physical examination and laboratory tests
would be required to screen for conditions that would preclude or restrict
access such as mental illness, epilepsy, or substance abuse.
NON-PROFIT COMMUNITY BOARD
A non-profit community board would be mandated to protect the users from exploitation
as well as the public from health and safety risks. Users, Pharmacists, Public
Health, the general community and the district attorney should be represented.
ABUSERS REFERRED TO TREATMENT OR ENFORCEMENT
Privileges are suspended and the abuser is referred to police or district attorney
if the drugs are furnished to a minor, used to poison, incapacitate, or impair
someone else. Driving while intoxicated, endangering others, fighting, or
being a danger to others would be generally handled by enforcement.
If the user exhibits dysfunctional behavior or impaired health that does not
directly harm someone else, then he/she is referred to an appropriate substance
abuse program. Reports from hospitals, emergency rooms, physicians' offices,
health facilities, workplace, family, or other source would initiate intervention
of the program. The pharmacy identification card would be suspended and the
abuser referred to the assessment team.
EVALUATION
Experienced substance abuse specialists would be utilized for "triage" to
determine the type of intervention appropriate to the individual problem. Intervention
would be based on the least restrictive possible to meet individual needs.
REFERRAL FOR SPECIALIZED TREAMENT
A spectrum of outpatient and in-patient service would be available as contractors
to the program for intervention in cases of drug abuse.
CONTINUING RESEARCH AND EDUCATION
The continuing study at Framingham, Massachusetts provided us with definitive
information concerning the connection between smoking, lung cancer, heart,
and other circulatory diseases. Unbiased and extensive morbidity information
would be collected from participating health resources for policy refinement.
In order to restore a source of legitimate and undistorted medical information
as to the connections between drugs and their hazards, treatments, and prevention,
and ongoing study is required on a large scale.
FUNDING FOR TREATMENT AND PREVENTION
Treatment would be available if needed since the current salient problem is
the lack of money for treatment. Nine out of ten substance abusers voluntarily
asking for treatment are turned away for lack of a way to pay for treatment.
The earmarking of taxes combined with transaction fees would provide an ongoing
source for funding that has been heretofore lacking.
Tod H. Mikuriya, M.D., Social Drug Institute
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