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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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