To the Editor: Dr McLellan and colleagues state that drug addiction should
be treated as a chronic medical disease.

This contradicts our experiences as a sheriff (L.A.) and an emergency
department physician (D.L.S.) who regularly encounter patients who provide
false histories concerning trauma or pain syndromes, insist on narcotic
analgesics, and vigorously refuse nonnarcotic analgesics or follow-up with
an office-based physician.

Our experience has been that the overwhelming majority of such patients
will not agree to enter a drug rehabilitation program or to go to
Alcoholics Anonymous or Narcotics Anonymous. Anecdotally, most patients who
have been in rehabilitation experience a relapse or a loss of control of
their drug dependency. Only a tiny minority of these patients will follow
up with a single physician or medical office for ongoing medical management
of their chronic illness.

The vast majority of drug-dependent individuals do not view their condition
as an illness, but rather spend tremendous resources and take great risks,
including that of jail or even death, to continue their lifestyle.

In our area we have discovered organized groups that travel from physician
to physician for the express purpose of obtaining drugs. Most people who
use illegal drugs make a conscious decision to do so. Although we believe
that treatment should be available, it must also be accompanied by
consequences, such as jail or involuntary commitment, for noncompliance
with detoxification. From our observations, many individuals use drugs to
insulate themselves from life and its problems.

It is impossible to view all drug users and addicts together, but practical
experience provides insight into a world that they choose to inhabit.

Larry Amerson
Calhoun County Sheriff

David Lee Smith, MD
Emergency Department Physician
Anniston, Ala

In Reply: Mr Amerson and Dr Smith have failed to understand 3 key points in
our article: (1) that substance-dependent individuals are responsible for
the onset of their illness; (2) that they are also responsible for active
participation in their recovery; and (3) that they should be treated
because of the demonstrated public health and safety benefits of treatment,
not merely because of compassion for those affected. Responsibility for
Onset of Illness. Addiction is initiated by a voluntary act but it is also
true that this initial voluntary behavior is shaped by preexisting genetic
factors.

These are also brain changes that begin with the very first drug or alcohol
uses, which may evolve into compulsive drug taking that is less subject to
voluntary control.

We are not yet able to explain the brain and cellular changes that
transform the initial, voluntary drug-taking behavior into a compulsion.
Responsibility for Recovery. Drug dependence erodes but does not erase a
dependent individual's responsibility for control of their behavior.

All patients, regardless of their illness, are responsible for actively
participating in their recovery.

Many patients with chronic illnesses fail to see the importance of their
symptoms and thus may ignore physician advice, fail to comply with
medication, and engage in behaviors that exacerbate their illnesses.

While such patients may not be as disruptive, demanding, or manipulative as
alcohol-or drug-dependent patients, the patterns of denial of symptoms,
failure to comply with medical care, and subsequent relapse are not
peculiar to addiction.

One thing that does separate addiction from other illnesses is the waiting
lists for treatment throughout the United States, which contradict
assertions that addicted persons do not want treatment. Efficacy as Basis
for Treatment. Compassion or sympathy is not the basis for our argument
that physicians should treat addicted individuals. Medically oriented
treatments are much more effective than socially oriented responses such as
incarceration. Also, addiction treatments have been combined effectively
with legal sanctions (eg, drug courts and court-mandated treatments) and
with civil sanctions (eg, welfare-to-work programs and involvement of child
protection services). Research has provided physicians with even more
effective medications and brief interventions to address addiction problems.

These new interventions should be taught in medical schools and primary
care residencies. Our review suggests that if physicians develop and apply
the skills available to diagnose, treat, monitor, and refer patients in the
early stages of substance dependence, there will be fewer late-stage
emergency department cases such as those that have frustrated and
disillusioned Amerson and Smith.

A. Thomas McLellan, PhD
Charles P. O'Brien, MD, PhD
Penn/VA Center for Studies of Addiction at the Veterans Affairs Medical
Center and the
University of Pennsylvania Philadelphia

Herbert D. Kleber, MD
National Center on Addiction and Substance Abuse at Columbia University
New York, NY

David Lewis, MD
Brown University Center for Alcohol and Addiction Studies
Providence, RI