THE NATIONAL WAR ON DRUGS: BUILD CLINICS, NOT PRISONS

Current thinking about how to treat drug addiction is in a state of rapid
flux. The basis of this revolution is the gradual accretion of knowledge
about the pathophysiology, treatment and social consequences of drug
addiction. All of this information is coming together into a coherent view
that points toward needed changes in public policy.

Since most drug addicts are adults with other medical disorders, internists
need to be part of this revolution. Internists need to adapt their practice
to new realities of treating drug addiction and must be leaders in seeking
changes in public policy. This article will lay out the basic facts and
their implications for physicians, patients and society.

Addiction is a chronic disorder. The decision to start taking drugs is
voluntary, although it is conditioned by heredity and environment. Most
first-time users do not become addicted, but many eventually lose the
ability to control their use of drugs and become addicted. Cure of the
essential feature of addiction—craving for drugs following withdrawal—is
possible but unlikely. In this sense, drug addiction is similar to diabetes
or hypertension.

The analogy between drug addiction and diseases like hypertension or
diabetes is appropriate because both conditions produce permanent anatomic
and functional changes that put the patient at risk for health problems.
Addictive drugs can produce changes in brain pathways that persist long
after a person stops taking drugs and place the individual at high risk of
relapse. Therefore, internists must think in terms of lifelong treatment of
drug addiction.

Drug addiction is similar to diseases like hypertension, diabetes and
asthma in other respects. Like many chronic diseases, successful treatment
requires behavioral change, and poor compliance is a constant threat. For
example, naltrexone is an opioid antagonist that works centrally to reduce
craving for alcohol and opioids. It markedly reduces recidivism among
alcoholics and opioid addicts, but opioid addicts show poor compliance and
alcoholics aren't much better.

Treatments

One way to successfully treat opioid addiction is methadone, which is a
weak-acting opioid agonist. Methadone does not produce euphoria, but it
blocks symptoms of opioid withdrawal and can be used in steadily reduced
doses to help opioid addicts withdraw from drug use.

However, the use of methadone that causes the most misunderstanding and
controversy is maintenance therapy, in which an addict takes a stable dose
indefinitely. When coupled with a comprehensive package of health benefits,
behavioral modification and social counseling, addicts using methadone
maintenance undergo a remarkable change, at least when viewed as a
population.

Consumption of all illicit drugs declines; heroin use drops to 40% of
pretreatment amounts in the first year and 15% in subsequent years.
Criminal behavior drops dramatically, to 70% of pretreatment levels. Other
health behaviors change, the most important of which is reduced use of
needles; while 26% of all untreated addicts become infected with HIV, only
5% of treated addicts become HIV-positive.

Because most studies of the effects of methadone maintenance therapy have
not been randomized trials, there are undoubtedly other factors that
contribute to these dramatic results. Nevertheless, it's a remarkable
success story for those who choose treatment.

Despite the successes attributed to methadone maintenance therapy, its use
is still limited. Many who want treatment cannot obtain it. The FDA, the
Drug Enforcement Administration, the Department of Health and Human
Services, and state and local governments all share in the task of
regulating methadone maintenance programs. Their regulations determine who
enters programs, acceptable doses and even the number of service sites. Ten
states forbid methadone maintenance programs entirely. Physicians who
dispense methadone must apply for a license every year, and programs are
subject to frequent inspections.

Because of these regulations, there are only 35,000 methadone maintenance
"slots" in New York City for approximately 200,000 injection drug addicts.
All of these slots are occupied at any given time. (New York has licensed
only five new methadone clinics in the past 20 years.) A 1995 Institute of
Medicine study concluded that such regulations are unnecessary and that
there are no medical reasons to regulate methadone any differently than any
other FDA-approved medication.

Societal costs

Society pays an enormous cost because of addiction to illicit drugs.
Shoplifting drives up the cost of goods. Muggings reduce tourism in our
large cities. HIV infection requires costly treatment and causes premature
death and reduced economic productivity.

Incarcerating large numbers of drug addicts is extremely costly. Prison
costs are the most rapidly increasing part of our federal drug budget;
because of harsh sentencing policies for drug users, two-thirds of all
prisoners are now addicts.

What can internists do? Probably the most important action is to rethink
our attitudes toward addiction to illicit drugs and to recognize it as a
chronic disease rather than a manifestation of psychological impairment. As
one expert has said, "Drug use is a choice, addiction is not." We need to
open our minds to methadone maintenance, which is a pharmacologically sound
approach to minimizing the harm from addiction.

Last July, a group of physician leaders, Physician Leadership on National
Drug Policy, issued a statement calling upon physicians to learn more about
substance abuse and its treatment. The group also called upon political
leaders to reallocate federal and state drug program resources toward
prevention and treatment, which reduces the demand for drugs, and away from
programs that have tried, unsuccessfully, to prevent illicit drugs from
entering the United States.

Changing government policy on such controversial issues will require the
support of physicians for adults. I hope ACP-ASIM will take up this matter
during the coming year and expend considerable effort to influence national
policy on illicit drugs. ACP-ASIM will need the support of its members if
we are to play our role as a professional organization whose first priority
is to address the needs of our patients, whatever their station and
whatever their affliction.

© 1998 by the American College of Physicians.

Checked-by: Richard Lake