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President's Column

The national war on drugs: Build clinics, not prisons

From the June 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

By Harold C. Sox, FACP

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.

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