By Maggie Mahar and Niko Karvounis, Health Beat. Posted June 25, 2008.
In 1986, Nancy Reagan made it clear that there is "no moral middle ground" when it comes to drug use. You either don't take drugs, which means you are a "good" person, or you do take drugs, which means you are a "bad" person."
The Reagan-era outlook on drug addiction has dominated our political culture for nearly three decades, though not without sharp criticism. In March, for instance, the writers of "The Wire," the critically acclaimed HBO series that brought the realpolitik of Baltimore's war on drugs to the small screen, made it clear what they thought of the Reagan approach: "What once began, perhaps, as a battle against dangerous substances, long ago transformed itself into a venal war on our underclass. Since declaring war on drugs nearly 40 years ago, we've been demonizing our most desperate citizens, isolating and incarcerating them and otherwise denying them a role in the American collective. All to no purpose. The prison population doubles and doubles again; the drugs remain."
They're right -- we are not winning the war on drugs. But the question remains: What should we do now? Those who view illicit drug use as willful behavior believe that we have no choice but to jail those who choose to continue committing crimes. Others who argue that drug addiction is a disease that weakens the addict's ability to choose argue that rather than stigmatizing the addict and punishing him, we must find new ways to "treat" the patient.
One could argue about who is right. But rather than engaging in yet another political argument about personal responsibility vs. society's responsibility to help its poorest citizens, it might be helpful to take a look at what medical science has been learning about drug addiction over the past few decades.
Addiction Treatment: Science and Policy for the Twenty-First Century (Johns Hopkins University Press, 2007) does just that, and in the process "highlights the amazing discord between scientific knowledge and public perception," according to a review by Stanford University's Dr. Alex Macario in the June 4 issue of JAMA.
In this collection of short, incisive essays, the authors don't always agree on specifics, but they do reach a consensus of sorts: The scientific community needs to educate the public about drug addiction -- and our approach to treatment should be based on medical evidence rather than personal ideology.
Today, medical technology allows scientists to observe firsthand what happens inside the brain when it is, in the words of William R. Miller, a psychiatrist at the University of New Mexico, "hijacked by drugs." Thanks to brain imaging, for example, we know that regular drug use disrupts the frontal cortex, which regulates cognitive activities like decision-making, planning and memory. In other words, drugs affect an individual's capacity to make the choices that the Reaganites insist addicts should be able to make (Just Say No!). Undoubtedly the drug user could have said "no" the very first time he or she let desire override good judgment. But after that, Miller notes, "neuroadaptation involves biological changes in response to drug use that increase the likelihood of repetition and escalation, undermining the person's capacity for volitional control." Recent studies have even shown that drug addiction changes our brains at the genetic level, influencing how our DNA is translated into enzymes and proteins.
As a result of this new information, experts are increasingly incorporating the recognition that addiction is, in part, a "brain disease" into their treatment recommendations. This perspective has even made headway in the halls of power. Last year Congress introduced the Recognizing Addiction as a Disease Act, which would institutionalize the disease model by changing the name of the National Institute on Drug Abuse to the National Institute on Diseases of Addiction and change the name of the National Institute on Alcohol Abuse and Alcoholism to the National Institute on Alcohol Disorders and Health.
The text of the act embraces the disease model, noting that "the pejorative term 'abuse' used in connection with diseases of addiction has the adverse effect of increasing social stigma and personal shame, both of which are so often barriers to an individual's decision to seek treatment."
This statement reflects the logic of Alan Leshner, CEO of the American Association for the Advancement of Science and former director of the National Institute on Drug Abuse, who notes in his contribution to Addiction Treatment that "addiction is ... at its core a brain disease," and that consequently, "addicts cannot simply will themselves to stop using drugs" because they are "in an altered brain state." If addiction is a disease, then addicts are patients -- and they need treatment, just as a cancer patient may need chemotherapy.
Yet putting too much emphasis on the "brain disease" model risks oversimplifying the issue. Addiction is not simply biological; it is psychological. There are treatments that work for some patients that involve behavior modification and decision-making. Consider a promising strategy known as "contingency management," which provides rewards for reduced drug use. In these treatments, patients leave multiple urine samples with researchers over the course of a week and receive rewards -- like vouchers that can be traded in for goods like clothing and theater tickets -- for each specimen that tests negative for drugs.
Or consider the successes of drug courts, community-based courts where drug offenders are sentenced to treatment and supervision programs. These programs, like contingency management, offer tantalizing rewards, like the reduction of prison sentences, for adherence to treatment, and the guarantee of punishment (jail time) if a patient fails. Studies show that drug courts are effective. Only 4 percent to 29 percent of drug court graduates relapse, compared to a whopping 48 percent recidivism rate among other users. Here we see the limits of thinking about drug addiction only as a disease -- that is, as an entirely biological condition. As Sally Satel, a physician at the American Enterprise Institute, notes in her contribution to Addiction Treatment, the fact that incentives can change drug behavior shows that there's more here than simply a biological problem. "Imagine bribing a cancer patient," she muses, "to keep her tumor from mestasizing or threatening her with jail if her tumor spread." Crude though this statement may be, Satel has a point: You can't really reason with disease -- yet it seems that sometimes you can reason with addiction.
In the preface to Addiction Treatment, the authors note: "When treating most medical conditions, health professionals will explore several treatment options with the patient to determine which is acceptable and effective, whereas with addiction treatment a person is typically offered a single option in a one-size-fits-all" approach that fails many.
Why do we offer the addict so few options? There's little doubt that our inflexibility is tied up with the fact that society has stigmatized not just addiction, but the addict himself. "Historically, people have disdained addicts because they thought addicts 'did it to themselves' and could just quit if they really wanted to," notes Leshner in his chapter, "Advancing the Science Base for the Treatment of Addiction."
As a result, we haven't been terribly generous in the treatments we offer addicts, even when we have clear medical evidence of what needs to be done. For example, "it has been established that psychosocial interventions alone do not work well for the majority of opioid-dependent individuals," points out Dr. H. Westley Clark, director of the Center for Substance Abuse Treatment. Most need medication in the form of a methadone maintenance program. Yet as Mark W. Parrino, president of the American Association for the Treatment of Opioid Dependence, points out in a later essay, "the stigma that surrounds heroin addiction has interfered with providing access to care both for the general public and for incarcerated" addicts.
In a study that surveyed how correction staff in a large Southwestern jail felt about methadone maintenance therapy for heroin addiction, researchers found "negative attitudes ... that appear to be related to negative judgments about the clients the program serves. The survey results indicate that people don't object to methadone treatment per se, but they object to drug users in general, and heroin users in particular, getting any kind of treatment that might ... condone their behavior. An unexpected finding was that the older jail staff was much more sympathetic to methadone maintenance treatment than the younger staff."
This may be because older staff came of age at a time when we were beginning to realize that alcoholism and other drug dependencies were diseases -- and not simply signs of a lack of character. Meanwhile, younger staff grew up in the post-Reagan era, when much of the public was led to believe that addiction is a moral crime that should be punished.
Yet, as Parrino notes, "the Rikers Island KEEP (Key Extended Entry Program) program has demonstrated that providing access to methadone treatment for inmates is extremely cost-effective." And for heroin addicts who are not in jail, "Methadone/buprenorphine treatment is a low-cost medical intervention. In most outpatient programs, the cost for providing access to this treatment generally amounts to $5,000 per patient per year. This is much lower than the roughly $22,000 per inmate per year cost of incarceration, especially in view of the fact that a large number of methadone patients pay for their own treatment."
But this does not mean that we want to simply "maintain" the heroin addict with methadone, and leave him or her on that lonely plateau. With proper incentives, counseling and reinforcement, addicts can still make choices. Like other patients, they need to be drawn into the treatment process, where they can share in decision-making.
Much of 21st century addiction research focuses on understanding the fundamentals of motivation. In Addiction Treatment, the University of London's Robert West offers the PRIME model, a compelling framework for understanding what drives us.
According to West, responses ("R") exist at the most basic level of the human motivation. These are basic actions, like starting or stopping an activity. At the next level are our impulses ("I"), which are catalysts for specific action (i.e. hunger impels us to eat). These impulses bridge our actions to higher-order mental states, like motives ("M"), our conscious desire for specific things, and evaluations ("E"), moral perspective on how the world works. At the most complex level lie our plans ("P"), which refers to how we think about and plan for the future.
This model does a good job of linking various dimensions of motivation. And in a PRIME treatment, says West, "both medication and psychological techniques should be considered." Patients could be given drugs that help regulate their impulses or reduce the discomfort associated with quitting cold turkey, while psychological techniques can be used to restructure motivations, future plans and habits.
PRIME gives you a real sense of how mind and body interact to trap the addict. As Maxine Stitzer, a professor at Johns Hopkins, suggests in her essay, drug addiction should not be thought of as either a choice or as a brain disease, but rather as a "chronic relapsing disorder." This is certainly true for some, if not all addictions. Again, there is no "one-size-fits-all" model or treatment for a disease that we are only beginning to understand.
Finally, while "society at large may consider injury from addiction to be the 'just desserts' of drug abuse, this perspective is not shared by those responsible for the public health," observes Dr. Curtis Wright. "From a public health perspective, the path forward is to recognize that these disorders are a major health problem."
Yet, "for whatever reason," he writes, today, "there are few physicians or medical institutions to speak to the need for addiction treatment. Many of the clinical experts and clinical researchers in this area were trained almost 40 years ago, and relatively few physicians are currently entering the field." Most likely, the Reagan-era notion that drug use is a moral problem discouraged many who might otherwise have seen it as a medical problem well worth exploring.
Meanwhile, Wright reports, "the lack of strong physician advocates has been one of the factors leading to why the FDA treats these disorders as lower-priority illnesses than many other diseases."
This is yet another area that the next FDA commissioner might want to investigate. We are very hopeful that 2009 will mark a rebirth of an agency that plays a major role in setting priorities for the nation's health.