Published in Sacramento Medicine, December 1998

Is addiction a disease? Is it treatable? How does it differ from casual ‘willful’ drug use? What makes addiction to illegal substances a cause for criminal penalties, while addiction to equally dangerous legal substances is not? Is our current emphasis on criminal justice approaches to illegal drug use effective at reducing drug-related harms, or is it causing more harm than good?

The public has received answers to these questions largely from media, law enforcement, and politicians. They have been influenced very little by medicine. Until relatively recent times, the profession was uninvolved with the illness of addiction, and the evidence for addiction as an illness has been ignored in favor of moralistic or criminal justice conceptions. Physicians were driven out of the addiction treatment field in the early part of this century by a powerful federal narcotics agency, with extreme prejudice against the concept of addiction as an illness doctors should be allowed to treat. Doctors were targeted in sting operations if they tried to treat addicts or chronic pain patients or unwittingly provided narcotics to dishonest patients. Thousands were arrested. Addicts received virtually no treatment until, in the 1960s, methadone treatment brought a small number of physicians into the newly emerging field of addiction medicine. This subspecialty has now established a solid foundation of scientific data on the biological basis of addictions and on effective treatments.

Addiction is an illness in two ways. First, it falls into a general category of compulsive behaviors, many of which have now been found to be associated biological abnormalities in brain chemistry, as well as inheritance patterns that suggest altered genes as the pathological etiology. Vulnerability to substance abuse has been shown to be genetically transmitted. Secondly, compulsive drug use itself alters brain chemistry, and perhaps brain structure, so that medical treatment is, at tunes, necessary to normalize function. For example, recent studies indicate that some people may have genetically abnormal mu opioid receptors, which do not respond normally to endogenous opiates. These patients may need opiate replacement therapy to normalize brain functioning. They may now be numbered among chronic pain patients and opiate addicts. Another documentation of medical illness is the case of former heroin addicts in stable long-term recovery from drug abuse, but not treated with methadone, who have been shown to have abnormal SPECT scans. If methadone treatment is added, the scans normalize. The functional brain problem that methadone corrects may be either an inherited genetic abnormality or an abnormality brought about by drug abuse itself.

As in other areas of medicine, treatment successes have, at times, preceded theoretical understanding. Endorphins and the opiate receptors were discovered after their existence was hypothesized based on successful treatment of opiate addicts with methadone. Research has now documented successful medical treatments for addictions to other drugs and alcohol. Addictions have been shown to be as treatable as other chronic conditions like diabetes, arthritis, or mental illness.

The scientific data is available to direct improvements in policy, and the medical profession is now beginning to address the important public health issues involving addiction to illegal substances. Through the leadership of Brown University professor Dr. David Lewis a new medical group, Physician Leadership on National Drug Policy (PLNDP), has been formed. The group includes editors of the major medical journals and presidents of the major medical societies, who bring their expertise to bear on a social problem that has been dominated by criminal justice and moral perspectives.

The group’s first task was to develop a consensus statement, which affirms among other things that:

We are impressed by the growing body of evidence that enhanced medical and public health approaches are the most effective method of reducing harmful use of illicit drugs... The current emphasis — on use of the criminal justice system and interdiction to reduce illegal drug use and the harmful effects of illegal drugs —is not adequate to address these problems.

Concerted efforts to eliminate the stigma associated with the diagnosis and treatment of drug problems are essential. Physicians ... have a major responsibility to train themselves and their students to be clinically competent in this area.’

The National Physician Leadership group is soliciting support and comment from medical societies and individual physicians. This issue is not just academic. There are important human rights and patients rights issues involved in national drug policy. If addiction is a treatable illness, as the research suggests, then are criminal penalties appropriate? Or are they as little justified as incarcerating a diabetic for carbohydrate abuse or a lung cancer patient for smoking? For what other illness would we tolerate criminal justice punishments and years in prison instead of proven medical interventions?

As with other illnesses, physicians should advocate for humane and proper treatment of those with addictive disorders. That is not happening under current drug polices. Treatment is often unavailable, especially to the poor. Insurance companies provide little or no substance abuse coverage. In the criminal justice system, proper medical treatment is often prevented by policy. There are cases of pregnant opiate addicts denied methadone treatment (based on the punishment mentality) whose babies have died in utero of acute opiate withdrawal. The medical profession should reject the current criminal justice shibboleth that punishment is a deterrent to drug use. Addiction is an illness that progresses in spite of adverse consequences, such as punishments. Punishment for a treatable illness is a human rights abuse. And abuse is a well-known cause of drug use, not a deterrence.

As physicians we must support a drug policy that is both scientific and compassionate. Our Medical Society should endorse the Physician Leadership Consensus Statement and take an active role in reshaping national and local drug policies.