Alternatives to the War on Drugs - The (Uncomfortable) Third Way

CrimProf blog tells us what anybody should already know - the "war on drugs" as presently fought is an extraordinarily costly failure, and the drug situation is not likely to improve unless we focus on demand instead of supply. But it's simplistic to suggest that treatment programs are the key to winning the drug war. Unless you're going to expand the meaning of "treatment" beyond the comfort zone of a lot of Americans.

Drug treatment is remarkably ineffective, not because we don't now have some pretty good programs and models for treating addicts, but because until an addict is ready for sobriety the odds of successful treatment are close to zero. If you're not an addict, this is really hard to grasp. I still can't quite fathom why somebody would spend time in a jail or prison, be completely broken from any physiological addiction to cigarettes, but then light up the moment they get out. It doesn't make sense, but that's addiction at work.

In a "war on drugs" parallel, a couple of years ago I met an addict who was in the process of detoxing from heroin, who described how he had previously spent a full year in a very expensive residential treatment center - about $30,000 per month. He had agreed to drug treatment as part of a one year drug diversion sentence for possession. His dad had picked up the tab to keep him out of jail. He indicated that although he was "clean" for the full year and passed all of his drug tests, he spent the entire year waiting for the moment his year was up. Within an hour of the court appearance at which he was discharged as having "successfully" completed the diversion program, he had a needle in his arm. He was back in treatment because he had been arrested again. My guess is that he's since again relapsed.

Meanwhile in Switzerland, they're experimenting with prescription heroin, administered in a clinical setting for a class of addicts for whom all else has failed. It's a bit jarring, but in fact if you want to reduce the demand for street drugs, sometimes you have to make their equivalent available in a clinical setting. This approach offers some benefits that may not be immediately apparent, including providing the addict with pharmaceutically pure drugs (the poisons and toxins in street drugs can carry serious health consequences), and opening the door to drug education, counseling, and the possibility of treatment. The U.S. has moved uncomfortably into the drug substitution and maintenance model, through methadone clinics, but an addict's participation in that type of program is often a result of desperation - they've reached a point in their addiction where their need for drugs exceeds their supply - and not about recovery.

Like it or not (and I don't), addiction is a part of human nature, and a consequence of human biology. There's not a country in this world that doesn't have a "drug problem", and there never will be. It makes sense to move into a model of a "war on drugs" that involves a sensible use of resources, and as much as possible removes the criminal element from the drug trade while treating addiction as a public health problem. But if the only tools we apply to the problem are "drug treatment" and "cutting off supply", we should not expect the situation to improve.

Tough Words To Say....

Our society makes it really hard to admit, but the excuses? Come on. A judge in disciplinary proceedings for being intoxicated on the bench explains,

during the alleged drunken appearances, he was taking the painkiller Vicodin for back and knee injuries from a car accident; an anti-inflammatory medicine; Ambien for sleep apnea; and medication for diabetes and high blood pressure.

Let's get one thing straight. You don't take Ambien (or any other sleep medication) for sleep apnea. You take it to help you sleep if you are having trouble with a CPAP or BiPAP machine, the actual treatment for sleep apnea. After you take it you go to sleep. You do not take Ambien and then go to work unless you are either intending to go to sleep on the bench or you are an addict.

He admitted that he went on the bench on two occasions after taking Vicodin and consuming alcohol.

On Dec. 6, 2006, he took three or four Vicodins before a 9 a.m. session in Bridgewater, and at lunch that day had two to three glasses of Chardonnay.

When you're gulping down a triple or quadruple dose of Vicodin, with a substantial alcohol chaser, you're either being extremely foolish and reckless in the treatment of your physical pain or you've moved well hinto the territory of addiction.

Sasso said he knew he should not take his daily Vicodin dosage all at once but added that he generally needs a large dose because he is 6'3" and weighs 290 pounds.

More likely, because if you take three or four times your prescribed dose you build up a tolerance. If you are taking prescribed pain relievers and they're not helping, here's what you do: You go back to your doctor and say, "These aren't helping at the dose you prescribed. What do you recommend?"

Similarly, if you find yourself taking Ambien and not falling asleep, you go back to your doctor and say "These aren't helping me sleep. Can we try something else?" If you take Abmien and intentionally stay awake, it's unlikely that you're taking it for any purpose other than its intoxicating effects (which, as Patrick Kennedy (and the officer who investigated his accident) can tell you, are a lot like alcohol intoxication).

Let's draw a line here between addiction and dependence. If you take certain medications for a long enough period of time, including opiates, you develop a physical dependence on those medications. You may also develop a tolerance that requires an adjustment of your dose or a change of medication, and may be dependent to the point that you will suffer withdrawal if you suddenly stop taking your medications. That's not addiction. Where you transition from dependence to addiction is when your medications stop improving your ability to lead a normal life, and your focus shifts to clock-watching or drug-seeking. There's also a syndrome called pseudoaddiction, where somebody who is receiving inadequate pain relief may demonstrate obsessive or drug-seeking behaviors that resemble those of an addict, but those symptoms resolve when their pain is adequately treated. But if you're buying shoeboxes of drugs from your maid (in addition to taking the drugs you get from your doctor), or gulping down huge doses of opiate medication with alcohol, it's safe to assume that you're an addict.

The AA/NA model for addiction dictates that the very first step in recovery is admitting your powerlessness over your drug of choice. I'm fortunate enough not to have a history of addiction, but I can say this: When the Rush Limbaughs, Patrick Kennedys, and even lesser known people like Judge Sasso avoid making that direct, honest concession - when they insist that their addictions are somehow more elevated because they claim to have physical pain, or are somehow more pure because they're abusing prescription pharmaceuticals - they're lying to themselves and to anybody who listens to them.

It would be really nice to hear one of these high profile addicts discard all of the excuses and finger pointing and simply admit, even if prefaced with an explanation of how they became addicted, "I did it because I am an addict." (e.g., "Although I didn't seek out this disease, and had no experience with addiction before I received opiate medication for a back injury, I stole drugs from my charity because I am an addict.")

Addendum: To be clear, I believe that if high profile addicts are honest about their addiction, they will help diminish the stigma of addiction. While we sometimes pretend otherwise, addiction strikes at all levels of our society and, while the rich and powerful are often better able to cover for their addiction or avoid street drugs, nobody is immune.