The major deleterious side effect of the use of mood altering drugs in our society is addiction. Behaviorally, this is defined as repetitive use despite adverse consequences. Physiologically, it now appears that the nerve cell itself is the site of pathological alteration sufficient to explain the phenomena of tolerance, withdrawal and craving that commonly accompany the addictive use of these agents. Despite the evidence that the repetitive use of these agents affecting the brain is beyond the willful control of the addict, our society continues to view the addicted person as a moral degenerate who lacks the selfdiscipline to abstain. This belief is evidenced by society's attempts to control drug use through the arrest and incarceration of illicit drug users and sellers. Punishment is poor treatment for a diseased brain, as any law enforcer who arrests the same offenders over and over again could testify. While the legal system clearly must continue to fight the criminal element associated with drug dealing and act to impede occasional, non-compulsive use, responsibility for the problem of compulsive use, drug addiction per se, must be shouldered by the medical care system.

Research into the neurochemistry of the brain supports the theory that neuronal receptors and neurotransmitters are altered by drugs acting on the central nervous system. Dopamine depletion from chronic cocaine usage theoretically explains the phenomenon of craving, depression, psychotic behavior and inability to experience pleasure through normal daily living that follow a cocaine binge. The nerve cell opioid receptors are thought to be modified by opioid use (e.g., heroin and morphine), resulting in drug hunger, tolerance and withdrawal symptoms if these drugs are stopped. The theory that neuronal structure and function may be irreversibly changed by drug use explains the frustrating phenomenon of relapse, associated particularly with opioids and cocaine. It also presents a powerful case for viewing the addict not as a criminal but as someone with an illness that renders the sufferer physiologically incapable of willful abstinence and forces him or her to continually seek drugs to stave off the agonizing torments of craving and withdrawal.

Despite the evidence that drug addiction is a neurological disease, the hands of physicians are tied in regard to providing care for addicts. This has been the case over the last 75 years. Under the Harrison Narcotic Act of 1914, the medical system was allowed only a limited role in the custodial care of addicts committed to sanitaria, whether by the courts or of their own volition. In the "Linder Case" of 1925 the courts stated: "It [the Harrison Act] says nothing of 'addicts' and does not undertake to prescribe methods for medical treatment. They are diseased and proper subjects for such treatment."

However, this judicial support for the disease concept of addiction was counteracted by what was to become the prevailing sentiment, that is, that addicts are criminals. According to the Hon. Lester Volk's testimony before Congress in 1922, a State's Attorney in the southern district of New York was alleged to have-espoused a policy "that the best method was to drive all addicts into the underworld for their supply, where they will become a police problem and can be dealt with by the criminal authorities by a voluntary or involuntary commitment." Such a mindset has produced regulations which curtail physicians' ability to prescribe drugs which prevent withdrawal and alleviate craving, thereby forcing users to seek relief from drug hunger through the black market.

The only form of approved medical treatment based on drug substitution therapy is methadone maintenance, but there are so few clinics and so many people seeking treatment that addicts are obligated to wait for up to a year, in some cases, before they can enter most programs. Of the nation's estimated 1.5 million IV drug users, only 150,000 or 10% are receiving treatment through the 14,000 public and private programs that are currently available. Some progress was made recently when the FDA granted a New York City clinic approval to issue daily doses of methadone unaccompanied by the customary array of additional social services and paperwork that tend to bog these programs down. If applied widely, this shift in policy should help to shorten waiting periods and to encourage the establishment of new programs.

Unfortunately, no methadone-like alternative has yet been found to be successful in the treatment of cocaine addiction. Hopefully, there is experimental evidence to suggest that buprenorphine will mitigate craving at least in experimental animals. The results of clinical trials of this medication are anxiously awaited. Support programs such as Cocaine Anonymous have helped some to abstain, as have longer-term residential programs like New York's Phoenix House, though installation of similar centers has been seriously impeded by the prevailing "not in my backyard" public sentiment. Until American citizens cease to view the addict as a criminal menace and come to accept the pressing need for treatment centers along with the possibility of having one installed in their own neighborhood, the adverse consequences of drug use will continue unabated.

With illicit drug use comes ever increasing drug-related crime and violence, producing even more depressing statistics than those presented by Mayor Kurt Schmoke of Baltimore in his testimony before Congress in 1987. "In the analysis of 573 narcotic users in Miami, who during a 12-month period were shown to have committed 6,000 robberies and assaults, almost 6,700 burglaries and more than 46,000 other events of larceny and fraud, it is indisputable that drug users are committing vast amounts of crime," he said. "Nationwide last year ['87], over 750,000 people were arrested for violating drug laws....Our federal prison system was built to house 28,000 prisoners and now has 44,000, one third of whom are there on drug charges. Fifteen years from now, it is expected that half of the 100,000 to 150,000 federal prisoners will be incarcerated for drug violations."

This data reflects the deleterious impact on our social matrix of criminal drug-seeking behavior, a behavior which is fostered by the very system that seeks to contain it. Limiting drug availability forces the addict into felonious activity to acquire drugs from a criminal enterprise of immense wealth and power; witness the internal destruction of the nation of Colombia. Our society and its leadership fail to grasp the simple fact that addiction is a chronic disease of the central nervous system in which relapse is commonplace. Addiction differs sharply from casual, intermittent drug use unaccompanied by drug seeking. Full blown addiction is a medical illness deserving of medical attention. Non addictive use of psychoactive agentiis a social issue. Problems relating to the latter form of chemical psychic alteration generally involve results of behavior stemming from episodes of intoxication. Efforts to prevent this form of drug use should include legal penalties for irresponsible injurious actions while under the influence. Responsibility and accountability of the individual are key issues here.

The question as to whether providing addicts with drugs such as methadone or even cocaine would be effective in producing favorable changes in society can be positively answered by data excerpted from Mayor Schmoke's testimony. "...Of the 6,910 Baltimore residents admitted to drug abuse treatment in fiscal year 1987, 4,386 or 63% had been arrested one or more times in the 24 month period prior to admission and treatment. Whereas, of the 6,698 Baltimore City residents who were discharged from drug treatment in fiscal year 1987, 6,152 or 91.8% were not arrested during the time of their treatment. These statistics tend to support the view that one way to greatly reduce drug-related crime is to assure addicts access to methadone or other drugs without having to resort to the black market."

Some who argue that easier access will abet drug taking among new users go on to claim that such a step would amount to genocide of minority groups already beset by IV drug use. The concept of clean needle distribution is opposed for the same reason. But in the face of the compulsive use that defines addiction, opposition to clean needles is irrational and truly homicidal in that the AIDS virus will continue to be spread among those sharing contaminated works. Understanding the morally correct view that abstinence is desirable does nothing to assuage an addices craving and compulsion. The belief that legal access to drugs will increase the numbers of addicts has not been substantiated and rests solely on conjecture. The experience of the Scandinavians appears to indicate that the number of new addicted drug users does not burgeon when their drugs of choice are made available.

Alcohol and tobacco do more damage to the public health through accidents, suicides and early deaths from cancer and cardiovascular disease than do the illegal drugs. Since the repeal of Prohibition in 1933, drinking alcohol, despite its vast potential for abuse, has been condoned. Societal attitudes toward sick alcoholics have improved greatly in the last twenty years and public support for those seeking treatment has increased. Employers assist in interventions and guarantee job protection for those participating in month-long recovery programs. The alcoholic who accepts treatment is assured anonymity and confidentiality, and insurance companies underwrite treatment costs.

Paradoxically, the unlucky person who is addicted to a proscribed chemical such as heroin or cocaine is viewed as a worthless, weak-willed criminal who belongs in jail. The public programs of methadone maintenance do little to maintain the anonymity or confidentiality of clients. Unsympathetic neighbors prevent establishment of programs and half-way houses in their areas.

Mayor Schmoke has recommended several steps that we should take immediately to initiate an effective drug policy. He stated that the role of the public health system should be expanded in the prevention and treatment of drug abuse. This should include a revision of  regulations and policies to insure that no bonafide addict need get drugs from the black market and that all addicts seeking treatment would have ready access to methadone or cocaine under medical auspices. He also recommended the appointment of a high-level commission to assess the potential impact of decriminalization of drug use.

There is a growing number of physicians in this country with knowledge and experience in the field of chemical dependency. Many of them are members of the American Society of Addiction Medicine. They serve as an important available resource in efforts to combat this pervasive illness. The membership stands ready to offer experience, strength and hope to those seeking individual or collective answers to drug issues. Regulated use of this pool of informed medical talent would be helpful to lay officials in providing for a widened and more available  methadone distribution system, for example.

It is reemphasized that careful distinction must be made between addicts and those whose use of drugs has not as yet made them physiologically dependent. The forrner must be considered helplessly caught up in craving and compulsion so that legal punitive measures and any treatment modality, whether short or long term, will not prevent a significant rate of recidivism. Methadone, in the case of heroin addiction, or legal supply at low cost of other particular drugs of dependence may be a logical solution to remove addicts from the criminal backwater of the black market. The supply of these chemicals should be controlled by federal, state and local health agencies, to avoid the enticement of easy acquisition to begin casual or experi-mental use. The problem, here, is the reasonable establishment of the diagnosis of true addiction. This must be a medical decision. Under no circumstances should drug acquisition be liberalized to the extent that some envision distribution of these agents via vending machines or at grocery checkout counters like gum or candy. Non-addictive use of all of these chemicals, where compulsion and craving are not in themselves responsible for drug seeking, must continue to be prevented by any and all means that society can muster, education being primary, but also including arrest, public trial and incarceration for those whose activities while intoxicated are harmful.

In conclusion, bona fide addicts, so diagnosed medically, should not be prosecuted and imprisoned but, rather, should have access to drugs through a controlled medical care system. This would return them to society, capable of functioning normally at home and in the workplace, free of craving and of the necessity for criminal behavior commonly associated with drug seeking. The black market for these chemicals would be sharply reduced, at least partially eliminating this malignant element in our midst. Physicians experienced in addiction medicine must be utilized as important resources in expanded and liberalized treatment of the chemically dependent in order to achieve these goals. Addicts will then have a chance to regain their self-esteem and to rejoin society to be embraced and loved as neighbors.