Drug Abuse

Freek Polak

THE MEDICALIZATION OF (PROBLEMATIC) INTOXICANT USE AND THE MEDICAL PROVISION OF PSYCHOACTIVE DRUGS

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Summary

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The prohibition of intoxicants was originally intended to protect public health. The damaging side effects of prohibition are in fact themselves a danger to public health, whereas prohibition has proved ineffective in preventing and fighting the dangers of intoxicant use, just as it has failed in the protection of vulnerable groups. These goals can be better achieved by way of other regulatory systems. For the moment however, we have to remain active in preventing still greater damage, and new forms of damage, arising as a result of drug prohibition.

It is generally thought that the medicalization of the dependency problem can offer some compensation for the damage to health and society resulting from repression. This medicalization can take the form not only of better medical care, but also of a medical definition of drug use, compulsory treatment and expanded medical prescription of drugs. Not only the advantages but also the disadvantages of medicalization are discussed, in relation to two main variations of the regulatory system: prohibition and legalization. The question is considered which elements of medicalization are beneficial to public health and which should be seen as dubious and possibly damaging to public health.

The shortcomings of doctors in their crucial role in drug policy and the weaknesses of common medical wisdom are discussed. The 'clinician's illusion', as contained in many and sometimes decisive considerations and documents in the ongoing debate about the optimal regulatory system for psychoactive drugs, has a harmful influence on drug policy decisions.

The author comes to the following conclusions:

Although medicalization of problematic drug use is bound to ameliorate in some degree the living conditions and health state of many drug users, it will never compensate fully for the senseless damages and injustices caused by the systematic prohibition of drugs.

Medical provision of illicit drugs outside acute situations is inevitably allied with a number of serious and fundamental disadvantages, so that it can be argued that this form of medicalization is in principle an incorrect one. In a repressive system it nonetheless represents a step forward, like medical care near a battle field.

Analogous to the function of medicalization in the normalization of abortion in the Netherlands, medical provision of psychoactive drugs can in the long term only be justified in the framework of a transition to the normalization and legally approved availability of intoxicants.

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A short history

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There is an extensive literature concerning both the history of intoxicant use and the role played in this by the medical profession. Within the scope of this paper, the most relevant aspects of this history can be summarized as follows:

Up until the beginning of this century, there was a long period in which the use of intoxicants in general was accepted. To what extent this led to social or medical problems is difficult to ascertain because these were often not perceived as problems at the time. Some intoxicants (especially newly imported ones) were temporarily forbidden because of their assumed dangers, but in the nineteenth century the use of opiates for any number of major and minor complaints was completely normal in many Western European countries.

Since then, intoxicants have been divided into three groups. Group 1 can be purchased in a normal way in more or less specialized shops (alcoholic drinks and tobacco); group 2 (pain killers, tranquilizers and sleeping pills) can only be obtained with a doctor's prescription, with the cost in some countries being paid for by health insurance; while group 3 is forbidden (the so-called hard drugs). There is a certain overlap between groups 2 and 3: use of some illicit drugs is legal if undertaken on medical prescription.

It is becoming increasingly clear that this division is not only irrational, but also that it forms the basis for a policy that has dangerous consequences for both public health and the structure of society itself.

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Medicalization

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The last few years have seen an increase in the medicalization (and psychiatrization) of intoxicant use. The term medicalization means that a phenomenon or problem area is brought into the medical domain: medical considerations have to be decisive for the interpretation of problems and for the actions that are taken. With respect to drug use medicalization can have different combinations of meanings and consequences.

1. provision of adequate medical care,

2. the definition of regular drug use as a mental disorder,

3. compulsory treatment for addicted criminals,

4. medical provision of illicit drugs to classified addicts.

Whether this medical domination is judged to be positive or negative depends not only on the perception of the phenomenon concerned and on one's attitude to doctors, but also on the perception of the effect of medical interventions. For example, during the Second World War psychiatry gained considerably in status after military psychiatrists were able to provide a useful diagnosis of those dropping out of the front lines, and to successfully indicate who would be capable of returning to the front and who would not.

However, when phenomena that are not primarily or obviously medical in character are turned into medical issues as a consequence of regulation or socio-cultural developments, evaluation becomes much more difficult. A situation in which adults could only obtain alcoholic drinks or cigarettes with a doctor's prescription, and after registration as an 'alcoholic' or 'tobacco addict', would at the moment without doubt be seen as an undesirable form of medicalization in most countries. Nonetheless, it is difficult to spot the difference in principle with the medical provision of methadone.2 In the case of the illegal drugs we have come to accept the situation as normal: all use is forbidden except on prescription.

Doctors have three roles in the medicalization of intoxicant use:

1. The monopoly in prescribing the drugs in group 2.

2. The responsibility for the treatment of people with dependency problems.

3. A crucial role in the debate concerning legalization or prohibition of intoxicants.

This situation is criticized from different positions.

1. There is reason to doubt the suitability of doctors when it comes to controlling the use of addictive substances by others. In a study of British law in relation to opiates, the sociologist Bean (1974, p.131) has pointed out that those using opiates on prescription and, through no fault of their own becoming dependent on them, have been dealt with severely by the introduction of repressive legislation. While the doctors, who initiated the use and were unable to prevent the development of dependency, are nonetheless seen as the appropriate people to regulate drug use.3

During the last few decades, the use of benzodiazepines has risen to extraordinary levels on a global scale. Despite the great familiarity that the phenomenon benzodiazepine-dependency now enjoys, and despite official warnings that their use is only beneficial for the first few weeks, an important percentage of the users nonetheless become dependent.

It is not clear which conclusion should be drawn from this. Have doctors been injudicious in prescription? Or does the fault lie with the structure within which the problem has arisen? I will come back to this later.

2. In his recent thesis, Dutch sociologist Gerritsen (1993) questioned why it was that regular medical professionals in large part leave the treatment of addicts to specialized institutions with more repressive forms of treatment. He attributes this to the low social status of heroin addicts.4 But the phenomenon can only be partially explained by this reasoning so characteristic of sociologists (everything is attributed to power and social status). The aloofness of many doctors is also based on unpleasant incidents with drug addicted patients that many doctors have experienced. Even if doctors realize that these events are primarily a product of a failing regulatory system, and that they say little about drugs and drug addicts, this does not alleviate the problems these doctors have with this group of clients.

In his essay 'Medicalization of Psychoactive Substance Use and the Doctor-Patient Relationship' Robert J. Levine has tried to imagine the effects on the practice of medicine of a policy in which cannabis, cocaine and heroin could be legally obtained on the prescription of a physician. He predicts US doctors will not cooperate in prescription for recreational use, nor for those people who want to decide for themselves when they are going to stop the use. On the basis of Talcott Parsons' conception of the roles of doctor and patient, he concludes that doctors will probably only prescribe these drugs for drug dependent people "willing to play the role of good patient as defined by the sick role".5

Whatever the case, it is clear that the medical profession has relatively little interest in the treatment of addiction related problems and that this reflects poorly on the attitude of doctors towards this category of potential patients.

3. Rightly or wrongly, doctors are in general respected. Their ideas carry weight in social discussions, even when the issues are only in part medical. Doctors have become accustomed to this, and accept the fact that their opinion in a number of controversial issues is overvalued. The best known examples of this are abortion, homosexuality and euthanasia.

In this context the question of how doctors obtain their knowledge and opinions is important. Doctors have the tendency to attribute a greater value to medical and pharmaceutical information than to the social, economic and cultural factors that play a role in the use of psychoactive substances and in the development of addiction. In addition, doctors are not exempt from moralizing. Nonetheless, it goes without saying that doctors also want to form an opinion about the drug problem. The chance is great that they go about doing so on the basis of a few cases known to them, patients in their practice or people in their surroundings. And that they think this opinion is a professional one, based upon expert knowledge.

However, in the evaluation of a phenomenon such as the use of illegal drugs, an important role is played by an epidemiological problem of which the majority of doctors are largely unaware: it is unavoidable that in the practice of medicine an image is formed of drug use and addiction that is greatly distorted.6 Doctors only see users in search of treatment, or via the police and the judiciary. In addition, they see a disproportional large number of serious and chronic cases. Patricia and Jacob Cohen have named this the 'clinician's illusion'. They show very convincingly the enormous differences that can exist between the distribution of illness duration in the daily practice of clinicians and in the population. The diagrams pertain to a hypothetical disease with a great variability in duration, which is not immediately life threatening and for which treatment is not very successful (like substance dependence).

In other words: doctors know little or nothing about normal, unproblematic use, or about people for whom dependence is a less serious problem, which is solved relatively quickly and without treatment.

This situation is not helped by the fact that there is little that can be done to alter these preconceptions. Although a great deal is said and written on the drug problem, doctors are not among the major participants in the controversy and there is very little in the way of inter-disciplinary debate on the subject.

Despite all of this, the medical order is allowed to perform a central function in the formation of public opinion concerning the question of drug use. The official, often tacit support by medical organizations is crucial to the continued irrational prohibition of a number of intoxicants.

After this discussion of the role of doctors I would like to turn our attention to the question of the medicalization of substance use. Because medicalization is a more humane approach than criminalization, its unfavorable consequences are often overlooked.

In order to discuss the advantages and disadvantages of medicalization, it is important to differentiate whether the regulatory system is based on prohibition, decriminalization or legalization.7 One direct result of the prohibition of hard drugs is the deterioration of the health of large groups of drug addicted people, many of whom also live in very poor social circumstances. The HIV epidemic has made painfully obvious how imprudent and irresponsible it has been to criminalize the users of some drugs and lower their social status still further. And in all probability this will not be the last lesson of its kind, given the disquieting amount of articles about an increase of multiresistant tuberculosis.

Prohibition excludes the possibility of quality control of drugs. Users are to a great extent dependent on dealers, leading to dangerous patterns of usage (injection, for example, instead of swallowing or sniffing), and to the use of heavier concentrations rather than lighter. When this is the case in a situation characterized by social isolation and marginalization, effective social and medical assistance remains an illusion.

The only acceptable function of medicalization of drug dependency should be to provide drug addicts with good medical care, like other citizens. But, while every improvement in this respect is valuable, in a prohibitive system the quality and quantity of medical care for drug addicts will never really be adequate. On the other hand medicalization entails important drawbacks, which are particularly obvious in a repressive system. Of these disadvantages I mention the following four.

1. The medicalization of dependency problems in general inherently implies that addiction is seen a priori as a medical or psychiatric problem, as a kind of sickness. With respect to illegal drugs this is even more so, leading to an even greater acceptance of the idea that treatment is a necessity and that abstinence is the only solution. In their generality, these views are unjustified and potentially harmful. In the scope of this paper I have to refer to the literature.8 Of course for a number of problematical users treatment can be beneficial, but for what percentage of the whole population of users this is true, remains as yet unknown.

2. Clinical research is restricted to aspects of intoxicant misuse. Because of the ongoing repression of what is termed "non-medical use", normal, non-problematic use escapes notice and is therefore hardly studied. As explained earlier, this is one of the factors that lead to an impoverishment of doctors' knowledge and contribute to the increasing tendency to medicalize patterns of drug use, that by themselves do not need medicalization.

3. Because the one-sided emphasis on clinical data produces a mistaken evaluation of the extent to which drug use is associated with problems, it is unavoidable that this leads to wrong decisions with respect to policy. A clear example of this is the situation regarding Lee Robins' research (1973, 1975, 1993) into heroin dependent Vietnam veterans. Her findings and conclusions have hardly had any effect on the dominant medical-pharmacological opinions concerning heroin addiction, despite the fact that they differed on important issues. One of her most fundamental points was that the prevalence and course of heroin dependence can be perceived in a much more positive light when studied among a general population than among drug addicts in treatment, or in the judiciary system.9 Cocaine research among non-deviant users undertaken by Waldorf, Reinarman and Murphy (1991), and by Cohen (1990), has shown that patterns of heavy usage rarely occur within the total group of cocaine users, and that when they do they usually decrease without treatment.10

Nonetheless, the policy of the IIN, the WHO, the INCB and numerous other organizations remains firmly based on the incorrect perception of cocaine and heroin use as leading in the majority of cases to a serious dependency problem. A view erroneously shared, as earlier stated, by most doctors.

4. A fundamentally different objection to the medicalization of drug use is the view that doctors and medical institutions are being used for the wrong purposes: moral control and law enforcement The function of doctors in the care and treatment of drug addiction has always been intertwined with, or an extension of, the police and judiciary, as Virginia Berridge (1993) has demonstrated.1l Specific medical applications of the law enforcement function of doctors in a repressive system are the provision of psychoactive drugs and compulsory treatment.

To conclude this section I would like to mention that there is an advantage of medicalization that can only be enjoyed however in a situation of legalization. Ideally, through their personal contacts with their patients12, doctors with the right attitude and with sufficient knowledge of intoxicants could achieve the position of "advisor on the use of drugs", just as they perform that function in other socio-medical matters. In this respect there is a gap in the market already recognized in Killarney, Ireland, where, written in big letters on a pub wall, one can find the term "DRINKING CONSULTANTS".

After this general discussion of medicalization, I will confine myself to the medical provision of psychoactive substances as a specific form of medicalization. Other applications of medicalization, like compulsory treatment, will be left out of consideration.

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The medical provision of intoxicants

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In many European countries, the question of the medical provision of other addictive drugs than methadone has become a hot topic lately, because of the impossible situation municipal authorities find themselves in, with respect to drug related criminality. On the one hand, for their political survival they 'have to do something about the drug problem'. On the other hand, most of them know by now that any hardening of law enforcement will only make things worse. Their hope is that medical treatment of addicts will be helpful and they exert pressure on those dealing with drug addiction, and especially on Municipal Health Services, to extend the range of intoxicants provided or, at the very least, to set up experiments with this aim in mind. Because of this, it is necessary to reconsider the possibilities, limitations and dangers of the medical provision of these substances.

In the Netherlands, in an earlier round of this debate some 10 years ago, the national authorities and the medical profession adopted a negative position with respect to the medical provision of heroin in addition to methadone. Most of the objections were medical in nature. One more practical argument against the provision of heroin was that the Amsterdam morphine project had just begun and that the results of the already institutionalized provision of methadone had as yet not been subjected to sufficient evaluation.

From a medical point of view, the following two fundamental objections were the ones most proffered: 1. the improper coupling of medical treatment with the fight against crime and the maintenance of public order and 2. the disputable and arbitrary nature of the medical indications.

To these objections, with which I agree in principle, I would like to add the following disadvantage, after which I will try to weigh these objections against the possible advantages of medical provision.

In practice, the provision of illegal psychoactive drugs by doctors is accompanied by unavoidable problems. In order to prescribe the drugs, the doctor has to trust the information provided by the patients themselves as, for example, is also the case with asthma. The relationship of trust that this requires, already under pressure in the treatment of addiction, is even more difficult to achieve under a repressive system. Because there is no other legal way of obtaining drugs, doctors are subject to disproportionate pressure from users. The aspirant user must have a sickness (or aggravate or fake one) in order to be considered for prescription, and the doctor is given a controlling rather than advisory role. Within this atmosphere of distrust and control a level of regulation is created that is both suffocating and inadequate, and which inevitably leads to snubbing and degrading treatment. When the client (who is not only dependent on one or more substances, but because of the structure of medical provision is dependent on the doctor too, and often also on a team of workers) asks for a higher or lower dosage, the doctor is inclined to resort to arbitrary and elusive arguments in order to find a reason for non-compliance. This results in misuse of medical power and distortion of the doctor-patient relationship.

At this point I would like to argue that it would be shortsighted to come to a standstill at the conclusion that the medical provision of intoxicants is in principle an undesirable form of medicalization. I agree that many serious objections can be made against this form of medical treatment, but that does not imply an absolute rejection of it.

In my view, medical provision of intoxicants (apart from acute situations) can only be considered sound and acceptable in a particular context, and in the name of a greater common good, as for instance in the case of medical care near a battle field.

I will return to the question of the conditions for medical provision of intoxicants, after a comparison with the role of doctors with regard to abortion. In the Netherlands in the 70's, after a long period during which it was totally banned, abortion was only permitted after a medical indication had been established by a commission composed primarily of doctors, of whom at least one was a psychiatrist. Gradually abortion became less controversial and the expected increase in the number of abortions failed to materialize. With the result that, after what I believe was roughly 15 years, the Abortion commissions could be abolished. Today the decision is taken by the woman concerned, and the degree to which she involves other people and/or her doctor is a question for her and her alone. The doctors that perform the abortions have the responsibility to assure themselves that the woman knows what she wants and to deliver good medical care.

By means of this comparison, one can see that a period of in principle undesirable and unnecessary medicalization (the establishment of indication for abortion by a committee of doctors) nevertheless can contribute to the acculturation and normalization of what was originally an extremely controversial phenomenon. It is probable that this will also be the case with respect to the complicated procedures involved in voluntary euthanasia and assistance with suicide.

In a similar fashion, in the long run the medical provision of illegal drugs can only be useful, when it forms part of a careful transition to a regulated availability of those drugs, and when it can contribute to the spread of knowledge of and experience with safe patterns of usage, bearing in mind the preferences and limitations of risk groups (fringe group youths, psychiatric patients).

A point of discussion is whether or not this process should first be agreed upon as a precondition necessary to the participation of doctors, or whether one can begin without concern, in the belief that this sort of medicalization, as in the case of abortion, will eventually make itself superfluous.

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Notes:

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I Berridge, Virginia & Griffith Edwards, 1981, Opium and the People, Yale University Press.

Musto, David F. 1987, The American Disease, Oxford University Press.

and the historical surveys in Derks, Jack 1990, Het Amsterdamse Morfine Verstrekkingsprogramma, proefschrift [The Amsterdam Morphine Dispensing Programme, thesis], Utrecht, Nederlands Centrum Geestelijke Volksgezondheid [Netherlands Center for Mental Health].

Van de Wijngaart, Govert, 1991, Competing Perspectives on Drug Use [the Dutch Experience], Amsterdam & Berwyn, Pa., Swets hE Zeitlinger.

Gerritsen, Jan Willem, 1993, De Politieke Economie van de Roes, Foefschrift [The Political Economy of Intoxication, thesis], Amsterdam University Press.

2 The comparison with alcohol or cigarettes as illidt drugs, avilable only on prescription, is not that far fetched. Especially in the United States, voices can be heard once again in favour of the prchibition of alcohol. Books and articles are being published with the purpose of demonstr ting that prohibition in the 1920's and 1930's was actually a success, contr ry to general belief. And, again especially in the USA, tobacco smokers already find themselves in a very unple saDt but interesting process of being marginalized. If the medicalization of h rd drup can be portrayed as successful, the t sk of subjecting tobacco and alcohol to the same regulation will be e sier.

3 Bean, Philip 1974, The Social Control of Drugs, Wiley & SODS.

4 Gerritsen, Jan Willem 1993, De Politieke Economie van de Roes, proefschrift [Ihe Politic l Economy of Intoxication, thesis], Amsterdam University Press.

5. Levine, Robert J. 1991, Medicalization of Psychoactive Substance Use and the Doctor-Patient Rel tionship, The Milbank Quarterly, 69, 4, 623-640. Levine refers to:

Parsons, Talcon, 1972, Definitions of Health and Illness in the Light of American Values and Sodal Structure. In: Patients, Physicians and Illness: A Sourcebook in Behavioral Science and Health, ed. E.G. J co, 107-127, Free Press, New York.

6. Cohen, Patricia and Jacob Cohen 1984, The Clinician's Illusion, Arch. Gen. Psychiatry, 41, 1178-1182.

Cohen, Peter 1990, Is Heroin Dependence Pathological? In P. Cohen, Drugs as a social constract, thesis, University of Amsterdam.

Duncan, David F.1993, Using Epidemiologic Measures to Assess Drug Policy. In: The

Faces of Change, Policy Track Manual for the Seventh International Conference on Drug

Policy Reform, Washington D.C., the Drug Policy Foundation.

Fromberg, Erik 1993, De Eenzijdige Blik van de Medid [The One-sided View of Doctors], puer presented at the Symposium "Doctors and Dope" (will be published by the Netherlands Institute on Drugs and Alcohol and the Dutch Psychiatric Society, Utrecht)

7 For a discussion of these main variations of regulatory systems, see

Maccoun, Robert J., James P. Kahan, James Gillespie, and Jeeyang Rhee 1993, A Content Analysis of the Drug Debate, Journal of Drug Issues, 23(4), 615-629, and in the "Political Pharmacology: Thinking About Drugs" issue of Daedalus (Proceedings of the American Academy of Arts and Sciences), 1992, 121, 3, the following uticles on systems with more subtle regulation:

Kleiman, Muk A. R. 1992, Neitha Prohibition Nor Legalization: Grudging Toleration in Drug Control Policy, S3-83, and

Nadelmann, Ethan A. 1992, Thinking Seriously About Alternatives to Drug Prohibition, 8S-132.

8. Cohen, Peter 1990, Is Heroin Dependence Pathological? In: Drugs as a Social Construct, University of Amsterdam.

Davies, John Booth 1992, The Myth of Addiction - an Awlication of the Psychological Theory of Attribution to Illicit Drug Use, Huwood Academic Publishers.

Peele, Stanton 198S, The Meaning of Addiction - Compulsive Experience and its Interpretation, Lexington Books.

Peele, Stuxton 1989, Diseasing of America - Addiction Treatment out of Control, Lexington Books.

Szasz, Thomas 1972, The Ethics of Addiction, Harper's Magazine, 4, 74-79.

Szasz. Thomas 1972, Bad Habits are not Diseases, Lancet, July 8, 2, 83-84

Szasz, Thomas 1973 (Revised Edition 198S) Ceremonial Chemistry - the Ritual Persecution of Drugs, Addicts, and Pushers, Leuning Publ., Holmes Beach, Florida.

Zinberg, Norman E. 1984, Drug, Set and Sening - the Basis for Controlled Intoxicant Use, Yale University Press.

9. "Addiction looks very different if you study it in a general population than if you study it in treated cases."

Robins, Lee N. 1993, Vietnam veterans' rapid recovery from heroin addiction: a fluke or normal expectation? Addiction, 88, 1041-lOS4: IOSI.

10. Cohen, Peter 1990, Cocaine Use in Amsterdam. In P. Cohen, Drugs as a social construct, thesis, University of Amsterdam.

Waldorf, Dux, Craig Reinuman and Sheigla Murphy 1991, Cocaine Changes: the Experience of Using and Ouining, Philadelphia: Temple University Press.

11 Berridge, Virginia 1993, paper presented at the Symposium "Doctors and Dope" (will be published by the Netherlands Institute on Drugs and Alcohol and the Dutch Psychieric Society, Utrecht).

12 The term 'patient' is used here in the same sense as when one talks about a family doctor's patients: the point is not that one is sick, but that the doctor has agreed to take responsibilky to provide medical care to a person.