Pubdate: Wed, 24 Jan 2001
Source: Journal of the American Medical Association (US)
Copyright: 2001 American Medical Association.
Contact:  515 N State St, Chicago, IL 60610
Fax: 312-464-4445
Website: http://jama.ama-assn.org/
Note: Letter to editor and letter of response to that letter are included 
in this item.

To the Editor: Dr McLellan and colleagues state that drug addiction should 
be treated as a chronic medical disease.

This contradicts our experiences as a sheriff (L.A.) and an emergency 
department physician (D.L.S.) who regularly encounter patients who provide 
false histories concerning trauma or pain syndromes, insist on narcotic 
analgesics, and vigorously refuse nonnarcotic analgesics or follow-up with 
an office-based physician.

Our experience has been that the overwhelming majority of such patients 
will not agree to enter a drug rehabilitation program or to go to 
Alcoholics Anonymous or Narcotics Anonymous. Anecdotally, most patients who 
have been in rehabilitation experience a relapse or a loss of control of 
their drug dependency. Only a tiny minority of these patients will follow 
up with a single physician or medical office for ongoing medical management 
of their chronic illness.

The vast majority of drug-dependent individuals do not view their condition 
as an illness, but rather spend tremendous resources and take great risks, 
including that of jail or even death, to continue their lifestyle.

In our area we have discovered organized groups that travel from physician 
to physician for the express purpose of obtaining drugs. Most people who 
use illegal drugs make a conscious decision to do so. Although we believe 
that treatment should be available, it must also be accompanied by 
consequences, such as jail or involuntary commitment, for noncompliance 
with detoxification. From our observations, many individuals use drugs to 
insulate themselves from life and its problems.

It is impossible to view all drug users and addicts together, but practical 
experience provides insight into a world that they choose to inhabit.

Larry Amerson
Calhoun County Sheriff

David Lee Smith, MD
Emergency Department Physician
Anniston, Ala

In Reply: Mr Amerson and Dr Smith have failed to understand 3 key points in 
our article: (1) that substance-dependent individuals are responsible for 
the onset of their illness; (2) that they are also responsible for active 
participation in their recovery; and (3) that they should be treated 
because of the demonstrated public health and safety benefits of treatment, 
not merely because of compassion for those affected. Responsibility for 
Onset of Illness. Addiction is initiated by a voluntary act but it is also 
true that this initial voluntary behavior is shaped by preexisting genetic 
factors.

These are also brain changes that begin with the very first drug or alcohol 
uses, which may evolve into compulsive drug taking that is less subject to 
voluntary control.

We are not yet able to explain the brain and cellular changes that 
transform the initial, voluntary drug-taking behavior into a compulsion. 
Responsibility for Recovery. Drug dependence erodes but does not erase a 
dependent individual's responsibility for control of their behavior.

All patients, regardless of their illness, are responsible for actively 
participating in their recovery.

Many patients with chronic illnesses fail to see the importance of their 
symptoms and thus may ignore physician advice, fail to comply with 
medication, and engage in behaviors that exacerbate their illnesses.

While such patients may not be as disruptive, demanding, or manipulative as 
alcohol-or drug-dependent patients, the patterns of denial of symptoms, 
failure to comply with medical care, and subsequent relapse are not 
peculiar to addiction.

One thing that does separate addiction from other illnesses is the waiting 
lists for treatment throughout the United States, which contradict 
assertions that addicted persons do not want treatment. Efficacy as Basis 
for Treatment. Compassion or sympathy is not the basis for our argument 
that physicians should treat addicted individuals. Medically oriented 
treatments are much more effective than socially oriented responses such as 
incarceration. Also, addiction treatments have been combined effectively 
with legal sanctions (eg, drug courts and court-mandated treatments) and 
with civil sanctions (eg, welfare-to-work programs and involvement of child 
protection services). Research has provided physicians with even more 
effective medications and brief interventions to address addiction problems.

These new interventions should be taught in medical schools and primary 
care residencies. Our review suggests that if physicians develop and apply 
the skills available to diagnose, treat, monitor, and refer patients in the 
early stages of substance dependence, there will be fewer late-stage 
emergency department cases such as those that have frustrated and 
disillusioned Amerson and Smith.

A. Thomas McLellan, PhD
Charles P. O'Brien, MD, PhD
Penn/VA Center for Studies of Addiction at the Veterans Affairs Medical 
Center and the
University of Pennsylvania Philadelphia

Herbert D. Kleber, MD
National Center on Addiction and Substance Abuse at Columbia University
New York, NY

David Lewis, MD
Brown University Center for Alcohol and Addiction Studies
Providence, RI
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