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Summary/Abstract

Drug Law policy continues its commitment to the drug war in 2014 despite the hyperbole in Washington.

Content

The Drug War will go down in history as one of the most ill conceived, inhumane and costly blunders in modern history and maybe, by some, classified as systematic genocide. Conceived in the Nixon Administration by an uneducated, ill informed and psychologically challenged President, the Drug War was the political answer to the epidemic created by a clandestine partnership between the CIA and the South Vietnamese army that funded covert operations in Cambodia with the proceeds of China White aka No. 4 heroin manufactured in southeast asia and exported to the US. Heroin addiction had historically been restricted primarily to poor inner city neighborhoods and the bohemian subculture. In 1969, Nixon launched Operation Intercept virtually closing down the border to reduce the supply of Marijuana entering the US which resulted in increased availability of other illicit substances. This was not a gateway drug issue but rather a function of availability. As incidence and prevalence of use of other “hard” substances spread to white middle America, drug use rapidly became a political and economic problem that required a dramatic solution to appease political constituencies at national and local levels. It was no longer an inner city black or Latino kid who was discovered dead in a bathroom stall with a needle hanging out of his arm but the golden boy who was the son of a prominent family who had been destined to become, by societal standards,  a prominent and productive asset in  mainstream society. Drugs had invaded white America and The Drug War was born and, along with it, a new free market, both black and corporate, emerged to feast on the carnage of broken lives. Carefully crafted media campaigns planted overt and subliminal messages in the consciousness of the moral majority depicting addiction as an incurable deviant behavior characterized by moral weakness and criminal behavior. Addiction was demonized and addicts became the lepers of biblical times, cast out to prison cells to rot leaving broken families and setting the stage for the next generation. A bleak scenario. A thinking person might ask, why do we as a society, allegedly civilized and attuned to human rights, continue to defend this policy and expend the economic and criminal justice resources that either directly or indirectly impacts over forty million Americans either in need of treatment or in recovery. How many trillions of dollars do we need to spend, how many people suffering from a disease do we need to incarcerate and how many people need to die before we as a nation can admit we were wrong. We have been creating and enforcing policies and laws based upon outdated information.

Alcoholism was first recognized as a disease in Sweden in 1848, the American Medical Association declared it a disease in 195x and finally The American Society of Addiction Medicine declared addiction a brain disease in  2011 and provided a comprehensive definition of the disease addressing the requisite elements of diagnosis, prognosis and treatment. This declaration was derived from new knowledge in neuroscience and genetics confirmed by empirical biological data illustrating the structural changes that occur in the brain of an addicted person.

Today I  shudder to think that corporate greed and political agendas have successfully and will continue to obscure the reality of addiction and dictate treatment policy in America. The drug war is not the black market nor the widespread availability of illicit substances but the misunderstanding by the American public of what is addiction. Research indicates that addiction and substance use are predominantly a result of environment and  genetics although there are three additional risk factors. The focus in this article is the impact of environment on substance use.

There is a direct correlation with the prevalence of substance use and poverty and the persistent pain of chronic hopelessness. The simple fact is that people will escape from pain and hopelessness by whatever means are available whether it be drugs, alcohol, food, sex or gambling. It is human nature and we are  hardwired in our midbrain area to avoid pain. No one willingly submits to acute chronic psychological, spiritual or physical pain. A well known study done by Lee Robins on the incidence of heroin use/addiction of returning Vietnam Vets found that only 5% relapsed within 10 months and only 12% relapsed briefly within three years. One might conclude then that a certain number of addicts can be categorized as chronic and they should receive the same level of health care services as any person suffering from a chronic disease and that these services should be dictated by efficacy and outcomes rather than morality or intervening economic interests.

The critical issue is reframing the epidemic of substance use and solving for the origin not the symptoms. To observe analogously,  American society has a compromised immune system. Our informal social institutions are diseased, poverty is rampant, our elementary educational system is approaching third world standards and our sense of accountability has been replaced by apathy. This is the war. New legislation must be passed commensurate with medical and scientific data and policies implemented to address addiction, its etiology and treatment, as both an individual and societal issue. The behaviors are symptomatic. As Sun Zu stated over 1500 years ago, one must adjust ones tactics according to the terrain. The terrain has changed.

I have included a study below that many will find controversial. It addresses the issue of morality and its impact, often fatal, on treatment. This study clearly indicates that there are better treatment options for the chronic opioid addict, in this case heroin, and yet surprisingly it has received little press as it is not politically correct and is certainly contentious even within the addiction treatment community. I ask the reader, why not replicate the study in the US and evaluate the evidence objectively. The objective is to save lives and reduce the societal impact of addiction not to pacify the moral majority or further political and economic interests. 

I have also provided below a table illustrating Federal Drug Control Spending by Function for the years 2012 - 2014 (budget) which clearly illustrates that although the government claims to now recognize substance use as a health problem the reality is that the emphasis remains on drug law enforcement and interdiction. The Drug War lives on.

View of NCT00175357 on 2013_01_17

Results

The primary outcomes were determined in 95.2% of the participants. On the basis of an intention-to-treat analysis, the rate of retention in addiction treatment in the diacetylmorphine group was 87.8%, as compared with 54.1% in the methadone group (rate ratio for retention, 1.62; 95% confidence interval [CI], 1.35 to 1.95; P<0.001). The reduction in rates of illicit-drug use or other illegal activity was 67.0% in the diacetylmorphine group and 47.7% in the methadone group (rate ratio, 1.40; 95% CI, 1.11 to 1.77; P = 0.004). The most common serious adverse events associated with diacetylmorphine injections were overdoses (in 10 patients) and seizures (in 6 patients).

Conclusions
Injectable diacetylmorphine was more effective than oral methadone. Because of a risk of overdoses and sezures, diacetylmorphine maintenance therapy should be delivered in settings where prompt medical intervention is available. (ClinicalTrials.gov number, NCT00175357.)
Copyright © 2009 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at MCGILL UNIVERSITY LIBRARY on June 21, 2010 .