This post was written by Maggie Mahar and Niko Karvounis

In 1986, Nancy Reagan made it clear that there is “no moral middle ground” when it comes to drug use. You either don’t take drugs—which means you are a “good” person—or you do take drugs, which means you are a “bad” person.”

The Reagan-era outlook on drug addiction has dominated our political culture for nearly three decades, though not without sharp criticism.  In March, for instance, the writers of "The Wire," the critically-acclaimed HBO series that brought the Realpolitik of Baltimore’s war on drugs to the small screen, made it clear what they thought of the Reagan approach: “what once began, perhaps, as a battle against dangerous substances, long ago transformed itself into a venal war on our underclass. Since declaring war on drugs nearly 40 years ago, we’ve been demonizing our most desperate citizens, isolating and incarcerating them and otherwise denying them a role in the American collective. All to no purpose. The prison population doubles and doubles again; the drugs remain.”

They’re right; we are not winning the war on drugs. But the question remains: what should we do now? Those who view illicit drug use as willful behavior believe that we have no choice but to jail those who choose to continue committing crimes. Others who argue that drug addiction is a disease that weakens the addict’s ability to choose argue that rather than stigmatizing the addict and punishing him, we must find new ways to “treat” the patient.

One could argue about who is right. But rather than engaging in yet another political argument about personal responsibility vs. society’s responsibility to help its poorest citizens, it might be helpful to take a look at what medical science has been learning about drug addiction over the past few decades.

Addiction Treatment: Science and Policy for the Twenty-first Century
(Johns Hopkins U. Press, 2007) does just that, and in the process
“highlights the amazing discord between scientific knowledge and public
perception,” according to a review by Stanford University’s Dr. Alex Macario in the June 4th JAMA.

In this collection of short, incisive essays, the authors don’t always
agree on specifics, but they do reach a consensus of sorts: the
scientific community needs to educate the public about drug
addiction—and our approach to treatment should be based on medical
evidence rather than personal ideology.

Today, medical technology allows scientists to observe first-hand what
happens inside the brain when it is, in the words of William R. Miller,
a psychiatrist at the University of New Mexico, “hijacked by drugs.”
Thanks to brain imaging, for example, we know that regular drug use
disrupts the frontal cortex, which regulates cognitive activities like
decision-making, planning, and memory. In other words, drugs affect an
individual’s capacity to make the choices that the Reaganites insist
addicts “should” be able to make (Just Say No!). Undoubtedly the drug
user could have said “no” the very first time he let desire over-ride
good judgment. But after that, Miller notes, “neuroadaptation involves
biological changes in response to drug use that increase the likelihood
of repetition and escalation, undermining the person’s capacity for
volitional control.”  Recent studies
have even shown that drug addiction changes our brains at the genetic
level, influencing how our DNA is translated into enzymes and proteins.

As a result of this new information, experts are increasingly
incorporating the recognition that addiction is, in part, a “brain
disease” into their treatment recommendations. This perspective has
even made headway in the halls of power. Last year Congress introduced
the Recognizing Addiction as a Disease Act, which would
institutionalize the disease model by changing into the name of the
National Institute on Drug Abuse to the National Institute on Diseases of Addiction and change the name of the National Institute on Alcohol Abuse and Alcoholism to the National Institute on Alcohol Disorders and Health.

The text of the act embraces the disease model, noting that “the
pejorative term ‘abuse’ used in connection with diseases of addiction
has the adverse effect of increasing social stigma and personal shame,
both of which are so often barriers to an individual’s decision to seek
treatment."

This statement reflects the logic of Alan Leshner, CEO of the American
Association for the Advancement of Science and former Director of the
National Institute on Drug Abuse, who notes in his contribution to Addiction Treatment,
that “addiction is…at its core a brain disease,” and that consequently,
“addicts cannot simply will themselves to stop using drugs” because
they are “in an altered brain state.” If addiction is a disease, than
addicts are patients—and they need treatment, just as a cancer patient
may need chemo.

Yet putting too much emphasis on the “brain disease” model risks
oversimplifying the issue. Addiction is not simply biological; it is
psychological. There are treatments that work for some patients that
involve behavior modification and decision-making. Consider a promising
strategy known as “contingency management,” which provides
rewards for reduced drug use. In these treatments, patients leave
multiple urine samples with researchers over the course of a week and
receive rewards—like vouchers that can be traded in for goods like
clothing and theater tickets—for each specimen that tests negative for
drugs.

Or consider the successes of drug courts, community-based courts where
drug offenders are sentenced to treatment and supervision programs.
These programs, like contingency management, offer tantalizing rewards,
like the reduction of prison sentences, for adherence to treatment, and
the guarantee of punishment (jail time) if a patient fails. Studies
show that drug courts are effective. Only 4 percent to 29 percent of
drug court graduates relapse, compared to a whopping 48 percent
recidivism rate amongst other users. Here we see the limits of thinking
about drug addiction only as a disease—that is, as an entirely
biological condition. As Sally Satel, a physician at the American
Enterprise Institute notes in her contribution to Addiction Treatment,
the fact that incentives can change drug behavior shows that there’s
more here than simply a biological problem. “Imagine bribing a cancer
patient,” she muses, “to keep her tumor from mestasizing or threatening
her with jail if her tumor spread.” Crude though this statement may be,
Satel has a point: you can’t really reason with disease—yet it seems
that sometimes you can reason with addiction.

In the Preface to Addiction Treatment, the authors note that: “When
treating most medical conditions, health professionals will explore
several treatment options with the patient to determine which is
acceptable and effective, whereas with addiction treatment a person is
typically offered a single option in a one-size fits all” approach that
fails many.

Why are we so niggardly in offering the addict so few options?  There’s
little doubt that our inflexibility is tied up with the fact that
society has “stigmatized” not just addiction, but the addict himself.
“Historically, people have disdained addicts because they thought
addicts ‘did it to themselves’ and could just quit if they really
wanted to,” notes Leshner in his chapter, “Advancing the Science Base
for the Treatment of Addiction.”

As a result, we haven’t been terribly generous in the treatments we
offer addicts, even when we have clear medical evidence of what needs
to be done.  For example, “it has been established that psychosocial
interventions alone do not work well for the majority of
opioid-dependent individuals,” points out Dr. H. Westley Clark ,
Director of the Center for Substance Abuse Treatment. Most need
medication in the form of a methadone maintenance program. Yet as Mark
W. Parrino, President of the American Association for the Treatment of
Opioid Dependence, points out in a later essay, “the stigma that
surrounds heroin addiction has interfered with  providing access to
care both for the general public and for incarcerated” addicts.

In a study that surveyed how correction staff in a large Southwestern
jail felt about methadone maintenance therapy for heroin addiction,
researchers found “negative attitudes…that appear to be related  to
negative judgments about the clients the program serves. The survey
results indicate that people don’t object to methadone treatment per
se, but they object to drug users in general, and heroin users in
particular, getting any kind of treatment that might to condone their
behavior. An unexpected finding was that the older jail staff was much more sympathetic to methadone maintenance treatment than the younger staff.”

This may be because older staff came of age at a time when we were
beginning to realize that alcoholism and other drug dependencies were
diseases—and not simply signs of a lack of character. Meanwhile,
younger staff grew up in the post-Reagan era, when much of the public
was led to believe that addiction is a moral crime that should be
punished.

Yet, as Parrino notes, “the Rikers Island KEEP program has demonstrated
that providing access to methadone treatment for inmates is extremely
cost-effective.” Correction facility staff would be better off if
addicts received treatment.

And for heroin addicts who are not in jail, “methadone/buprenorphine
treatment is a low-cost medical intervention. In most outpatient
program, the cost for providing access to this treatment generally
amounts to $5,000 per patient per year. This is much lower than the
roughly $22,000 per inmate per year cost of incarceration, especially
in view of the fact that a large number of methadone patients pay for
their own treatment.”

But this does not mean that we want to simply “maintain” the heroin
addict with methadone, and leave him on that lonely plateau. With
proper incentives, counseling and reinforcement, addicts can still make
choices.  Like other patients, they need to be drawn into the treatment
process, where they can share in decision-making.

Much of 21st century addiction research focuses understanding the fundamentals of motivation. In Addiction Treatment,
the University of London’s  Robert West offers a compelling framework
for understanding what drives us,  called the PRIME model.

According to West, responses (“R”) exist at the most basic level of the
human motivation. These are basic actions, like starting or stopping an
activity. At the next level are our impulses (“I”), which are catalysts
for specific action (i.e. hunger impels us to eat). These impulses
bridge our actions to higher-order mental states, like motives (“M”),
our conscious desire for specific things, and evaluations (“E”), moral
perspective on how the world works. At the most complex level lie our
plans (“P”), which refers to how we think about and plan for the
future.

This model does a good job of linking various dimensions of
motivation.  And in a PRIME treatment, says West, “both medication and
psychological techniques should be considered.” Patients could be given
drugs that help regulate their impulses or reduce the discomfort
associated with quitting cold turkey, while psychological techniques
can be used to restructure motivations, future plans, and habits. 

PRIME gives you get a real sense of how mind and body interact to trap
the addict. As Maxine Stitzer, a professor at Johns Hopkins, suggests
in her essay, drug addiction should be thought of not as either as a
choice OR as a brain disease, but rather as a “chronic relapsing
disorder.”  This is certainly true for some, if not all addictions.
Again there is no “one-size-fits-all” model or treatment for a disease
that we are only beginning to understand.

Finally, while “society at large may consider injury from addiction to
be the ‘just desserts’ of drug abuse, this perspective is not shared by
those responsible for the public health,” observes Dr. Curtis Wright .
From a public health perspective, the path forward is to recognize that
these disorders are a major health problem.”

Yet, ‘for whatever reason,” he writes, today “there are few physicians
or medical institutions to speak to the need for addiction treatment.
Many of the clinical experts and clinical researchers in this area were
trained almost 40 years ago, and relatively few physicians are
currently entering the field.”  Most likely, the Reagan-era notion that
drug use is a moral problem discouraged many who might otherwise have
seen it as a medical problem well-worth exploring.

Meanwhile, Wright reports, “the lack of strong physician advocates has
been one of the factors leading to why the FDA treats these disorders
as lower priority illnesses than many other diseases.”

This is yet another area that the next FDA commissioner might want to
investigate. We are very hopeful that 2009 will mark a re-birth of an
agency that plays a major role in setting priorities for the nation’s
health.