Drug dependence changes the lives of users and those around them. Tobacco, for example, is the single greatest cause of preventable death in the United States (CDC, 2001). Certainly, then, tobacco is a menace to public health and its continued popularity supports nicotine(Drug information on nicotine) dependence as a chronic, relapsing disease in which volitional choice becomes but one negotiable variable in the struggle to achieve good health throughout the life cycle.
Moral rejectionists mislabel drug dependence as a failure of volition only and, thereby, claim a right to assign judgment and blame. The absurdity of looking through such a narrow lens is that if addiction really were merely a choice, people would stop after experiencing more harm than perceived benefits!
Accepting drug dependence as another mental illness does not typically abrogate responsibility for an addict's actions: Thousands each year are arrested, prosecuted and sentenced to serve jail time for simple drug possession, and, as for mental illness in general, consider that the two psychiatric inpatient facilities in the United States in which the largest numbers of patients reside are the Los Angeles County Jail and New York City Rikers Island Prison (Geller, 2000; Torrey, 1999; Watson et al., 2001). Obviously, such individuals' moment-to-moment decision-making can have long-term consequences that were never wished for or accurately anticipated.
Not all choices can be equally entertained at every given moment either, and sometimes other options are not even known. For example, a young woman, supporting herself and her drug habit through prostitution, may not know of the different "ethical" choices available to her, especially when as a child she had been introduced to both drugs and her career by her mother's example. The reasons for experimenting with addictive drugs, then, may be quite different from the motivations fueling continued use. Relapse is not due to an absolute loss of volitional control but rather to loss of a perspective that cherishes good health and mental well-being above other, less healthy choices. In high-risk situations, this long-term desire for maintaining better health through abstinence is overwhelmed by the cued wish to re-experience a known, anticipated "high" available at that moment.
Stigmatization of illness continues against many patients afflicted with brain pathology. Substance dependence is particularly stigmatized by those who wish to make this illness a debate over volition while denying the biological underpinnings of behavior. Moreover, demands for precise linguistic definitions of addiction and disease, as if they must forever be hermetically sealed within specific denotations of legalese and ethics, is of little value to physicians charged with the observation and treatment of pathology. History reveals many examples of debates over illness versus individual responsibility: Hansen's disease ("leprosy" from Mycobacterium leprae), seizure disorders ("epilepsy"), cancer and major depression are some examples of medical disorders now vindicated with the discovery of effective medications and procedures. Physicians, and psychiatrists in particular, are needed now more than ever to stand up and explain to the lay public how substance abuse and dependence can significantly alter brain function and physical health and that a variety of treatment modalities are available.
Effective management of drug dependence requires a medical model so as to tailor therapy according to the condition of the individual. Faith-based support groups, Alcohol(Drug information on alcohol)ics Anonymous and its affiliates, and long-term residential programs have a long history of assisting people in achieving and maintaining abstinence via a combination of direct therapy, education, cognitive skill-building exercises, expanded non-drug social supports and providing a drug-free environment. Contingency management skills can be taught to provide individuals with extra time to anticipate the high-risk situations and emotions for relapse and then, hopefully, re-script behavior to minimize such exposures (Carroll et al., 2001). This helps individuals learn to avoid night clubs or other users because such settings and people may make the choice for continued abstinence appear less valuable than the immediate reward anticipated with use.
Current pharmacotherapy for drug dependence includes screening for an underlying psychiatric condition after the patient has successfully completed detoxification. People may choose to self-medicate with an addictive drug, all the while unaware that they have a treatable psychiatric illness. For example, rates for alcoholism and other drug abuse are much higher in people with untreated bipolar disorder and depression. For motivated individuals, disulfiram(Drug information on disulfiram) (Antabuse) may particularly aid in maintaining sobriety from alcohol. Smoking tobacco while on the antidepressant buproprion (Zyban, Wellbutrin) is another aversive treatment, as the drug induces an undesirable taste when some smokers relapse. Agonist replacement medications assist with detoxification and/or offer a stable, safer maintenance therapy for those who repeatedly fail pure abstinence (e.g., methadone(Drug information on methadone) for opiate dependence, nicotine gum or patch for tobacco dependence). Many new medications are also in development including more opiate antagonists for the treatment of alcoholism and opiate dependence and NMDA antagonists such as acamprosate(Drug information on acamprosate) [Campral] for alcoholism (Tempesta et al., 2000). One day, perhaps there will even be a vaccine to confer natural immunity against cocaine (Schabacker et al., 2000). As Krystal et al. (2001) reported regarding the efficacy of naltrexone(Drug information on naltrexone) (ReVia), an opioid antagonist, in the treatment of alcoholism, sometimes medications do not prove to be as effective as promised. Evidence still suggests, however, that naltrexone may be quite effective if taken intermittently on the days that the individual feels at greater risk for relapse, rather than ingesting it every day (Boening et al., 2001).
Whether addiction is a disease or merely a choice, the utility of the medical model is needed to address resultant risks to public and individual health. A careful review of this growing body of scientific literature should offer hope that real solutions are possible. All other models for addressing drug dependence have, to date, proven to be costly failures, and doctors are not going to ignore viable treatment options for healing those suffering with drug dependence. Defining addiction as a choice only abdicates our responsibility for seeking health and true healing for our patients and, instead, leaves crushed lives dehumanized by a chronic relapsing condition with no hope for cure. As every doctor knows, "Remember to do some good" should quickly follow the first rule to "do no harm."