SAN FRANCISCOMEDICINE - California Society of Addiction ...

Addiction and Recovery
A Time of Critical Change
Drug Addiction, Addiction Services, and Public Policy
Philip R. Lee, MD, and Dorothy Lee
The 2010 Patient Protection and Affordable
Care Act has the potential
to facilitate change. Promising to
insure more than 30 million people who
are uninsured now, with addiction and
mental health services included as part
of the essential benefits, it provides an
excellent opportunity for the medical
profession to collaborate with other
stakeholders to take a leading role in
the development of enlightened policies
related to drug addiction. Attitudes about
drug addiction and treatment have been
slow to change, and public policy even
slower, and the momentum built up by
the medical profession in recent decades
can ensure that the hope held out for the
well-being of present and future generations
is realized.
Punitive drug laws have been in place
in the United States for about 100 years,
at an exceedingly high cost, in dollars
and in human terms. Significant progress
has been made in research; addiction
medicine has been established as a specialty;
and a wide variety of preventions,
interventions, treatments, and paths to
recovery exist and are acknowledged to
be cost-effective in comparison to law
enforcement. Yet the nation keeps its
blinders on, stigmatizing, ostracizing, and
imprisoning drug addicts.
Production, sales, and use of drugs
were initially unregulated in the U.S., and
in the mid-nineteenth century opium,
cocaine, ether, and chloral hydrate were
not only medical mainstays but were
used for pleasure, even in lieu of alcoholic
beverages. To some extent the antialcohol
Temperance Movement affected the habits
of women: Drinking was considered
immoral; taking commonly prescribed
opiates and anaesthetics, or discreetly
self-medicating with patent medicines
containing low dosages of opium, cannabis,
or cocaine, was not. Late nineteenthcentury
surveys in U.S. cities found that
more than half of opium and morphine
users were women.
The 1909 Opium Exclusion Act prohibited
importation of smoking opium
into the U.S., and many addicts switched
to heroin, morphine, and other yetunregulated
drugs. Revenue legislation,
the Harrison Narcotic Act of 1914, categorized
both opiates and cocaine as “narcotics”
and was the initial step in federal
control (marijuana would not be added to
the category of illegal drugs until 1937).
The law’s successful enforcement penalized
and marginalized drug users and the
doctors and pharmacists who supplied
maintenance dosages of narcotics. Public
health addiction treatment clinics existed
for a short time—and only in some major
U.S. cities—but afterward there were no
options left and addicts were increasingly
treated as criminals. Doctors changed
their prescribing habits, legal opiates
became unavailable, and fewer women
than men were now addicts.
The prohibition of narcotics in concert
with alcohol’s prohibition in 1919
(deemed unsuccessful and repealed in
1933) created unprecedented opportunities
for organized crime; corruption, homicides,
and violent crime increased. By
the end of the 1920s, the nation’s prisons
were overcrowded, and drug offenders
comprised an estimated one-third of the
inmates.
To relieve some of the burden on the
prisons, Public Health Service “narcotic
farms” for detoxification were established
in Lexington, Kentucky, in 1935 and
in Fort Worth, Texas, in 1938. Federal
inmates as well as voluntary patients
were treated, and intensive research into
many drugs and aspects of addiction was
carried out in Lexington at the Addiction
Research Center (later transferred to the
National Institutes of Health).
The National Institute of Mental
Health (NIMH), a major advance for the
Public Health Service, was established
in 1949. The Health Amendments Act of
1956 included funding for the new NIMH
Psychopharmacology Service Center, the
origin of the NIMH program for research
on substance abuse.
Drug use was on the rise in America
in the 1960s, and there were new drugs,
new trends, and a new “drug culture”—
fueled to some extent by media frenzy.
The Drug Abuse Control Amendments of
1965 broadened enforcement to include
the illegal use of depressants, stimulants,
and hallucinogens. Heroin addiction was
increasing among U.S. soldiers in Vietnam
and among returning veterans. Mandatory
minimum sentencing for drug offenses,
which had been introduced by the Boggs
Act in 1951, included two to ten years for
first-time marijuana possession. Harsh
punishment wasn’t an effective deterrent,
and lucrative incentives for enforcement
may have played a role in the swift rise
in the number of marijuana arrests:
from 169 in 1960 to more than 15,000
in 1966. Two decades later, according to
federal data, marijuana use comprised
about 60 percent of illegal drug abuse
in the U.S. A 2008 international survey
reported lifetime marijuana usage in the
U.S. at more than 40 percent, more than
twice that of the Netherlands, where it is
12 San Francisco Medicine April 2010 www.sfms.org