Article published in Fordham Urban Law Journal vol. XXVIII October 2000
© Copyright 2000 Fredrick Polak. All rights reserved. Reprinted with permission from the author.
Thinking about drug law reform: Some political dynamics of medicalization
Many people believe that medicalization offers the most reasonable approach to drug policy because it promises a dignified solution to the conflicting goals of prohibition and humane treatment of addicts.The medicalization model, by encompassing in the medical domain some phenomenon or problem, allows medical considerations to be decisive in the interpretation of that problem and in the choice of measures to resolve the situation. With respect to drug use, medicalization can have a broad range of meanings and consequences. When it means providing normal, good quality medical care to drug addicts, including the prescription of illicit drugs, it should be applauded as a positive development.
However, medicalization also may define regular, frequent drug use as a mental disorder; designate abstinence as the only acceptable treatment outcome; and/or recommend compulsory treatment for all users of illegal drugs, be they dependent or casual users. The latter three versions of medicalization demonstrate that, while the medicalization approach for drug policy seems more humane than repression of drug use, it risks becoming a form of repression itself.
One reason medicalization often is hailed as a more humane approach to drug policy than reliance upon the criminal justice system alone is because of the expectation that in the medical model, addiction no longer will be stigmatizing because it is considered a disease, and, hence, addicts no longer will be accused of being the cause of their problems. Another reason is that it still seems impossible to promote serious discussion of the more radical approach of repealing drug prohibition and creating a set of legal regulations for the different groups of substances. Therefore, some proponents of legal regulation hope that medicalization may be an instrument in the transition to a legalized system, while other "legalizers" accept medicalization as the second-best alternative.
On the other end of the political spectrum, some hard-core prohibitionists expect medicalization to leave punitive repression in place. One example of the rhetorical excesses to which this application of the medicalization paradigm can be taken is drug czar General McCaffrey's benevolently telling the American people that the war on drugs metaphor really is not appropriate (shortly before expanding the drug war in Colombia) and that fighting drug addiction can better be compared to fighting cancer.What does this medical analogy mean? In surgery, cancers have to be eradicated, often along with a wide margin of healthy tissue, for safety. Further, chemotherapy kills many healthy cells. So here, the medicalization paradigm is used as a legitimization of collateral damage-no different than in a war. It provides the rhetorical cover for continuing the current repressive policies in the war on drugs.
On the whole, criticism of the medicalization approach-particularly from drug law reformers-is not welcome in the current climate of support for a policy of repression. This lack of receptivity to such criticism exists both among policy makers and the public at large. Some drug law reformers have advanced arguments that drug addiction is not a disease which requires a "cure," but a complex phenomenon, resulting from individual desires, and for which one must accept personal responsibility.This seems to have alienated the public, thus diminishing the reformers' chances of progress through building public support.
Being aware of this difficulty, and acknowledging possible positive aspects of medicalization, I begin this essay by offering a few critical words on the position of the medical profession in drug policy.Then, I will attempt to stimulate the drug policy debate by outlining certain negative political ramifications and social consequences of an abstinence-directed medicalization policy. I will argue that:
The position of the medical profession in drug policy
Doctors have both the responsibility for the treatment of people with dependency problems and the monopoly in prescribing some otherwise illicit drugs. Furthermore, doctors occupy a unique dual position in the drug policy debate: an official one, as individual medical experts and as professionals; and an unofficial one, as physicians to and friends of influential people. Although presidents and prime ministers typically are not experts on drugs, they do not accept automatically the recommendations of expert committees. Our leaders understand that experts can be found to support any number of opinions and viewpoints. For their own comfort, leaders informally may consult their private physicians, whose opinions they have learned to trust, and ask for their thoughts on the legalization of drugs. Unfortunately, most doctors suffer from the Clinician's Illusion. Therefore, those doctors' answers are more likely to be, "Oh, no, that would be too risky" rather than, "Yes, that will have a beneficial effect on public health, not to mention the other areas that you know more about."
Some doctors do not believe that their medical responsibility is at stake in such a situation, and that a formal advisory function should accompany their medical expertise. This attitude may result in the situation in which doctors would have to collaborate in coerced treatment-with poor results-but not feel free to say that the medical argument for prohibition fails. One could call this the "half-medicalization" scenario. These doctors may assume that the decision to prohibit drugs is a political one, and the status of being a doctor does not render their opinion on national drug policy to be any more important than the opinions of other citizens. Nevertheless, every official text on drug policy contains medical arguments and health considerations that are advanced as important, if not essential, reasons for prohibition. Doctors, therefore, are in a unique position to understand and explain that many of the pro-repression health arguments, such as the risks of toxicity and addiction, are abused by proponents of prohibition. Doctors, both individually and collectively, should educate the public and the policymakers that there are no sufficient reasons to treat illicit drugs so differently from alcohol and cigarettes, and that health and medical arguments actually plead for legal regulation.
The crucial importance of doctors' opinions on the subject of drugs was underlined at the Eighth International Conference on the Reduction of Drug-Related Harm, March 1997 in Paris. A hot topic at the conference was the resistance by French medical specialists, especially psychiatrists, to the introduction of harm reduction methods. At the closing session of the conference, three French ex-ministers of health, Barzach, Kouchner, and Veil, accused the medical profession of systematically sabotaging necessary reforms. Simone Veil even compared the potential role of doctors in the drug policy debate to that played by doctors in reaction to the scandal of HIV-infected transfusion blood, explaining that it had been general practitioners who successfully initiated policy changes in France to promote greater safety. The ex-ministers painted a picture of negligence, abuse of power, self-interest and prejudice on the part of the medical community with respect to the issue of drug policy. For example, the results of the only French methadone project, the famous "25 places" in Paris, were kept secret, probably because they were positive and provided support for continuing the project. Further, French psychiatrists who were considered specialists on the subject of drug use have long claimed that every addict should be treated and cured only psychotherapeutically. Indeed, methadone prescription was not considered a therapy. These specialists expressed an unwillingness to explore literature from which they could have learned about other developments in the field. Even when they did peruse such studies, these specialists found excuses for rejecting the articles' findings, such as the belief that foreign articles were not reliable.
That doctors are publicly blamed by prominent politicians for the inferior French drug policy and for their indirect involvement in hundreds of AIDS and other drug-related deaths, provides a compelling reason for the profession to reexamine its role in the drug policy debate. Doctors are blamed not just for negligence, but also for their lack of knowledge and refusal to learn from experiences in other countries. Even in the most favorable analysis, prejudice accounted for this situation, because doctors confused their personal, ideological opinions with professional knowledge.
The background of this confusion is that the medical attitude towards drugs consists of a number of factors. I will discuss two of these factors. First, there is the specific problem of the "Clinician's Illusion, an epidemiological phenomenon described by the American epidemiologists Patricia and Jacob Cohen of which few doctors are aware. Doctors see users only in treatment, or via the police and the judiciary, which means they see a disproportionately large number of serious and chronic cases. Additionally, in medical conditions with great variability in seriousness and duration, such as drug dependence, doctors systematically underestimate the percentage of cases that are lighter or have a shorter duration. In the case of drug use, the resulting "Illusion" would be a mistaken belief that drug use is predominantly chronic and life-threatening. Second, the war on drugs has created a media image of drug use that is excessively negative, and doctors, no less than the general population, are exposed to this distortion. The crucial point is that this distorted image, which begins as a general phenomenon, is seemingly confirmed by the impressions of doctors working under the influence of the Clinician's Illusion.
Negative political and social aspects and consequences of an abstinence-directed medicalization policy
1. Making Addicts Responsible For Their Own Cure
Because addiction is currently defined as a disease, addicts must be "treated" (which in the United States is more often coercive than voluntary), and "cured" (which is defined as remaining abstinent). However, the well-known weakness of drug treatment is that a large majority of patients will not reach this goal. This is also true in the treatment of alcoholics and addicted cigarette smokers. Drug users often will fail to fulfill their conditions of probation or requirements set by a drug court, which results in incarceration or further coerced treatment. So, while it may seem as if under medicalization addicts are no longer accused of being the cause of their own problems (because addiction is defined as a disease), what happens when treatment fails? A consequence of the treatment paradigm, where abstinence is the dominant treatment goal, is that addicts are held responsible for their own "cure." When addicts are not cured on the orders of the state and the judicial system, they will be punished, and put in prison anyway-just as they would have been under a strict prohibition, or criminal justice approach. Forced treatment may appear more humane than straight incarceration, but in practice, for the majority of addicts who are not helped by treatment, or do not wish to be completely abstinent, this scheme will mean long stretches of lost freedom. This is because they suffer from a "disease" for which other addicts-alcoholics or cigarette smokers-are not treated involuntarily or punished, and, on top of that, for which treatment often fails. Since their "disease" is proclaimed intolerable, coercing them to be "cured" is considered ethical.
The argument is often advanced that without coercion there is insufficient incentive to enter treatment and, within a medical paradigm, not wanting to enter treatment is considered a symptom of the disease. However, this is an inversion of reality. Since voluntary treatment is scarcely available in the United States, for many people treatment is only accessible when they are incarcerated.
2. An Obsessive Fear Of Loss Of Control And Failure To Distinguish Between Controlled And Problematic Drug Use
Inherent in the current medical conception of addiction in the United States is the importance of external control over an individual's drug use by the criminal justice system. This conception of addiction negates controlled use, which may be defined as self-imposed, regular, moderate, non-problematic use. Judging from movies and television, one gets the impression that the American people's belief in strong external control is linked to an obsessive fear of loss of personal control-to such a degree that it has become impossible for many to believe that people can indeed learn to use drugs moderately and responsibly. By extension, the negation of controlled drug use would lead to the idea that, without external control, there would not be many people other than alcoholics drinking alcohol. This is at odds with reality. It is well known from experience in more liberal countries and from historical, anthropological, and current epidemiological research that without professional help and on their own, more addicts learn to stop using drugs, or learn to use them in a controlled way that conforms to the conventional roles of productive citizens and parents, than do in treatment programs.
In the United States, it is standard policy to call every form of use of illegal drugs either "abuse" or "addiction." In the United Kingdom, a similar ideology labels all drug use as "misuse." This shows that the current repression model of drug policy is not directed at problematic users or at addicts in general, but that it is aimed at all users of illegal drugs. The failure to distinguish between recreational and responsible drug use on the one hand, and problematic or "addictive" use on the other, gives prohibitionists the power to exert control over every user of illegal drugs, regardless of whether the use is moderate or excessive and regardless of whether it needs to be treated. In this respect, medicalization is different from criminal justice models only in that physicians will be in control of the policy and enforcement.
3. The Hidden Link Between Medicalization And Racial Discrimination
The number of blacks and Latinos in detention in the United States is disproportionately large, but not because blacks and Latinos use more drugs. They are poorer, their use is more visible, and they are more often targeted by law enforcement. The term "disproportionately" is used somewhat euphemistically here. To me, the number of minorities in detention is unbelievable. Every American who is confronted with this reality will need to find some kind of justification for these racial disparities.
Today, genetic factors are cited to make it seem that there are sound reasons for this horrible situation. Unfortunately, there are many historical examples of medicalization providing the justification for sexist or racist policies. Drug use is systematically associated with aggression and criminality. The media has reported about genetic factors contributing to addiction, aggression, and criminality. These reports often are accompanied by images of minorities. This fallaciously implies that drug use is genetically determined. It suggests that genetic traits leading to addiction, aggression, and criminal behavior are more prevalent in some minorities than in whites, and that this is why so many minorities are incarcerated for drug offenses. This untruth perpetuates the idea that the U.S. drug problem is specific to African-American and Latino communities, rather than that it is a general social problem.
The contemporary popularity of genetic explanations for behavior has prompted many medical experts to provide information and give their views on various social problems. Medicalization should mean that doctors make their views heard, individually and as a group. When the social problems resulting from current drug policies are treated as personal medical problems, doctors should not through their silence lend tacit support to the current and fallacious genetic explanation for drug use or incarceration rates.
4. Tolerance Towards "Addictions" To Consumer Goods Diminishes Personal Responsibility
A significant portion of the U.S. population believes in the idea of addiction as a disease in which one cannot sufficiently control oneself. On the one hand, this leads to a hard approach towards drug addicts and an acceptance of punishing them for their lack of personal control. On the other hand, many people apply this concept to themselves in a remarkably softened way. A function of this conception of addiction is that it diminishes the burden of personal responsibility in our daily behavior. Of course, it does not completely eliminate personal responsibility, but it diminishes it to an important degree. This image of addiction, as a condition for which one is not completely responsible, has a peculiar attraction. The theme of addiction is often noticeable in ad campaigns for consumer goods. The addiction concept is so banal that addiction becomes something from which everyone suffers. This concept facilitates acceptance of one's weakness as a consumer, but at the same time allows for the belief that one's addiction is not as bad as that suffered by others. Mass consumption becomes an inability to resist the desire to buy a product, such as a piece of chocolate or a car, rather than a controllable urge. That is exactly what advertising is about-getting people to allow themselves to buy a specific article, which they want so badly, but do not really need.
5. Medicalization Creates A New Elite Class That Benefits From Drug Prohibition And Is Capable Of Creating New "Patients"
The rising status and influence of addiction medicine and addiction psychiatry provide for a new caste of professionals who profit from drug prohibition. The addiction medical elite make believe that the status of addiction as a brain disease is firmly established. In reality, the scientific discussion on the nature of addiction is far from closed.The National Institute on Drug Abuse ("NIDA") (a remarkable name: aren't they interested in drug use?) pays hundreds of millions of dollars per year for the construction of the unwarranted dominance of clinical biopsychopharmacological research.
When the disease concept is not strictly reserved for medical conditions but is expanded to regular drug use and to other socially unacceptable behavior, repression and prohibition of deviant behaviors flourish. This is not a new idea, but in thinking about drug users, habitually or ritually called "abusers," it is generally not recognized that many regular users of alcohol and cigarettes also would be viewed as addicts if the substances they used were illegal. Because alcohol and cigarettes are still legal, drinkers and smokers can function as normal citizens, and the question of whether their pattern of usage should be called addiction does not seriously arise for most of them.
Under current prohibition policies, medicalization creates its own patients. Many drug users officially are considered and treated as addicts. However, under a legal regulation regime, they generally would be viewed as regular, heavy users, and not as addicts. There are at least two reasons for this categorization: First, the most widely used psychiatric diagnostic system is the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders ("DSM").This system uses two criteria which are strongly context-dependent in the definition of substance dependence, and as a result, many users of illicit drugs will be included in this definition primarily because of the illegal status of their drugs, not because of any physical or mental impairment. When doctors espouse the view that drug dependence is a disease, they should at least point out to the general public that most drug users are normal, healthy people and that, if addiction is a disease, it is a very special kind of disease. Few diseases exist in which the patient can decide to say, at almost any point during the course of the disease, "All right, I am fed up with this disease. I am going to be cured from now on." This does not fit the medical model. It can only be explained by the combined influences of psychological, social, and biological factors on drug users, and on the course and development of usage patterns. This shows the necessity of applying the biopsychosocial model to drug dependence discourse.
Second, the penal system, and especially the drug courts, refer large numbers of users to treatment systems after an arrest for possession or sales, not because of addictive behavior. To its discredit, the treatment system in general accepts these "patients." Of course, under prohibition, the "patients" also profit from this situation, because it offers them a milder type of punishment than incarceration.
When drug prohibition and the abstinence paradigm are kept in place, medicalization will mean even less voluntary and more coerced treatment, which is ineffective for most people, and no freedom for recreational or other forms of controlled drug use. The most important political consequence of this kind of medicalization is that it allows for the continuation of excessive control over all drug users by the criminal justice system.
The medical profession carries an important part of the responsibility for not informing the general public about the effects of drugs and the nature of drug use, and for keeping in place a system of drug prohibition which has proved to be harmful to public health and especially to minorities. Doctors should explain that drug prohibition lacks a scientific foundation and that public health would be better served by legal regulation.
Alternative drug policies subject to inappropriate research whereas repressive policies, and drug prohibition itself, were never subject to serious scientific scrutiny
All over the world, new repressive drug policy measures with direct implications for public health, are introduced regularly without any serious scientific evaluation. However, with respect to research on harm reduction measures such as, for instance, the distribution of heroin, there seems to be a general consensus that only one design can be applied, the randomized controlled trial (RCT).
Randomized controlled trial inadequate for the development of drug policy
Whereas this design may be the preferred design for clinical pharmaceutical research, it is of limited value in the effort to improve drug policy and addiction care. The RCT is appropriate for the introduction of new therapeutic substances, such as antidepressants and antipsychotics, but heroin is not a new substance. And the addicts who are the subjects of the research have been injecting or smoking heroin for years, and in far worse circumstances. The difference is that the heroin is provided on prescription, for a reasonable price, or even for free, so the addicts are in a position to make changes in their lives. It is a social experiment with a new care arrangement.
To indicate what this means, I would suggest that besides the usual kind of control group, in this situation a second group of patients should be selected who receive a monthly allowance equivalent to what the dope would cost in that period. Maybe that group would do even better, and in any case, this would provide us with useful information.
In prescribing heroin to heroin addicts, the randomized controlled trial design creates a new and artificial pattern of usage - and what is subsequently studied is this artificial pattern of use. As a consequence, the findings are of limited value. Yet, despite this inadequate research design, some positive results are noteworthy. Probably the most important result is that the public-at-large and politicians in particular become accustomed to the idea of providing heroin to addicts in poor physical and mental condition, and learn that instead of dying, they become healthier and function better.
The consumer perspective: stimulating internal control
Heroin distribution is usually considered within the paradigm of treatment: frequent heroin use is seen as a manifestation of a chronic or recurrent disorder. But why not look at it from the users´ perspective: more or less frequent use, which is more or less problematic, with more or less self-control. The central issue here is control. In any other context, it would be only logical to take the consumers point of view into consideration. What do we need to know from that perspective? What we (should) want to know is how legal restrictions on the drug trade and drug use can best be repealed or softened, and how personal, internal control and informal and group norms can be stimulated to replace external control. And for the design of new regulatory systems, we need to determine the nature and minimum extent of external control needed in new situations. The current heroin projects with their clinical-pharmaceutical approach obviously cannot provide this information. For this purpose, research is needed with an orientation toward social science rather than medical and pharmaceutical paradigms.
Lack of scientific evaluation of the effects of UN drug conventions
Of course, new harm reduction methods should be judged by the scientific community. But as a consequence of medicalization, inappropriate demands are made for the research on heroin prescription and other alternative methods, whereas no serious official scientific evaluation takes place of the consequences of drug prohibition for public health. One of the few scholarly evaluations of drug prohibition, Drug Prohibition And Public Health by Ernest Drucker, convincingly demonstrates this policy's devastating consequences for public health (Drug Prohibition and Public Health, Public Health Reports, Jan.-Feb., 1999). At the United Nations Drug Summit in June 1998, an evaluation of the last decade of international drug policy was initially planned, but later dropped from the agenda. WHY should science require far more stringent evidence for recommending the reversal of bad drug policy than for supporting its continuation? This disparity between the demands for scientific evaluation of repressive and of liberal policies is unfounded and unacceptable.
* The author is psychiatrist at the Department of Mental Health, Municipal Health Service of the City of Amsterdam, in the Netherlands and member of the board of the Dutch Drug Policy Foundation. E-mail: email@example.com (back)
Last update: May 25, 2016