Addiction: A Medical Rather Than A Moral Issue

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Vincent P. Dole
Title: “Addiction: A Medical Rather Than A Moral Issue”
VTR: 9/11/88

I’m Richard Heffner, your host on THE OPEN MIND.

Given the extraordinary damage that drug abuse has done to our national life, and to so many of us personally…given the cost of drugs in human suffering no less than in dollars…given now the scourge of AIDS, so closely drug-related…it is hard to be concerned for drug addicts rather than angry and vengeful toward them. It’s hard, indeed, for many of us to hold on to what in other areas perhaps is a much over-used medical model when dealing with addiction itself. Fortunately, however, there are those who have kept the faith of reason…and, indeed, the 1988 prestigious Albert Lasker Clinical Medical Research Award has gone now to our guest, Dr. Vincent Dole, Professor and Senior Physician Emeritus at Rockefeller University for “postulating the physiological basis of narcotic addiction and developing an effective method for its medical management”. This medical approach to the management of narcotics dependency, of course, revolves around the methadone treatment for heroin addiction pioneered by Dr. Dole and by his wife, the late, great clinician, Dr. Marie Nyswander.

As long ago as 1965, Dr. Dole insisted that “drug abuse must be approached professionally as a medical problem rather than a moral issue, since moralizing cures nothing”. And a generation later another leader in the field could write that “Vincent Dole brought addiction out of the criminal realm and into the sphere of medicine”. Yet one wonders today whether that most basic issue has, indeed, been resolved…land whether one is talking about drug, alcohol, nicotine or other addictions – they are today appropriately considered more the province of medicine than of morality, more and better subject to medical rather than to social and political considerations. Dr. Dole, in 1980 you wrote “As with efforts to control plagues in the Middle Ages, today’s governmental policies toward addiction are politically determined, contradictory and ineffective”. And I wonder whether you have any more hopeful comment on that today?

Dole: I wish I did. The fact is this political climate today, with the Presidential race emphasizes the old sterile punitive approach of attempting to punish the addicts and attempting to punish the people that are supplying the addicts. In whole it is a denial approach that is designed to prevent the addict from getting drugs, with no particular emphasis on improved treatment of the addicts.

Heffner: And its effectiveness, this approach?

Dole: The effect is counter-productive at a certain point. Obviously with a dangerous drug one wants to limit the supply of it. But beyond a certain point, if supply is reduced and demand continues inelastic and strong, it simply promotes criminality. It escalates the price. It rewards the drug sellers. It produces corruption in government and administration, and it imprisons the addicts. It does not solve the problem to press on supply without reducing demand.

Heffner: Well you, as a medical researcher and Dr. Nyswander as a psychiatrist…

Dole: Yes.

Heffner: …how did you explain this opposition to what you see as so clearly a more appropriate approach to the problem?

Dole: It’s the general problem of trying to explain prejudice. People, including the medical profession, see the addict as a sinner, see the addict as a deviate and a frightening person, instead of a sick person. It’s that simple. If you are prepared to admit that the addict is a sick person, with a mysterious diversion of his drive processes so that he’s hooked, not only to heroin, but another person to alcohol, another person to cigarettes, the question is “what are the causes of that and what can you do most effectively to relieve it”? To blame them is not to solve the problem.

Heffner: Do you think that we have used the, or perhaps over-used the medical model so much in other areas of crime in this country that perhaps that accounts to some extent, for this refusal to accept it in this area where it is so clearly appropriate?

Dole: Well, even the term “medical model” is something of a slogan. Why don’t you recast the question in terms of effectiveness? What can you do to relieve a problem that is a very bad problem? If punishment does not solve the problem then let us try other means of approach. Let’s not go into the theory of the thing at the beginning, so much as ask ourselves “what works”.

Heffner: Yes, but you’re the one who points out to me that t is a problem of attitudes. Attitudes aren’t corrected by the kind of rationality that you present. You say “why not deal with what is effective”? And I don’t embrace this notion of medical model, but I’ve heard the criticism of it enough when it comes to crime and punishment to know that it is an effective slogan, in the wrong direction.

Dole: Well, it’s likewise an effective slogan in the political sense in the field of addiction. And you can witness that in the over-use of all the frightening slogans and pressures that are being produced in our present campaign. This, I think, is expressing what the public feels.

Heffner: Well now that’s the thing that concerns me. It expresses what the public feels. It’s not simply a matter of response to rabble-rousing. You see it, too, as a response to very basic human attitudes. What do we do about those?

Dole: Well, I don’t think they are intrinsic attitudes, they are learned attitudes. When plague struck us in the Middle Ages, the response was hysterical. And all sorts of punishments were inflicted upon people and witches and various other cultists that were regarded as responsible. The fact is that it didn’t work, it was not the solution to the plague. And I think that to some extent we need here leadership to point out, not a theoretical issue, it’s a practical fact that these punitive measures have not succeeded and to keep repeating them is merely to repeat and magnify failure.

Heffner: Well now you and Dr. Nyswander demonstrated…oh, twenty years ago and more…

Dole: Yes.

Heffner: …the effectiveness of methadone. What has happened?

Dole: It’s around the world now. It’s very warmly accepted. It’s in all countries of Europe and Asia…States. There are far more people on this treatment and effectively being treated then all the rest of the treatments combined. So it’s by no means been pushed aside. There’s much talk about it, many wrong things are said, but in reality this is the treatment that is successful, and more and more as people become frightened with the AIDS epidemic, they turn to treatments that they must acknowledge to have the greatest success of any one that’s available.

Heffner: And yet the statistics in this very city in which we are sitting, New York, the statistics, I gather, are such as to indicate that methadone, as effective as it is, is not available to the largest possible percentage…

Dole: Yes.

Heffner: …of addicts.

Dole: That’s right.

Heffner: How do we explain that?

Dole: Well, partly it’s a matter of community attitudes, partly a matter of funding, and partly a matter of the leadership. If twice as many treatment units were available that are available now, I’m sure they could be filled up and people who are now in the street using drugs, stealing, spreading AIDS would be brought effectively into treatment.

Heffner: I gathered from some of the things that I’ve read that one of the flies in the ointment here is the governmental insistence upon a host of, Dr. Newman calls them, “a host of supportive services demanded for every patient. Federal regulations make it an offense to prescribe methadone without Social Service intervention, even if there are no social problems for which to intervene”. Does that…

Dole: Yes.

Heffner: …add a problem, a dimension that…

Dole: It certainly adds a restriction. I think these regulations stem from the assumption by Federal authorities that you could not trust the medical profession, that the Federal government needed to establish very rigid guidelines under which a few licensed people would be privileged to administer this treatment which was a very unusual step in the practice of medicine. A problem with the guidelines is that they become invariant, instead of responding to peoples’ needs and providing supportive services where supports are needed, the guidelines will mandate services where none are needed. And, of course, that does restrict the number of available treatment units.

Heffner: Back in 1965 when you and Dr. Nyswander wrote “A Medical Treatment for Heroin Addiction”, I won’t use the chemical name because I couldn’t pronounce it, in the summary to begin the article you conclude, “In our opinion both the medication and the supporting program are essential”. Do you regret those words now?

Dole: No, I don’t because the objective in treating an addict is to enable that person to live a decent life. And the sort of people that we were working with were destitute minority groups with no education, no family background, no job experience, no hope of getting a decent place in society, even apart from addiction. Our objective was to permit these people to live a productive and successful life, not to just to stop heroin addiction. The heroin was merely an incident in a career that was down and I would still stand with it. However, one’s common sense says you do not require a person to quit his job to get counseled on how to get a job.

Heffner: Is that kind of nonsense prevalent today?

Dole: Less prevalent than it was ten years ago, and I think the pressure of the AIDS epidemic has begun to let people think a little bit more sensibly about it. But, there have been places in the country that, indeed, literally have required people to quit their jobs in order to attend twice weekly counseling sessions.

Heffner: That’s the dead hand of bureaucracy I presume.

Dole: I would say that both adjectives are correct.

Heffner: But you know back, back in your firsts writings about the subject, the problem, you say now the government “seemingly” is second guessing the medical profession, back in those days you weren’t so keen on what the medical profession was doing about trusting itself and teaching itself about drug addiction.
Dole: That’s right.

Heffner: Have you…have things changed?

Dole: No. I’m still concerned that this treatment has not fully entered into the mainstream of medicine. In a sense it is regarded by the medical practitioners as a medical specialty that’s comparable to the treatment of diabetes or other endocrine diseases or comparable infectious diseases and the like. A person can be in the business of treating say, tuberculosis and have chronic medications given and have a routine that is appropriate for that person’s needs and it’s part of medicine. I think, still, the whole treatment of addictions is regarded as something outside the mainstream of medicine by many doctors. And I’m sorry about that.

Heffner: Do many of them still shy away from dealing with addicts?

Dole: Oh, I think most do, yes.

Heffner: Even though you feel that you have at your disposal now a chemical approach that could be administered b y general practitioners?

Dole: Oh, no, it cannot be. It’s complicated.

Heffner: Cannot be.

Dole: Under the Federal guidelines a general practitioner is barred from this, so that it actually would be an indictable offense if a person were to start prescribing methadone even in an appropriate way.

Heffner: A medical person?

Dole: A medical person. He must have a special licensing from the Federal government.

Heffner: So that it really isn’t so much a matter of the medical people themselves, as it is these restrictions that you refer to.

Dole: The restrictions tend to confirm, in the overall medical feeling, that this is not ordinary medicine, this is a part of a very special thing.

Heffner: Do you think that that overall medical feeling is as much a throwback to medievalism as government’s attitude is, it’s part of a general social attitude that is wrong-minded?

Dole: Well, it certainly has its roots in the medieval. I suspect that…it’s only a hundred years ago or so that the insane people were taken out of chains and regarded as medical problems. We, in the medical profession have had a rather different view of behavioral problems than we have of things that are more manifest, like fevers and traumas and fractures and the like. Those are tangible, concrete things that the medical profession has been trained to take as diseases. Behavioral problems tend to grade off into a variety of undesirable actions that you can’t truly claim to be medical.

Heffner: Of course, the question that I know I need to ask you is whether we’re too late in the game, whether the arrival and spread of crack, which I gather doesn’t respond…

Dole: Oh, no, not at all, not to methadone. No, no.

Heffner: Then are we just too darned late? Have we missed the boat?

Dole: You’re on the boat, you haven’t missed it. The point is that there’s no way of getting off the boat. This is only a piece of a wider set of drug dependencies I suspect that the human race is going to have to confront. The more we are able to invent chemicals that affect the brain, affect behavior and mood and so on, the more likely we are to find misuse. I think that we have to, in fact, learn from a rather limited immediate experience with heroin and methadone to the broader business of what treatments are we going to develop for crack and for a variety of other potential psychotropic evils. This is a…I think the beginning of an era, not off the boat.

Heffner: Do you feel that we’re moving close to the same kind of treatment that you developed with methadone for heroin addiction in the area of alcoholism, in the area of crack, other addictions?

Dole: Well, I wish I could say “yes” on positive grounds. I certainly hope so. And there are very competent people that are searching for chemotherapeutic approaches to alcoholism and to cocaine addiction and others. It will not be the same thing as methadone because the pharmacology of these other drugs are very different from that of methadone. So, to some extent the principle will survive, but the particular technique will not.

Heffner: You say “to some extent the principle will survive”. Are you talking about a major approach or are you talking about something that is not quite so hopeful as the developments that you and Dr. Nyhswander pursued.

Dole: Well, it’s hard to measure hope. It’s hard to justify having it or not having it in realistic terms. Marie Nyswander and I were just lucky. We were able to come to a medicine which had been used for other purposes in detoxifying people for a long time, it was well worked out, and to our great surprise, the patients that we were studying in an expe4rimental program showed much more normal behavior when they were on methadone than they had with any other narcotic. And so it took us a while to understand why that’s so. But that quite honestly was a lucky accident. Now the pharmacology of cocaine, the alcohol, the nicotine and so on, they’re all different. They’re affecting different parts of the nervous system in different ways and so on. There may be a general principle and that is, I’m quite convinced in my own mind, that the root of the addictive behavior with heroin and other related narcotics is a derangement of the narcotic receptors in the brain and in the gut. And no doubt as people get into studying receptors and cellular function in these other drugs, there’ll be an opportunity to come at that. But I can’t speak of hope because I do not know anything right in front of us that I can say “there is the lead we’re going to follow”.

Heffner: But you feel that we’re going to make an awful mistake if we’re going to continue as a society to think in terms of moral and immoral receptors.

Dole: (Laughter) Yes. I don’t know anything that’s immoral about biology except people, not the receptors.

Heffner: But you know, you wrote in 1980, after saying that no one really understands addictive behavior, you wrote “in fact, it is the availability of drugs rather than the quality of life that seems to be the most important factor in determining the prevalence of drug abuse”. And, yet I gather from something you said just before we went on the air, that the approach, the armed forces, military approach…

Dole: Yes.

Heffner: …to limiting the quantity of drugs is something you really don’t approve of.

Dole: Oh, yes, I think…if you’re dealing with an epidemic you need to limit the exposure of susceptible people so far as you can. And you need also to deal with people who have already been infected or involved, those are two related problems. If you have a large population of people that produce a strong inelastic demand for a commodity then, at a certain point pressing on the supply will simply escalate the price. It will not reduce the supply because there will always be people who are willing to take the risk to supply it, if the price is high enough. So there is a paradox that you want to limit exposure of susceptible, at the same time you do not want to create a situation where an inelastic demand has so escalated the price that you’re producing a new problem.

Heffner: How would you deal with that paradoxical situation?

Dole: Well, in the first place…right now in heroin the crying need is to bring into treatment a much larger number of people who have this inelastic demand. Unless you can begin to strike at this market, you’re not going to have much chance to cut back the supply. The greatest threat to the susceptible young person is the existence of the untreated addict in the streets who is pulling in the supply.

Heffner: So you would say treat that person, practically speaking, with methadone and make that break into the…

Dole: Yes. And I wouldn’t limit the treatment to methadone, for heaven sakes, the problem’s complex. There are many people who are beginning users, who are experimental or multi-drug users, who have various psychological problems, a whole range of concomitants. You need to have a spectrum of treatments. It just happens that in terms of the large scale mass treatment modality, methadone is the only one that has promised to treat thousands and thousands of people. But it’s not to say that you should limit, you should not exclude any treatment that I s honestly given and is evaluated.

Heffner: There are those who say you don’t fight fire with fire, which isn’t true of firefighters…

Dole: No.

Heffner: …Lord knows. But I wondered how much that has been a source of the opposition that you have referred to.

Dole: Yes. Well you, of course, are familiar with the slogan that his is just one drug for another.

Heffner: Yes.

Dole: And, that’s true. It is one drug for another, and as you say, under certain circumstances, it’s useful to back-fire on a fire. The fact is you should judge a treatment by its results, not by the slogans. And the results are so consistently affirmative when the treatment is properly administered that its very difficult to see how that is wiped out by a slogan.

Heffner: …I should say “administered”…does that play into the hands of those who would say there are only a select few who can administer the drug?

Dole: Well, I don’t think it requires that much sophistication or special qualities, if you’re trained. One thing is you have to give an adequate does. There have been programs which have been based upon the philosophy that this is just kind of keeping the addict happy and not doing anything and they give too small doses because they don’t really approve of the treatment. The result is that the patient is never really blocked in his craving for heroin, they’re not blocked against the injection of heroin. So an inadequate does is a reason for failure. Also, some programs have still held to the model that this really is sort of sinful behavior, not medical behavior, and so they have coupled their methadone giving, in a grudging way with so many punitive regulations as to grind a person out of treatment. You’d have to really be completely reduced to pulp in order to accept some of the contempts that you get from the people giving the program. Now that type of a punitive, contemptuous attitude is a recipe for failure. So there are bad programs.

Heffner: Dr. Dole, I’m sure that your response to a question concerning making heroin available, would be to make methadone available.

Dole: Not in the same way. I think that his idea of just handing out drugs is not treatment. Certainly it’s not feasible for heroin because the effect of heroin is only for two or three or maybe four hours, depending on the dose. So that an addict taking heroin needs to give himself an injection three or four or more times a day. Now, as a practical matter, you have either the choice of giving every addict a pocketful of heroin and syringes to out and shoot himself as much as he wants, which would be an unthinkable burden on the community because that very soon would drift all around to everybody. Or of trying to set up a situation where addicts would spend all day long sitting in a clinic waiting for the next injection. It’s just not a technically feasible thing, so anybody that is talking about handing out heroin doesn’t know the pharmacology.

Heffner: And what’s your reaction to the suggestion that syringes be handed out?

Dole: I think that’s really a token.

Heffner: One that you would accept?

Dole: I can’t object to it. But I think it’s , it’s…I’m bothered by it because one substitutes trivial useless tokens for real action. It’s the sort of thing that is able to sort of give the image of political leadership, and bold, new initiatives and so forth. It will not have any significant impact on the passing of heroin around in the streets, and it will have no impact on AIDS.

Heffner: I get the signal that we have one minute left. What would you say would constitute bold, social action?

Dole: I think that announcing that every addict who wants treatment will get it, and more than that going into an affirmative program of outreach. Consider that you’re not doing the addict a favor in giving him a treatment, you’re doing society a favor. You need the benefit of society to get this fellow off the needle and off the streets.

Heffner: Has the refusal of communities to accept methadone centers been a major problem?

Dole: A big problem. Yes.

Heffner: Maybe you can help lick that.

Dole: Well, maybe this program should help lick that.

Heffner: Dr. Dole, I do appreciate your joining me today and I hope that you’re right, I hope it does.

Dole: Thank you.
Heffner: And thanks, too, to you in the audience. I hope you’ll join us again next week. And if you care to share your thoughts about today’s program, please write to THE OPEN MIND, P.OL. Box 7977, FDR Station, New York, NY 10150. For transcripts, send $2.00 in check or money order. Meanwhile, as an old friend used to say, “Good night and good luck”.

Continuing production of this series has generously been made possible by grants from: the Rosalind P. Walter Foundation; the M. Weiner Foundation of New Jersey; The Mediators and Richard and Gloria Manney; The Richard Lounsbery Foundation; Mr. Lawrence A. Wein; and the New York Times Company Foundation.