The uppers and downers of medicalising addiction

Jeff Brownscombe weighs the benefits produced by applying the medical model to addiction against the need to understand its limitations

PANNEAU/SPL

Patching up the problem of nicotine addiction

Is it supposed to feel like this?" cries enigmatic Melbourne singer Peter Coles. Reality can be disturbing, either because of life's traumas or the yearning for new frontiers, which helps explain drug use and plenty more as well. Yet you will not read about it in many journals; sometimes music says it better than science.

The medicalisation of addiction is a complex and emotive concept, but in general terms it refers to the modern tendency to view addiction as an illness, develop interventions, and measure their effectiveness according to discrete outcomes—that is, reported drug use and overdose rates. Medicalisation can contribute positively to our understanding and response to addiction but provides an oversimplified incomplete view when taken in isolation.

Uppers

Medicalisation provides an acceptable framework to provide information to patients, families, and the community. For the individual, a diagnostic label may increase their understanding, normalise the experience, and provide hope for the future; conversely, it may be depersonalising and stigmatising. Tailoring your approach is part of the art of medicine.

Expressing the consequences of addiction in medical terms is one way to maintain it on the public agenda. Overdose rates, morbidity and mortality data, and indices of social dysfunction are highly relevant measures. Implementing programmes which have a positive impact on these figures is crucial. Furthermore, this approach may secure the financial resources necessary for a wide ranging response in the community and stimulate debate and education in the community.

Medicalisation may deepen our understanding of a complex phenomenon. But the illness model of addiction is fundamentally flawed—it was part of a wider movement away from viewing addiction as a moral failure and focused on the experience and needs of the addict. These often include family dysfunction, social disadvantage, and psychiatric comorbidity. The professional language of relapses and remissions helps to generate realistic goals and diffuses some of the anger associated with an addict's lifestyle choices. Understanding the physical and neurochemical basis of both drug dependence and withdrawal help explain the intense grasp of addiction.

The efficacy of certain medical interventions rises in prominence considering tobacco and alcohol are the largest contributors to the global burden of preventable disease.¹ Nicotine patches and the anticraving tricyclic drug buprion (bupropion) are useful adjuncts for some. But well timed doctor's advice remains the most effective external prompt for smoking cessation.² However, when it comes to achieving effective change at a population level, these pale in comparison to the impact of policy and legislative reform.

In alcohol dependence, the anticraving drugs naltrexone and acamprosate may reduce consumption. However, the disproportionate energy spent showing this fact and teasing out subtle clinical nuances says far more about the power and priorities of the pharmaceutical industry. Holistic care is more valuable and deeper issues remain to be tackled.

The unquantifiable non-medical aspects of the drug debate are of great importance. Addiction gets to the core of who we are, so what is it telling us about our vulnerabilities and need for dependent relationships? Is modern day disintegration of spiritual and family values to blame? Do our attitudes and laws reflect sound understanding and reasoned debate or fear, prejudice, and self interest? The answers to these questions lie outside the confines of the script pad.

Multiple viewpoints, including self help, religious, and user advocacy groups, welfare agencies, and police, add to our understanding of addiction. They must be heard if the community response is to be broad and cross sectional. Medical services will improve if they respond to consumers' demands. Doctors must not dominate public discourse.

Medical strategies such as harm reduction are pragmatic in nature, but debate in the community often revolves around ideology (see page 92 for further discussion). Needle syringe programmes prevent the spread of blood borne viruses.³ These programmes are vital considering injection of opiates and amphetamines has become a considerable mode of transmitting HIV in many parts of Asia.⁴ But they fail to gain acceptance by the community unless coupled with culturally sensitive efforts to tackle the systemic reasons for escalating injecting. Opiate substitution by treating with methadone and buprenorphine, though repeatedly proved,⁵ remains controversial in some quarters, highlighting how strongly we still cling to the ideal of abstinence. This needs to be explored.

Though founded on a holistic model, current medical approaches do not consider the root social causes of addiction, hence may be fairly accused of treating the symptoms not the disease. This is a collective social phenomenon, created by doctors' mindsets, knowledge and expectations of consumers, and our system of social organisation. Doctors must inform public debate, but achieving reform is also a collective task.

Equally valid is the question, "Why do we need to medicalise addiction at all?" Addiction is age old, never before have we medicalised it so much, and never before have we had such a big "problem." Is it all in our perceptions? Or has a negative mindset led us to a self fulfilling prophecy?

The drug debate parallels drugs themselves—nothing is ever as it seems. Neuro-depressants such as alcohol and cannabis can initially cause excitation due to selective suppression of inhibitory neural pathways. Neurostimulants such as amphetamines may be calmative and anxiolytic due to increased mental concentration and elimination of worrisome external stimuli. It turns out that uppers can also be downers and vice versa.

There are many "cures" for addiction but here are the four most common I see—healthy relationships, rewarding jobs, spiritual revelations, and caring for a child. The unifying characteristic is the individual's autonomous journey of self discovery, not the imposition of a structured framework, even if it is well intentioned and evidence based. Overindulgence on the symptom based medical model will produce instinctive resistance not better treatment outcomes.

So to what extent should we embrace medicalisation of addiction? I feel led back to that slightly boring but nonetheless profound old adage: everything in moderation.

1. Murray C, Lopez A. The Global Burden of Disease: World Health Organisation, Harvard School of Public Health, World Bank, 2002.
2. Roche A, Hotham E, Richmond R. The general practitioner's role in AOD issues: overcoming individual, professional and systemic barriers. Drug and Alcohol Review 2002;21(3):223-230.
3. Commonwealth Department of Health and Ageing. Return on investment in needle and syringe programs in Australia. Canberra: Department of Health and Ageing, 2002. Available at: http://www.health.gov.au/pubhlth/publicat/hac.htm (accessed Sept 2003).
4. Revisiting "The Hidden Epidemic" - a situation assessment of drug use in Asia in the context of HIV/AIDS. Melbourne: Burnet Institute, 2003.
5. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2003(2):CD002209.
6. Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2003(2):CD002207.