It's Time To Get Rid of the Good-People-vs.-Bad-People View of Drug Use

By Maggie Mahar and Niko Karvounis, Health Beat. Posted June 25, 2008.

This article originally appeared on Health Beat.

In 1986, Nancy Reagan made it clear that there is "no moral middle ground" when it comes to drug use. You either don't take drugs, which means you are a "good" person, or you do take drugs, which means you are a "bad" person."

The Reagan-era outlook on drug addiction has dominated our political culture for nearly three decades, though not without sharp criticism. In March, for instance, the writers of "The Wire," the critically acclaimed HBO series that brought the realpolitik of Baltimore's war on drugs to the small screen, made it clear what they thought of the Reagan approach: "What once began, perhaps, as a battle against dangerous substances, long ago transformed itself into a venal war on our underclass. Since declaring war on drugs nearly 40 years ago, we've been demonizing our most desperate citizens, isolating and incarcerating them and otherwise denying them a role in the American collective. All to no purpose. The prison population doubles and doubles again; the drugs remain."

They're right -- we are not winning the war on drugs. But the question remains: What should we do now? Those who view illicit drug use as willful behavior believe that we have no choice but to jail those who choose to continue committing crimes. Others who argue that drug addiction is a disease that weakens the addict's ability to choose argue that rather than stigmatizing the addict and punishing him, we must find new ways to "treat" the patient.

One could argue about who is right. But rather than engaging in yet another political argument about personal responsibility vs. society's responsibility to help its poorest citizens, it might be helpful to take a look at what medical science has been learning about drug addiction over the past few decades.

Addiction Treatment: Science and Policy for the Twenty-First Century (Johns Hopkins University Press, 2007) does just that, and in the process "highlights the amazing discord between scientific knowledge and public perception," according to a review by Stanford University's Dr. Alex Macario in the June 4 issue of JAMA.

In this collection of short, incisive essays, the authors don't always agree on specifics, but they do reach a consensus of sorts: The scientific community needs to educate the public about drug addiction -- and our approach to treatment should be based on medical evidence rather than personal ideology.

Today, medical technology allows scientists to observe firsthand what happens inside the brain when it is, in the words of William R. Miller, a psychiatrist at the University of New Mexico, "hijacked by drugs." Thanks to brain imaging, for example, we know that regular drug use disrupts the frontal cortex, which regulates cognitive activities like decision-making, planning and memory. In other words, drugs affect an individual's capacity to make the choices that the Reaganites insist addicts should be able to make (Just Say No!). Undoubtedly the drug user could have said "no" the very first time he or she let desire override good judgment. But after that, Miller notes, "neuroadaptation involves biological changes in response to drug use that increase the likelihood of repetition and escalation, undermining the person's capacity for volitional control." Recent studies have even shown that drug addiction changes our brains at the genetic level, influencing how our DNA is translated into enzymes and proteins.

As a result of this new information, experts are increasingly incorporating the recognition that addiction is, in part, a "brain disease" into their treatment recommendations. This perspective has even made headway in the halls of power. Last year Congress introduced the Recognizing Addiction as a Disease Act, which would institutionalize the disease model by changing the name of the National Institute on Drug Abuse to the National Institute on Diseases of Addiction and change the name of the National Institute on Alcohol Abuse and Alcoholism to the National Institute on Alcohol Disorders and Health.

The text of the act embraces the disease model, noting that "the pejorative term 'abuse' used in connection with diseases of addiction has the adverse effect of increasing social stigma and personal shame, both of which are so often barriers to an individual's decision to seek treatment."

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Maggie Mahar is a fellow at the Century Foundation and the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006).

Niko Karvounis is a program officer with the Century Foundation in New York City, where he works on issues of socioeconomic inequality and health care. He is a regular contributor to Health Beat, the foundation’s health care blog.