The Pharmaceutical Journal
Vol 280 No 7489 p177-178
16 February 2008

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• Drug addiction (3)
• Controlled drugs
• NHS
• EHC
• Statins
• Community pharmacy (3)
• The Society (3)

Letters to the Editor

Drug addiction

Treatment gives society value for money

From Mr C. A. Boucker, MRPharmS

I was interested to read R. C. Jacob’s comments (PJ, 2 February 2008, p120) that money spent treating drug addiction could be better used to treat illnesses that are not “self-inflicted”.

On the one hand, I think that, by treating addiction, society gets value for money from the reduction in drug-associated crime and trauma to victims thereof.

However, I do wonder if condemning patients to a lifetime on methadone is really in their best interests. All too often we attempt to solve social problems with medical intervention, because this seems to be the easy option.

There can be little argument that the greatest advance in modern healthcare was in 1854 when John Snow curbed the Soho cholera epidemic by removing the handle from the Broad Street water pump.

We would do well to remember that the standard of our health has more to do with the refuse-collectors and water companies than GPs and hospitals.

The irony is that ill health today is often due to our hectic lifestyle and choices such as poor diet and lack of exercise. However, do we really have much “choice” in a society where the adults in each household need to work long hours to earn enough money to pay the mortgage and put food on the table?

Should the resulting medical problems be considered self-inflicted and hence not funded from the public purse?

Increasingly, we give our children a dose of Ritalin before leaving them with the childminder and we rely on care organisations to medicate our elderly relatives because we do not have the time or social structure to cope with them in a family setting.

We have a generation growing up to find themselves with a high disposable income but little hope of buying a property and moving on to an independent life. It is a small wonder that their earnings end up funding night-clubs and breweries.

Overall, the situation is far too complex for a simple answer. However, it seems to me that our preference is to leave the handle attached to the pump and use our resources to tackle the resulting problems.

Indeed, it could be said that drug companies and healthcare professionals have a vested interest in ensuring that this continues to be the case.

Colin Boucker
Gloucester

Our attitudes to addiction must follow the science

From Mr F. A. Harvie, MRPharmS

I read with interest the letters from R. C. Jacob (PJ, 2 February 2008, p120) and John Tait (PJ, 9 February 2008, p151) replying to my article (PJ, 19 January 2008, p59) about addiction and the Pharmacist’s Health Support Programme.

The disease model of addiction holds that addiction is a disease, coming about as a result of the impairment of brain structure and neurochemistry. It is a chronic, progressive, often fatal disorder similar to other diseases such as type 2 diabetes or cardiovascular disease.

The moral model holds that addictions are the result of human weakness, and are defects of character.

Any individual exposed to alcohol or drugs has the potential to become an addict irrespective of intelligence, education, gender, upbringing or spiritual maturity. There is a huge difference between addiction and simple alcohol or drug use to change the way a person feels.

People who drink too much or misuse a drug occasionally may still exert control over their behaviour. However, once they become addicted, their brains change in such a way that they lose the ability to stop.

People who espouse the moral view have scant sympathy for people with addictions believing either that a person with greater moral strength could have the force of will to break the addiction, or that the addict demonstrated great moral failure in the first place by starting the addiction.

This model ignores, though, the pharmacology of the substance and the physiology of the brain, and has no therapeutic value in modern medicine.

Recognition that addiction is a brain disease does not mean that the addict is simply a hapless victim. Addiction begins with the voluntary behaviour of using alcohol or drugs and the addict must take responsibility for this.

Having this brain disease does not absolve the individual of responsibility for his or her behaviour, but it does explain why an addict cannot simply stop using drugs by force of will power alone. The very fact that an addict cannot stop is precisely what addiction is.

Stigma is one of the most difficult aspects of alcoholism or addiction because it makes it harder for individuals and their families to get the help they need.

There will be thousands of intelligent, educated, caring doctors, dentists, pharmacists and nurses in the UK who are in serious difficulty with drink or drugs, or both, and they need as much help as we can give them.

Our attitudes and the way we deal with addiction and addicting chemicals should follow the science. If it were even remotely possible that weakness was the cause of the addiction then all we would have to do would be to run a few “will power workshops” and the problems would disappear.

Fraser Harvie
Congleton, Cheshire

Education is the answer

From Mr J. J. Mee

I wish to comment on the letter from R. C. Jacob (PJ, 2 February 2008, p120) in which he refers to Fraser Harvie’s article (PJ, 19 January 2008, p59) regarding addictive disease. Dr Jacobs disputes the “disease” classification of addiction as it is accepted by the World Health Organization, the General Medical Council, the General Dental Council, the Nursing and Midwifery Council and the Royal Pharmaceutical Society.

One has to question his disregard of the health committees of all of these organisations, each of which deals with problems caused by alcoholism and other addictions as a health problem. If not accepted as a disease why not have an “immorality”, “stupidity”, “irresponsibility” or “weakness” committee instead?

Historically, diseases that were not, as yet, understood, particularly those that caused anomalies in brain function, were frequently attributed to moral lack or weakness or, indeed, to witchcraft and evil spirits. Witchcraft was associated with seizures and sufferers were tortured and frequently killed.

Epileptics were, at one time, considered to be possessed of evil spirits and were burned at the stake. Similar but less dramatic attitudes have persisted in relation to alcoholism and other drug addictions but have no place in modem medical thinking.

The Pharmacists Health Support Programme (PHSP), and other health professional programmes like it, is trying to pour some water on the “stake” fire.

The disease is adequately defined by the American Society of Addictive Medicine, which states: “Chemical dependency is a primary chronic disease with genetic, psychosocial and environmental factors influencing its development and manifestations.

The disease is often progressive and fatal. It is characterised by continuous or periodical impaired control over drug use, preoccupation with drugs despite adverse consequences and distortions in thinking, most notably denial.”

Research on the human dopamine-2 receptor gene DRD2 A1 allele identified it as the gene transmitted in addiction (Dr Kenneth Blum, University of Texas, ‘Alcohol and the addicted brain’). A vast amount of research has gone into this branch of medicine over the past 40 years which has put its classification as a disease beyond any reasonable doubt.

Addiction acts on the “pleasure/reward” system in the mid-brain, which comprises the amygdala, the ventral tegmental area and the nucleus acumbens septi. This system is “fuelled” by dopamine.

Dr Jacob asks: “What is prejudice?” My dictionary gives the meaning as “an opinion formed beforehand, especially an unfavourable one, based on inadequate facts”.

Addiction is a world problem. It pervades all levels of modem world culture and society. However, it can be dealt with in a positive way. As with all diseases, prevention is the best form of treatment.

Education from an early age in the general population is a potent solution. This means that children need to be taught before they reach the age when they are likely to have come under the influence of the drug market, ideally in the home.

Later, at primary and secondary school and in tertiary establishments, there should be adequate education and support.

As co-ordinator of the PHSP, I have made strenuous efforts to introduce lectures on addiction as part of the pharmacy curriculum but without any success. It seems futile that students qualify as pharmacists, only to be prevented from practising their profession two, three or four years after qualifying merely because they developed a drug or excessive drinking habit at university.

Drug abuse is rife in our universities but, most importantly, pharmacists are at the cutting edge of the problem when they qualify.

Joe Mee
Co-ordinator, Pharmacists Health Support Programme
Royal Pharmaceutical Society

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