Medicalization of Drug Abuse Control:

Pharmacy Based Voluntary Drug Users Co-operatives

A Proposal

Tod H. Mikuriya. M.D.

Reinvolve Medicine in Drug Policy

To bring medicine back to involvement with issues of drug dependence, the laws need revision to make the treatment of addicts a medical matter.

Redefine an addict as ill rather than criminal in substantive terms.

The doctrine of prohibiting physicians from maintaining opiate and cocaine addicts must be eliminated. Transfer control of treatment protocols and standards from the Department of Justice to the Department of Health Services. Mandate development of maintenance or drug hygiene standards with participation of the California Medical Association.

A joint California Medical Association and California Bar Association committee to draft legislation to revise laws to optimize freedom to appropriately treat substance abuse, safeguard patient's rights, and protect the public health. Safeguards must be included to discourage excessive consumption or abuse.

Pharmacy Based Voluntary Drug Users' Co-operatives

A new category of legal non-therapeutic users of controlled substances is created. Include all drugs listed in the Controlled Substances Act of 1970 et seq. for actual controlled use. Users would obtain these drugs at participating pharmacies utilizing special ID. Entry to the program at the age of majority would be by written test. No intervention by the program unless there is a problem. Supported by transaction fees, community treatment resources would be paid for by the program.

Success of the program is based on the premise that the rate of morbidity will be acceptably low in an informed group of users. Chronic users learn to develop functional stable use patterns that may continue for long periods without disruption. Dysfunctional behavior associated with use would result in being dropped from the program.

Reacting to some adversity a chronic user will increase his/her dose in an effort to suppress adverse emotions through distracting analgesia. The consequent psychosocial dysfunction, health problems, or financial crisis motivates seeking of treatment or results in external intervention.

Upon entering a detoxification program the habitual user typically forswears the habit, vowing to stay "clean" from now on. The rare dependent will truthfully admit to an authentic treatment goal of reducing a habit to manageable levels.

Even with success in completing detoxification and maintaining a period of abstinence, drug dependence is a chronic relapsing illness.

The mission of VDUC is to control, treat, and prevent drug abuse in a flexible and appropriate fashion. The dispensing of controlled substances through participating pharmacies to registered users is included.

Price structure based upon abuse/use ratio of a substance would encourage the use of less toxic or dangerous products. A harmfulness tax is an idea that has been recently proposed by Grinspoon.

The VDUC would be somewhat more controlled than differential toxicity tax rates because written and physical tests would be required for entry into a pharmacy-based program using an identification card.

Another VDUC goal is to institutionalize connections between cost/benefit or actuarial facts with social policy and the marketplace. These connections only dimly exist for alcohol and tobacco industries and their users. Unlike these hazardous substances, drugs sold through VDUC would not be granted exemption from product liability laws.

Transaction fees and all taxes would be earmarked to support the administration of the co-operative and contracting community treatment providers for users needing services.

Different from the British "System"

The contemporary British "system" derives from their national health service that is represented by local health councils which manage medical resources. The availability of physicians who are addiction specialists and priorities of local councils determines whether the addict will obtain appropriate treatment.

The rapid increase of heroin addicts and small numbers of addiction specialists has overwhelmed that system. The illicit free market filled the drug needs of the users the National Health Service could not meet.

Substance abuse treatment services in Great Britain are just as fragmented as that in the United States but with differences in dynamics of control, economics, and influences of special interest groups. Both are ill-equipped and overwhelmed by the impact of problems connected with substance abuse.

But at least they don't turn the addicts into criminals as we do in the United States.

Unlike prescriptive medical clinic models the proposed Voluntary Drug Users Co-operative is not vulnerable to oversubscription with waiting lists.

Users are dispersed to pharmacies and only come to a treatment program if there is a problem.

Since the scheme is transaction fee supported, the larger the number of users, the more money becomes available for treatment, prevention, and education.

Since there would be no intervention unless there was evidence of dysfunction, costs would be lower than a clinic or physician visit type of maintenance program. This lower level of control and services for problem-free users would support a spectrum of services for those suffering drug-related illness or dysfunction. Flexibility and range of response is based on the principle that control is exerted from within or imposed from without.

More importantly, the program would provide an ongoing source of reliable data on which to refine policies and develop products that would optimize use/morbidity patterns.

Eligibility

The age of majority would permit the taking of a written test on drug effects, side effects as well as the conditions of the VDUC program including consequences of misuse or violation of conditions. Passing of these tests would constitute informed consent.

An entry medical evaluation including physical examination and laboratory tests would be required to screen for conditions that would preclude or restrict access such as mental illness, epilepsy, or substance abuse.

These high risk individuals if allowed access would be more closely supervised by health providers.

Non-profit community board

A non-profit community board would be mandated to protect the users from exploitation as well as the public from health and safety risks. Users, pharmacists, public Health, legal and the general community should be represented.

Abusers referred to treatment or enforcement

All transactions are reported to the executive office of the VDUC and any patterns of unusual or exceptional use are investigated in addition to any reports of medical, surgical, or antisocial incidents.

Privileges are suspended and the abuser is referred to police or district attorney if the drugs are furnished to a minor, used to poison, incapacitate, or impair someone else. Driving while intoxicated, endangering others, fighting, or being a danger to others would be generally handled by enforcement.

If the user exhibits dysfunctional behavior or impaired health that does not directly harm someone else, then he/she is referred to an appropriate substance abuse program. Reports from hospitals, emergency rooms, physicians offices, health facilities, workplace, family, dispensing pharmacy, or other source would initiate intervention. The program identification card would be suspended and the abuser referred to the assessment team.

Evaluation

Experienced substance abuse specialists would be utilized for "triage" to determine the type of intervention appropriate to the individual problem. Intervention would be the least intrusive or restrictive possible.

Referral for specialized treatment

A spectrum of outpatient and in-patient service would be available as contractors to the program for intervention in cases of drug abuse.

Continuing research and education

The continuing study at Framingham, Massachusetts provided us with definitive information concerning the connection between smoking, lung cancer, heart, and other circulatory diseases. Unbiased and extensive morbidity information would be collected from participating health resources for policy refinement.

In order to restore a source of legitimate and undistorted medical information as to the connections between drugs and their hazards, treatments, and prevention, ongoing study is required on a large scale.

Funding for Treatment and Prevention

Treatment would be available if needed since the current salient problem is the lack of money for treatment. Nine out of ten substance abusers voluntarily asking for treatment are turned away for lack of a way to pay for treatment. The earmarking of taxes combined with transaction fees would provide an ongoing source for funding that has been heretofore lacking.

THM 8-21-90

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