I support harm reduction but propose that reorganization to improve evaluation and evidence-based medical treatment will resolve the overdose epidemic that plagues our state, more than most. Harm reduction approaches the problems of stigmatization and evidence-based treatment indirectly, but it risks amplifying stigmatization by seeming to support the non-medical use of dangerous drugs. For example, continuing the practice of repeated antagonistic (naloxone) resuscitations is further increasing overdose deaths in Tennessee because overdose victims are often resuscitated many times before their fatal overdose.
Motivational interviewing is a superb technique for establishing a therapeutic alliance but a person experiencing the pain, anxiety and acute drug hunger of precipitated withdrawal from opioids is laser-focused on finding more powerful illicit opioids. Such missed opportunities to initiate treatment further increase the demand for illicit drugs in our communities. I argue that substance use disorders are bona fide psychiatric illnesses and that lives will be saved by involuntary psychiatric hospitalization to evaluate and offer treatment, which will begin to reduce stigmatization and reverse the increasingly high demand for more powerful and deadly illicit drugs in our state.
There are two major views on substance use disorders, one a neoliberal view, holds that drug use is always a choice and bad behavior merits consequences, but it’s hard to see this as anything other than the criminalization of incredibly vulnerable people1. The other is a disease model, that exposing the brain to toxic chemical molecules, viruses, bacteria, and other biological, psychological, and social disruptions may alter a person’s mental capacity. Decisional competence, like fitness to stand trial, is a judicial determination based on evidence. Ironically, decisional competence is rarely considered in substance use disorders once intoxication resolves or the danger of acute withdrawal is past2. Tragically, although insanity is sometimes defined as doing the same thing over again and expecting different results, relapse to opioid use may trigger expulsion from treatment instead of initiating the appropriately higher level of care.
Impaired behavioral control related to drug hunger and addiction3 (decisional competence) were called “Derangements of the will,” by Dr. Benjamin Rush (Rush on Mind4, the first American Textbook of Psychiatry5) who espoused medical evaluation and treatment instead of the arm of the law. Over the subsequent century patent medicines laced with cocaine, morphine, and heroin (diacetyl morphine) and the hypodermic syringe increased drug use to epidemic status but many physicians had established successful harm reduction clinics6. In fact, the Shreveport Clinic (1919-1923)7,8 led by Willis P. Butler, (1888-1991) a 1911 graduate of Vanderbilt School of Medicine is the best-documented example of successful harm reduction management of opioid dependence by dispensing morphine to manage opioid hunger. Butler’s unacknowledged mentor, Lucius Polk Brown, Tennessee’s first Commissioner of Food and Drugs (1907-1915) who taught at Vanderbilt Medical School, had developed a Tennessee-wide harm reduction program9 based upon 1913 legislation that preceded the Harrison Tax Act.
The Treasury Board (1915-20) decided administratively and without medical evidence, that medical practice did not include treating addiction. The ruling simplified its resource-intensive, national responsibility for medical narcotic use during the public hysteria that led to the 13th Amendment in 1920. Enforcement agents were emboldened by amplified sensationalism in press reports about crime and drug raids. The last successful clinic was forced to close in 1923. Stigmatization of patients suffering from substance use disorders began to flourish as criminalization expanded and many thousands of physicians have been prosecuted for the intent to relieve suffering10.
Tennessee already has the manpower and resources, if properly organized and managed, to start over again and reduce the overdose death rate while simultaneously decreasing the availability of dangerous illicit drugs in the state - economic science calls it simply the law of supply and demand! It makes sense to integrate behavioral health care because a) comorbid substance use and psychiatric disorders are the leading cause of morbidity and mortality, b) it could simplify funding, operations, coordination of resources for clinical management, and research c) and catapult Tennessee ‘Back to the Future’ as an example of successful public healthcare8.
TREAT ADDICTION SAVE LIVES©ASAM is a simple solution, but it won’t be easy. Basically, it will require coordinating all the providers, agencies, and resources that are separately trying to address the overdose issue with medical (addiction psychiatry) leadership – what Brown and Butler each accomplished within a few short years - a century ago!
Reducing stigma by saving the lives of drug overdose victims is the best way to initiate change in Tennessee’s overdose death rate and would reduce the demand for illicit drugs. Demonstration that medical treatment allows moribund opioid overdose victims to recover their lives will gradually begin to change public opinion. Existing Tennessee legislation already permits 72-hour involuntary commitment, for evaluation of life-threatening psychiatric illness, including drug dependence. The false belief that decisional capacity is not affected by opioid withdrawal originated in prohibition hysteria over a century ago. I submit that 72-hour psychiatric commitment following overdose resuscitation for substance use disorders is the best initiative to reduce the overdose death epidemic in Tennessee. Half-measures will be less successful and often perpetuate stigma. Believe me, I know how helpful involuntary commitment and stigma reduction can be.
Question and slides submitted by Reid Finlayson, MD, Professor of Psychiatry and Behavioral Sciences, VUMC
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