Saturday, February 27, 1999

Addiction is a disease,
not a crime

Mackey Feary's death provides
opportunity for re-evaluating
how addicts are treated

By Kevin Kunz, M.D.
Special to the Star-Bulletin


The tragic death of Mackey Feary cannot be ignored. I grieve with his family and his friends. Mackey's path and mine first crossed 22 years ago, before I became a physician and before either of us learned that drugs rain acid on the soul.

Now his life has touched mine again. As his music plays, I feel my loss and would like to honor his life by sharing some lessons that I have learned.

bullet Lesson One: Addiction is a disease. It is not a crime, not a lack of will, not a moral issue. It is a disease of the brain.

This is a medical certainty; there is no debate. Like other brain diseases, such as stroke, Parkinson's, schizophrenia or Alzheimer's, addiction disrupts brain systems that direct our thinking, emotions and social behavior.

Circumstance or poor judgment may facilitate the voluntary decision to try addictive drugs. But for persons with genetic or acquired vulnerability, these chemicals will eventually subvert and then hijack the brain's survival and reward center.

By mimicking or modifying the brain's own messengers, the neurotransmitters, drugs of abuse actually reshape the brain cells and circuitry, causing one to crave the drug or become sick in its absence.

The natural high that is an appropriate reward for survival activities -- quenching thirst, satisfying hunger, sleeping and sex -- is replaced by a drug shortcut to which the brain adapts.

When these changes were first defined several years ago, scientists began referring to the "plasticity of the brain." These changes take months or years to repair, and even then they leave a permanent memory, a memory that will awaken after even brief exposure.

This explains the drive, against all reason, of the addicted person to continue using drugs. It arises from the force of our own survival instinct, the physiological reward system necessary for the very existence of mankind.

Drug-induced brain cell changes are convincingly demonstrated in Positron Emission Tomography (PET) scans and in biochemical alterations of neurotransmitters. These brain changes have explained why addiction is a chronic and relapsing illness.

Changes in the addicted brain also explain the disease-specific characteristics of drug tolerance, loss of control, compulsion to use and continued use despite adverse consequences.

Denial, another hallmark of addiction, is a defense mechanism which is not well understood. Yet the addict is not alone in his or her denial. Denial of some degree is usually shared by family, employer and community. Some may not only deny the illness, but enable it to continue. Even people who should know better, like physicians, policymakers and guardians of social welfare, can hold an inaccurate and stigmatized view of this disease.

At every level, from the powerless victim to that of the highest social institutions, denial is the principal barrier in providing effective treatment. A common form of denial is "that only happens to people like..." In fact, most persons with addictive disease are employed, have families and represent the diverse demographics of our island population.

Addiction crosses all social, educational, ethnic and economic strata. It affects the "typical" Hawaii family.

Both legal and illegal drugs cause dependence and addiction in the some manner, affecting the same cells and circuitry. The drive to have another cigarette is essentially no different than the drive to smoke more ice or to shoot more heroin.

Addiction is responsible for more U.S. deaths than any other condition. Nicotine is directly responsible for over 425,000 deaths a year, alcohol for 125,000, and ice, cocaine and heroin for tens of thousands more.

Addiction is a prime cause of ill health and death, crime and violence, social ills and economic burdens to society. It is the equal of war and poverty.

bullet Lesson Two: Treatment for drug addiction works.

A recent review sponsored by Physician Leadership on National Drug Policy, a group led by 37 nationally known doctors, compared the efficacy of drug addiction treatment to the treatment of other chronic disease. This review, in which more than 600 peer-reviewed research studies were included, showed that treatment for chemical dependency is as and often more effective than is treatment for other chronic diseases such as diabetes, asthma and high blood pressure.

Another study, from the Harvard School of Public Health, ranked addiction treatment in the top 10 percent of the most effective medical measures from a list of over 500 medical and safety interventions.

We rarely blame the victim of other chronic diseases, although like addiction, genetic susceptibility and the behavior of the individual -- eating, smoking, lack of exercise -- alters the disease course. Nor do we proclaim the disease cured after initial diagnosis and treatment: We do not give up.

Relapse is a feature of most chronic diseases. Treatment for addiction also needs to be long-term or life-long.

There is unequivocal evidence that every dollar spent for the treatment of chemical dependency multiplies in cost savings from the prevention of crime, incarceration, social discord and disease complications (HIV, hepatitis C, depression, trauma, etc.).

Treatment can prevent or eliminate dysfunction in the family (abuse, neglect), in the workplace (injuries), and lessens the heartache and desperation of the addicted person and their family.

We know that treatment can be effective whether the patients seek help on their own, or through coercion. The recovery rates are identical, disproving the myth that someone has to "hit bottom" before getting well.

Hawaii's network of addiction recovery resources -- from 12-step meetings to residential care programs -- continues to validate the slogan, "Treatment works!"

bullet Lesson Three: Use of the criminal justice system and interdiction to reduce illegal drugs, and their harmful effects, is misguided and inadequate.

Dealers and violent offenders should be dealt with by law, but most addicts are ordinary people without criminal connection. Many of them are crying out for help. They know they're sick. They need treatment.

Yet only 25 percent of state and federal funds for drug abuse go for treatment, while 75 percent go to law enforcement. This ratio needs to be reversed.

It has become clear in Hawaii and elsewhere that legal disincentives and incarceration only minimally impact drug use. Hawaii prisons are overcrowded and overflowing. We haven't been able to build new ones fast enough. The overwhelming majority of inmates in Hawaii's prison cells are there because of drug-related problems.

Elements of the criminal justice system that must be strengthened include drug courts, which offer the sick drug user the option of treatment; effective prison rehabilitation programs, which have been proven to reduce recidivism; and parolee treatment programs. A stronger, institutionalized, collaborative approach among judicial forces, the substance-abuse treatment and social care systems is sorely needed.

The time is here to aggressively utilize medical and public health approaches for our state's drug problem. Currently, we are simply throwing good money after bad into a bottomless pit. And we are wasting lives.

bullet Lesson Four: Substance abuse must be treated like any other disease by Hawaii's health-care providers and insurance companies.

Care discrimination based on stigma and outdated science should be unacceptable. The benefits of treatment were obvious, and the cost of our present approach is now intolerable. The economic drive of insurers to avoid the treatment of addiction is shortsighted, and if necessary should be removed by legislative or legal persuasion.

Unfortunately, for other groups with illnesses limiting their ability to fight for equity -- the mentally ill and disadvantaged children -- legal mandates were required as a last resort. Hawaii needs to mandate parity for health-plan coverage of additional mental-health care.

Mackey Feary was a great artist. He suffered from a common, treatable disease. His loss is a tragedy for Hawaii. Let us not compound the tragedy through ignorance and indifference. We must come together. Mackey Feary's life -- and his death --was a song we all can hear.

Kevin Kunz, M.D., is a staff physician at Kona
Community Hospital and a specialist in addiction treatment.

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