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Controlled Substances, A Public Health Model

                         Tod H. Mikuriya. M.D.

The underlying assumption of a public health model is the optimization of benefits versus costs or risks for the individual and society.

A second premise is that users, producers, and the marketplace be accountable to themselves, family, and society in general.

Awareness of connections between costs and benefits must be institutionalized. Existing product liability laws and other safeguards of purity, efficacy, and strength provide one feedback mechanism.

Resulting industry restraint would obviate the need to censor advertising.

Earmarking of tax revenues for treatment and casualty losses instead of to the general fund provides another functional social reality check. The current inherent conflict of interest arrangement encourages government acting at cross purposes.
 

Accountable and self-supporting:
Voluntary Drug Users Cooperatives (VDUC)

Accountability is demonstrated by "picking up after oneself". Transaction fees and all drug taxes are earmarked to support administration of pharmacy based drug users' co-operatives. Contracting community treatment providers treat the inevitable abusers needing services are paid for by the program.

It has been estimated that some 10% of users are abusers of alcohol. It would not be unreasonable for the 9 users to pay for the 1 abuser's problems should that be the experience of the program.

         Maximize Individual Responsibility. Minimize Intervention.

A major assumption is that the informed user will exert responsibility and common sense and require minimal intervention.

No intervention unless there is 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.

     Harm and Risk Management

A salient emphasis of the VDUC would be the minimizing unsafe drug use through education starting with the program entry testing and continuing with periodic health screens and user information updates.

Needle exchange and safe practices are an important part of the education program.

The VDUC's provide incentives for the use of low concentration psychoactive preparations over high concentration drugs.

                 Informed Consent/Entry

Users gain entry by taking a test to demonstrate knowledge of drug effects, side effects, and risks. This same test would be prima facie evidence of informed consent and understanding of responsibilities and consequences of violating program rules.

A special program identification card is presented at any contracting pharmacy to verify authorization to purchase up to a month's supply of drugs. Information from the transaction is sent to the program's office. Any unusual increase warrants inquiry from the office.

Users of high risk groups such as mentally ill, substance abusers, alcoholics, or developmentally disabled are under closer supervision by contracting addiction specialists.

                     Non-profit community board

The huge revenues at stake with inherent risks of greed necessitates oversight.

A non-profit community board is mandated to protect the users from avoidable harm, exploitation and the public from health and safety risks. Users, Pharmacists, Public Health, general community and district attorney are represented.

                     Abusers referred to treatment or enforcement

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

Abusers are referred to detoxification and treatment program providers if the abuser is not a danger to others.

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, or other source initiates intervention of the program. The pharmacy identification card is suspended and the abuser referred to the assessment team.
 

                        Evaluation

Experienced substance abuse specialists "triage" to determine the sorts of intervention appropriate to the individual problem.

                     Referral for specialized treatment

A spectrum of outpatient and in-patient service is 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 is collected from participating health resources for policy refinement.

Psychoactive drugs with the lesser harm are developed and marketed to substitute for more toxic drugs. Crude coca products are made available to compete with the concentrated smokeable forms. Combination drugs like disulfiram or neuroleptics with opiates are evaluated.

Infectious intercurrent disease would utilize opioids, stimulants, and sedatives combined with antibiotics to improve compliance with treatment of illnesses like tuberculosis.

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 studies are required on a large scale.

                Suggested Reading

2 U.S. Studies Criticize Plan To Ease Access to Methadone  Associated Press in the New York Times A11, August 4, 1989

Dole, V.P., Nyswander, M., and Kreek, M.J.  Narcotic Blockade Archives of Internal Medicine 118 October 1966, 304-309.

Dole, V.P. and Nyswander, M.  Heroin Addiction- A Metabolic Disease, Archives of Internal Medicine 120 July 1967 19-20. Heroin Addicts

Goodman and Gilman's The Pharmacological Basis of Therapeutics 7th Edition
Macmillan New York  1985  1839 pp

Grinspoon, L. The Harmfulness Tax: A proposal for regulation and taxation
of Drugs Unpublished. Address to International Meeting on Antiprohibitionism
Brussels September 29, 1989 11 pp.

King, R. The Drug Hangup; America's Fifty-Year Folly. Charles C. Thomas
Springfield IL 1972 389 pp

The Merck Manual Fifteenth Edition. Merck, Sharp and Dohme Research
Laboratories  Rahway, NJ 1987 2,696 pp

Mikuriya, T.H. Taming drug-dependency with a credit card  Medical World News
Dec 12, 1980 P 100

_____________  Physical, Mental, and Moral Effects of Marijuana: The Indian
Hemp Drugs Commission Report. Internat J. Addictions vol 3 No 2, Fall 1968
253-270

Nadelmann, E.A. Drug Prohibition in the United States: Costs, Consequences,
and Alternatives Science 245: September 1, 1989, 939-947

Report of the Indian Hemp Drugs Commission 1893-94 Simla, India: Government
Central Printing House, 1894, 7 Vols 3,281 pp.

_____________  Supplementary Vols 1 & 2: 417 pp (Classified military data
published separately)

Syllabus for the Psychopharmacology Course  Harvard Medical School
Sept 30 Oct 2, 1988 Harvard Medical School Department of Continuing Education,
Boston, MA 514 pp.

Terry, C.E. and Pellens, M. The Opium Problem.  Bureau of Social Hygiene
New York 1928 1045 pp (Reprinted by Patterson Smith, Montclair NJ 1970)

Trebach, A.S. The Heroin Solution  Yale University Press, New Haven, CT
1982  331 pp

____________  The Great Drug War  Macmillan, New York 1987  401 pp

Tod H. Mikuriya, M.D.
         12-17-92