William Haning, MD, DFASAM, DFAPA
Dostoevsky’s original title for “Crime and Punishment” was “The Drunkards,” intended to be a fictionalized discussion of the disorganization of a family under the influence of alcohol. Most in my generation will recall reading the novel for high school Advanced Placement English or in college, and possibly recall sympathizing with the protagonist, Raskolnikov. His character is painted in highly sympathetic terms that appealed well to adolescents or young adults, even at the same time that his anguish and guilt were not easy for us all to understand. The task became easier when we had decades of experience with addiction, direct or through our patients.
In the 29 May New York Times editorial, “If Addiction Is a Disease, Why Is Relapsing a Crime?
” the author cites a case before the Massachusetts Supreme Judicial Court regarding the incarceration of an addict who resumed drug use. If I re-state the previous phrase as, “…the imprisonment of a patient with substance use disorder because of worsening condition and relapse,” the action appears imbecilic. This is not bowdlerization or sweetening of language; it is an important reframing. Our patients do not do stupid things because they are intrinsically evil, but without question they do stupid things; alcohol and drugs are solvents of good judgment. The public servants who would care for them and for the community are similarly conflicted; that ambivalence is reflected in the title given to a prison in which almost 2/3 of the inmates were voluntary, the Lexington Federal Medical Center. The argument for treating people with addiction differently from other types of patients comes from a model based on epidemic control [see below, You’re Not a Drug Dealer? Here’s Why the Police Might Disagree]: the notion is that the carriers of illness must be isolated from the rest of the population. But prisons are rarely good treatment centers or hospitals, and release into the community of an untreated person still carrying the illness makes no sense. Batya Swift Yasgur in the 29 May Psychiatry Advisor, “Court-Mandated Substance Abuse Treatment: Exploring the Ethics and Efficacy
,” provides a thoughtful review of the efficacy of mandated treatment, noting particularly the many and sometimes conflicting meanings of “treatment”.
A cynical juxtaposition occurs when next reading the article from New York, “Purdue Pharma Knew Its Opioids Were Widely Abused by Late ’90s [below]”. The piece describes an example of institutional antisocial behavior with severe national consequences, that went largely unpunished. Just as with the person who relapses, so we have certainly seen recurrence of these behaviors by some manufacturers despite being confronted. But unlike the case with the person who relapses, the issue is one of greed rather than illness. Here is an instance where the public weal would be better served by application of consequences to self-interested bad behavior; rather than as in the case of the person with addiction, with applying penalties as a substitute for treating sickness.
I’m with Billl!