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| Get the Facts Straight |
| Columns - On the Web | ||||||||
| Written by Stuart. Gitlow, MD | ||||||||
| Friday, 04 January 2008 | ||||||||
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There was big news on July 16. A news story circulated by the
Associated Press (AP) was widely published. The story: one of every 12
full-time workers in the United States acknowledged using illegal drugs
at least once in the previous month. A clinical psychologist was quoted
in the story as saying that this finding was “very worrisome” because
there are too few treatment programs to assist those with dependence on
drugs. At that point, I said, “huh?” The story is not about people with
addiction or people with dependence, but is rather simply about use.
Let’s look at one such person:
Mary is a 25- year-old college graduate. She smokes marijuana with her friends each day after the end of her second job, a waitress position that she uses for extra income beyond the income she gets from her job as a dental assistant. Her marijuana usage is less than it was in college. She does not use other substances. She successfully quit smoking cigarettes a year ago. She is not in a workplace that performs any type of drug screening. Her work history is excellent. She is in a good relationship with her boyfriend of several years. She has no evident medical complications of her substance use. She meets none of the DSM criteria for abuse. Last month, she took a two week trip to Israel. Due to the international airline travel and screening, she brought no marijuana with her and did not use the drug during the two week period. She reports that her discontinuation of marijuana use led to no obvious discomfort or withdrawal symptoms. She resumed her use upon her return. There was no evidence of any change of tolerance. She does not meet any of the DSM criteria for dependence. There are no psychiatric complaints or difficulties. She is not seeking any treatment and does not wish to discontinue her use. Her significant other, her employers and her friends all like her, get along with her, and have no concern regarding her use of marijuana. I referred to Mary not as a patient or a case, but as a person. She doesn’t meet criteria for any substance use disorder. Though she uses a considerable amount of marijuana, she is not suffering from addictive illness, psychiatric disease or medical complications (to the best of our knowledge). She is clearly at risk, but equally clearly should not be admitted to a treatment program, though it would be an excellent idea to talk with her about her use to make certain she is aware of the potential health consequences of her decision. The AP news writer and the psychologist interviewed both confused the medical disease marked by substance use and substance use itself. This confusion as to what addictive disease is appears similar to the difficulties we discussed last time with respect to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) website on college drinking. And it points yet again to the issues with definitions that we’ve focused on time after time within this column. Risk-taking does not equal disease There is no disease called “Uses Too Much” just like there is no disease based upon “Plays Baseball Too Much” or “Spends Hours Playing Videogames.” People enjoy interesting activities. They often focus on such activity as a critical part of their relaxation. These activities can be dangerous: rock-climbing, skydiving, motorcycling; or can be safe: knitting, watching television, stamp collecting. We do not base the presence of a disease upon ongoing risk-taking activity in and of itself. Therefore, an individual who is performing a risky activity regularly and consistently is not suffering from a disease state unless symptoms of a disease state exist. Mary has no such symptoms, and while she is engaged in a risk-taking behavior, this alone does not mean she is ill. All of this brings us to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), something you’ll hear a great deal about in coming years. This survey, described at: http://pubs.niaaa.nih.gov/publications/AA70/AA70.htm. One of the discussions within this page focuses on so-called underage drinking. We know that people who drink at a young age have a higher risk of developing problems with alcohol later in life. This does not mean, of course, that stopping an individual from drinking at a young age is in any way preventive against alcoholism, since the causality here may be that those with alcoholism are more likely to start drinking at a younger age than their non-alcoholic peers. Let’s look, though, at part of the text describing the underage drinking findings: “Early drinkers also experienced multiple episodes of dependence; that is, they had bouts of dependence followed by times of nondependence. This is a unique aspect of alcoholism and the primary reason this disease is classified as a chronic and relapsing condition. These findings on the risks of early drinking stress the importance of screening and counseling adolescents about alcohol use as well as implementing policies and programs that delay alcohol consumption.” That entire paragraph makes no sense whatsoever. You can’t have multiple episodes of dependence. You can either have the disease of alcohol dependence, or not. The fact that alcohol intake is often variable over a given course of time is not at all unique to alcoholism, but can be reflected in degree of severity of many diseases — major depression, to name one. And the findings in no way indicate that delaying alcohol consumption will solve any medical problem. Rather, this is a political goal being reflected as if it represents a medical finding. I don’t wish to be misunderstood here. I’m not arguing for alcohol intake by young people, nor am I ignoring the public health complications that can result from youth and alcohol mixing. But we have got to work hard to get our national information services to provide accurate information, not political rhetoric that will only be thrown back in our faces when the public discovers the rather obvious inaccuracies. Agree? Disagree? Let me know. As always, I welcome your thoughts and comments at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
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