This week we bring to Points an interview with Dr. Robert B. Whitney as part of an ongoing interdisciplinary dialogue inspired by last month’s “Courtwright Symposium.” Whitney served as Clinical Director of the Division of Chemical Dependency at Erie County Medical Center from 1976 to 2011. In addition, Dr. Whitney worked for the Research Institute on Addictions in Buffalo, NY in the early ‘90s.
Can you tell us a bit about your unique professional experience, and perspective regarding addiction and the War on Drugs?
I have a slightly different perspective than people whose primary focus is research, including historical research. My experience has been in trying to synthesize relevant information from any source and to apply that information in helping people cope with their drinking and drug problems. Over the years, I’ve also been on different committees at the county and state level looking at addiction policy questions. So most of my experience as a clinician, was a little different. But I have some sense of what the policy issues are and how ill-informed most of it is. So I have a slightly different take on the whole thing.
In your 35 years of experience, did the patient demographics change significantly? If so, how?
Yes. In many ways the demographics changed some. People got younger. I still don’t really know if that’s a product of changes in prevalence of drug use or whether we just got better at catching people earlier in the course of their problems. I think it’s probably some of both. We found other ways to engage people before they are having trouble with the law for example, or having trouble on the job. So the age has changed and certainly the patterns of drug use have changed. Ten years ago in Buffalo if we saw one or two people a month who were primarily in trouble with prescription drugs that was a lot out of say 100 admissions. When I left in September , and I don’t think it’s changed very much since, it was around 40% of admissions. That’s a huge, huge, change.
My research focuses on drug policy reform in the mid-to-late 1980s, reform largely associated with the emergence of crack. Can you point to any significant changes in your own facility at ECMC during this period?
We certainly began to see people with shorter drug histories. Clinical populations tend to be people who are more troubled than your average user or abuser. If you’re having trouble spending too much money on cocaine every once in awhile you don’t necessarily end up in treatment. If you spent the family fortune on it and everyone has given up on you we might expect to see you in treatment. So often, it would be a number of years before they ended up in treatment. I think when crack came to Buffalo, we did see a lot of people with crack as the main reason that got them to treatment earlier. It seemed like they would get deep into trouble in months, rather than several years. People were getting into trouble with it, I think, because you could get started on it with smaller amounts of money. You didn’t have to have a great deal of money in your pocket to get going. This seemed to be a difference in typical patterns. Moreover, because of the rapid onset of inhaled cocaine, the drug is particularly reinforcing, contributing to more rapid progression of problems.
Lately we have been talking a great deal about the differences between a spectrum of disciplines involved in the study of addiction. Care to comment?
Ultimately, the issue gets down to… I think clinicians try to be more pragmatic. We can sit here and talk until we’re blue in the face and it’s interesting but ultimately it seems to me the question is, can we get around to applying all this knowledge in ways that are helpful? … People need to find better ways of communicating and need to develop thicker skins. Perhaps we need to find common language—possibly jargon-free ordinary language—to foster discussions across disciplines. The baseline has to be an acknowledgement of mutual respect. I believe all debates should start with, “what do we agree on?”
Much dialogue and debate between historians and those in addiction science pertains to the NIDA paradigm. Is it “all about the dopamine”? Do you align yourself with this assessment of addiction as a chronic relapsing brain disorder?
No. For several reasons. One is that alcohol and drug use and abuse is really a continuum. By focusing exclusively on the biologic part for the most severely effected people, it helps us understand their cases. But that’s not the whole story, the context in which drug use occurs in, how people get to that point, is not, I don’t think, purely biologic. Very few health conditions are that simple. Infectious disease is to my mind the best analogy. The flu is everywhere, but you know, some people don’t get sick. So if we only focus on one part of the equation, we’re essentially missing the point. In terms of prevention, or community intervention, there are a vast majority of people who aren’t yet severe cases that we need to pay attention to. The NIDA paradigm is useful, but it’s a gross oversimplification that misses many of the relevant questions to prevention, policy, and treatment. It has produced some wonderful research and some great grant money but in terms of broad public policy it’s a serious oversimplification of what we should be doing in terms of prevention.
Drinking and drug use have been essential parts of nearly all societies. To understand variations we must understand social context. This is particularly relevant in the U.S. because of our multicultural society; just defining what is “normal” has been problematic. While there are likely some biologic elements which factor into addiction, other dimensions are likely more critical. Finally, the history of most research lies in the fact that what we think is “true” this year often turns out to be “wrong” later because we have over-simplified things. I expect dopamine and the reward center will be seen as key elements of much more complicated brain biology in the future.
Many critics have argued that the NIDA paradigm individualizes addiction thereby eschewing the social, political, economic and cultural dimensions of the issue. Do you agree that the paradigm does not sufficiently address said dimensions?
When you look at most human conditions, whether you’re looking at things we would all generally agree are diseases, there’s generally more to it than the biology anyways. It is an important and relevant part to finding better answers, but it’s only a part. Look at where we are on Diabetes. Now we have an epidemic of Diabetes. Now is this because people’s biology has radically changed? No, it’s because we’re eating differently and exercising less and so on.
If the NIDA paradigm is now widely accepted by the medical field and outlying research facilities, why is addiction and recovery rhetoric still so heavily steeped in issues of morality and individual responsibility?
On the surface of it, it’s a contradiction. Many people whether its research or treatment would acknowledge that addiction is a disease and then the next thing they do is bring in morality. So we have the NIDA paradigm, but what do you do with that information? How does it help you? As a practical way of working with people it is helpful as a means of moving beyond criticisms of morality and other personal failings. But, often, morality is still part of the culture. Do people in general believe addiction is a disease? No. It is still not as widely accepted as one might think.
Biologic based research studies have not yet provided us with many practical and no powerful clinical tools. As such, we tend to cling to old approaches. In addition, the treatment field is still largely staffed by people without training of specific tools that might flow from this approach. For example, even standard treatments such as appropriate use of antidepressants or opiate replacement therapies are probably underutilized.
On the War on Drugs:
So the issue is—what is the right public health response? Instead of a simple-minded legal response, what ought to be the right public response certainly does not include locking up the wrong people and making whatever troubles they had even worse. Unfortunately, what we actually do know rarely guides policy. A lot of it turns to how do you actually implement policy? Systems, structures, and people don’t change their minds necessarily based on the facts. It’s more about, well, how do you sell it? The public process can’t handle anything that is too complicated.