Angry Doctor

Tuesday, July 25, 2006

Use and Abuse 2

I did not expect the Central Narcotics Bureau (CNB) to respond the the letter by Dr Soo which we discussed in this post two weeks ago, but they did so in a letter to Today today.


Providing substitute drugs will only prolong addiction

Letter from Dawn Sim
Public Affairs, For Director
Central Narcotics Bureau

WE REFER to the letter "Drug for heroin dependence can turn lives around" by Dr Soo Inn Choong (July 10).

Abusing drugs such as heroin is a deliberate act of taking a psychoactive substance against the law.

Drug addicts must account for their actions and take personal responsibility to stop their undesirable habits which have serious repercussions on their lives, careers and families.

Providing addicts, who are unwilling to take personal responsibility, with a substitute drug merely encourages them to prolong their addiction from one drug to another.

In our experience, rehabilitating drug addicts can only be achieved through a comprehensive programme of treatment through rehabilitation and aftercare. Unless they are compelled to stop and supported to take responsibility for their actions as part of a holistic rehabilitation programme, many will continue to dither and languish in the embrace of one drug or another.

For every case cited by Dr Soo, we know of many others who have thoroughly cleaned themselves from their addictions and lead healthy and productive lives without the need to be under the bondage of any drugs.

It is with this approach that we have managed to keep Singaporeans relatively drug-free. The Central Narcotics Bureau and the Ministry of Health have been monitoring the Subutex situation closely.

The two agencies are also working together to assess if additional measures are needed.


We are presented with two different views of the same 'problem', which likely stems from the fact that the CNB and Dr Soo probably see two rather different groups of addicts in the course of their work - the one with addicts who did not voluntarily seek help, and the other with those who came forward willingly, after the decision to quit.

Dr Soo sees addiction to heroin as 'a disease that should be treated like every other'.

The CNB sees addiction to heroin as 'a deliberate act... against the law'.

Of course, there is no reason why it can't be both.

But Dr Soo also sees Subutex as a medication, and he believes that '(i)n the same way that people with other mental disorders such as schizophrenia or depression need medication, so do those with heroin dependence.'

Whereas the CNB believes the use of Subutex 'merely encourages (addicts) to prolong their addiction from one drug to another'.

Well, these two positions are a little harder to reconcile, but there is no reason why it cannot be the case of the former in some people, and the case of the latter in others. In fact, that is almost certainly the reality, since we know some people quit their heroin addiction with Subutex, and some people abuse Subutex.

Addiction is a complex phenomenon involving many aspects of a person, including genetics, biology and psychology. Add to that the social implications or stigma of the term 'addiction', and the picture gets even more complex. There probably isn't a one-size-fits-all solution to heroin or Subutex addiction, not to mention other forms of addiction. The 'best' solution depends on which spectrum of the 'problem' you have to deal with.

As politically-incorrect as it seems, angry doc tends to agree with the idea that taking personal responsibility is an important step in quitting any addiction (or controlling many chronic medical conditions, for that matter). While we may argue over individual susceptibility to addiction and what the best method of quitting is, I believe one thing all successful 'quitters' must have had in common was the personal decision to quit, and the continued decision to see the rehabilitation process through, be it cold-turkey, or drug-assissted.

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10 Comments:

  • True, personal responsibility is an essential step in overcoming addiction. But if drug addiction is seen, as it increasingly is, as a psychiatric condition, then coexisting pharmacological therapy would be reasonable and critical.
    We know now patients with major depression, schizophrenia etc can't just 'snap out of it'. So what about addiction?

    By Blogger huajern, At July 25, 2006 8:45 pm  

  • Well, you can't 'snap out' of schizophrenia, but many people have 'snapped out' of addictions with determination and cold-turkey. I don't have any statistics on this - I do wish CNB had given us some in their letter.

    More importantly, people don't choose to become schizophrenics, or having recovered from it, choose to return to that state.

    Many people have quit substance-addictions without the use of drugs, so on the surface it might be fair to say that many 'cases' can be 'treated' without drugs. Which is not to say that drugs should not be used at all, or that drugs should be used for all addicts.

    By Blogger angry doc, At July 25, 2006 9:12 pm  

  • Or, if given that heroin addiction is a 'pure disease' as schizophrenia is, what makes one addict who is given Subutex take it as instructed and recover, and another to inject it into his vein to get a high?

    By Blogger angry doc, At July 25, 2006 9:18 pm  

  • At the end of the day, its a case to case situation.

    To try to fit everyone into 1 mold is simply impossible.

    Sometimes, it is just the emotional support of their families that lets them succeed, in others its the environment that makes them fail.

    While its difficult to know just how what when where and who....its up to the person rather than the policing of his activities that would let him break free.

    By Blogger Tigerkiller, At July 26, 2006 9:11 am  

  • I find that the Dr Soo used too much biology to explain the condition addressing only the physical dependence but not the issues that lead to drug abuse in the first place. I think a more holistic approach would be better. Treatment should involve both pharmacotheraphy and counselling.

    I have not read any trials done on the effectiveness of using subutex but I am sure the Schering people would probably have given the doctors the figures :) However I do not perceive it as superior unless there is a clear indication to use it. Maybe when withdrawal of drugs can cause fatalities.

    Letting the drug users quit by themselves sound empowering but I wonder if they were given the necessary counselling to take on the responsibility.

    Another problem is after they quit do they still go back. My friend tells me they check in and out of changi hotel quite frequently. :) Haven't verified the facts but I think the aim/goal of theraphy should not be just for them to quit but also to stay free.

    By Blogger palmist, At July 26, 2006 2:32 pm  

  • My personal view on this is that if the addict is serious and committed to quitting, he does not NEED Subutex or another "replacement" type drug.

    Put it this way. Have people quit without the use of Subutex? Yes.

    Have people quit smoking without using Nicotine gum? Yes.

    So are these things necessary? No they are not.

    Do they really truly independently INCREASE the quit success rates? I don't think that can ever be proven because the variables eg individual subject personality, motivation, etc are too wide to cross match.

    Which is why CNB is not convinced because introducing these "replacements" basically means another player into the game.

    Has it been shown that since Subutex came on there have been fewer Heroin addicts in Singapore? I don't think so otherwise ST will report that I am sure.

    Is Subutex necessary in Singapore? No. Hence why promote it?

    By Blogger Dr Oz bloke, At July 26, 2006 4:17 pm  

  • angrydoc,
    sorry, i don't understand what's 'pure disease'. yes, some don't do well with subutex, but some don't respond to anti-psychotics either. doesn't mean the medication doesn't work for others. it such a new and developing branch of medicine, nothing is certain and we can only go with the odds; actually like all branches of medicine.
    if 'addictions' are so easily overcomed, then it wouldn't be called addictions, would it? ;)
    true, many have overcome addictions cold turkey; whether drugs, alcohol, smoking etc. but we all know the dismal success rates.
    definitely patient motivation its essential , along with a supportive environment. it is not about promoting subutex, it is about having an extra weapon in dealing with drug addiction. does it increase success rates? i believe it does. does subutex cause increased incidence of heroin or other drug abuse? no, it does not. the current abuse seems to be limited to the heroin using population. it is not as if it is attractin non-addicts. so to me the advantages seem to outweigh the pitfalls.

    By Blogger huajern, At July 26, 2006 7:59 pm  

  • Yes, I suppose 'pure disease' is a rather silly term. I meant that as a disease that is purely physiological or biochemical, as opposed to having a significant psychological component.

    As for Subutex, what we are seeing locally is more people turning to it, either abusing it in substitution of heroin, or as their first taste of substance abuse, since it is technically not illegal. When a drug used to combat abuse is itself abused, and perhaps with more severe consequences (due to the manner of its administration) and more prevelance (due to its easier availability), the disadvantages begin to outweigh the potential gain.

    By Blogger angry doc, At July 26, 2006 8:31 pm  

  • Frankly, from what I have heard, there is some fishy stuff going on with Subutex.

    Even when getting it via "legitimate" means, patients already have the intention to abuse it.

    I guess doctors are not very good judge of characters or they are simply overlooking it.

    I think we should have a centralised DOTS system if we stil want to have Subutex on the market.

    By Blogger Dr Oz bloke, At July 27, 2006 6:18 pm  

  • Great site, I think most doctors in Singapore are angry.

    http://right-hospital.blogspot.com

    By Anonymous Anonymous, At July 28, 2006 1:28 am  

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