Drug dependence as a chronic medical illness.

To the Editor: Dr McLellan and colleagues state that drug addiction should be treated as a chronic medical disease. This contradicts our experiences as a sheriff (L.A.) and an emergency department physician (D.L.S.) who regularly encounter patients who provide false histories concerning trauma or pain syndromes, insist on narcotic analgesics, and vigorously refuse nonnarcotic analgesics or follow-up with an office-based physician. Our experience has been that the overwhelming majority of such patients will not agree to enter a drug rehabilitation program or to go to Alcoholics Anonymous or Narcotics Anonymous. Anecdotally, most patients who have been in rehabilitation experience a relapse or a loss of control of their drug dependency. Only a tiny minority of these patients will follow up with a single physician or medical office for ongoing medical management of their chronic illness. The vast majority of drugdependent individuals do not view their condition as an illness, but rather spend tremendous resources and take great risks, including that of jail or even death, to continue their lifestyle. In our area we have discovered organized groups that travel from physician to physician for the express purpose of obtaining drugs. Most people who use illegal drugs make a conscious decision to do so. Although we believe that treatment should be available, it must also be accompanied by consequences, such as jail or involuntary commitment, for noncompliance with detoxification. From our observations, many individuals use drugs to insulate themselves from life and its problems. It is impossible to view all drug users and addicts together, but practical experience provides insight into a world that they choose to inhabit.