Past Issues

As a relatively “senior” member of the Taiwanese psychiatric community, this writer grew up and received his earlier education in a society that was relatively less complex and complicated, at least in terms of addiction and the use of various substances for “recreational” purposes. For sure, some of us experimented on cigarette smoking and alcohol imbibing at a tender age, but by and large we stayed out of harms way. For the same reason, Taiwanese psychiatrists of my vintage were rarely exposed to clinical experiences with patients laden with drug abuse problems during the formative years of their professional careers. While in the ensuing decades, the mental health professions in Taiwan have witnessed exceptional progress in many ways, it is probably fair to say that, until most recently, most of us have remained oblivious, and one might say, blissfully ignorant, of the mushrooming problems associated with addictive disorders. Consequently, our training programs still do not include adequate coverage in this regard; treatment programs are sparse and fragmented; rehabilitation resources are almost nonexistent; linkage between the law enforcement and health care systems is rudimentary at best; and, research efforts have been sporadic and nonsystematic, excellent contributions notwithstanding.

This state of affairs is particularly troublesome since, as is true with practically all major health problems confronting modern societies. They are diabetes and hypertension, ills related to addiction maybe regarded as a price we pay for affl uence, personal freedom (in the sense that individuals in modern societies are less subjected to social sanctions and internalized indoctrinations) and accelerating social changes. Whatever the reasons might have been, what is clear is that the prevalence of serious addictive problems have been on the rise in Taiwan at a steady pace, and they are impacting the health care system, the judicial system, and the society as a whole. Since data documenting these trends and infl uences have been reviewed and summarized in a number of extremely well-prepared reports and monographs, including a comprehensive chapter in the upcoming volume titled “Healthy Taiwan 2020,” they will not be further restated here. Suffi ce it to say that substance use and abuses (and other forms of addiction) represent major challenges for us, for health professionals collectively in Taiwan, and for the society as a whole (as well as for the whole world) that these problems can no longer be swept under the rug. In order to hope to keep them at bay, somehow not to allow them to further aggravate and get out of hand, we need to put our best concerted efforts into it if we still hope to gain some control over it. The train is leaving the platform, it is time we jump on board and gain control of its direction, even if we cannot stop it.

Have we been too complacent in dealing with substance abuse issues? Has our profession been guilty of neglecting such major behavioral and social problems that entangle so much and so intimately with our existence? Of course not. For more than half a century, Taiwanese psychiatrists have made substantive contributions to the world literature on substance abuse, especially in the directions of epidemiology and genetics. This notwithstanding, until most recently, we did not have a viable infrastructure for the care of the rapidly expanding substance abuse populations. We do not yet have set policies regarding the prevention, treatment and rehabilitation of these patients, whose care is fragmented and limited at best. Detoxifi cation and abstinence programs remain outside of any health insurance coverage. Funding related to substance abuse has been meager and unorganized (for example, we still do not have anything remotely comparable to the National Institute on Drug Abuse [NIDA], the National Institute on Alcohol Abuse and Alcoholism [NIAAA] or the Substance Abuse and Mental Health Services Administration [SAMHSA], and our National Bureau of Controlled Drugs [NBCD] is the smallest unit within the Department of Health [DOH] bureaucratic system). Although reasons for such gross neglect maybe complex and multi-layered, they probably all refl ect the deeply rooted stigma and biases against substance abuse: prevailing beliefs widely held by professionals and the general populace (and especially the society’s opinion leaders) that addiction is purely a refl ection of personal moral weaknesses, that it is hopeless, that treatment is of dubious effect, and that it is a waste of money and time to make any investment on these “social rejects.” To a large extent, similar stigmata and biases have plagued the mental health fi elds. Schizophrenia, autism and depression have been progressively better understood and accepted as diseases in recent years by the general public. We have to be grateful for the tireless efforts of many of our pioneers and leaders as well as those who have supported our fi eld. Although in theory such experiences should equip us to more effectively achieve similar goals in the substance abuse arena, in practice there maybe even more obstacles, if for nothing else, simply for the reason that addiction is even less likely to be regarded as a medical affl iction, and more deeply entangled with moral and legal sentiments and judgments.

The introduction of the methadone clinics and other harm reduction programs, such as the needle exchange programs, represents a major milestone in the development of addiction psychiatry. Although these programs were initiated way too late, and were pushed into existence for reasons not centrally related to addiction, they nevertheless for the fi rst time drew a large number of those chronically trapped in the often downward spiraling course of heroin addiction to the medical care system. Previously, they had been bouncing back and forth between jails, emergency rooms and the shady underworld. Now they are coming to us, opening up to us to try to provide something that might stabilize their life, at least to some extent. We have something specifi c to offer that might work, at least some of the time. To the extent these interventions work, they keep patients out of harm’s way, and protect the society from problems associated with substance abuse. While far from a perfect solution, these programs make it possible for combating the ravages of HIV/AIDS and other blood –borne infections, and likely will reduce drug-associated crimes and enhance productivity in the long run.

That we have been able to achieve so much in such a relatively short period of time is a testimony to the passion, ingenuity and dedication of many among us, as well as the generally accepting and supportive atmosphere from policymakers and the general public. Unfortunately, experiences from other countries with a longer history in promoting harm reduction indicate that such a “honeymoon” period will not last forever. Unless adequate resources and expanded support are in place, our colleagues are not likely to continue to maintain such high level of enthusiasm, optimism and dedication. In other words, staff “burn-out” is a given, waiting to happen, if not already happening. Cynicism would seep in and poison the system. We could soon lose that precious sense of mission, and start to regard the added responsibility of running such harm reduction programs as yet another “dirty work” dumped upon us by the bureaucrats. Patients would sense the pessimism and the programs that appear so exciting and promising at the moment might lose their luster and fade away.

Similarly, public opinions and attention tend to be cyclical and general attitudes might swing back and forth depending on fortuitous events and societal whims. Assuming that the promotion of harm reduction and the care of substance abuse patients (as well as more broadly, health care for all) are more likely to be the agenda of those with more liberal leanings, a swing towards a more conservative direction might mean a resurgence of focus on law and order, at the expense of social justice and human services. This is not to say what is right and what is wrong, but to point out that in an open society there always will be differing opinions and attitudes, and social policies are not purely determined by rational considerations. Thus, while things are still going well, we need to expect and prepared for coming waves of backlashes and setbacks, which could come just around the corner. When that time comes, what we have labored so hard and so long to establish could be totally wiped out. To prevent that, we need to archieve that we already have some infrastructures in place; that we know what we are doing; that we can demonstrate effi cacy, utility and even cost-effectiveness in what we have to offer; that we are sure that our programs do what they promise to do, that there is accountability and credibility, that they represent quality work we could be proud of; and that we have formed a durable network of seasoned clinicians, academicians and policy makers who are able to support one another’s work, sustain their momentum and morale. In other words, to move things forward (and there still is much to be done), we need ongoing efforts in training, doing research and fostering professional identities. We need to be sure that the houses we are building are not houses of cards or houses on sand. They need to be able to weather storms, adversities, and we need to have the blueprints ready when opportunities knock on the door.

Given that most of us had had at most limited experiences in the running of methadone programs, it is indeed truly remarkable that in less than two years we have been able to establish close to 70 such programs that appear to be going well, with minimal disruptions and practically no major catastrophe. There is no question that this is a remarkable and exceptional achievement, of which we should take credit and be extremely proud. But this should not be taken to mean that preparation, training and quality assurance are not at issue. How long will we continue to be in luck? When will our relative lack of experiences and training come to haunt us? To be sure, motivation and enthusiasm go a long way, but sooner or latter that sense of excitement will wane, and professionalism and professional standards rooted in adequacy in training and ongoing education will be the main driving force to ensure the quality of care. This is thus high time that we start prepare our colleagues well before sending them to the battlefi elds. At the minimum, we need to start planning for training selected psychiatrists who will be equipped with adequate knowledge base and tools, as well as clinical, community and research experiences, to work with our senior experts in the fi eld as future leaders for promoting of addiction psychiatry. To this end, the National Health Research Institutes has initiated a post-residency subspecialty program and is currently recruiting candidates. But even this will just be the beginning of a long and ongoing process. We need to also provide training for other professionals (psychiatric nurses, case workers, therapists, community workers) to prepare them for careers in such a direction. It may be argued that “on the job training” and “learning by doing” are the most effective way of acquiring new skills, but without standards, formal instructions, and structured clinical and community experiences, quality would suffer, and the sense of “amateurism” will continue to linger, impeding any further progress of the fi eld.

We have all the reasons to believe that our methadone programs (and maybe the needle exchange programs) have already made substantive impact on the lives of the participants (now numbering close to 20,000). And indeed this must have been the case. The mere fact that so many addicts came out of the woodwork and have stayed with us is already a major coup and a measure of success. Based on world literature and our own experiences, we assume that they have stayed with us because we have helped them, in terms of curbing their desire to use heroin and urge to engage in risky behaviors for achieving the “highs.” We expect them to be less inclined to commit crimes, to be re-arrested less often, to be more likely to gain employment, to lead a more stable life, to amend their relationships with their loved ones, or to form new and meaningful relationships. In short, to lead a happier, more meaningful and more productive life. Are these assumptions true? To what extent are they true? To the best of my knowledge, we still have no objective data to backup these claims. When the chips are down, the public will want to know if their investments have been worthwhile (in terms of expenditure, public safety and productivity) and if it is worth more investment (the answer of which is apparent to us, but not necessarily so for the politicians and tax payers).

Are we utilizing our weapons and ammunitions in the optimal manner? To what extent is the dose range of methadone used for our patients appropriate and optimal? How often are these patients under-treated, leading to dropping out, or over-dosed, leading to side effects, toxicity and dropping out? Are there ways to capitalize on some of the modern advances in pharmacogenomics and therapeutic drug monitoring to individualize methadone therapy? Who respond better to methadone as versus Suboxone (buprenorphine + naloxone)? What are some of the characteristics of the individuals that might lead to better treatment response? How about characteristics of the programs that are conducive to replacement therapy? What might be the best way to provide for psychosocial interventions, given the limited resources available to most programs? Are there other innovative ways for treating these patients? Will it ever be possible to develop truly anti-craving agents that could be used clinically?

These are but some of the questions that will continue to shout at us, demanding answers. We have a window of opportunity to systematically address these questions: The research methodology, the population, and research talents are here, and the results will have major public health impact. The results (and the process for achieving these results) will be translational research at its best. Translational not only in terms of taking laboratory fi ndings to clinical applications (from the bedside to the bench) but even more importantly, tackling major clinical and public health questions with state of the art research tools and methodologies.

Ultimately, to exert real and lasting impact on the prevention and management of substance abuse problems, this level of translation needs to be further strengthened by another level of translation, that of translation of practice from research settings to the general practice. For such a purpose, we need to establish demonstration centers that ideally will serve not only as the focal points for conducting some of the research projects indicated above, but also provide the infrastructure for training, for stimulating and promoting the formulation of consensus and guidelines, and for disseminating the information and practices throughout the country and internationally. The research programs and the demonstration centers should also be conducive in promoting the formation of collaborations among clinical and academic institutions, as well as the linking and collaborations across agencies, which is particularly important in the addiction fi eld as problems associated with substance abuse are multifaceted. We also need data, input and leadership beyond the health care professions, reaching out to the legal, labor, educational systems if we are going to make a dent on these modern day plagues.

Can we do all of these, or some of them? It would appear that capability is not an issue, and at the moment we do have a window of opportunity, ironically being presented because of the public’s fear of a perceived HIV/AIDS epidemic. It is up to us to best utilize such an opportunity, combating many of the myths associated with addiction. As the title of this commentary suggested, one of the messages we need to convey is that no drugs are poisons when used in the right context. Labeling some of the “illicit drugs” as “poisons,” as is commonly practiced in Taiwan and throughout the Chinese-speaking world, over-simplifi es issues (all drugs are poisons; many are more dangerous than illicit drugs) involved and shifts the focus from the behavior to the substances. The term also conveys a message of passivity and pessimism (“being poisoned”) and evoke sometimes unnecessary and irrational fear. Stigma related to addiction is bad enough without all the thoughts associated with poisons. We need to fi nd a way to minimize such misinformation, such that we could move forward with our explorations on behavior, temperament, genetic, developmental, environmental and social forces that are responsible for tendencies for addiction, which exist in all of us, and not demonize those unfortunately encumbered with addictive problems. There are many major tasks that are awaiting us, confronting us. But perhaps, among any number of these tasks, the most fundamental and most urgent one is fi nding ways to deal with stigma that has been so deeply rooted in anything associated with addiction.