I find Dr Ian MacDonald’s comments in the letter published in the April issue of the BCMJ resonate with my own [2008;50:123-124], and more particularly with my own experience both in treatment/management of an addict during my general practice, and later, after a residency year in psychiatry, during my tenure as clinical director of the Narcotic Addiction Foundation in 1974–75.
There is little doubt that the Insite proponents as well as the provincial and federal government politicians are failing to recognize that:
• All drug-abusing persons (no matter the kind of drug) demonstrate a personality disorder.
• The most common major heroin-addicted person’s personality disorder is a sociopathic personality disorder.
• There is no easy “treatment” of the above; however, there is a therapeutic management usually referred to as “behavioral modification” which can—and does—produce socially acceptable results, although it is always intense, protracted, and one-on-one.
• Demonstrably, all my heroin-addicted patients had/have a remarkable and always-successful cure to their problem: simply provide more heroin ad libitum (their consistent total lack of insight into the underlying psychodynamics is just as remarkable!).
• A few—but very few—of the addiction treatment/management personnel understand that the value of methadone is solely to take the edge off the addicted person’s withdrawal symptoms and provide some respite, allowing alternative lifestyles to be learned and internalized.
One of my powerful mentors (Dr Larson, medical director at the psychiatric hospital in North Battleford, Saskatchewan) observed that the sole process lacking in all personality disorders—particularly sociopathic personality disorders—is the person’s failure to mature (or, as he phrased it, to grow up).
Thus this truism demands that all treatment be based on this underlying premise. Insite obviously lacks any element of this.
—David J. Brant, MD