Fiat is an economic and legal term that isn’t often used in science and medicine, so it needs a bit of explaining. A fiat currency is a currency that has no actual value and is only money because the government says it is. Many years ago a dollar bill said on it that it was a debt to the holder and if you wanted, you could go to the bank and exchange for money made of silver or gold. The paper money then was backed by metal. It had value because the metal had value. Now, the paper is just paper and it has value because the government says it’s legal tender. That’s fiat money. If the government didn’t say it was valuable we wouldn’t use it.
So what is fiat medication? Fiat medication is medication that people wouldn’t use unless someone made them.
Let’s assume a reasonable person who wants to get better and is given a medication. He’ll generally take it unless it causes bad side effects or doesn’t work. Everyone has a cost/benefit analysis going on in their head all the time. If it doesn’t do me any good or is causing more harm than good, I’m not likely to continue to take it. People generally suffer from illnesses themselves and so society lets them make this choice. But, not always.
In cases where the illness threatens society and the person won’t take medication, for instance, tuberculosis, the government can mandate treatment even to the point of confining a person if necessary to ensure that they are treated. This would be an example of a fiat medication. It’s not a medicine because I want it or it has value to me. It is a medicine for me because the government says it is.
In our democratic society, there are a lot of hoops to jump through before you can take away someone’s rights and make them take a medication. That’s as it should be. And in the case of tuberculosis, it’s pretty clear that the person doesn’t feel worse with the treatment and gets a benefit too even if they don’t see it at the time.
There are other examples of medication that is used or formulated for people who won’t take it. People with schizophrenia for instance, who are so psychotic that they can’t take their medication, can be given a monthly shot of depot medication to ensure compliance. In this case the patients do sometimes feel worse with the medication but, again, society can override their objections with arguments that they may pose a danger if unmedicated. And so the same logic is used for addiction.
There is a depot once a month shot that is marketed as treatment for addiction to opioids and alcohol. It’s attracted a lot of interest especially among people who are tasked with legal aspects of addiction. In fact, I recently heard that the head of the addicted professionals board for a major southern state has stated that she wants every pharmacist who is on contract with the board on this medication whether they have addiction to the drugs it indicated for or not. It’s a very attractive prospect, sort of like a shoot and forget weapon. There’s only one problem. While it stops drug use, it doesn’t make anyone really feel better. They had to formulate the once a month shot because most people who have addiction just won’t take it when it’s up to them.
So now there’s a fiat medication for addiction. It’s not medication because most people experience that they are helped by it but rather because someone else said it is medication for addiction. You can see why someone else would say that too. If you experience someone else’s addiction as drug taking and the consequences, but have no insight into the symptoms they feel when they aren’t taking drugs, you’ll define addiction as drug taking, and any medication that stops drug taking will look like treatment for addiction. This leads us to fiat diagnosis.
Addiction stands alone in medicine as a diagnosis imposed by others for the purpose of others. Nowhere in DSM IV are there biological symptoms of distress that addicts complain about early in the disease. The diagnosis of addiction in modern psychiatry is made very late in the course when behavior is greatly changed by the need to suppress symptoms that are disturbing. What no one seems to have asked people with addiction is, “When did these symptoms start?” When you do, you’ll often here that they have never felt right, never felt well, until they took the first hit of whatever did the trick, and all of a sudden they felt like they think the rest of the people around them feel. When you ask addicts what the symptoms of addiction are, they don’t generally talk about how they feel when they are loaded but rather how they feel when they aren’t, and rather than this being a response to voluntary drug use, most can relate to the symptoms coming before the first drug use.
Recent genetic studies seem to bear that out, and my own experience with looking at the genetic data of some patients bear it out as well. Most addicts are different before their first drug. If this was any other disease in medicine we’d be trying to find medications that alleviate the primary symptoms rather than stop the behavior that the patient perceives as the only relief from the symptoms. I really can’t blame those in power who create fiats for treatment given how the medical world has defined addiction. Hopefully, with more people reading and learning about the primary neurobiology of the illness, more will come to understand the primary chronic nature of the illness.
© Howard C Wetsman MD FASAM