When I think about it, there are few terms in the addiction treatment field that are more silly than “Drug of Choice.” As if we get to choose which drug makes the brain go BAM. When you talk to an addict and ask, “What’s your drug of choice?,” what you get is the answer to “What drug that is available to you lately at a price you can afford that makes you feel better with the least side effects?” Quite a mouthful, huh?
Would we ask a diabetic if their toxin of choice is sugar? How did they choose sugar? Why didn’t they choose to have an abnormal reaction to arsenic instead of sugar? What a stupid choice! Using the concept of choice, as in which would you choose if they were all lined up, can confuse us and strengthen the stigma and the idea that addicts are normal people who choose to use drugs. If we asked an addict if they chose to have cocaine work the way it works with them or if they chose to have an abnormal reaction to alcohol we’d hear a resounding “no.” “If I had the choice of what my brain reacted to I’d have picked something a lot cheaper and easier to get than cocaine.” Something like wildflowers or dandelions, no doubt.
What is it we really want to know when we ask the question? And why? Well, up to now we really haven’t had a good reason. We just needed a word to write down in the “Drug of Choice” box on the assessment. In many cases it meant something, for instance when the person used only one drug. Most of the time however it doesn’t actually mean much with regard to choosing treatment. However because researchers like things that come in boxes there has been a lot of research on “Drug of Choice.” It’s been used to predict treatment outcomes with regard to which treatment is used. One example of such a research question would be, “Do alcoholics or opioid addicts do better when given naltrexone?” By dividing people up by “Drug of Choice” we manage to make one population (alcoholics) which is heterogeneous sound different from another (opioid addicts) which is heterogeneous in a different and overlapping way with regard to neurobiology. It’s really no wonder most addiction research doesn’t make much sense.
But still insurance companies ask the question and the government asks the question so we ask the question, as if we get to choose. But modern science actually gives us a new reason to ask a question about “Drug of Choice.” It’s just not the question we’ve been asking.
We don’t have lab tests that we can use clinically in addiction medicine. It would be great if we had rapid, inexpensive genetic testing or PET scans that actually could predict something in individual patients instead of groups of subjects. But we don’t and they don’t, yet. In the meantime we get to ask the patient about the drugs he’s used and with the knowledge of how those drugs work in the brain we can make some informed choices about which medications might help the patient. The problem is that people use the drug they use for a lot of different reasons and we need to know those reasons as well for it to mean anything clinically.
For instance, we may ask a person if he likes to use cocaine? He says no, that he hates it. If we take it that far and no further we think that cocaine doesn’t work for him and that a dopamine reuptake blocker such as buproprion wouldn’t work as a medication for him. But if we ask him why he doesn’t like cocaine, we may get more information. He may tell us he doesn’t like the crash or the paranoia, but that he can feel normal for about 10 minutes when he uses cocaine. If it was the only drug that worked for him he’d use it but fortunately alcohol works as well and lasts longer so he drinks. It tells us first that he would likely do better on buproprion and second that he’s not likely to respond to naltrexone as some alcoholics do.
So we do need a question; it’s just not, “What’s your Drug of Choice.” It’s more like “What drug or drugs work to make your brain feel normal at the peak of the experience regardless of what side effects or time course may make you not like the experience in general.” You know, the DODWTMYBFNATPOTEROWSEOTCMMYNLTEIG. We need a shorter acronym; the government wouldn’t even use that one, and they thought up SAMHSA! And while we’re at it we need a term that doesn’t make people think that addicts get to choose what makes them feel better. Cocaine doesn’t have a street value because a lot of people choose it; it has a street value because it works to make a lot of people with addiction feel normal for a brief period of time. When we use the word “choose” society gets the wrong idea and will come up with the wrong solution.
© Howard C Wetsman MD FASAM