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Addiction and Crime

It is not a good idea to treat someone for an illness they do not have. In fact, it could be considered unethical. We have a successful model now in the professional health world for treating addiction as an illness. And if someone has that illness they should be diagnosed and treated. And there are plenty who do need treatment. Unfortunately, it is not rare in my practice to see people misdiagnosed. I think the largest group of those are individuals who commit a crime related to substance use, such as fraudulent prescribing or driving under the influence, and bias makes us want to diagnose them with a substance use disorder. We can treat addiction. We understand addiction. But it is not always addiction. I believe some of these folks do have a substance use disorder but some are just unethical and have committed criminal behavior. The distinction is important and can be made.

Some years ago, a state Medical Board I worked with considered a new rule that would have prevented any physician who had committed a crime (associated with their addiction) from being eligible to enter their state Physician Health Program. This would have been disastrous because almost all addicts commit crimes (DUI, diversion, etc.). The converse is not true, however, not all crimes involving drugs or alcohol are caused by addiction. These are important distinctions. Here’s an example of what I am talking about.

Take the case of a nurse who worked at a busy clinic. The nurse says she asked the doctor at the clinic if he would write a prescription for Adderall because she was too busy to go to her own doctor. The nurse claims the doctor said go ahead. He was busy so she signed his name. Big mistake. This went on for months. The prescription was for the same low dosage she was previously taking, Adderall 10mg BID. She was writing for #60 per month and signing his name. One day the pharmacist noticed the signature was not right and he refused to fill the prescription. He was going to call the doctor. The nurse mentioned to the doctor that the pharmacist might call and he denied ever giving her permission to write ongoing prescriptions. A physician’s assistant overheard the conversation and reported it. The nurse was fired. The clinic reported it to the police and the district attorney decided to press charges for fraudulent prescribing. The nurse pled guilty to a felony. She completed court ordered treatment among other penalties. Then, of course, the nursing board got involved. She was referred to me for evaluation (the first evaluation she had had). When I saw her and took an exhaustive history, she met none of the DSM 5 criteria for substance use disorder. She had committed a crime, diverting a controlled substance. Yet, the nursing board ultimately insisted, despite the fact that she did not have a substance use disorder diagnosis, that she undergo further treatment and be in monitoring for 5 years.

This issue seems to come up frequently. For example, the doctor who gets arrested for a DUI but does not meet DSM 5 criteria for Substance Use Disorder (about 46% of 1st time DUI offenders meet DSM 5 criteria for a Substance Use Disorder ). Or consider the airline pilot who made the poor decision to go out with his girlfriend in Paris the night before flying and still had alcohol on his breath when he showed up for work the next day but does not meet DSM 5 criteria. Or, as above, the health professional who decides to write their own prescription for controlled substance, or even writing the prescription for someone else and taking them. Are all of these people addicts? Some are. Maybe not all.

Maybe these folks who commit crimes but are not addicted should go to jail, or be fined and likely they should be in diagnostic monitoring but forcing someone to undergo addiction treatment who does not have an addiction is wrong. It is not good for them and it is not good for other patients in treatment. It is too obvious that it is an abuse of power.

One way we rationalize this is by loose interpretation of the DSM 5 criteria. For example, if someone returns to drinking after a DUI and they have not been required to be abstinent we could stretch things and say “they were drinking more than planned” because they should not have returned to drinking. Or we could say they “continued to drink after attempting to cut down or quit drinking” even if they insist they quit during the court ordered period and then resumed drinking alcohol intentionally after the court commitment was complete. This is wrong interpretation of the DSM 5 criteria. In this way, other of the DSM 5 criteria have been misused and misinterpreted.

Conducting thorough but fair evaluations is very important. Our great system of care will be threatened if we are not accurate. We need to strive to not let bias sway our diagnostic accuracy. If it looks like addiction but is not then maybe we should monitor and wait and see. We do not treat someone for cancer because it looks almost like cancer. It is best if we are sure.

1 Comment »

  1. Dynasty Building Solutions Victor Lupis

    Addiction and Crime | Center for Professional Recovery

    Trackback by Dynasty Building Solutions Victor Lupis — January 15, 2020 @ 4:17 pm

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