It’s time to stop talking out of both sides of our mouth. Drug addiction is now recognized as a chronic medical disease just as heart disease and diabetes and cancer are chronic medical diseases. In that sense, addiction is a traditional disease. It should be covered the same way.
What happens when a patient with heart disease, who’s had several heart attacks, has another? Is he turned away from medical treatment because he’s had too many heart attacks? Does his insurance no longer cover his treatment – again, because he’s exceeded his quota? Of course he isn’t – unless his health insurance premiums aren’t paid, and even then the hospital will go through heroic measures in order to save the patient’s life. But when the patient is an addict – addicted to drugs or alcohol – the all-too-often attitude on the part of physicians is that the person should be referred to a psychiatrist or go to a 28-day treatment program. “In the past, the specialty was very much targeted toward psychiatrists,” said Nora D. Volkow, the neuroscientist in charge of the National Institute on Drug Abuse (NIDA). “It’s a gap in our training program.” Going even further, Volkow called the lack of substance-abuse education among general practitioners “a very serious problem.”
No One Chooses Addiction
Here’s another parallel between those with addiction and those with heart disease, diabetes, epilepsy, cancer or other chronic diseases. No one chooses to have the disease. You don’t wake up one day and say, “I choose to have cancer.” The statement sounds ridiculous, and it is. But the truth is that no one chooses to become an addict, either.
Relapse is Common in Chronic Disease
Think of family members, friends, co-workers, or the neighbor down the street – people who’ve had numerous trips to the hospital due to a relapse for a chronic medical disease. They may suffer a setback following cessation of treatment or a change in medication or lack of adequate support. They aren’t condemned, they’re treated. It doesn’t matter how many times they relapse. They get the treatment they need. And it’s most likely covered by their insurance. Why shouldn’t treatment for drug and alcohol addiction be covered the same way?
Stop the Blame Game
Despite the slowly changing views toward addiction, there’s still an awful lot of blame going on. The stigma attached to drug and alcohol addiction is notoriously difficult to eradicate. It’s almost as if those of us who aren’t addicted feel a sense of repugnance toward anyone who’s struggling with addiction. We may feel, even if we don’t verbalize it, that addicts are the way they are – addicted – because of their choice of lifestyle or where they live and whom they associate with. While some of these are contributing factors to addiction, the same thing could be said about people who have heart disease or get cancer. They smoke too much, eat high-fat, cholesterol-rich foods, are sedentary, become obese – the list goes on. But there’s no stigma attached and the blame game doesn’t get played much at all. Instead, the patients who have another heart attack or whose chemotherapy or other medical treatment fails go back in and doctors try something else. It’s not the fault of the patient. And the continuing treatment is covered, no problem (or, usually no problem).
Chronic Diseases Require Continuing Treatment
Let’s face it. When you or someone you know or love has a chronic disease, it’s more likely than not that there’ll be continuing treatment. For some people, treatment is required the rest of their lives, while for others, it’s more a matter of maintenance and occasional minor or major treatment episodes. If you’re a person who’s suffered a heart attack, you’re going to be on cholesterol and blood pressure medication, possibly taking nitroglycerine from time to time, and perhaps a variety of other drugs. You’ll be seeing your doctor regularly, going for various tests, and be encouraged to adopt a healthier lifestyle, including more exercise, better diet, practicing techniques to reduce stress and tension – the whole lot. If you’re a person in recovery from addiction, the picture is much the same. That is, from the standpoint of requiring ongoing maintenance, possibly medication, adopting a healthier lifestyle, regular check-ups with your doctor – and continuing counseling and participation in 12-step meetings. You never know when or if you’ll have a relapse – just like the heart attack or cancer patient has no idea when their medical outlook will take a turn for the worse.
Something happened July 1 that promises a change in direction with addiction medicine. As reported in The New York Times (//www.nytimes.com/2011/07/11/health/11addictions.html?_r=3), the medical establishment is putting its weight behind looking at the physical diagnosis of addiction. Ten medical institutions have just introduced the first accredited residency programs in addiction medicine. In the residency programs, doctors who have completed medical school and a primary residency will be able to spend a year studying the relationship between brain chemistry and addiction. The ultimate goal of the residency programs, which began July 1 with 20 students across the 10 institutions, is to establish addiction medicine as a standard specialty. In that way, addiction medicine will be a specialty just as oncology is, or pediatrics or dermatology. The residents in this residency program will treat patients with a range of addictions – drugs, alcohol, nicotine, prescription medicines and more – and study the involvement of brain chemistry as well as the role of heredity in addiction. How groundbreaking is this? The head of the residency program at the Marworth Alcohol and Chemical Dependency Treatment Center in Waverly, Pennsylvania, David Withers, puts it this way: “This is a first step toward bringing recognition, respectability and rigor to addiction medicine.” The new accreditation is the result of efforts by the American Board of Addiction Medicine, also known as ABAM, which was founded in 2007 to promote the medical treatment of addiction. The board has a goal firmly in sight to also get the residency program in addiction medicine accredited by the Accreditation Council for Graduate Medical Education. This step requires establishing the program at a minimum of 20 institutions, among other things. So the 10 institutions currently offering the residency program must be supplemented by at least 10 more. Once the recognition is achieved, it means that addiction specialty would then qualify as a primary residency – one that the newly trained doctor could go into right out of med school. As for how the effort to get more schools involved in the residency program, Richard Blondell, ABAM training committee chairman, said that the group expects to accredit another 10 to 15 institutions yet this year. Institutions currently offering the one-year addiction medicine residency program (besides Marworth) include: Boston University Medical Center, the John A. Burns School of Medicine at the University of Hawaii, St. Luke’s-Roosevelt Hospital in New York, the University at Buffalo School of Medicine, the University of Cincinnati College of Medicine, the University of Florida College of Medicine, the University of Minnesota Medical School, the University of Maryland Medical System, and the University of Wisconsin School of Medicine and Public Health. To show how important this development is, consider the quote from Dr. Daniel Alford, who oversees the new residency program at Boston University Medical Center.” The management of folks with addiction becomes very much like the management of other chronic diseases, such as asthma, hypertension or diabetes. It’s hard necessarily to cure people, but you can certainly manage the problem to the point where they are able to function.” Such management to the ability to function often includes a combination of pharmaceuticals and therapy. In The New York Times piece, Dr. Alford pointed out that the key to understanding addiction as a physical ailment is the belief that treatment must be ongoing in order to avoid a relapse. A diabetes patient isn’t cured after six weeks of insulin management and diet, and it’s not realistic to expect most drug and alcohol addicts to be completely recovered after just 28 days in a detoxification or drug and alcohol rehab facility.
Biology and Heredity
Back to the roots of addiction and other chronic medical diseases, there’s much to be learned about the contributions of biology and heredity. Genes predisposing an individual to cancer, diabetes, and addiction can play an important contributing part in whether or not the individual eventually develops the disease. Brain imaging research shows that the brain undergoes physical changes during addiction. There’s a raft of research and clinical studies underway that seeks to determine if various pharmaceuticals, alone or in combination with various forms of therapy, can work to block the effects of substance abuse, prevent it, mitigate the symptoms, reduce or eliminate cravings, even to someday “cure” addiction. Targeting certain markers for addiction, such drugs may hold a great deal of promise. But drug research and approval takes years of testing and clinical trials. And drugs alone are not the answer.
Insurers Need to Step Up Coverage
With all the hard work already underway to rethink addiction as a treatable medical disease, the evidence seems pretty overwhelming that there’s more here than just hyperbole or wishful thinking. There are hard-core and undisputable facts underlying the notion. Although insurers who provide health insurance for millions of Americans may be reluctant to accept the reality of addiction as a chronic medical disease that deserves parity with any other chronic medical disease, the tide of public opinion may be starting to swell. The more publicity efforts like the new residency program in addiction medicine and the move to accredit the program so that the addiction specialty can be a primary residency receive, the more the general public will understand that addiction can be treated. In 2009, according to the National Survey on Drug Use and Health (NSDUH), an estimated 22.5 million persons aged 12 or older were classified with substance dependence or use in the past year. Of these, 3.2 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.9 million were dependent on or abused illicit drugs but not alcohol, and 15.4 million were dependent on or abused alcohol but not illicit drugs. In 2009, an estimated 69.7 million Americans aged 12 or older were current (past month) users of a tobacco product. In 2009, of the 23.5 million people who needed treatment for drug or alcohol use, only 2.6 million received treatment at a specialty facility. This leaves 20.9 million persons who needed treatment but did not receive it. Among the reasons why people who required treatment but didn’t get it, the biggest one was that they had no health coverage and couldn’t afford the cost of treatment (36.8 percent), and another 8.8 percent had health coverage but it did not cover treatment or did not cover the cost. This is a huge discrepancy. And it isn’t just 2009. The figures have remained fairly constant for surveys done in 2002 through 2008. Think of it: millions of Americans dependent upon or abusing drugs or alcohol, requiring treatment and not getting it – or not being able to have it continued due to lack of adequate (or any) health insurance coverage. Isn’t it time that drug addiction gets covered the same way heart disease is? Isn’t it time we stop talking out of both sides of our mouth? When looking at the whole picture, it seems that the only way things are going to get better is if enough people clamor for change. Demand coverage. It should be your right – if you have insurance, you should be covered for addiction treatment, however long and however many times it takes. Results from innovative and bold initiatives like the addiction residency program and accreditation of addiction specialty as a primary residency will perhaps help pave the way. The time is now. The need is great. And it’s not going to go away anytime soon.