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Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation

A team of prominent addiction researchers told skeptical doctors that drug dependence has much in common with chronic illnesses such as diabetes, hypertension and asthma, and should be insured, treated and evaluated in a like manner.

Writing in the Oct. 4, 2000 edition of the Journal of the American Medical Association, researchers Tom McLellan, Ph.D., David Lewis, M.D., Charles O'Brien, M.D., Ph.D., and Herbert Kleber, M.D., said that while many physicians believe there are no effective interventions for addiction, the research says otherwise. This is especially true when outcomes are compared with those for type 2 diabetes, hypertension and asthma, diseases that are "well studied and are widely believed to have effective treatments, although they are not yet curable."

The JAMA article pointed out that addiction has a strong genetic component: studies of twins reveal rates of genetic predisposition to drug dependency similar to those for the other diseases studied. Addiction, diabetes, hypertension and asthma also are alike in that personal responsibility often plays a strong role in developing the disease and/or success in treatment.

Obesity, stress level and inactivity are all behavior-related risk factors for hypertension, for instance, the authors noted. And while 40 to 60 percent of drug-dependent individuals resume drug use within a year of treatment, the JAMA article points out that less than 30 percent of diabetics, asthmatics and individuals with hypertension adhere to dietary or behavioral recommendations that would improve their health and prevent recurrence of their disorder.

In addition to education and counseling, wrote McClellan, Lewis, O'Brien and Kleber, a number of medications have been developed in recent years that have been proven effective in treating addiction, from nicotine patches to opiate agonists like methadone, naltrexone and buprenorphine. Both naltrexone and acamprosate have been used successfully as part of alcoholism treatment, they point out, and medications are under development to treat cocaine dependence.

"These similarities in heritability, course and particularly response to treatment raise the question of why medical treatments are not seen as appropriate or effective when applied to alcohol and drug dependence," the JAMA article concluded. Part of the problem, the authors said, is that addiction -- a chronic disorder that causes long-term biological changes -- is often treated as an acute condition, with detoxification and short-term counseling. Also, few medical schools adequately train physicians about the nature of addictive illnesses.

But perhaps the biggest factor contributing to addiction treatment's image problem among physicians is simply that the outcome bar is set artificially high. "The usual outcome evaluated is whether the patient has been continuously abstinent after leaving treatment," the authors wrote. "Imagine the same strategy applied to the treatment of hypertension." How effective would treatment for hypertension be considered, the authors ask, if patients received short-term counseling, had their medication limited or eliminated by insurance cost-constraints, and were considered failures if they didn't keep their blood pressure under control from the point of discharge on?

"It is interesting that relapse among patients with diabetes, hypertension and asthma following cessation of treatment has been considered evidence of the effectiveness of those treatments and the need to retain patients in medical monitoring," the authors said. "In contrast, relapse to drug or alcohol use following discharge has been considered evidence of treatment failure." The JAMA article ends with a call for physicians to "adapt the care and medical monitoring strategies currently used in the treatment of other chronic illnesses to the treatment of drug dependence."

William L. White, an addiction treatment and recovery historian and author, called the JAMA article a milestone for the field. "You must get it and read it and discuss it," he told the audience at the Mobilizing Recovery Through Technology conference, held last month in New Orleans. "This may radically redefine ideas about treatment and recovery."

At the same meeting, article co-author David Lewis urged attendees to use the paper as an advocacy tool. "Take it to a physician who you think is on your side, and ask if they will help you and bring it to other doctors," he said.

Using the paper to illustrate his point, Lewis said that leadership from the medical community has been missing when it comes to addiction issues, which largely have been directed by law-enforcement concerns. Coordinated by Lewis, the group Physician Leadership on National Drug Policy is working to fill this gap with a "dream team" of leading physicians weighing in on critical policy issues.

Like others at the conference, Lewis acknowledged the advocacy role of the recovery community, but added, "Recovery is not the only game in town." The addiction field includes thousands of researchers and treatment professionals -- most of whom are not in personal recovery - - who can "carry the ball over the goal line" when it comes to issues like treatment parity, he said.

"Your role is unique, but you are not alone," Lewis told recovery advocates. "The measure of the success of empowerment in our community is not just going forward in advocacy, but embracing people in science, treatment and non 12-steppers. We have to go in that direction: We need you, and you need us."

 

Alexander DeLuca, M.D., FASAM.
Copyright 1999. All rights reserved.                            [Top of Page]
Revised: March 21, 2001.