Treating addiction as a chronic disease - how do we get from here to there?

We are at a watershed moment in the field of substance abuse treatment. Public awareness about addiction is growing, the research base is expanding so that we can better address social and biological determinants of the disease, and health reform and parity legislation will change the way substance use disorders are managed within healthcare. Now, more than ever before in history, there is a real opportunity to prevent, intervene earlier and effectively treat substance use disorders – but only if we come together to demand comprehensive quality that is on par with treatments for other chronic medical illnesses.

Like other chronic medical illnesses, substance use disorders have biological, social and behavioral components; and effective management of the disease requires attention to each of these pieces (similar to Type-II Diabetes). According to the Food and Drug Administration’s standards for effectiveness, there are presently four prevention interventions, five medications and more than a dozen behavioral therapies that can be called effective in preventing, intervening early and managing substance use disorders. We know the best outcomes are achieved when the disease is identified and intervened upon early in its trajectory. But even serious, chronic cases can be treated effectively.  Self-managed, continuing recovery is now the expectable outcome from all addiction treatments. So why does this statement seem so surprising – where does one go to get these effective treatments?

A recent call from a family member of a patient illustrates just how bad the situation is. This call was from a very senior level executive at a prestigious medical school, asking for advice on how to help his 26 year old son who has a serious heroin addiction. The son had been through five residential treatment programs over the past several years, at a cost to the family of over $150,000. The first troubling thing about this call was the reason this man reached out to me.  He called me because I have been public about my own son’s drug overdose – he was calling me as another affected father and had no idea that I had any familiarity with the field other than my family experience. Let’s just stop there. Consider if this high-level executive’s son had been suffering from a rare tropical disease; he would have unhesitatingly sought and received guidance from a leading medical expert – not a father who had lost his child to that disease. In this case, he was literally too ashamed to contact one of his own organization’s physicians.  This extraordinary degree of stigma and sense of isolation that families still experience is unjustified and incapacitating. The second thing that troubles me about this interaction is that although his son had been to five residential treatment programs, he was unaware that there were any FDA-approved medications for the treatment of opioid dependence. No treatment program had informed him or his son about these treatments, even in the face of repeated, potentially deadly relapses. This is not simply inappropriate – it is unethical. 

Unfortunately this is not an isolated case, and this potentially lethal level of ignorance is not restricted just to patients or parents. Many physicians and counselors have never even heard of these medications or of many other “evidence-based” behavioral interventions and most were never trained in how to manage substance use disorders. Many specialty addiction treatment programs are not staffed to provide anything other than basic group counseling; other programs are not licensed or funded to provide these more effective but more costly therapies and medications; and still, other programs refuse to provide them on ideological grounds. For example, there are currently three FDA-approved medications for the treatment of opioid addiction, yet less than 30% of addiction treatment programs offer addiction medications, and less than half of the eligible patients in those programs ever receive them. Based on a recent review of the issue by ASAM, TRI and the Avisa Group, it appears that the most significant reasons for the lack of physician utilization are lack of training, legal and regulatory controls on the medications and, most significantly, written and unwritten insurance coverage limitations.

Most of us recall a time when AIDS patients could not get full access to potentially helpful medications and treatments. At that time, gay, IV drug-using, usually minority AIDS patients were the most stigmatized and discriminated group of patients in America. But they would not remain silent or become shamed into inaction by the nature of their illness. We all know what happened – because of unrelenting patient requests, broad public support developed and there were demands for basic fairness and equitable care. Now, essentially all medical, nursing and pharmacy schools train students in care for HIV/AIDS and other infectious diseases, and there is broad public awareness of available, evidence-based standards of care for this disease. I believe that fathers of sons affected with HIV/AIDS can quickly learn where to get effective care. They no longer have to call fathers who have lost their sons to the disease. 

It is time and it is possible for individuals with emerging substance use disorders to have all available medical facts associated with the progression of addictive disease; to receive full disclosure and information about all evidence-based treatment options for their condition; and to have full access to all evidence-based therapies, medications and services. I am hopeful that the Affordable Care Act and the Parity Legislation together will create basic fairness for individuals and families affected by the disease of addiction. But if those landmark pieces of legislation are not enough, it will be time to stand together to demand the already available health benefits for the prevention and treatment of substance use.