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

July 2, 2013
by A. Thomas McLellan
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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. 

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Bravo. Another great/inspiring piece from Tom McLellan. Reminds me of the recent works from author/researcher Anne Fletcher, William White, Mark Willenbring. Great article.

Thank you Tom McClellan. Another credible voice calling out the presence of the elephant in our collective living rooms. We only, call it, a "chronic disease", just like we throw around the term "evidence based", and pretend to groom our treatment protocols to this reality. The stigma associated with medication assisted treatment is astounding, in a field that professes to care so deeply for the "suffering addict".
My only disagreement with Tom's call to action is his belief that the primary causes for failure to utilize medications are ignorance, regulatory controls and the failure of health insurers to provide reimbursement. Ignorance would imply that physicians/programs don't know about medications. Given the plethora of dissension in the field, it would be hard not to have heard of buprenorphine and other forms of medication assisted treatment. Having used buprenorphine for nine years, in our outpatient program, we have yet to encounter regulatory limitations that preclude our use of MAT. Lastly, we have found health insurers, most notably United Behavioral Health, to be extremely supportive of efforts to use MAT and to learn forms of best practice.
Our negative experiences are within our own field, and it, typically, revolves around inpatient programs' resistance to utilization of medication, including buprenorphine. When pressed for reasons for this resistance the responses have ranged from "what would we tell our other patients who aren't on buprenorphine" to "buprenorphine eliminates their ability to access their spirituality and/or feelings". The simple truth is that there is a stigma that is perpetuated by too many professionals in the addiction field. How many times have I heard "buprenorphine just trades one drug for another". How many of the major providers have co-signed the boycott of ASAM's conference because they focused too much on medications and had become, allegedly, the "lackeys" of the pharmaceutical industry.
Tom McLellan is absolutely right in his call for the field to read the studies related to buprenorphine and consider that young people are dying every day behind the failure of this field to embrace the best practice, regardless of what it might do to our census. Hazelden has taken the lead in acknowledging the need for individualized treatment that may include buprenorphine or other medications to come. I am not afraid of the greed of the pharmaceutical industry, I'm afraid of the greed in the field that I have called mine for thirty years. Tom is right, we need to stand up and tell the truth that the policies, of too many programs are participating in the unnecessary deaths of many of our patients.
I, too, believe that ACA and parity are going to give us the opportunity to create a whole new field. One that is focused, exclusively, on the health and welfare of the people that we treat and not bound by the bias, stigma and greed that has already lasted far too long.
We have become an industry of "boutique" programs who use call centers staffed with salespeople to do screening and assessments. It is time for some major changes.

It is encouraging to hear the positive experience your team has had with utilizing medications – this is not what we have seen in the majority of practices and I hope that this is a sign that the tides are turning. As to your comments regarding the ideological battles that have divided our field - I couldn’t agree more. We must come together as a field to ensure that patients have access to ALL the effective therapies for treating substance use disorders.

According to recent examinations of treatment programs, most are rooted in outdated methods rather than newer approaches shown in scientific studies to be more effective in helping people achieve and maintain addiction-free lives. People typically do more research when shopping for a new car than when seeking treatment for addiction.

Interesting article. It caught my attention that the example used was of a 26 year old whose family had $150,000 to drop on sending the kid to rehabs. Although there are plenty of addicted people from wealthy families, by far most opiod addicts don't have those kinds of opportunities and resources to get help, especially at age 26. The drug user of today has changed and treating them has become much more of a challenge. This current and upcoming generation of young people who abuse substances as a whole are much less motivated, have greater prevalence of coexisting emotional and behavioral issues, and tend to be less motivated and hopeful about the future, creating huge challenges for treatment providers at all levels. A paradigm shift has been in need for quite a while. Taking the Escalator

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There is controversy over whether people with addiction have choice over anti-social and dangerous behaviors.The disease creates distortions in thinking, feelings and perceptions, which drive people to behave in ways that are not understandable to others around them. Addiction is considered a brain disease because alcohol and drugs changes the brain chemically, structurally and functionally. While it’s true that for most people the initial decision to participate of alcohol or drugs is undertaken, over time these substances literally change numerous aspects of the brain to the point where the individual cannot stop using or drinking even if the desire to do so is high.

For those who are addicted, and their families, it is SO important to have the right information on how to treat the addiction. From personal experience, because there is a lot of competition between treatment centers…. money becomes more important than treatment quality, on occasion. Access to good, local addiction treatment is hard to come by!

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