It’s been ten years since a special communication in the Journal of the American Medical Association by four leading experts declared that drug dependence (including alcohol) should be treated as a chronic medical problem, not a social problem. This was not a brand new idea, but seeing it in JAMA was like the golden seal of approval. Or it should have been.
Ten years later, are we closer to that goal? There’s been a lot more thinking about how we should integrate treatment of substance use disorders into primary care and public health systems. A few places are doing it, including some pilot projects. But when it comes to health system-wide, daily clinical level — that remains abysmal.
Here’s what the White House Office of National Drug Control Policy’s National Drug Control Strategy 2010 says about the failure to integrate treatment into health care:
“…addiction treatment is the only specialty in medicine that is not an integral part of the rest of the healthcare system There is a great divide between addiction treatment programs and mainstream health care.”
The 2000 JAMA article broke ground because it showed that chronic conditions such as diabetes, hypertension and asthma were very similar to drug dependence but treated entirely differently. Drug dependence was treated as an acute rather than chronic problem – quick detox, short rehab (that’s all insurers cover), here’s an AA meeting list, good-bye — and results were disappointing. The best outcomes were when substance use disorders received the same long-term care we use for diabetes, hypertension and asthma.
One problem the 2000 article noted was that the medical establishment itself didn’t agree that substance use disorders should be medical issues.
“Few medical schools or residency programs have an adequate required course in addiction. Most physicians fail to screen for alcohol or drug dependence during routine examinations. Many health professionals view such screening efforts as a waste of time.”
Today? The ONDCP National Drug Control Policy 2010 sounds the same ten-year old deprecations:
“The mainstream healthcare system has little knowledge of addiction as a disease, nor has it dedicated sufficient resources to responding to addiction…”
Some things are happening, like the screening and brief intervention movement, which identifies people with substance use disorders in trauma and emergency settings. And some wrap-around HMOs like Kaiser Permanente integrate chemical dependency and other behavioral care in primary care, though at different levels in different locations. Other organizations develop systems on paper and push them out as pilot projects.
My problem is that all this is going on above the heads of patients (as usual) and nobody’s bothering to explain it to them. So, here goes. The National Institute on Alcoholism and Alcohol Abuse has an old set of four questions for clinicians; it’s as good a place to start as any:
Patient: Huh? Well… my wife thinks I should. She tells me about it pretty regular. So yeah, I guess I think about it.
Doctor: Have people annoyed you by criticizing your drinking?
Patient: Like I said, my wife. And my oldest daughter. She thinks I’m an idiot sometimes on Sundays after we go to a barbeque. My brother says I need to knock it off. But I’m not hurting any of them.
Doctor: Have you ever felt bad or guilty about your drinking?
Patient: I mean, hasn’t everybody? Like when my wife tells me something that I said the next day and I know I only said it because I had a few too many. You know…
Doctor: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
Patient: Now I’m not like that, Doc. I haven’t done that in awhile. I can keep it under control better than that.
Doctor: Well, I’m going to refer you to a specialist about this. I’ll have my assistant make an appointment for you.
Patient: I know what you’re getting at, and I’m not an alcoholic. I’m positive of that.
Doctor: It’s not that. We’re just going to have you screened for now. If you had recurrent headaches, we’d send you to a neurologist, right? That’s what you’d want, isn’t it?
Patient: I guess so, but I’m not an alcoholic.
Doctor: So no problem going to a specialist.
Then, an addiction specialist screens the patient, diagnoses him and develops a plan for – and these are the important words — treatment until recovery. Just like for any other chronic disorder. That treatment might include individual counseling, group counseling, outpatient treatment, inpatient treatment, medication, psychiatry, AA or NA meetings, the whole panoply of treatment possibilities. And it would be integrated with care received by any other clinicians.
And this same could be done for people with addictive disorders co-occurring with other disorders, such as bipolar, which happens a lot.
Noncompliant substance use disorder patients would be treated the same as noncompliant diabetes patients. We try to get them to be compliant. Pretty much all patients are noncompliant at some point. We don’t throw up our hands and say it’s all a failure like we do with substance use disorders. Instead, we continue treatment until recovery.
Sounds simple, doesn’t it? Yet so far it’s been impossible. Insurers and other special interests say it’s too expensive. They team up with these behavioral health carve-outs – you’ll find their phone number on the back of your HMO card – which are one of the biggest impediments to integrating treatment and behavior health into primary care. They must be eliminated.
Also, the social model recovery movement – recovery programs usually based on 12-step or therapeutic community models – fear that integrating treatment with health care will put them out of business. I don’t agree. Social model programs provide excellent, affordable inpatient and outpatient treatment services that always will be necessary.
Oh, by the way, integrating medical and substance use disorder treatment save a bundle of money. It would be cheaper than the system we have now, according to a utilization and cost review:
“…among the subset of patients with substance abuse related medical conditions, integrated care patients had significant decreases in hospitalization rates, inpatient days and ER use. Total medical costs per member month declined from $431.12 to $200.03…”
Integration of treatment and medical care is endorsed in Obama health care reform, and some states are passing their own laws. But it’s all been promised before in parity legislation yet never seems to happen. As the Obama health care plan gets closer, expect a full frontal assault against integration by insurers and other special interests.
So, are we closer to the vision expressed by the authors of the JAMA article a decade ago? Maybe those more optimistic than me will say so.