The American College of Physicians recently published a position paper reminding us that addiction is a chronic illness and should be treated as one. As with other chronic illnesses such as hypertension, asthma or heart disease, addiction has both genetic and environmental influences. Repeated drug use rewires brain circuits involved in reward, memory, impulse and motivation. As a result, the person with addiction loses control over their use, experiences intense drug cravings and continues to use even as the problems in their life multiply. Cues in the environment that call attention to drugs or alcohol (let’s face it, every third TV commercial seems to promote beer) trigger an intense stress response in the addict who is trying to stay clean.
Like other chronic diseases, successful addiction treatment requires ongoing care that includes monitoring and disease management to ensure the safety and efficacy of the recovery process. Yet few people receive the comprehensive care they need to sustain their recovery because that type of care isn’t widely available. Here are a few ways the standard of care in addiction treatment differs from treatment for other chronic diseases — and why that needs to change:
#1 Addiction Carries a Stigma
Few people with diabetes or heart disease feel their disease is secret or shameful. This was not always the case for those suffering from certain diseases. Even today, there is considerable stigma associated with myths and beliefs about cancer, which outside the U.S. contributes to excess numbers of deaths. Although many people are beginning to accept that addiction is a chronic disease that has genetic and environmental components, a stigma lingers that it is shameful because it is somehow connected to weakness of will or questionable morals.
In fact, addiction may be the most stigmatized of all illnesses. Compared with people suffering from other mental disorders, people with alcohol dependency are held to be more responsible for their condition, are less frequently regarded as mentally ill, provoke more social rejection and negative emotions, and are at high risk for discrimination. As a result of this stigma, many addicts and their families try to keep the disease hidden from others — and this can be a barrier to seeking proper treatment.
#2 Addiction Is Treated as an Acute Illness
Many addiction treatment programs and insurance providers still approach addiction as an acute illness. For example, an addict may go through detox and be discharged without enrollment in a program of continuing care. Or, someone may enroll in short-term outpatient addiction treatment, without being referred to extended care for ongoing disease management. Further, health insurance may only partially cover the rehab program, and ongoing maintenance may be an out-of-pocket expense.
In these scenarios, the patient may be advised to continue seeking support independently through private therapy or self-help support groups to maintain their sobriety. Those kinds of support networks, while critical, do not constitute a comprehensive continuum of medical and behavioral care that is necessary to manage a chronic disease. Detox or a short stint in rehab will not cure addiction. The addict may have detoxified the substance from their system and received coaching in healthier coping mechanisms, but the underlying disease is still there, as is the risk for relapse.
This mismatch of an acute treatment approach applied to a chronic disease is not typically seen elsewhere in medicine. We would never send a cancer patient home after one course of radiation or chemotherapy with just a list of resources and self-help groups for them to contact on their own. With cancer, even after treatment and remission there is always the risk that the cancer cells can return or become active again, so regular medical monitoring of the patient is necessary.
With addiction, even after treatment and the transition to recovery there is always the risk that triggers in the environment can cause the addict to relapse and start actively using again. Like cancer, addiction should be handled through comprehensive, evidence-based, long-term treatment followed by monitoring, ongoing management and nonjudgmental return to care in the case of relapse.
#3 Relapse Is Perceived as Failure
Management throughout recovery is critical for those with addiction, says the American Society of Addiction Medicine (ASAM), because addiction, like other chronic conditions, often involves cycles of relapse and remission. The National Institute on Drug Abuse (NIDA) reports that the relapse rate for those who have been treated for drug or alcohol addiction ranges from 40 to 60 percent, which is comparable to the relapse rates for those with diabetes (30-50 percent), hypertension (50-70 percent) and asthma (50-70 percent). NIDA points out that relapse is common and similar across these chronic illnesses, all of which require adherence to a medical disease management plan and/or medication.
Without ongoing treatment and monitoring, addiction is progressive and can result in disability or premature death. And though we respond with compassion and an immediate return to treatment if someone with diabetes or heart disease relapses, many view a relapse back into active addiction as a personal “failure,” which makes a setback more difficult to identify and address.
#4 Structured, Long-Term Care Is Difficult to Find
Fewer than 10 percent of medical schools offer courses in treating addiction. So even though doctors are trained to provide comprehensive services for other chronic diseases, which routinely integrate medications, behavioral therapies, monitoring and management, they aren’t necessarily trained to provide these same services to people with addiction.
Let’s compare the health care services that people with cancer typically receive. The National Coalition for Cancer Survivorship (NCCS) reports that oncology care programs typically provide structured plans for continuing care. In addition to information about joining cancer survivor groups for emotional support, NCCS notes that cancer care plans generally include ongoing or follow-up medical treatment, information on side effects and interactions with other medications, and a treatment summary to share with other health care providers for safe and coordinated care (e.g., treatment received, prescribed medications, ongoing issues that need to be addressed).
NCCS further states that even after receiving chemotherapy or radiation treatment, “cancer survivors need to be monitored for the rest of their lives and have different health care needs than before they were diagnosed.”
This is true for addiction survivors as well. Providing individuals in recovery with a structured plan for continuing care, possibly including maintenance medication with medical supervision, anti-overdose drugs like naloxone for those with opiate addiction, regular drug testing, and continued monitoring and support, would be a step in the right direction. Physician health programs and treatment programs for addicted professionals are a good example of how longer stays in treatment (many follow 90-day plans) and long-term monitoring and support can lead to more successful outcomes.
Recognizing the Need for Change
Thanks to a growing body of scientific research and the work of advocacy organizations like Faces & Voices of Recovery, we are making progress toward reducing stigma and bringing treatment closer in line with the medical approaches that are used in treating other chronic diseases. Legislation such as the Affordable Care Act also has advanced our progress by helping more people access care for mental health conditions that, in many cases, were not previously covered by insurance.
Still, there’s much room for improvement so that those affected by addiction feel comfortable seeking treatment and are able to find high-quality, comprehensive and evidence-based care that they can afford. This shift won’t happen overnight, but it can’t come soon enough. There are 23.5 million people in the U.S. who need drug or alcohol addiction treatment, but only 2.6 million (11.2 percent) receive the specialized treatment they need. Compare this to the 28.9 million people who were reported to have diabetes in 2012, 20.9 million of whom received evaluation and/or treatment, including specialized medications. Clearly, we can do better — and we have a model that shows us how.
David Sack, MD, is board certified in psychiatry, addiction psychiatry and addiction medicine. As chief medical officer of Elements Behavioral Health, he oversees a network of addiction treatment centers that includes The Right Step drug rehabs in Texas and The Ranch rehab center.
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.