Drug
Dependence, a Chronic Medical Illness
Implications
for Treatment, Insurance, and Outcomes Evaluation
The
effects of drug dependence on social systems has helped shape
the generally held view that drug dependence is primarily a
social problem, not a health problem. In turn, medical
approaches to prevention and treatment are lacking. We examined
evidence that drug (including alcohol) dependence is a chronic
medical illness. A literature review compared the diagnoses,
heritability, etiology (genetic and environmental factors),
pathophysiology, and response to treatments (adherence and
relapse) of drug dependence vs type 2 diabetes mellitus,
hypertension, and asthma. Genetic heritability, personal choice,
and environmental factors are comparably involved in the
etiology and course of all of these disorders. Drug dependence
produces significant and lasting changes in brain chemistry and
function. Effective medications are available for treating
nicotine, alcohol, and opiate dependence but not stimulant or
marijuana dependence. Medication adherence and relapse rates are
similar across these illnesses. Drug dependence generally has
been treated as if it were an acute illness. Review results
suggest that long-term care strategies of medication management
and continued monitoring produce lasting benefits. Drug
dependence should be insured, treated, and evaluated like other
chronic illnesses.A. Thomas McLellan, PhD; David C. Lewis, MD; Charles P. O'Brien, MD, PhD;
Herbert D. Kleber, MD
The Logic (Why Parity is a MUST)
Purchasers and public policy makers should
consider the following logic and current state of practice:
1. health insurance provides
financial coverage for diagnosis, treatment, and prevention of
acute and chronic diseases
2. addiction medicine is involved
in the diagnosis, treatment, and prevention of substance related
disorders, which are acute or chronic diseases
3. addiction is a complex
neurobehavioral disorder, involving biochemical abnormalities of
the brain that involve reinforcement and reward systems of the
central nervous system; addiction is manifested by aberrant
behaviors that can compulsively persist despite adverse
consequences from those behaviors; addiction is not a character
weakness.
4. addiction diagnosis is
objective, standardized, and scientific, no less so than for
other chronic diseases
5. addiction treatment is
effective
6. barriers to effectiveness of
addiction treatment are the same as barriers to effectiveness of
treatment interventions for other chronic diseases: patient
compliance and readiness to change, socioeconomic complications
to care -delivery and management, and co-morbid
emotional-behavioral conditions all adversely impact treatment
success for substance addiction and for other chronic illnesses.
There is nothing intrinsic to addiction treatment that should
generate pessimism about treatment efficacy rates, and such
pessimism is not supported by clinical research or experience.
7. relapse is inherent in
addictive disease, but also inherent in virtually all chronic
disease; relapse is usually a sign of chronicity, not a sign of
treatment failure. By relapse, we mean a return to the signs and
symptoms meeting criteria for a substance use disorder, not a
return to use per se.
8. insurance benefits for
addiction treatment should be equivalent to benefits for the
treatment of other chronic diseases
9. treatment for the disease of
addiction is cost-effective, and can be cost-saving for the
health care system overall
10. because of medical cost
offsets, to NOT treat the disease of addiction is costly -
economically as well as socially; benefit structures should not
create barriers to effective intervention to diagnose and treat
addiction
Action Steps:
A national dialogue must take
place among consumers, family members, professions, managed care
organizations, employers, and state and federal government
addressing the following critical issues:
1. In an environment of global
competition, increasing health care needs ,an aging population,
and constraints on tax revenues, we need to identify best
practices that demonstrate comprehensive coverage and its
affordability, and we need to encourage the adoption of these
best practices in public and private benefit plans.
2. We need to reduce the amount
of variability between states regarding the interpretation of
parity legislation, increase the consistency between various
state laws on this issue, and prevent legislation on federal and
state levels that inhibit the adoption of the best practices we
have identified.
3. It is necessary to achieve
consensus on what it means for a service to be "medically or
clinically necessary", "appropriate" and a legitimate use of a
benefit plan for behavioral health problems and services.
Adopted by the ASAM Board of Directors October
1997
& AMBHA Membership October 1997
Louisiana Parity by Dr. Ken Roy
Additional ASAM links:
Profiles
Addiction is a
Brain disease
State ASAM Directories
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