Breaking The Wall of Addiction

For far too long, alcoholism and drug abuse have been primarily considered social and criminal problems.  As a result, addiction was treated wholly separate and apart from general medical care.  This practice continued throughout most of human history, even in the face of growing evidence that addiction is a brain disorder, with considerable crossover to other diseases.  The US Surgeon General’s report “Facing Addiction in America” (the “Report”), makes a strong case for finally destroying the “Chinese Wall” of separation, in the interests of more effective addiction treatment AND better overall medical care. Substance use disorder often doubles the odds that a person will develop another chronic and costly medical illness, in some very clear and specific ways.  Cocaine use is associated with cardiovascular complications, marijuana with chronic bronchitis and asthma, and alcohol is known to cause liver and pancreatic diseases. The list goes on and on.  Numerous studies document high rates of substance use disorders among patients and have noted that mainstream healthcare often fails to recognize or address the substance use element of the problem.  One such study discovered that one-third of the most common and costly medical conditions were more prevalent among patients with substance use disorders.  Individuals with chronic medical conditions incur costs two to three times higher when substance use disorder is involved.  Moreover, substance abuse also complicates many other medical conditions.  So basically, by keeping addiction treatment in its own little bubble, doctors have frequently been missing out on the big picture.  How can we expect to achieve best outcomes with less than full information?

This issue also presents itself in Natal Abstinence Syndrome (NAS), when babies are born to addicted mothers.  These babies typically have low birth weights and respiratory complications, as they themselves go through withdrawal during their precious early days of life.

Newborns with NAS require hospital stays averaging 16.9 days; 8 times more than a usual stay, and cost hospitals upwards of $1.5 billion, per year.

Then there’s the adolescents.  I’ve gone to great length in previous articles to explain the urgency of addiction as a disease most damaging to adolescents and young adults.  In fact, the majority of people who meet the criteria for a substance use disorder in their lifetime, started using substances during adolescence and met the criteria by age 20 to 25.  But that’s not all.  Adolescent addicts experience higher rates of other physical and mental illnesses, as well as diminished overall well being and educational outcomes – for LIFE.  We’re talking about long-lasting, permanent damage, because the brain, immune system and most key organs never get a chance to fully develop; the “Norm” is far from normal in these adolescents.

Finally, and this applies to all addicts, they are more likely to engage in risky behavior.  HIV/AIDS, sexually transmitted infections and a higher rate of accidents (not to mention crime and incarceration), are just some of the ways that substance abuse, again, directly correlates to general medical care.

That’s Why It’s Time To Take The Gloves Off!

Well supported scientific evidence demonstrates that traditional separation of substance use disorder from mainstream health care has created obstacles to successful results.  It further proves that closer integration will add value to both systems, increasing the quality, effectiveness and efficiency of healthcare.

Now, onto the heavy lifting.  The reality is; most people with substance use disorders do not seek treatment on their own because they don’t think they need it or they’re not ready for it.  In addition, doctors, nurses, psychologists and basically everyone in general medical care, are not well trained to tackle the issue of addiction head on.  Therefore, too many patients fall through the cracks.  We are missing out on a powerful opportunity to attack addiction at its earliest stages when it’s cheapest and most easily counteracted.  Early detection has been the keystone of modern medicine, adding years onto people’s lives.  Mammograms, colonoscopies, prostate exams and even simple regular blood tests and blood pressure screenings help to identify problems before they get out of control.  Imagine ignoring a disease as it steadily grows before everyone’s eyes and then only treating it once it becomes serious and chronic.  We wouldn’t accept that in any other aspect of medical care and we shouldn’t accept it when it comes to fighting addiction.

So What Can We Do About It?

First of all, get used to this acronym SBIRT – Screening, Brief Intervention, Referral and Treatment.  We need to help foster an environment that encourages inclusion of prevention, treatment and recovery, as part of general medical care.

  1. Health professionals should regularly screen for substance misuse and abuse as part of a regular check-up, like checking blood pressure, temperature, weight and heart rate. 

  2. Health professionals must engage in conversations about addiction with patients. 

  3. Health professionals should refer patients indicating signs of addiction to a specialist, just as they would for any other disease. 

  4. Health professionals must subsequently follow-up with patients, just as they would for any other disease.

  5. Health professionals with patients in recovery should continue to screen them during regular check-ups, but now with more targeted screenings (i.e. urine tests, etc.).

  6. Health professionals should co-locate substance abuse care with or near general medical care facilities.  Co-location motivates cooperation and leads to quicker treatment. The fastest growing segments of clients for the KIPU EMR is Detox facilities located in hospitals and managed by traditional treatment centers. 

  7. Patients should take a copy of prior treatment with them when seeing their health care professional. That way healthcare providers are immediately made aware of the entire patient history, and will therefore be more careful in prescribing medication for pain management, among other things. 

  8. The medical profession needs to better coordinate care across the entire health and social service systems, and have better access to a patient’s entire medical history. 

This last point is vital.  For years, lack of communication between doctors and pharmacists led to problems when prescribed medications proved lethal when inadvertently combined.  One study mentioned in the Report found that doctors continued to prescribe opioids for 91 percent of patients who suffered a non-fatal overdose, with 64 percent of these patients continuing to receive high doses.  17 percent of these patients overdosed again within 2 years.  This shocked me. This lack of communication between emergency rooms and doctors borders on criminal.

Finally, the medical profession needs to fully embrace technology in every aspect of medical care.  Acceptance is high when it comes to the latest technique or expensive new machine, however it seems to lag when it comes to general medical care. For example, it took longer than most other industries to adopt electronic record keeping (commonly known as Electronic Medical Records or Electronic Health Records – EMR/EHR and it still has a long way to go.  Doctors were also reluctant to switch to e-prescribing, all too comfortable in the security of the old-fashioned, often illegible, paper ‘scripts’.  However, there are some key signs of change, with some new clinics being re-imagined, centered around technology, looking like a cross between an iPhone and something straight out of Star Trek.  Better implementation of IT will play a major role toward successfully integrating addiction treatment into the full panoply of medical care. 

So Where Does That Leave Us?

I do not suggest all of this is going to be easy.  The medical community is entrenched in its ways;  it will be like trying to move a large ocean liner, slowly and with great effort.  HIPAA in particular poses some unique challenges. We need to change the mindset of both doctor and patient to arrive at a new normal in medical care, one in which the shame of addiction is cast aside so that addiction can be averted altogether, or at least treated in its earliest stages, when it can most effectively be stopped in its tracks. The good news is, we now also have reasons for optimism and hope. The medical and addiction treatment communities have responded almost universally, in a unified voice, to the Surgeon General’s call.  The opioid epidemic in particular has provided a major impetus to reach common ground.  As a result, I strongly believe that we will soon be transforming the state of both addiction treatment and medical care, for the benefit of all.