Medical science tells us substance use disorder is a chronic disease, much like diabetes or hypertension. However, the medical establishment—hospitals, emergency rooms, physicians, insurers, physicians—still treats substance use disorder as if it is acute and episodic. This continued treatment of emergent, acute episodes as singular events is worsening today's addiction crisis and leads to many of the deaths we are trying to prevent.
Until we truly treat addiction as a chronic illness—one that can be managed with proper assessment, diagnosis, medication, treatment and a long-term disease management plan—we will not make the headway we need to end this epidemic.
We must change our thinking about addiction, instigating several major changes that will have significant impact in the quality of care we provide:
Flexible length of stay. By currently proscribing a standardized length of stay for substance use disorder treatment, regardless of acuity, insurance reimbursement assumes that everyone with this disorder is the same. The average length of stay under Medicaid is under a week, barely enough time to detoxify from substance use, much less address the underlying physical, psychological and health issues complicating the disease. What we need, instead, is to let board-certified medical professionals make decisions about what is best for a particular patient, to not only stabilize them but also facilitate entry into long-term recovery.
Long-term support. The key to success in managing chronic diseases such as diabetes or heart disease is on-going and integrated follow-up with patients. Success with addiction also depends on long-term follow-up. Recovery is a lifelong process, and treatment shouldn't end when someone leaves an inpatient setting. Instead, we need programs that combine ongoing, outpatient recovery support and psychological counseling with toxicological monitoring. As with all chronic diseases, there will be relapses. If you have recovery supports in place, along with monitoring to pick up a relapse early, there is a better chance of getting people back into stable recovery.
Prevention and early detection. The public has bought into the idea of early cancer screening, because it is proven to save lives. We must adopt the same mindset around addiction. We need to incorporate early detection into our prevention initiatives in middle and high school. We need not just education but also universal screening of all ninth-graders to identify, reduce and prevent harmful and hazardous use, abuse, and dependence on alcohol and illicit drugs. The earlier that substance use is caught, the better.
Physician training. There is typically little formal coursework on addiction in medical school. Medical students currently get a few hours' worth of training about addiction. Compare that to the attention given to other chronic diseases such as diabetes, hypertension or HIV infection. We need to educate medical school students not just on how to prescribe opioids responsibly but also how to recognize and refer substance use disorder.
Research. Last, but by no means least, there is a need for research to understand, diagnose, treat and monitor addiction. With diabetes, physicians can use hemoglobin A1C, fasting blood sugar, and a myriad other blood tests to see where a patient is objectively. The same holds for COPD, where pulmonary function studies, imaging studies, and other tools track the disease objectively. With addiction, everything is subjective. Addiction is a brain disease, and it is difficult to get real-time data on the brain. Functional MRI and similar neuroimaging technologies hold promise, but we need more money and innovation around addiction research. Genetic markers could be another important area of research, helping us understand who is vulnerable to developing addiction or who will respond to certain medications.
It is easy enough to say that addiction is a chronic illness, but until we change the way we treat it, knowing this won't do anyone much good. A concerted effort at research, physician education, early detection and prevention, and long-term disease management has helped thousands, if not millions, of patients with cancer, or diabetes, to lead better lives. We can, and should, do the same for addiction.
Dr. Joseph Garbely is vice president of medical services and medical director at Caron Treatment Centers based in Wernersville, Pa.
