The silver lining of the opioid epidemic—if a silver lining can be found for a public health tragedy that has killed more people than the Iraq and Vietnam wars combined—is the medical profession is finally forced to contend with the problem of addiction. Our complicity through egregious opioid overprescribing, and the sheer scale of drug overdose deaths, has meant we can no longer turn a blind eye.
Yet for hundreds of years we did. The fight to get addiction recognized as a bona fide illness within the U.S. health care system has been a long and losing battle. Almost 200 years ago, Dr. Benjamin Rush published An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind: With an Account of the Means of Preventing, and of the Remedies for Curing Them (1819), in which he argued that chronic drunkenness is a biological disease, a radical belief for its time. Most of his contemporaries still viewed excessive and problematic substance use as a moral failing, a sin.
Today, addiction affects 16 percent of the U.S. population, about 40 million people, far exceeding the number of people afflicted with heart disease (27 million), diabetes (26 million), or cancer (19 million). The number of people dying from and addicted to opioids is rising every year. In 2016 alone, more than 50,000 Americans died from drug overdoses (53,000 per the Centers for Disease Control and Prevention, 65,000 per a New York Times report), as compared with 36,000 from car crashes and 35,000 from gun violence. Four million Americans are addicted to opioids, 11 million are using prescription opioids recreationally, and more than 2 million are using heroin recreationally. Disease burden due to addiction exceeds half a trillion dollars annually. Yet only 1 percent of the total health care budget goes to treating addiction, and fewer than 1 in 10 persons with addiction receives treatment.
I believe the opioid epidemic has made the debate over whether addiction should be treated as a disease a moot point. We must embrace addiction as a disease and treat it as such within mainstream medical care, even if we don’t believe it is one. Here are three reasons why.
First, addiction has long been the neglected stepchild of the progressive pathologization of everyday life, wherein we turn everything from indigestion to sexual drive to high energy into a disease. Biologizing problems is how contemporary culture solves them. The disease model of addiction is the model for our time. It destigmatizes, legitimizes, and opens the way to health insurance and research dollars.
Second, the disease model is the best response to a public health crisis that otherwise shows no signs of abating. Addiction treatment, when integrated within the house of medicine, works better than siloed care in specialty addiction treatment centers. We need a robust infrastructure within mainstream medical care, such that anyone struggling with a substance use disorder (SUD) can walk into any primary care clinic, maternity ward, or emergency department in the country; say, “I have addiction; will you help me?”; and hear a resounding, “Yes!”
To make this vision a reality, insurance companies and other third-party payers must pay for addiction treatment on par with other medical conditions. Despite the passage of the Mental Health Parity and Addictions Equity Act of 2008, getting insurance companies to pay for addiction treatment is still a bureaucratic maze of “carve-outs,” “prior authorizations,” and “fail first criteria,” making it cumbersome and in some cases impossible to get this care reimbursed. If doctors and hospitals aren’t reimbursed to provide this kind of treatment, it won’t happen. On the other hand, if you pay them, they will come.
Third and most importantly, if we in the medical profession fail to take the lead in addressing what many have rightly likened to the modern-day plague, we will continue to perpetuate the problem. The rise in opioid overdose and addiction directly correlates with the rise in doctors’ prescriptions for opioid analgesics. One of the biggest risk factors for addiction is sheer access to that drug. What began as a well-intended effort to improve the care of patients in pain has led to a runaway train of opioid overprescribing, which puts many more people at risk for addiction and accidental death.
Although opioid prescribing has decreased by about 15 percent since its peak in 2012, U.S. doctors today continue to prescribe three times as many opioids as they did in the late 1990s, four times as many opioids as are prescribed in Europe, and more than 10 times as many opioids as are prescribed in Japan. Europe and Japan are apt comparisons for the United States because they too are rich countries with aging populations and comparable rates of physical pain in the population, yet they consume far fewer prescription opioids. Indeed, the United States is reported to consume over 80 percent of the world’s opioids, while representing less than 5 percent of the world’s population.
I recently got a phone call from a colleague, a pain medicine specialist who works for a large integrated health care center, who had been tasked by her institution to identify all patients in the system taking Opana ER. Opana ER, an opioid painkiller, was at the center of the HIV outbreak in Indiana in the spring of 2015, and due to its high risk of misuse and addiction, the Food and Drug Administration recommended it be pulled from the market in July 2017.
My colleague was seeking my advice on the case of a 28-year-old man with chronic pain. This young man had no identifiable organic pathology for that pain. Young, otherwise healthy people showing up to doctor’s offices describing crippling full-body pain, despite the absence of any known trauma or disease process to explain that pain, is an increasingly common phenomenon. The patient was taking the following medication, prescribed by a single doctor: Opana ER (an opioid) 40 mg twice a day, Dilaudid (an opioid) 30 mg once a day, oxycodone (an opioid) 60 mg once a day, phenobarbital (a barbiturate) 65 mg once a day, Valium (a benzodiazepine) 20 mg once a day, Restoril (a benzodiazepine) 30 mg once a day, and Xanax (a benzodiazepine) 8 mg once a day.
This young man with no objective reason for being in pain was being prescribed 450 morphine milligram equivalents daily of opioids (four times as much as the average heroin-addicted person consumes in a day), in combination with powerful sedative-hypnotics (phenobarbital and three different benzodiazepines), also at extraordinarily high doses. His immediate problem was risk of death due to accidental overdose. His longer-term problem was iatrogenic (doctor-caused) addiction. When I asked my colleague if she knew anything about the doctor prescribing these medications, she said, “She’s his primary care physician. Really nice. Really caring. She inherited him from an older doctor who retired, and she just continued the same regimen.”
Only whole-scale institutional denial of addiction explains how a “really nice, really caring” physician could continue to prescribe these drugs in this way to this patient. But I’m finally beginning to see the seeds of change: medical students and residents expressing an interest in learning how to treat addiction; continuing medical education courses on addiction treatment quadrupling in size and number, mostly catering to mid-career practicing physicians who are seeing more and more patients with substance use problems in their practice; the American Board of Medical Specialties declaring “addiction medicine” its own medical subspecialty in March 2016, a major milestone in the recognition of the need for specialized treatment of patients struggling with SUDs. So as tragic and devastating as the opioid epidemic has been for its victims and their families, at least medicine is standing up, taking notice, and doing something about it. Dr. Benjamin Rush would be proud.
The scientific argument in favor of addiction as a brain disease goes like this. Approximately 50 percent of the risk of becoming addicted is genetic, more than for any other mental illness. A child with a biological parent or grandparent with a substance use disorder (“substance” being the general medical term to refer to any addictive molecule) has a two to four times increased chance of developing addiction when compared to the general population, even when raised outside the substance-using home. Chronic heavy substance use changes the brain over time, such that the individual needs more of the substance to get the same effect (tolerance), and “natural rewards” (food, clothing, finding a mate) are no longer reinforcing.
Proponents of the disease model often compare addiction to type 2 diabetes mellitus. Both are chronic, relapsing, and remitting diseases with a behavioral component. In the case of diabetes, the behavioral component is the ingestion of a high-sugar diet. In the case of addiction, it is the user’s “drug of choice.” In both cases, the ingestion of that substance can lead to irreversible chemical and morphological changes in the body. In the case of diabetes, insulin resistance leads to an inability to properly absorb sugar from the bloodstream. In the case of addiction, chronic, heavy exposure to addictive drugs changes the brain’s reward threshold, creating intense dysphoria when the drug is not available. In other words, the brain’s reward pathway has been “hijacked” by the substance, not only when intoxicated or withdrawing, but also in the in-between time, when the craving for drugs can crowd out rational thought and propel behavior beyond that individual’s willful control. A patient of mine likened it to being very, very thirsty, to the point where you too might go outside your moral compass to obtain a small drink of water. Acquiring and using the substance becomes synonymous with survival itself.
In both diabetes and addiction, a radical lifestyle change—a change in diet or the cession of drug use—can restore the body to baseline. When the damage is irreversible, a medication can be used to treat it. Insulin, for example, is used to treat diabetes. Long-acting opioids like buprenorphine or methadone are effective treatments for opioid use disorder. A seminal paper by McClellan and colleagues published in the Journal of the American Medical Association in 2000 shows that addiction and type 2 diabetes have the same rates of response, recurrence (relapse), and adherence to treatment when addiction too is treated like a medical disease.
Dissenters of the disease model argue that brain changes are not sufficient to categorize addiction as a disease. Piano virtuosos also exhibit brain changes after years of practice. More importantly, no other disease involves the element of choice in recovery the way addiction does. People with cancer can’t decide that their malignant cells should stop dividing. On a philosophical level, the disease model cannot answer what many consider to be the root cause of addiction: the psycho-spiritual search for transcendence in an increasingly materialistic and socially transgressive world.
It is this last point that resonates most strongly with me. I agree that the disease model does not begin to address the psychosocial and psycho-spiritual challenges of modern-day life that have given birth to the terrible problems of addiction we are facing today. Nonetheless, embracing addiction as a disease and building an infrastructure within the house of medicine to treat it are the best ways out of the worst drug crisis in U.S. history.
If we are to embrace addiction as a disease, how do we reconcile the legal, interpersonal, and moral transgressions that are common in persons who become addicted, with a traditional sick role that absolves sick individuals of responsibility for their actions?
This question is all the more pressing because people with addiction are well-known to lie, cheat, and steal in the process of acquiring substances or hiding use. While intoxicated or withdrawing, they can perpetrate shocking acts of violence and harm on others. Addiction is the only disorder in which immoral, illegal, and violent behavior are a consistent and pervasive “symptom” of the disorder, distinguishing addiction from all other illnesses and disorders, including other forms of mental illness.
Last year, I was asked to provide expert medical consultation in the case of an individual who, under the influence of a prescription drug, got behind the wheel of his car, swerved off the road while driving, and killed a teenager who happened to be walking along the side of the road at the time. The case hinged on whether that individual had knowingly taken those pills midmorning with the intent of becoming intoxicated, or whether the ingestion had been accidental, in which case his altered mental status was also unintentional, absolving him of some degree of responsibility.
Looking at the evidence, I determined that this individual had intentionally and knowingly taken a larger-than-therapeutic dose of the drug in order to get high. In essence, my testimony contributed to his burden of guilt. I also surmised that he was likely struggling with a covert addictive disorder, given his prior history of driving while under the influence and evidence of long-standing prescription drug misuse. He seemed to have no insight into his addictive problems and apparently felt little or no shame for the crime he had committed, repeatedly endeavoring to blame the victim for “walking out into the road,” which was contrary to witnessed reports.
It was only later, after I had written my opinion, that it occurred to me that if we are going to take seriously the notion that addiction is a disease that “hijacks” the individual’s ability to choose whether or not to use substances, and compels them to use even after periods of abstinence and in a state of clear sensorium, and if I believed that this individual was suffering from the signs and symptoms of addiction, then shouldn’t his “disease of addiction” mitigate his burden of guilt? According to the Model Penal Code provisions, “a person is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality [wrongfulness] of his conduct or to conform his conduct to the requirements of the law.”
Yet, even after realizing the inherent contradiction between my advocacy for the disease model and my judgment in this case, I was loathe to invoke the disease model. Why? I could not at first understand it. When I began to puzzle it out, I realized that my differential application of the disease model in this circumstance was driven by my own sense of righteousness (no doubt one of my many character flaws), my deep-seated pragmatism, and my gut instinct born of experience and intuition from decades of treating people with addiction. Let me explain.
First, the crime involved the death of a human being, an innocent child no less. To my mind this warranted severe punishment, independent of intention or mental capacity. Simply put, he deserved it. (Remarkable how deep the human desire for revenge can go, an eye for an eye and all that.)
Second, it seemed imperative to remove this individual from the public sphere, at least temporarily, to protect the public health and safety. This reasoning is consistent with what most courts have resolved regarding the question of whether the “disease of addiction” absolves the individual of responsibility for his or her crime. According to William L. Corbett from the University of Montana School of Law, “Courts have been unwilling to hold that the addict or alcoholic consumed intoxicants involuntarily, because to do so would be to hold him not liable for any criminal activity; this would be contrary to public policy.”
Third, and this was the hardest to understand, I was reluctant to invoke the disease model because of this individual’s lack of insight and remorse for what he had done. After many years of treating persons with addiction, I have come to realize that without some degree of insight and the capacity to experience shame, recovery is not possible. Not that insight and shame are enough . . . and indeed shame itself can be an obstacle to recovery from addiction. But without insight and the capacity for remorse, a lighter criminal punishment in the spirit of providing treatment in place of punishment seems like an exercise in futility. The point of conceptualizing addiction as a disease is because to do so provides the promise of a solution. To make the disease model worth pursuing, addiction treatment has to work. Addiction treatment, even mandatory treatment, works, but not unless that individual is willing and able to engage in an authentic way with the treatment provided.
Were this person to acquire insight and an appropriate sense of remorse at some later date, would I be more willing to apply the disease model in his case? I believe that I would. And the two approaches need not be mutually exclusive. Punishment can be provided alongside a “treatment” plan that focuses on promoting insight, motivation to change, and prosocial behaviors (honesty, reliability, commitment, follow through), all of which are fundamental to addiction recovery.
One of the most consistent findings in the field of addiction medicine is the effectiveness of contingency management in the treatment of people with SUDs. Contingency management is a system of rewards and punishments to curb substance use, relying on a set of overriding principles: (1) certain punishment is more effective at shaping behavior than uncertain punishment, (2) swift interventions work better than delayed ones, (3) the punishment should be commensurate with the transgression, and (4) individuals should be rewarded for good behavior. Anyone who has ever been a parent will recognize these familiar, commonsense principles.
Contingency management is at its core a behavioral contract between two people/parties, which recognizes the inherent tendency of all individuals to behave in ways that are self-serving (lying, cheating, stealing). Indeed, the original conception of “sin” was not individual transgression but the propensity in all humans to stray. Contingency management is relational and attachment oriented. Those who play by the rules will be rewarded by a strengthened attachment and growing mutual trust.
Effective real-world examples of contingency management can be found in drug courts. Hawaii’s Opportunity Probation with Enforcement (HOPE) is one example. HOPE uses contingency management to reduce drug and alcohol use among nonviolent offenders on parole for drug- or alcohol-related crimes. Urine drug testing is done at parole meetings. If the parolee tests positive and subsequently admits to having used substances, he or she immediately spends two to three days in jail—swift and certain punishment. If the individual tests positive but denies having used substances, he or she spends 15 to 20 days in jail. Note how lying, an antisocial behavior, is punished more severely as a way to promote truth telling in the future, even when the behavior (having used substances) is the same. If the parolee fails even to present for a parole meeting, he or she is apprehended by law enforcement and spends 30 days in jail. The punishment is commensurate with the transgression. Using this strategy, HOPE has been able to cut arrests and failed drug tests by more than half.
This approach differs from the failed War on Drugs that has marked our nation’s drug policy for the past three decades. The War on Drugs got it wrong. Jailing a person for a decade for carrying an ounce of marijuana, two years after the original request, defies all of the rules of contingency management and does not change behavior.
I advocate for the conceptualization of the disease model of addiction inside of medicine because it is the most expedient and practical approach for our time. Yet, the model feels inadequate when considering the moral, interpersonal, and legal transgressions that are so common in persons with addiction. We know punishment alone doesn’t work, given three decades of the failed War on Drugs. Perhaps the answer is punishment combined with treatment and consequences that are thoughtfully crafted to reduce substance use and promote prosocial behavior, similar to contingency management strategies used to treat SUDs. By studying the active ingredients of programs that are working, like HOPE in Hawaii, we may find answers.
A rising number of people who started using drugs conservatively and responsibly to medicate intolerable physical pain are now addicted to those drugs. How did this happen and why? Who is responsible and what can be done? In my car on the way to work one day, on my local NPR station I was lucky to hear Dr. Anna Lembke discussing the rise in alcoholism. That program led to the article she wrote for this issue and to my reading her recent book, which is focused on addiction to prescription drugs and to answering those questions. She dedicates her book “to every patient who has been addicted to prescription drugs, to their loved ones, and to all the doctors who went into medicine to do good but feel trapped by a system gone awry.” The dedication is appropriate, as the book’s content delivers beautifully to that audience and to anyone interested in learning about how drugs prescribed for pain often end up causing more and different types of pain than could have previously been imagined.
A highly trained and clearly compassionate physician, Dr. Lembke is also a talented writer. Although prescription drugs are emphasized, Dr. Lembke weaves several stories from her patients with what science has revealed about substance abuse of all kinds, the history and evolution of pain treatment, physician training, insurance coverage issues, and drug marketing. The stories put human faces on this personal, family, and societal problem, making subject matter that is challenging on multiple levels easily accessible. She provides the lay reader with an in-depth, yet highly readable and concise, analysis of addiction, its costs, and possible solutions.
Although Dr. Lembke pulls no punches in describing the roles played in the current crisis by patients, physicians, medical societies, and pharmaceutical companies, the book is not about ascribing blame. Instead, it is a thoughtful exploration that concludes with a compelling call to “tease apart the strands of this web . . . and find our way out.” Ultimately, radical changes to our health systems may provide the only meaningful answers. Dr. Lembke calls for revamping the care provided to those with chronic pain, medication delivery, and physician education, and provides an example: a Pain Management Rehabilitation Program instituted in 2011 that has enjoyed promising success. The book is clearly essential reading for health professionals, but will prove useful and informative to judges as well—and to all who are affected by the public health crisis that is addiction in all of its forms.
—Reviewed by Mary-Margaret Anderson