Addiction is a Health Problem Substance Use is a Public Health Problem

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Addiction is a Health ProblemSubstance Use is a
Public Health Problem

• Michael M. Miller, M.D., FASAM

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Alternative Formulations of the Problem

• Addiction is a Criminal Justice Problem
• Addiction is a Moral Problem/Personal Weakness
• Addiction is a Societal Problem
• Addiction is Willful Misconduct

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• When most policy makers hear the term
  addiction, what they think of is illegal drug
  use.

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• Substance use is widespread.
• Addiction is common.
• Not all heavy/frequent
• substance users are addicts.
• Not all addicts are daily users
• or users of large quantities of
• substances.

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Addiction is a disease

• --a condition with well-defined clinical features
  (signs/symptoms)
• --a condition definable via inclusion criteria
  and exclusion criteria
• --a condition that involves alteration in the
  structure or function of the body
• --a condition with a well-defined natural history
  and prognosis
• --a condition for which treatment affects the
  course (natural hx and px)

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What are the clinical features of addiction?

• Substance use
• Use behaviors and procurement behaviors persist
  despite problems due to use
• Return to use after periods of abstinence,
  despite previous problems
• Inability to consistently control use
• Preoccupation with use/procurement salience of
  use-related behaviors
• Cognitive changes (over-valuation, de-valuation,
  minimization/denial)
• Enhanced cue responsiveness via conditioning and
  generalization

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What is the natural history of addiction?

• some variants are more malignant in course than
  others
• some variants are pediatric diseases (onset
  before adulthood)
• chronic disease pattern waxing and waning of
  signs/symptoms
• usually progressive
• insidious atrophy of judgment, coping skills,
  relationships, values
• sometimes fatal

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What is the main feature of addiction?

• Inconsistent control of use

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What is the use pattern of non-addicts?

• Onset in adolescence
• Heaviest during phases of life most unencumbered
  by use-incompatible behaviors
• If problems arise, use patterns adapt to avoid
  future problems

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What is the use pattern of non-addicts?

• Hangovers, poisoning
• Occupational problems
• Legal problems
• Marital problems

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What makes addiction so hard to understand?
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• Most people use, and use responsibly, with intact
  control
• Loss of control is a counterintuitive
  phenomenon
• Everyone knows someone who has a substance use
  disorder
• Most people think that their colloquial
  experience equates to technical knowledge
• Societal mores about use are ingrained and often
  unconscious

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Addiction occurs as a result of interactions
among

• Agent factors
• Host factors
• Environmental factors

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Its not only the agents (self-reinforcing
euphoriants)
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• --if it were only the agents, control of supplies
  would solve the problem
• --there will always be new agents
• --no substance is universally addictive in all
  hosts, in all environments

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Its not only the hosts (susceptible individuals)
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• --but for alcohol addiction, 60 of the risk is
  heritable
• Altered metabolism
• Diminished physiologic/behavioral response
• Differential preference for certain substances

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• --there is no individual, or personality style,
  that is universally addictive
• --if it were only the hosts, we would focus all
  interventions on at-risk kids

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Its not only the environments (cultures,
neighborhoods, homes, settings)
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• --set/setting do make a difference
• --not everyone from a given cultural/ethnic group
  become addicted
• --not everyone from a given bad neighborhood
  becomes addicted
• --not everyone from a bad household upbringing
  becomes addicted
• --not everyone from the same intrauterine
  environment becomes addicted
• --not everyone in a drug-infested environment
  becomes addicted

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Drug-liking is an important variable
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Drug-craving is an important variable
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Addiction is a stigmatized illness
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What is stigma?

• Branded as shameful, contemptible, or condemned.

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What other diseases have been stigmatized over
the centuries?

• Epilepsy
• Leprosy
• Schizophrenia
• Cancer
• AIDS

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What is the basis of stigma?

• False beliefs
• Unwillingness to attend to evidence
• Bigotry
• The designation of the stigmatized group as
  non-people

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What are the beliefs about addiction?

• its a problem of lower classes
• its a problem of urban areas
• its a problem of people of color
• its evidence of personal weakness

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What are the beliefs about addiction?

• its secondary to psychiatric illness
• its secondary to social stress
• the disease model is a myth and self-serving
• the diagnosis is overly subjective and, like in
  psychiatry,is soft-science

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What are the beliefs about addiction?

• the treatment isnt effective
• the prognosis is hopeless
• reoccurrences of active disease are evidence of
  treatment failure
• patients are non-compliant with treatment

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What are the beliefs about addiction?

• its a behavior-based (i.e., self-imposed)
  condition
• only end-stage cases are true cases

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What are the facts about addiction?

• it occurs secondary to biological vulnerability
• it is a disease of the brain, manifested in
  aberrant behavior
• it is a chronic disease, in which relapse and
  remission recur episodically

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• it is a primary illness with
• dramatic secondary effects
• medical
• psychological
• familial
• occupational
• legal
• economic

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What are the facts about addiction treatment?

• addiction treatment is very effective, when
  delivered appropriately
• addiction treatment produces significant
  remissions

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• addiction treatment reduces economic damage
• addiction treatment reduces crime
• addiction treatment reduces absenteeism and
  increases job productivity

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• addiction treatment reduces family disruption
  and child welfare problems
• addiction treatment reduces medical costs

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• Addiction treatment is held to unreasonable
  standards of treatment of other chronic diseases

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• in addiction care, an acute intervention is
  expected to produce permanent remission
• in addiction care, symptom reduction is not a
  valued measure of success
• in addiction care, treatment outcome is measured
  after treatment has terminated, rather than
  during a phase of continued exposure to treatment

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• Non-compliance with addiction treatment
  recommendations parallels that for other chronic
  illnesses

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• Addiction is only one of many chronic diseases
  which are behaviorally based, or whose treatment
  success depends on personal behavior change

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• obesity
• ischemic heart disease
• skin cancer
• diabetes
• pelvic inflammatory disease
• congestive heart failure
• and emphysemalargely due to nicotine addiction

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• Physicians do not screen for addiction in order
  to detect early-stage cases

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Addiction occurs with various substances

• Alcohol addiction
• Nicotine addiction
• Sedative addiction
• Opiate addiction
• Stimulant addiction (cocaine and amphetamines)
• Hallucinogen addiction

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Not all substance use involves addiction

• college-age binge drinking
• driving while under the influence
• injection drug use
• inhalant use

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• alcohol/sedative use leading to suicide attempts
• alcohol/sedative use associated with unwanted
  pregnancy

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• alcohol/sedative use associated with sexual
  assault
• alcohol/sedative use associated with domestic
  violence
• stimulant use associated with domestic violence

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• stimulant use and PCP use associated with random
  aggression
• tobacco use associated with progressive substance
  use

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What do we know about the results of substance
use?

• it can result in physical illnesses
• from alcohol gastritis, GERD, PUD,
  pancreatitis, fatty liver, cirrhosis,
  arrhythmias, anemia, bleeding problems, HBP,
  neuropathy, cerebellar degeneration, dementia,
  Korsakoffs syndrome, cancers of the liver,
  stomach, esophagus, colon, bladder
• from cocaine seizures, arrythmias, coronary
  artery spasm
• from tobacco emphysema, lung cancer, bladder
  cancer, heart disease, HBP

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• It can result in psychiatric illnesses
• anxiety, depression, psychosis, delirium,
  dementia

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The route of use can lead to physical illnesses

• intravenous drug use can lead to
• abscesses
• sepsis
• bacterial infections of heart valves
• HIV infection
• Hepatitis B and Hepatitis C infection

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The route of use can lead to physical illnesses

• intranasal drug use can lead to
• perforation of the nasal septum requiring
  reconstruction
• inflammation of the lung

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• There is a relationship between quantity/duration
  of substance use and the amount of resultant
  morbidity and mortality (illness and death)

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• Reduction of use is an important public health
  strategy

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Reduction of harmful use is an important public
health strategy

• If you use, dont drive
• If you use, dont use in high-risk situations for
  you
• If you use, dont use via dangerous routes of
  administration
• If you use IV, use clean needles/syringes
• If you use, use lower quantities

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• Individuals with addiction DO contribute to use
  rates in a population
• Individuals with addiction DO participate in
  harmful behaviors

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• Individuals with addiction DO NOT have the
  ability to voluntarily reduce use rates and
  maintain control indefinitely over such reduced
  use rates (quantity/frequency)

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• Substance use IS amenable to preventive medicine
  strategies
• Addiction IS amenable to preventive medicine
  strategies

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Primary prevention

• reduce INCIDENCE of new cases by managing risk
  factors

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Secondary prevention

• reduce PREVALENCE of cases by reducing incidence
  and duration
• reduce duration of active disease via effective
  treatment

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Tertiary prevention

• reduce the DISABILITY due to illness
• Improve level of functioning
• Reduce the consequences of
• the illness

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Primary prevention

• For substance use use community coalitions,
  increase watchfulness over youth, involve dads
• For substance use delay age of onset of first
  use
• For substance use delay age of onset of first
  tobacco use

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• For addiction reduce substance use
• For addiction identify at-risk populations

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Secondary prevention

• For addiction professional treatment
• For addiction there are pharmacologic therapies
  available
• For addiction early detection and intervention

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Tertiary prevention

• For substance use harm reduction strategies
• For addiction dont just detect and intervene
  with late-stage cases
• For addiction multi-modality rehabilitation

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To control our substance use problems in America

• For addiction, control of supplies is important,
  but not sufficient.
• For addiction, treatment of diagnosed illness is
  the answer.
• For substance use (in addicts and non-addicts)
  social proscriptions help.

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To have a system of effective addiction treatment
in America

• Stigma about addiction must be overcome
• Addiction must be understood as a primary,
  chronic disease
• Treatment must be available to the ill
• The ill must receive treatment, not punishment
  alone
• Health insurance benefits for addiction must be
  equal to those benefits for other chronic
  illnesses

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If we do not propose that addiction treatment
benefits must be equal to those for other
illnesses
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• We must believe that addiction is not a disease
• Or
• We must believe that to try to treat addiction is
  futile
• Or
• We must believe that individuals with addiction
  are non-people or non-deserving of treatment
• And

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• We must be willing to accept high rates of
  physical illness secondary to substance use and
  addiction
• We must be willing to accept high rates of
  psychiatric illness secondary to substance use
  and addiction

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• We must be willing to accept the high costs to
  government of cleaning up the damage from
  addiction
• Health care costs (Medicare and Medicaid)
• Child welfare costs
• Special education costs
• Criminal justice costs
• Incarceration costs
• Interminable costs of interdiction and supply
• control

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If employers do not insist upon early detection
and referral to effective treatment of the
chronic disease of addiction,
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they must be willing to accept the costs of
treating the health care conditions caused by
addiction, plus the costs of absenteeism, reduced
productivity, increased turnover, and
recruitment/training costs for workers lost to
the workplace due to addictionas well as costs
of effects on family members.