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    McLellan Et Al

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    Maria Cecilia Oñederra Llanos
    2000

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    MMUNICATION Drug Dependence, a Chronic Medical Illness Implications for Treatment, Insurance, and Outcomes Evaluation A Thomas MeLellan, PhD David © Lewis, MD Gharles P. O'Brien, MD, PhD Herbert D, Klcher, MD ANY EXPENSIVE AND DIS- tubing social problems can be traced directly 10 drug dependence. Re- ccont studies estimated that drug de- pendence costs the United States ap- proximately $67 billion annually in crime, lost work productivity, foster care, and other social problems." These expensive effects of drugs on all social systems have been important in shap- ing the public view that drug depen- dence is primarily a social problem that requires interdiction and law enforce- ment rather than a health problem that requires prevention and treatment. This view is apparently shared by many physicians. Few medical schools or residency programs have an ad- equate required course in addiction, Most physicians fail to screen for aleo- hol of drug dependence during rou- line examinations.” Many health pro- fessionals view such sereening efforts asawaste of time. A survey® of general practice physicians and nurses indi- ceated that most believed no available medical or health care interventions ‘would be “appropriate or effective in treating addiction.” In fact, 40% to 60% ‘of patients treated for aleohol or other drug dependence return to active sub- stance use within a year following treat- (©2000 American Medial Association, All rights reserved. (Repited) IMA, Occber ‘The effects of drug dependence on social systems has helped shape the gen- erally held view that drug dependence is primarily a social problem, not a health problem. In tum, 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, heri- tability, 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, per- sonal choice, and environmental factors are comparably involved in the et ology and course of all of these disorders. Drug dependence produces sig- nificant and lasting changes in brain chemistry and function. Effective ‘medications are available for treating nicotine, alcohol, and opiate depen- dence but not stimulant or marijuana dependence. Medication adherence and relapse rates are similar across these illnesses. Drug dependence gen- erally has been treated asif it were an acute illness. Review results suggest ‘that long-term care strategies of medication management and continued moni- toring produce lasting benefits. Drug dependence should be insured, treated, and evaluated like other chronic illnesses. JAMA, 2000286 1689-1695, ww jamacom rent discharge."’ One implication is were selected because they have been that these disappointing results con- well studied and are widely believed to firm the suspicion that drug depen- have elective treatments, although they dence isnot a medical illness and thus are notyet curable, Our review searched is not significantly affected by health all English-language medical and health care interventions. Another possibil- journals in MEDLINE from 1980 to the ity is that current treatment strategies present using the following key words: and outcome expectations view drug heritability, pathophysiology, diagno dependence as a curable, acute condi- sis, course, treatment, compliance, ad tion, Ifdrug dependence is more ke | chronic illness, the appropriate stan- Aug Affliatons: Th Teste! Rese st dards for treatment and outcome ex- ter fr Sdes of Aacton at he Veterans Aas : cripother Medical Center an the Univesity of Pema Pectations would be found amongother Pyisgepha (Ore Melelan and O Bren The ron chronic illnesses. Univers Center for Asha an Adlon Ste, To explore this possibility, we un- Provence. Rr Lew) nd Te Naa! Cater tn Adon and Substance Abuse st Columbia Us dertook a literature review comparing Sassen one i ekeoen drug dependence with 3 chronic ill: Coresponding Autor end Rept: A Thomas aaan nei rltbetee ellie: hgper, Metstan POs the restment Rese ste, 180 type 2 NPE SIndependence Mall W,Sste 600, Pid, PA tension, and asthma. These examples 191063475 lems tmclelandteseuch of ‘Downloaded From: htp:/fjmna jamanstorork.com/by « Pontificia Universidad Catolica de Chile User on 07/31/2016 DRUG DEPENDENCE AS A CHRONIC ILLNESS erence, relapse, and reoccurrence. Lm- portantly, our definition of drugand our review criteria included all over-the- counter (alcohol and nicotine), pre- scription (benzodiazepines, amphet- amines, opiates), and illegal (heroin, marijuana, cocaine) drugs The review is presented in 2 parts The first part considers some charac- teristic aspects of chronic illness, such as diagnosis, heritability, etiology, and pathophysiology. The second part re- views recent advances in the medical treatment of drug dependence and con- siders treatment response, particu- larly medication adherence and re- lapse oF recurrence. Although we are aware that arguments by analogy are limited, we believe this comparative analysis of drug dependence with other chronic illnesses offers some instruc- live and provocative implications. DIAGNOSIS, HERITABILITY, ETIOLOGY, AND PATHOPHYSIOLOGY Diagnosis Most adults have used alcohol and/or other drugs, sometimes heavily to the point of abuse but rarely to the point where that use could reasonably be called an illness, There is no labora- tory test for dependence, but the diag- nostic differentiation of use, abuse, and dependence has been operationally r lined and repeatedly shown to be rell- able and valid.!® Dependence or what is commonly. called addictions operationally defined inthe Diagnostic and Statistical Manual (of Mental Disorders, Fourth Edition" as 4 pathologie condition manifested by Sormore of 7 criteria. Two of these eri teria, tolerance and withdrawal, indi- cate neurologic adaptation or so- called physiologic dependence. However, as has been pointed out," physiologic adaptation (tolerance or withdrawal) by itself is neither net sary norsuflicient for adiagnosis of sub- stance dependence. Indeed, those receiving a dependence diagnosis are required to show a “compulsive desire for and use of the drug(s) despite seri- cous adverse consequences” such as "use 1690 JAMA, Ccsher 4, 2000Vol 284 ‘Downloaded From: htp:/fjmna jamanstorork.com/by « Pontificia Universidad Catolica de Chile User on 07/31/2016 io. 13 epited) instead of or while performing impor tant responsibilities." There are several short (<5 min- tutes of patient or practitioner time) questionnaires that ean screen for al- cohol and other drug dependence di orders with high rates of sensitivity and specificity.” Pollowing a positive screening result, standardized diagnos- Lic checklists can be applied during the medical evaluation, Diagnoses that re- sult from these standardized and eas- Aly applied eriteria have been reliable and valid across a range of clinical and nonclinical populations." Genetic Heritability One of the best methods for estimat- {ng the level of genetic contribution is to compare the rates of a disorder in monozygotic and dizygotic twins. Heri- ability estimates [rom twin stud {es of hypertension range from 0.25 to 0.50, depending on the sample and the diagnostic criteria used. Twin stud- es of diabetes offer heritability esti- ‘mates of approximately 0.80 for type 2° and 0.30 to 0.55 for type 1 diabetes mellitus.” Finally, twin studies! of adult-onset asthma have produced a somewhat broader range of heritabil- lay estimates, ranging from 0.36 100.70. Several twin studies" have been published in the substance depen- dence field, all showing significantly higher rates of dependence among twins than among nontwin siblings and higher rates among monozygotic than dizygotic twins. Published heritability estimates include 0.34 for males de- pendent on heroin, 0.55 for males de- pendent on alcohol, 0.52 for females dependent on marijuana, and 0.61 for cigaretie-dependent twins of both sexes. More studies of heritability are needed across drug types and sexes, butthe evidence suggests significant ge- netic contribution to the risk of addic- don comparable to that seen in other chronic illnesses, Role of Personal Responsibility Since the use of any drug is « volun- tary action, behavioral control or will- power is important in the onset of de- pendence. Thus, at some level an addicted individual is at fault for inii- ‘ing the behaviors that lead to a d pendence disorder. Doesnt this volun- lary initiation of the disease process set drug dependence apart, etiologically, Irom other medical illnesses? There are many illnesses in which voluntary choice affects initiation and maintenance, especially when thes untary behaviors interact with genetic and cultural factors. For exampl among males, sall sensitivity is a ge- netically transmitted risk factor for the eventual development of one form of hypertension.** those who inherit salt sensitivity de- velop hypertension, This isbecause the use of salts determined by familial salt use patterns and individual choice. Similarly, risk factors such as obesity stress level, and inactivity are prod- ucts of familial, cultural, and personal choice factors." Thus, even among those with demonstrated genetic risk, ‘significant part ofthe total risk ford veloping hypertension can be traced to individual behaviors There are also involuntary compo- nents embedded within seemingly vo- litional choices. For example, al- though the choice to try adrug may be voluntary, the elfects of the drug can bbe influenced profoundly by genetic fac- tors, Those whose initial, involuntary physiologic responses to aleohol of other drugs are extremely pleasurable will be more likely to repeat the drug taking than those whose reaetion is new tral or negative. Work by Schuckit® and Schuckit and Smith has shown that sons of alcohol-dependent fathers in- hherit more tolerance to alcohal’s ef fects and are less likely to experience hangovers than sons of non-aleohol- dependent fathers. In contrast, the in- hherited presence of an aldehyde dehy- drogenase genotype (associated with alcohol metabolism) causes an invol- untary skin “flushing” response to al- cohol.” Individuals who are homo- 2zygous for this allele (approximately 35% of the Chinese population, and 20% of Jewish males in Israel) have an especially unpleasant initial reaction to * However, not all of (©2000 American Medical Association, All rights reserved. voluntary alcohol use tothe point where there are virtually no alcoholics found ‘with this genotype ~athophysiology The acute effects of alcohol and other drugs have been well characterized, However, even a complete understand ing of these acute effects cannot ex- plain how repeated doses of alcohol and other drugs produce paradoxically in- creasing tolerance to the ellects of those drugs concurrent with decreasing vo- litional ability to forgo the drug. As sug- gested by Koob and Bloom,” the chal- lenge is to find an internally consistent sequence by which molecular events modify cellular events and in turn pro- duce profound and lasting changes in cognition, motivation, and behavior. Research on the neurochemical, new roendocrine, and cellular changes as- sociated with drug dependence has led to remarkable findings during the past decade, as summarized in the recent lit- erature. Herein, we summarize just 3 areas of investigation, ‘Addictive drugs have well-speciied el fects on the brain circuitry involved in the control of motivated and learned be- hhaviors.*** Anatomically, the brain cit- ccuitry involved in most of the actions of addictive drugs is the ventral tegmen- tal area connecting the limbic cortex through the midbrain to the nucleus ac- cumbens."""* Newrochemically, aleo- hhol, opiates, cocaine, and nicotine have significant effects on the dopamine sys- tem, although through different mechs- nisms. Cocaine increases synaptic do- pamine by blocking reuptake into presynaptic neurons; amphetamine pro- duces increased presynaptic release of dopamine, whereas opiates and aleo- hhol disinhibit dopamine neurons, pro- ducing inereased firing rates. Opiates and alcohol also have direct effecison the en- ddogenous opioid and possibly the y-ami- nobutyric acid systems.*"* Significantly, the ventral tegmental area and the dopamine system have been associated with Feelings of eupho- via} Animals that receive mild el trical stimulation of the dopamine sys- tem contingent on a lever press will (©2000 American Medical Association, All rights reserved, ‘Downloaded From: htp:/fjmna jamanstorork.com/by « Pontificia Universidad Catolica de Chile User on 07/31/2016 ‘DRUG DEPENDENCE AS A CHRONIC ILLNESS rapidly learn to press that lever thou- sands of times, ignoring normal needs for water, food, oF est.™* Cocaine, opi- ates, and several other addictive drugs produce supranormal stimulation of this reward eireuitry.2»> Given the fundamental neuro- anatomy and neuropharmacology of this system, itis understandable that ad dictive drugs could produce immedi ate and profound desire for their read- ‘ministration. Less clear is why simply preventing the administration of these rugs for some period would not cor- rect the situation, return the system to normal, and lead toa “sadder but wiser" individual who would be less instead of more likely to reuse those drugs. Its known that use of these drugs atsome dose, frequency, and chronic~ ity will reliably produce enduring and possibly permanent pathophysiologic changes in the reward circuitry, in the normal levels of many neurochemi- cals, and in the stress response sys- tem?!" Volkow et ab™ found impairments in the dopamine system of abstinent former cocaine users 3 months afer their last use. Other stud- es" have documented sustained changes in the stress response system following abstinence from opiate or co- caine dependence. Researchers do not know how much drug use is required toereate these changes or whether these effects ever return to normal. Somatic signs of withdrawal last several days, motivational and cognitive impair- ‘ments may last several months,” but the learned aspects of tolerance tothe drug ray never return to normal." ‘second explanation for the endur- ing pathology seen among drug- dependent persons and their ten- deney to relapse lies in the integration of the reward circuitry with the moti- vational, emotional, and memory cen- ters that are colocated within the lim bic system. These interconnected regions allow the organism not only to experience the pleasure of rewards but also to learn the signals for them and to respond in an anticipatory man- ner.*"! Repeated pairing ofa person (Grug-using friend), place (comer bar), thing (paycheck), or even an emo- tional state (anger, depression) with drug use can lead to rapid and en- trenched learning or conditioning, Thus, previously drug-dependent ine dividuals who have been abstinent for long periods may encounter a person, place, or thing that previously was as- sociated with their drug use, produe- ing significant, conditioned phy logic reactions, such as withdrawal- like symptomsand profound subjective desire oF craving forthe drug." Thes responses can combine to fuel the “loss of control” that is considered a halle mark of drug dependence.” These conditioned physiologic responses have been shown in labora- tory studies!" of currently abstinent former opiate, cocaine, and alcohol dependent individuals. Childress etal, using positron emission tomography, examined limbie and control brain regions of detoxified, male, cocaine- dependent subjects and cocaine-naive controls during videos of cocaine- related seenes. During the video, these currently abstinent former cocaine- dependent subjects experienced in- creased craving and showeda pattern of limbic increases and basal ganglia decreases in regional cerebral blood flow that mimicked the effects of the drug itself. This pattern did not occur in cocaine-naive controls oramong the for merly eoeaine-dependent patients in response toaneutral video Thus, even artificial video scenes of cocain: related stimuli, presented in the sterile context ofa positron emission tomog- raphy laboratory, produced excitation of brain reward regions and triggered drug eraving TREATMENT RESPONSE A central question in the comparison fof drug dependence with other ill- nesses is whether dependence will d crease without treatment and whether itwill respond to medications and other interventions, There is a large re- search literature on drug dependence lreatment outcomes." The treatment of addiction has been de- seribed ina manual” and 2 detailed vol- (Reprinted) JAMA, Over 4, 2090Nol 284, No. 131694 DRUG DEPENDENCE AS A CHRONIC ILLNESS umes." Space permits only a few ex- amples from that lierature, addressing {questions of particular import to phy Untreated Persons Examinations of untreated, dependent persons offer some indication of the natural course of addiction. Forexampl Metzger et al” measured drug use, necdie-sharing practices, and human immunodeficiency virus (HIV) infe lion rates of 2 large samples of opiat dlependent persons in Philadelphia, Pa The in-treatment (IT) group ineluded 152 patients randomly selected atadmis- sion toa methadone maintenance pro- gram. OutoFtreatment (OT) subjects were also heroin-dependent individ- alsmatched tothe T group by age race, sex, neighborhood, and other relevant Irackgroutnd factors, slthough none of the 103 OF subjects had received treat- ment. Both groups were interviewed and tested for HIV stats every 6 months for 7 years. Atte initial assessnent, 139% of the IT sample and 21% of the OT sample were HIV positive. By 7 years, 51% of the OT group but only 21% of the IT group tested HIV positive.” Of course, even this substantial between sroup difference does not prove that treatment participation was the causal agent Its likely thatthe OT subjects licked the motivation for change found among the weated patients Thus, lack of desir for personal change, rather than the elfets ofthe treatment itself, could hhave produced the diferences seen. ‘One way toseparate theeffets of drug dependence treatment from the elects ‘of motivations to compare treated and untreated substance-dependent indi- viduals who were explicitly not inter ested in treatment, Booth and col- leagues" studied 4000 intravenous drug users seeking HIV tesling as part of a multisite acquired immunodeliciency syndrome initiative in 15 cities. Sub- jects were randomly assigned to either standard HIV testing alone oF to stan- dard testing pls 3 sessions of mouiva- tional counseling fom a health edea- tor. AL o-month follow-up, those who received additional counseling showed 1692 JAMA, Cush 4, 2000Vol 284 ‘Downloaded From: htp:/fjmna jamanstorork.com/by « Pontificia Universidad Catolica de Chile User on 07/31/2016 io. 13 epited) half the rate of drug injection (20% vs 45%), 4 times the likelihood of absti- rence (confirmed by urinalysis), and sig- nificantly lower arrest rates (14% vs 2496) than those randomly assigned 10 receive just HIV testing.” Studies of other illnesses show that screening and brief advice from physicians can allect the motivation for change among pa- tients and the longer-term course oftheir health, The data of Booth et al suggest this is true even for seriously addicted individuals Svikis etal studied drug abuse treat- ‘ment in pregnant, cocaine-dependent women who did not originally apply for treatment. All women had simply ap- plied for prenatal care and were found tobe positive for cocaine use on a rou tine drug screen. They were compared with 46 pregnant, demographically ‘matched women who tested positive for cocaine use and received standard pre- natal eare during the year before the op- ening of the experimental treatment program. Drug dependence treatment consisted of 1 week of residential care followed by twice-weekly addiction counseling in the context of the sched- ued prenatal visits Acdelivery, 37% of the treated patients tested positive for cocaine use compared with 63% of the untreated women. Infants of the treated women averaged higher birth weights (2034 vs 2530 g) and longer gestational periods (9534 weeks) than those of the com- parison group. Following delivery, 10% of infants in the treated group required care in the neonatal intensive care unit (mean, 7 days). In comparison, 26% of {infants in the untreated group required Intensive care (mean, 39 days). Aver- age costs of eare were $14500 for the treated group and $4670 for the com- parison group. These data indicate that nug-dependent women canbescreened and motivated during prenatal eare and that drug dependence treatment can be combined with traditional prenatal eare {in an extremely cost-effective manner. ‘Medications In addition to medications for nico- tine dependence, such as nicotine gum and patch and bupropion hydrochlo- ride, medications for aleohol and opi- ate addiction have been developed un- der Food and Drug Administration uldelines, have been researched in rane domized clinical tials, and have reached the market. Herein, we dis- ces few recent developments, but a ‘complete review has been published by the Institute of Medicine.” Opioid Dependence. Opioid ago- nists, partial agonists, and antagonists are the 3 primary types of medications available lor the treatment of opioid pendence, all acting directly on opioid receptors, particularly y-receptors.” Agonist medications, such as metha- done hydrochloride, are prescribed in the short-term as part of an opioid d toxilication protocol or ia the long- lerm as a maintenance regimen Double-blind, placebo-controlled ti als have shown methadone tobe ef fective in both inpatient and outpa- tient detoxification, although the long- term effects of detoxification alone, without continuing treatment, have heen uniformly poor. As a mainte- nance medication, methadone’s oral route of administration, slow onset of action, and long half-life have been ef fective in reducing opiate use, erime, and the spread of infectious diseases as was recently validated by a Na- ional Institutes of Health Consensus Conference.” The partial agonist buprenorphine hydrochloride is administered sublin- ually and is active for approximately 24 to 36 hours.” Large double-blind, placebo-controlled trials of buprenor- phine have shown reductions in opi- ate use comparable with methadone but swith fewer withdrawal symptoms on discontinuation.”” Importantly, the ‘combination of buprenorphine plus nal- oxone hydrochloride, designed 10 r duce injection use, will soon be re- leased for prescription in primary care settings" Opioid antagonists such as naltzex- ‘one block the actions of heroin through competitive binding for 48 o 72 hours, producing neither euphoria nor dy phoria in abstinent patients." Nal- (©2000 American Medical Association, All rights reserved. trexone is used asa maintenance medi- cation, designed as an “insurance in situations where the patient ly to be confronted with relapse risks. Naltrexone in combination with social or criminal justice sanctions is routinely used in the monitored treat- ment of physicians, nurses, and other professionals.* In a recent controlled trial, Cornish andl colleagues” showed that naltrexone added to standard fed- eral probation produced 70% less opi- ate use and 50% less reinearceration than standard probation alone Aleohol Dependence. Naltrexone has been found elfective at 50 mgd for re- ducing drinking among aleohol- dependent patients." It works by Dlockingat least some of the “high” pro- duced by aleohol's effects on yropiate receptors, More recently, European re- searchers have found encouraging Fe- sults using the y-aminobutyri acid ago- nist acamprosate to block craving and relapse to alcohol abuse.*" Aleohol- dependent patients prescribed acam- prosate showed 30% higher absti- hence rates at 6-month follow-up than those randomized to placebo. Further- more, those who returned to drinking while receiving acamprosate reported less heavy drinking (25 drinks per day) than those receiving placebo.”” Stimulant Dependence. Although there are not yet effective medications for the treatment of cocaine or amphet- amine dependence,” there are proven bbchavioral treatments *"" There also are promising animal studies of a poten- tial vaccine that binds to and inaeti- vvates metabolites of cocaine," but clini- cal trials will not be scheduled for several years. ‘Comparing Treatments for Drug Dependence With Treatments for Other Chronic Diseases There is no reliable cure for drug de- pendence. Dependent patients who comply with the recommended regi- men of education, counseling, and medication have favorable outcomes during and usually for at least 6 10 12 months following treatment.” Fa vorable outcomes typically continue in (©2000 American Medical Association, All rights reserved, ‘Downloaded From: htp:/fjmna jamanstorork.com/by « Pontificia Universidad Catolica de Chile User on 07/31/2016 ‘DRUG DEPENDENCE AS A CHRONIC ILLNESS patients who remain in methadone maintenance or in abstinence mainte- nance through participation in Aleo- holies Anonymous (AA) oF other self help programs.**° However, because of insurance restrictions, many pa- tients receive only detoxification oF acute stabilization with no continuing care.!*° Others drop out of rehabilita- tion-oriented treatment and/or they ig- nore physician advice to continue tak- ing medications and participating in AA. Thus, 1-year, postdischarge follow-up studies!” have typically shown that only about 40% to 60% of discharged patients are continuously abstinent, alk though an additional 15% to 30% have not resumed dependent use during this period. Problems of low socioeco- homie status, comorbid psychiatric con- ditions, and lack of family and social supports are among the most impor- tant predictors of poor adherence dur- ing addietion treatment and of relapse following treatment." Hypertension, diabetes, and asthma are also chronic disorders, requiring continuing eare throughout a patient's life. Treatments for these illnesses are effective but heavily dependent on adherence to the medical regimen for thateffectiveness. Unfortunately, stud- ies have shown that less than 60% of adult patients with ype 1 diabetes melli- tus fully adhere to with their medliea- tion schedule,” and less than 40% of patients with hypertension or asthma adhere fully to their medication re mens.” The problem is even worse forthe behavioral and diet changes that are so important for the maintenance ofgainsin these chronic illnesses. Again, studies indicate that less than 30% of patients withadult-onset asthma, hyper- tension, or diabetes adhere to pre- scribed diet and/or behavioral changes that are designed to increase fane- tional status and to reduce risk fae for recurrence of the disorders.” Acrossall 3 of thes nesses, adherence and ulimately out- come are poorest among patients with lowsocioeconomie status, lack of fatn- lly and social supports, of significant psychiatric comorbidity." chronic medical ill- Perhaps because of the similarity in treatment adherence, there are also similar relapse rates across these dis- orders. Outcome studies indicate that 30% to 50% of adult patients with type 1 diabetes and approximately 50% to 70% of adult patients with hyperte sion or asthma experience recurrence of symptoms each year to the point where they require additional medical care to reestablish symptom rem ‘COMMENT Few persons who try drugs or regu- larly use drugs become dependent. However, once initiated, there isa pr dictable pathogenesis to dependence marked by significant and persistent changes in brain chemistry and func- lion, ILis not yet possible to explain the physiologic and psychological pro- cesses that transform controlled, vol- untary use of alcohol and other drugs into uncontrolled, involuntary deper dence. Twin studies indicate adefinite role for genetic heritability. Noneths less, personal choice and environmet lal factors are clearly involved in the expression of dependence. In terms of vulnerability, onset, and course, drug dependence is similar to other chronic illnesses, such as type 2 diabetes, hyper- tension, and asthma, (Our review of treatment response found more than 100 randomized con- trolled trials of addiction treatments, most showing significant reductions in drug use, improved personal health, and reduiced social pathology but not eure."9"47258 Recent treat ment advances include potent, well- tolerated medications for nicotine, aleo- hhol,and opioid dependence" but not marijuana or stimulant depen- dence. There is little evidence of elfec- liveness from detoxification oF short term stabilization alone without maintenance oF monitoring such as in methadone maintenance or AA.‘ However, as in treatments for other chronic disorders, we found major prob- lems of medication adherence, early drop-out, and relapse among drug- dependent patients. In fact, problems (Reprinted) JAMA, Over 4, 2090Nol 284, No 131698 DRUG DEPENDENCE AS A CHRONIC ILLNESS of poverty, lack of family support, and psychiatric comorbidity were majorand approximately equal predictors of non- compliance and relapse across all chronic illnesses examined." Thus, our review suggests that drug dependence shares many features with other chronic illnesses, We are aware that arguments by analogy are lim- ited, and even marked similarities 1o other illnesses are not proof that drug dependence is a chronic illness. None- theless, these similarities in heritabil- ity, course, and particularly response 10 treatment raise the question of why medical treatments are not seen as ap- propriate or effective when applied to alcohol and drug dependence. One pos- sibility is the way drug dependence treatments have traditionally been de- livered and evaluated, Many drug dependence treatments are delivered in a manner that is more appropriate for acute care disorders. Many patients receive detoxification only.» Others are admitted to spe- cialty treatment programs, where the goal has been to rehabilitate and dis- charge them as one might rehabilitate 4 surgical patient following a joint re- placement,” Outcome evaluations are typically conducted 6 to 12: months fol- lowing treatment discharge. The usual ‘outcome evaluated is whether the pa- tient has been continuously abstinent after leaving treatment Imagine this same strategy applied to the treatment of hypertension. Hyper tensive pal 28-day hypertension rehabilitation pro- ‘gram, where they would receive group ‘and individual counseling regarding be- havioral control of dit, exercise, andlife- style. Very few would be prescribed medications, since the prevailing insur ance restrictions would discourage main tenance medications, Patients complet ing the program would be discharged to community resources, typically with- ‘out continued medical monitoring. An evaluation of these patients 6 10 12 months following discharge would ‘count as successes only those who had remained continuously normotensive for the entire posidischarge period ents would be admitted toa 1694 JAMA, Occ $, 2000 Vo ‘Downloaded From: htp:/fjmna jamanstorork.com/by « Pontificia Universidad Catolica de Chile User on 07/31/2016 1, No. 13 (Reprinted) In this regard, itis interesting that relapse among patients with diabetes, hypertension, and asthma following ce=- salion of treatment has been consid cred evidence ofthe effectiveness of those Uweatmentsand the need to retain patients in medical monitoring. In contrast, relapse to drug oralcohol use following discharge from addiction treatment has been considered evidence of treatment failure. The best outcomes from treat- ments of drug dependence have been seeniamong patients long-term metha- done maintenance programs” =" and among the many who have continued participating in AA support groups." IMPLICATIONS For primary cate physicians, this re- view suggests that addiction screening, diagnosis, brief interventions, medica tion management, and referral criteria should be taught as part of medical schooland residency curricula and rou- tinely incorporated into elinical prac- tice." For those in health policy, our review olfers support for recent insur ance parity initiatives.** Like other chronic illnesses, the ellects of drug de- pendence treatment are optimized when patients remain in continuing care and monitoring without limits oF restric tionson the numberof days oF visits cov- ered, Although itis unknown whether care delivered ina specialty program or coordinated through primary care will provide the maximal benefits for pa tientsand society itis essential that prac- Litioners adapt the care and medical monitoring strategies currently used in the treatment of other chronic illnesses to the treatment of drug dependence. Funding Support: Tse wae supported by aan from the Department of Veterans Afals, the Ha tonal state on Drug Abuse, the Centr fr Sub ance Abuse Trestman, The Robert Wood Jason Feundston andthe Oice of National Dr Cont Posey ‘Aeknowkdgmnt: The manuscitnae reve "ot sported ancaly) bythe Pysan Leader ‘hip fr National Drag Poy efore submission, nd Drewes member of ta organization RERENES 4. Rice DP, Kelman, MilerLS. Estimates ofthe co- omic cot of sea and dug abuse and mental ter, 985 and 1988 Pubic elt Rep, 1991106: 20.282 2 ind Bar Substance Abuse and Ameria Prion Poputaton. New York NY: National Center for Aa {don and SusanceAbuee st Columba Univers ‘98, 3 Alcohol and Heath: Tenth Speci Report the Us. Congress Washington, OC: US Dept of Health fd Human Sees 1957 44 French MT, Rahal V, Harwood Hubba RL ‘ocr dug abut treatment affect emptyment and fring: cents? 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