As the United States copes with the extraordinary health and social costs of our latest opioid addiction crisis, this solutions-oriented book—Overcoming Opioid Addiction—is particularly welcome. For those suffering from an opioid use disorder, their families, and the clinicians who treat them, Dr. Bisaga offers the most advanced, science-based methods for diagnosing, treating, and managing opioid addiction. As the book makes clear, even serious opioid addictions can be overcome. With comprehensive, continuing care full recovery is now an expectable result. The rationale and methods to achieve this goal are amply detailed in the book, and I can only hope all physicians and all families adopt the principles and practices Dr. Bisaga sets forth.
But there is a broader social context to the current addiction crisis that is also addressed by this book. Dr Bisaga shows why and how our country must get past our outdated and largely incorrect conceptions about addiction, substantially revise our antiquated set of addiction treatment programs, and fully integrate addiction prevention, early intervention, and treatment into mainstream healthcare—if we truly wish to overcome opioid (and other) addictions. In this regard, I do have some historical and conceptual comments that I hope will amplify the position Dr. Bisaga has taken.
Historically, addiction to alcohol and other drugs has been conceptualized as a sign of weak character, a personality disorder, or a habitual series of bad personal choices. This is easy to understand. Cardinal features of all addictions include failure to carry out normal adult role functions because of cravings for and uncontrolled use of alcohol or other drugs. For many seriously affected patients, lying, stealing, and negligent, dangerous acts (e.g. drunk driving) are all too common behavioral effects of the addiction. It’s understandable then, why addictions have been stigmatized, and why they have been considered public safety problems to be dealt with through laws and punishments—rather than personal health problems better addressed through prevention, early intervention, and medical management.
For these reasons, since the late 1960s, virtually all available treatments for addiction have been provided by “addiction treatment programs” whose focus was on correcting the behavioral and character problems so typical among the seriously addicted. This was accomplished, usually by first treating the physical withdrawal and craving symptoms that were thought to fuel relapse; and then confronting the dishonesty and impulsive character traits that were thought to underlie an “addictive personality.” Who better to lead this effort than peer counselors who were themselves modeling a new “recovery” lifestyle emphasizing personal honesty, social responsibility, and abstinence from all substance use. Under this conceptual framework and care delivery model, there was little need for physicians, medications, information systems, professional therapies, or most of the prominent features of modern healthcare.
So, it should not be surprising that the administration, regulation, and financing of the addiction treatment system occurred outside the mainstream healthcare system; or that addiction treatment was organized and financed primarily as an acute care system. The prevailing concept of addiction as a character or personality disorder did not fit well within the mainstream healthcare systems of the day, and physicians were neither trained for, nor particularly eager to accept patients with addictive disorders. A new system was purposely designed and financed to be separate from the rest of healthcare. Over the ensuing decades, as healthcare spending became an increasingly important issue within the private sector, employers made special efforts to reduce employee healthcare benefits for addiction treatment by purchasing “carved-out” insurance for addiction treatment, typically under the auspices of separate “behavioral health managed care organizations.” By 2000, most addiction treatment was purchased with government funding (primarily state block grant and Medicaid dollars) and private insurance accounted for less than 12% of all care episodes.
There are two important but seldom acknowledged implications of this planned, purposeful segregation of addiction treatment. First, most major healthcare organizations eliminated addiction treatment. In turn, the great majority of medical, nursing, and pharmacy schools eliminated addiction education/training. Meanwhile, in mainstream healthcare, pharmaceutical benefits from private insurance packages fostered development of new medications with the promise of cheaper and more effective treatments; and there was a growing consumer movement—epitomized by those affected by HIV/AIDS—demanding more access and better treatments. These forces were never present in the addiction field, in part because the condition was so stigmatized that consumers felt unable to demand their rights. Because addiction was not accepted as an illness, medications were considered inappropriate by some providers, unnecessary by many state Medicaid systems, and clearly not profitable by most pharmaceutical companies. Drug counselors became the major professional group in the addiction field and group counseling became the most prevalent—often the only—available component of care. The result is that the approach and the content of addiction treatment has changed very little from its inception in the late 1960s until today. The remarkable advances in treating other diseases spurred by medical and pharmaceutical research and the consumer movement simply did not occur in the segregated addiction treatment system.
The critical, system-level point conveyed in this excellent book is that, as designed and constructed, the current addiction treatment system not only does not—it cannot provide the personalized care, management, and professionalism necessary to overcome opioid addiction. Dr. Bisaga’s clinical guidelines for treating people with opioid or other addictions are, counterintuitively, more relevant and more achievable within today’s primary care practices—though that would be news to most primary care physicians—than in most “traditional,” non-medical addiction treatment programs. The clinical procedures described in this book offer an excellent basis for improving care for anybody with an opioid use disorder. But overcoming opioid addiction in this country will require addiction education in medical and nursing schools; addiction treatment coverage at parity in healthcare insurance; and addiction prevention, early intervention, and treatment integrated throughout mainstream healthcare systems.
Put differently, without the transformation of concept, organization, financing, and management methods, addiction treatment is not likely to improve—regardless of scientific advances or public pressure. With an evidence-based rethinking of addiction as a chronic illness, training of primary care physicians, development of disease management protocols, adaptation of clinical information systems, benchmarking of standard measures of illness progression and patient improvement, and the development of personalized care monitoring and management practices, we will not only overcome opioid addiction—we will substantially improve the quality, effectiveness, and efficiency of mainstream healthcare.
A. Thomas McLellan, PhD
Emeritus, Department of Psychiatry,
Perelman School of Medicine, University of Pennsylvania
Former Deputy Director of the White House Office
of National Drug Control Policy