Dear Mr. President: A Modest Proposal

By Susan E. Foster 10/08/12

No need to debate this: Treating addiction as a disease is America’s greatest single opportunity to reduce costs to taxpayers, improve health and reduce crime.

Can the two candidates walk the walk?

Unless you live under a distant rock, you know that last week's presidential debate on the economy ignited the campaigns of President Barack Obama and Governor Mitt Romney. Romney, according to the punditocracy, won handily; Obama, accordingly, was flat. The big subject? Spending. And although Obama and Romney don’t agree on much, they both say that reducing the budget is a priority. What neither candidate realizes (or acknowledges) is a substantial cut that's hiding in plain sight: call addiction a disease. Taking this simple step would not only reduce the federal tab, it also would cut state and local spending, lower crime, traffic accidents, suicides, domestic violence, homelessness, birth defects and a host of other devastating and costly health and social ills. This relatively simply policy change also would improve the health and productivity of Americans across the country. It's a no-brainer.

Except that it's not. While the science on addiction is generally clear, public policy, opinion and health care practice lag decades behind at a huge cost to society. Here are the facts: Addiction is a complex disease of the brain that is reflected in pathological pursuit of reward or relief through substance use. Looking only at addiction involving tobacco, alcohol and other drugs, it is an epidemic affecting 16 percent of the United States over age 12—more than those with cancer, diabetes or heart disease. Another 32 percent of Americans are classified as risky users of addictive substances, meaning people may not have the disease of addiction, but use substances in ways that everyone's health and safety.

Americans turn a blind eye to the disease of addiction and instead deal with its consequences—a tab that costs every person in America nearly $1,500 each year. Our public policy approach is one of shoveling up after preventable disasters.

The National Center on Addiction and Substance Abuse at Columbia University (CASAColumbiaTM) documented in a recently-released report, Addiction Medicine: Closing the Gap Between Science and Practice, a broad range of effective screening, intervention and treatment options exist, but they are not routinely offered to patients. Less than 11 percent of people with the disease receive any form of treatment. Compare that to the 70 to 80 percent who receive treatment for other diseases like hypertension, diabetes and major depression. Rather than providing treatment for addiction, we turn a blind eye to the symptoms and instead cope with the costly consequences.

The result, as quantified in CASAColumbia’s 2009 report on the costs of risky substance use and addiction to government, is that federal, state and local governments spend at least $467 billion each year on these problems. That was approximately 10 percent of the federal budget and 16 percent of state budgets in 2005. Of that spending, less than two cents of every dollar goes to prevention and treatment, two and one-half cents go to research, taxation, regulation and interdiction while the rest of the money—almost 96 cents of every dollar—goes to cope with the consequences of our failure to prevent risky use and treat addiction. Just covering the bill for these consequences costs every person in America nearly $1,500 each year.

The two largest areas of government spending on the consequences of risky substance use and addiction are health care and crime. Approximately one third of all hospital inpatient costs result from risky use and addiction which drive more than 70 other diseases requiring medical care. And in America, 86 percent of all inmates in our prisons and jails are substance-involved; two-thirds report meeting medical criteria for addiction. America’s public policy approach to this disease is one of shoveling up after completely predictable and preventable disasters.

Rather than educate the public about this very real public health crisis, its risk factors, how to prevent it and provide quality treatment and disease management as we do for other health concerns, public policy makers choose to wait for a crisis to occur. Then we pay, and pay, and pay.  For example, on average we spend over $25,000 per year to incarcerate each substance-involved offender but fail to provide treatment for their disease, insuring that they will be far likelier to be a repeat offender and be re-incarcerated.  The American public pays for these consequences not just in the form of tax dollars, but in human suffering. And, we pay with our lives as millions of Americans each year succumb to this deadly disease. The fact is, very few people in this country have not been affected by addiction in one or more of its manifestations.

Public opinion, while conflicted, is somewhat more advanced than public policy.  This nation has a long history of isolating and stigmatizing individuals with health problems that were not well understood, from tuberculosis to cancer, depression and HIV-AIDS.  Once scientific understanding of the condition is solidified and the information permeates public understanding, public attitudes towards the condition and those who have it often change.  The availability of effective treatments also can have a profound impact on driving this change.  Addiction is a prime example of a disease where public attitudes have yet to catch up with the science, although attitudes are shifting. Recent national polls reveal that while there is still significant stigma attached to this disease, approximately eight out of 10 people recognize addiction as a chronic disease.

The main challenge we face to addressing addiction as the disease it is involves integrating its prevention and treatment into routine health care. Addiction treatment today is largely disconnected from mainstream medical practice. Most medical professionals who should be providing treatment are not sufficiently trained to diagnose or treat addiction. Many of those providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to provide the full range of evidence-based services. There are no clearly delineated, consistent and regulated national standards that stipulate who may provide addiction treatment in the U.S. The standards for treating this serious illness vary by state and by payer, and most treatment providers are unable to provide effective, evidence-based care. Moreover, insurance coverage of these treatment practices is often inadequate and based on a misunderstanding of this disease; for example paying for detox only but not comprehensive treatment and disease management.

We now have a solid understanding of the nature of the disease; we know many of the risk factors. We have screening and intervention tools of proven efficacy. We have a broad range of effective behavioral and pharmaceutical treatments to deliver in the context of routine health care. We need to use this knowledge.

Clearly, health care providers must step up to the plate and educate themselves on how to prevent risky use and how to effectively treat addiction. And, insurance companies must cover costs of effective prevention and treatment rather than paying a much larger tab to treat resulting diseases. But perhaps the greatest leverage can be found within the U.S. government. To reduce costs to government and improve health, safety and productivity, the federal government should require that health care providers receiving federal funding (including Medicaid and Medicare) offer comprehensive and evidence-based screening, intervention and diagnostic services for all manifestations of addiction as well as provide treatment and disease management or connect patients with specialty care as appropriate as is done for other health conditions.

The federal government also should require that addiction treatment programs and facilities be licensed as health care providers, require adherence to national accreditation standards based on the science of addiction and its treatment and immediately work to expand the addiction medicine workforce. And, it should identify patients at risk in government funded programs and services where costs of our failure to prevent and treat addiction are high and assure that patients receive the prevention, intervention, treatment and disease management services they desperately need.

Although making a cost-benefit argument for saving lives and reducing suffering is not a threshold requirement for any other area of health care practice, study after study has shown that the benefits of addiction treatment outweigh the costs. We all agree that the so called war on drugs has failed, but the answer is not legalization. The answer lies in understanding what we face—a public health and medical problem—and responding accordingly. It makes good sense to keep dangerous and harmful substances out of the public marketplace, but enforcement alone will not treat a disease. Providing preventive care and effective medical care will, and it will save us all a lot of money and heartache.

No matter what side of the political spectrum you are on, addiction is a disease that touches virtually every family and circle of friends in America. I urge both President Obama and Governor Romney to part the smoke and mirrors of the health care debate and agree on this one fundamental change. 

Susan E. Foster is Vice President for Policy at The National Center on Addiction and Substance Abuse at Columbia University (CASAColumbiaTM). 

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Susan E. Foster is Executive Director of The Addiction Medicine Foundation’s National Center for Physician Training in Addiction Medicine. She has been responsible for a wide range of national studies on risky substance use and addiction and for developing collaborations, tools and practice guides to translate research results into health care practice, public policy and public understanding of the disease. Susan has held policy and management positions in the non-profit sector and in federal, state and local government, and was founder and partner of a public policy consulting firm providing services to the nation’s governors. Serving as a spokesperson on addiction prevention and treatment, she has appeared in a wide range of media venues, presented to national, regional, state and international groups, testified before federal and state legislative bodies, and consulted with representatives of other countries about addiction policy. (CASAColumbiaTM). 

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