Treating Addiction As A Chronic Disease

Feb 25, 2016
Originally published on February 26, 2016 3:09 pm

With the opioid epidemic reaching into every corner of the U.S., more people are talking about addiction as a chronic disease rather than a moral failing.

For researcher A. Thomas McLellan, who has spent his entire career studying substance abuse, the shift is a welcome one, though it has come frustratingly late.

McLellan is co-founder of the Treatment Research Institute in Philadelphia and former deputy director of the White House Office of National Drug Control Policy. His work has focused on understanding addiction as a disease and improving the ways it is treated, a mission that took a personal turn midway through his career when he lost a son to overdose.

NPR's Audie Cornish spoke with McLellan about how addiction is viewed and how that view has shaped the treatment system we have today. He also has suggestions on how to make it better.

Here are interview highlights, edited for length and clarity.

On why addiction has traditionally been seen as a criminal justice issue, not a health issue

Think about it. If you didn't have brain science, which has just really emerged in the last two or three decades, all you had to look at was the behavior of addicted people. They are not pleasant people when they are in full addiction. They steal, they lie, they swear they're going to do something and they don't. It's quite easy to think of this as it has been thought of for literally hundreds of years: as a character disorder, as poor upbringing as a problem of parenting. And that's how we approached it. It's not coincidence that the Justice Department has played such a pivotal role. The emerging science shows this is a brain disease. It's got the same genetic transmutability as a lot of chronic illnesses. And the organ that it affects is the brain, and within the brain it is motivation, inhibition, cognition, all those things that produce the aberrant, unpleasant behaviors that are associated with addiction.

On whether the drug treatment system is prepared to address the current opioid crisis

So there are two ways you have to think of it. First, there's the traditional addiction treatment system. It was purposely set up to be separate from all of health care and that's the way it's been for four decades. They've been doing heroic things, but they've been underfunded, undertrained and they have been unable to provide the most contemporary kinds of treatment and monitoring. So then you turn to the rest of health care, mainstream health care. What we found is that less than 10 percent of American medical schools have a course in addiction. Ditto nursing, ditto pharmacy schools. So, contemporary physicians are not equipped to do it. Yet it's those same kind of services, medications, behavioral therapies, monitoring and management, they now do routinely for diabetes, hypertension, chronic pain.

On the idea that addiction has to be treated over the long haul, the way diabetes and other chronic diseases are

It's a tough sell on two sides. No. 1, it's a tough sell for people who suffer from addiction. It's tough to hear, "I'm sorry, we don't have a cure. You can't get detoxed, go away for 30 days, get your head straight and not be affected." Same is true for diabetes. There is no place that I know of that gives you 30 days of insulin treatment and a hearty handshake and sends you off to a church basement. It just won't work, so that's tough.

It's been tough for medicine, too. These are doctors who have never learned about addiction in school. Why in the world, if they're already busy trying to treat other chronic illnesses, why should they take this on? And here is actually the best answer. You may say that expanding insurance options, providing more and better care for addicts is a waste of money, or it's a gift to someone who doesn't deserve it. The real gift is for the rest of health care, because it is impossible to manage most chronic illnesses without some attention to substance use disorders. They've been willfully ignored by medicine for decades and it's costing them roughly $200 billion a year in wasted or inappropriate medical care.

On what has changed for people whose families are affected by addiction

The people that I know who have lost spouses, children, some of them are so ashamed that they wouldn't even acknowledge it as a cause of death. And one thing I've found is that in health care, you don't get the kind of health care that science dictates or that is even economically prudent. You get the health care that you negotiate and that is politically motivated. So for most of my life, there has been no groundswell demanding the kind of care that other illnesses have rightfully come to expect. In my life, the best thing that has ever happened and given people like me hope that your grandkids won't have the same illness is the Affordable Care Act. It now mandates that the same kinds of care that are available for other illnesses of the body are also available for illnesses of the mind. We can do it. It's economically sensible to do. We just haven't had the political will.

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Transcript

AUDIE CORNISH, HOST:

Think about an illness. Now imagine if only a fraction of people with that illness were to get treatment. That's how more and more people are talking about substance addiction these days. Health officials estimate 22 million people in the U.S. abuse alcohol or drugs or both and only around 10 percent of them are in treatment. Yesterday, we heard from one of the vast majority who's not, Andrea Towson. She's known in her West Baltimore neighborhood as Teacup. She's used heroin on and off for decades.

ANDREA TOWSON: I want this chapter of my lift to close - just end. And it's not happening fast enough.

CORNISH: So why isn't it? Well, we're going to talk with someone who's spent his career trying to solve that problem, Thomas McLellan. He's co-founder of the Treatment Research Institute in Philadelphia. His work has focused on understanding addiction as a disease and improving the ways we treat it. He says for years, our entire approach to addiction was wrong. And that's in part because the necessary science wasn't there.

THOMAS MCLELLAN: Think about it. If you didn't have brain science, which has just really emerged in the last 2 or 3 decades, all you had to look at was the behavior of addictive people. They are not pleasant people when they are in full addiction. They steal, they lie, they swear they're going to do something, they don't. It's quite easy to think of this, as it has been thought of for literally hundreds of years, as a character disorder, as poor upbringing, as a problem of parenting. And that's how we approached it. It's no coincidence that the Justice Department has played such a pivotal role. Well, the emerging science shows - this is not my opinion. As the science shows, this is a brain disease. It's got the same genetic transmissibility as lots of other chronic illnesses and the organ that it affects is the brain. And within the brain, it's motivation, inhibition, cognition. All those things that produce the aberrant, unpleasant behaviors that are associated with addiction.

CORNISH: All right, so turning to, say, Opioid addiction, drug addiction, where is our medical or treatment system on this, right? If you look at all the treatment centers out there and rehab and programs, I guess you would call it an infrastructure. Is it prepared?

MCLELLAN: So there are two ways you have to think of it. First, there's the traditional addiction treatment system. It was purposely set up to be separate from all of healthcare, and that's the way it's been for now four decades. They've been doing heroic things, but they've been underfunded, undertrained and they have been unable to provide the most contemporary kinds of treatment and monitoring. So then you turn to the rest of healthcare, mainstream healthcare. What we found is that less than 10 percent of American medical schools have a course in addiction - ditto nursing, ditto pharmacy school. So contemporary physicians are not equipped to do it, yet it's those kinds of services, medications, behavioral therapies, monitoring and management - the same kinds of things that they now do routinely for diabetes, hypertension, chronic pain, all kinds of other illnesses

CORNISH: Let me stop you there because I think when people hear you describing addiction the way you're talking about, say, diabetes - right? - something you have to manage, something that involves kind of kind of long-term perpetual care, how hard a sell is that? Not just to private insurers, to the public. We're already in this culture talking about medical programs being sort of unsustainable - right? - like, the cost to the broader culture. How hard is it then to look to the public and say, yeah, you should do that for addicts too?

MCLELLAN: Right, good point. And it's a tough sell on two sides. Number one, it's a tough sell for people like Teacup. It's tough to hear that, I'm sorry, we don't have a cure. You can't get detoxed, go away for 30 days, get your head straight and not be affected. And the same is true for diabetes. There's no place that I know of that gives you 30 days of insulin treatment and a hearty handshake and send you off to a church basement someplace. It just won't work. So that's tough, OK? It's been tough for medicine too. These are doctors that have never learned about addiction in school. They don't know anything about it. And why in the world if they're already busy trying to treat other chronic illnesses, why should they take this on? And here's actually the best answer. You may say that expanding insurance options, providing more and better care for addicts is a waste of money or it's a gift to somebody who doesn't deserve it. I've heard all those things. The real gift is for the rest of healthcare because it is impossible to manage most chronic illnesses without some attention to substance use disorders. They've been willfully ignored by medicine for decades. And it's costing them roughly $200 billion a year in wasted or inappropriate medical care.

CORNISH: You've also had personal experience losing a son to addiction, other members of your family, you know, in and out of treatment. What do you think has changed over the years for people dealing with addiction in their families?

MCLELLAN: Well, the people that I know who've lost children, spouses whatever, so many of them were so ashamed, they wouldn't even acknowledge it as a cause of death. And like it or not, one thing I found is that in healthcare, you don't get the kind of healthcare that science dictates or that is even economically prudent. You get the healthcare that you negotiate, and that is politically motivated. So for most of my life, there has been no groundswell demanding the kind of care that other illnesses have rightfully come to expect. In my life, the best thing that's ever happened and given people like me a hope that your grandkids won't have the same lethal illness is the Affordable Care Act. It now mandates that the same kinds of care that's available for other illnesses of the body are also available for the illnesses of the mind. We can do it. It's economically sensible to do. We just simply haven't had the political will.

CORNISH: How hard is that for you to think of given the way addiction has affected your life?

MCLELLAN: The rest of my life is spent trying to prevent what happened to me and many other people in the early part of my life. And I have to simply say, I'm an expert. I've been studying treatment my whole life and it happened to me. How about a schoolteacher? How about a fireman? How about a policeman? The frustration is that it is possible to deliver effective, attractive, compassionate care. We can. It's in all our interest to do it. We need the political will to do it.

CORNISH: Thomas McLellan is founder of the Treatment Research Institute in Philadelphia. Thank you so much for speaking with us.

MCLELLAN: Very happy to do so. Transcript provided by NPR, Copyright NPR.