The Greatest Failure of the Medical and Public Health Professions
July 19th, 2010
The greatest and most costly failure of the medical profession and public health community is their failure to explain to the American people that addiction to alcohol and other drugs is a disease.
Against the scientific knowledge we now have, physicians’ refusal to give alcohol- and other drug-addicted patients the same medical care and attention they provide individuals with other chronic illnesses like hypertension and diabetes is inconsistent with their Hippocratic oath to “prescribe regimen for the good of my patients…and never to do harm to anyone.” The harm due to this long term failure of the medical profession and public health community is measured in untold lives lost and ruined and the incalculable human misery of families, friends and colleagues of alcoholics and drug addicts.
Why has this happened?
When I started CASA in 1992, former First Lady Betty Ford, one of the founding directors, said, “Joe, if you do nothing else, if you can only get the stigma off this disease, we will have accomplished a great deal.”
At the time I didn’t realize how prescient the former First Lady was. As many will remember, Betty Ford revealed her own addiction to mood altering prescription pills and alcohol in an effort to put an end to the stigma that clings this disease.
Well, today I like to think that we’ve achieved a great deal over these past two decades at CASA, educating our people and policy makers about how drug and alcohol addiction causes and exacerbates just about every social problem the nation faces–crime, health care costs, lousy public schools and besotted college campuses, domestic violence, child abuse, teen pregnancy, homelessness–and developing effective prevention and treatment programs for the most vulnerable in our society, like high risk children and mothers on welfare. But we haven’t peeled the stigma off this disease of addiction.
I now believe we won’t be able to do that until the medical and public health professions accord addiction to alcohol and other drugs the respect they pay to other chronic illnesses. Addiction ranks as the nation’s most prevalent ailment. Indeed, if ten percent of our people had the flu or measles, we’d all call it a monstrous epidemic and pull out all the stops to confront it. Yet that many people in our country–some 30 million–are likely addicted to alcohol, prescription and illegal drugs and steroids, and we ignore this elephantine epidemic.
Why?
Because so many Americans don’t consider addiction to alcohol or illegal or prescription drugs a disease. They think it’s just a personal indulgence or a moral failing that the addicted individual ought to be able to shed like a winter coat in warm weather.
Well, I hold the medical and public health professionals responsible for that gross misunderstanding and the havoc it wreaks.
Remember AIDS? Most Americans considered AIDS a social curse for homosexuals. Then the doctors and the public health pros mounted an all fronts education campaign, and in just a few years Americans accepted the fact that AIDS was a serious disease–and acted on that fact raising money for research and volunteering to help afflicted individuals.
Remember when smoking was a common practice everywhere? Well, it took a little longer, but the public health community organized a relentless education campaign and doctors urged their patients to quit-and now all except the hard-core nicotine pushers like Altria (nee Philip Morris) and Brown and Williamson accept that nicotine addiction can be cured with pharmaceuticals and attentive physician care. And the smoker who once said, “Would you like a cigarette?”, now asks, “Do you mind if I smoke?”, and most people respond, “You bet I do!”
Well the time has come for physicians and public health professionals to say to the American people, “Addiction to alcohol and other drugs is a disease and we are going to accord it the same medical attention we accord other chronic diseases.” Setting that example in their own practices, the doctors will have the credibility needed to support a massive public health campaign to get our people to understand that addiction is indeed a disease and a preventable and treatable one.
It will take years, perhaps a generation as it did with smoking (I started the national anti-smoking campaign in 1978), but eventually as we curb this disease we will sharply reduce the consequential crime, health care costs and other social ills, shut down the huge market for illegal drugs that exists in our nation and spawns so much violence in other nations like Mexico, and save millions of lives and the related misery for the families and friends of those who suffer from the disease of addiction.
Comments:
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Thank you and indeed the medical community is a far greater drug dealer than a street vendor. In this Sunday of the Houston Chronicle, a reporter revealed the latest in our having the highest rate of prescription pain clinics in the USA. This picture is clear because I became addicted at the age of 16, tried to kill myself while in the US Air Force and thanks be to “Praying Grandmothers” have survived.
Today I share my story at http://www.HopeAfter.org to the first 1 Million persons in need of having some Hope that one can survive. Thanks Mr. Chairman and I Pray that others understand that it is a community problem for all of us to join.
Timing is everything, and parents need to take charge. Parents need to do their job and protect their teens from themselves. Be vigilant, be clear that you will not tolerate any drug abuse, and strong, that you will do what is necessary to prevent it.
Parents, even divorced parents, need to stand together to protect the child. If one parent suspects a problem, both parents need to act together, united for the sake of their child. They could be on the cusp of addiction.
As a recovering addict for the past 30 years and someone who works in the field of addiction treatment I could not agree more with your position. Until the medical profession and public health community step up to their responsibility to explain that addiction is a disease the stigma, shame and national crisis will remain and continue to grow.
To “cure” the addiction to tobacco products, as a nation we have focussed on the initial factor: stop smoking. This was done through a massive campaign publicizing the harmful effects of smoking and raising taxes on cigarettes, cigars, etc. to reduce their availability. What have we done to treat the potentially harmful effects of sex addiction? There is little need to describe the results. In addition to the basic human drive, our culture has glamorized the right to behave with little or no restrictions. The causes are several. Increasingly, movies, magazines, TV programs, newspapers, and other media that depend on paying customers, advertise and dramatise the joy of largely uninhibited sexual practices. In this way, there is an “entertainment world” that depends on the theme of sex to succeed. Young people are thus heavily influenced. A resolution I introduced to the United Church of Christ in 1993 which was passed, called attention to the hazards of substance abuse to personal, social, economic, health and moral conditions. It also described actions to counter the growing presence of factors which encourage substance abuse, particularly to young people. The coorelation of substance abuse and sexual “abuse” was clear. Unfortunately, other than a couple of written statements, no actual steps were taken to implement the resolution. Apart from this negative situation and without any further reference to sex, I feel that CASA and other organizations concerned with human health should concentrate on methods to PREVENT substance abuse as a primary action rather than on actions to treat addiction. One further comment: Where would we be if the medical profession over the ages disregarded methods to prevent diseases and instead only promoted ways to ameliorate pain?
Thank you.
The greatest failure is not with the Medical and Health professions but with a society that does not shoulder it’s own burden. There is no gentle way out of addiction.
Stigma means different things to different people. Making all or most substance use problems a disease rather than being “bad” or immoral behavior may remove the stigma for some but not all. I think it has helped many to seek out treatment where they might not have if was still seen as immoral. However for other people being labeled “sick”, “ill” or “dysfunctional” is still not without its own stigma and risks. Who really wants to be labeled as sick?
Less than 10% of those with substance use problems get treatment. Most have to be mandated to get help. Why is that? What does this say about the value of what we have to offer? Cost is a huge factor that we all know and resources are becoming more scarce by the minute. On another note when consumers were polled about why they wouldn’t seek therapy surprisingly “stigma” is not at the top of the list. The number one reason given why people who do not seek treatment is that they do not believe it will work for them: it’s ineffective! We the Treatment Professionals have a credibility and a cost problem more than we have a stigma problem. But still if services were non-stigmatizing (no negative labels applied and no iatrogenic effects) and we treated people with the same dignity, respect and welcoming attitude that any person deserves and if it were available (affordable) to everyone who wants it then we might be able to act like we are better than the medical profession at getting people the help they need and want!
I totally agree. Many argue that it’s not a disease because it is a choice. Well how many cases of diabetes are around these days because of obesity? How did these people become obese? Choice maybe? How many people have lung cancer due to smoking? Choice maybe? It is extremely frustrating to see this not come to pass. Most people these days have been touched (or smacked in the head) with addiction in their family or world, yet it is such a secret!!! I think it is time for a new era in thinking, including not only considering this as a disease and treating it that way, but also to get more dialog going and less “anonymity and secrecy.
Spot-on to these comments about public health and the medical profession. However there is another colony of culprits out there impeding appropriate public health policies and services. That “colony” is our state and federal governments that refuse to provide appropriate public health funding for dealing with the downsides from the sale of tobacco, alcohol and prescription drugs. They are the only ones with the “deep pockets” for addressing this issue.
Unless another Bill Gates who is championing AIDS prevention and treatment willing to take on tobacco, alcohol and the pharmaceutical industries emerges our government has the responsibility. With the billions governments collects from taxing these products there is no excuse for not diverting some of these tax revenues to the public health programs and services charged with the responsibility for reducing the harmful consequences from their use. Thankfully there are some public health advocates trying to turn this around. Thank you Joseph A. Califano, Jr.
One huge medical factor that keeps getting ignored is the effects of prenatal alcohol exposure, which has scrambled the brains of between 1 and 5% of us–from just a little AD/HD-type function all the way to severe mental retardation (prenatal alcohol being the largest diagnosable cause of MR). Fetal Alcohol Spectrum Disorders are almost never recognized or even considered, let alone diagnosed, partly because usually the person looks totally normal–but with behavior that can be interpreted as a simple bad attitude. But partly also because society has yet to accept the reality of prenatal alcohol damage.
I’m working to gain recognition for FASD as a widespread physiological condition with behavioral manifestations–just like addiction is. And to help dissolve the denial that keeps the whole alcohol-related ball of wax in the cellar, dark and creepy.
Yes, we are still in the Puritan age when it comes to stigma of addiction. However, doctors are as responsible for creating addiction as anyone — doctors who give out opiate pain killers like candy, doctors who prescribe benzodiazepines for longer than their standardized use of 3 months. There is a movement afoot to have all PCP’s ask their patients about substance use/misuse. I say, physicans, heal thyselves! Don’t be hypocrites. Look to your own practice standards first before trying to target your patients.
Thank You Mr. Califano, Jr. & CASA . . . Your vigilance is admirable, compassionate, and to the point of the matter. You have made it clear that…1. Addiction is a Disease, 2. The malady that The Disease has on its users and; to more than a few bewildered Love Ones that there IS most definitely a much needed allocation of funds for therapy, education, and direct Clinical care for substance abuse - as it is for the prevention, and treatment of other health illnesses. I truly agree that America’s Healthcare Professionals should step up their commitments to up hold oath by accountability towards the wellbeing of ALL. I am a Phoenix; and an advocate working on credentialing… I am part of the solution NOT the problem thanks to many …May ALL who cry out…receive relief…and May ALL who need help; and yet have not had the level of a drowning man’s desperation … May a source of LIGHT among the likes of Me…glowing from rays of Hope shine bright enough… long enough… and strong enough.
I have worked in the addiction field for thirty years. What continues to amaze me is the education and information medical and other treatment professionals lack about alcoholism and drug addiction.
Many mental health professionals still see addiction as a symptom of a larger underlying problem. And physicians get little, if any training in addictions.
Last week I was visiting a friend in the hospital and overheard a doctor speaking to a few nurses about a newly admitted patient who was being detoxed from alcohol. She described the medication protocol and how long it would take for the patient’s delerium tremons to abate. She asked them to come to her for any further help because “the other doctor on the floor knows nothing about alcoholism.” That patient was lucky to have a doctor who knew what she was doing.
I have been to several of the educational programs at CASA and each one was excellent. I applaud your committement to educate professionals with cutting edge research and application.
Just a short note to JAC Jr saying that I so thoroughly enjoyed reading “Inside”. I’m fascinated by Joe’s profundity in his beliefs.
I’m not sure I completely accept addiction as a disease as much as it is a self-medicating behavior indicating a deeper condition like depression. Still, the omnipresence of relapse indicates a chronic condition that many studies have shown can be successfully treated in the manner of other chronic health conditions. Problem is we do not punish people who relapse on their diabetic regimens or send hyper-intensive people to prison for relapsing in their use of salt and causing severe hyper-tension. If we truly want to treat addiction, illicit drug addiction, as a chronic health issue we would have to decriminalize possession of those substances for personal use. We would also need to accept different outcomes from our treatment protocols and accept that successful treatment does not have to be a perfect recovery but also one that includes moderate and responsible use of some substances.
Joe:
After 38 years in this field (and still in it), we face the same nagging issue of stigma, misunderstanding, judgment, and bias. Sure the medical professionals have come only a short way down the path to recognition and treatment. But don’t forget to toss in the insurance and “managed” care industry that has capitalized on social and professioanl apathy to beat the pulp out of treatment–restricting, denying, and limiting. Parity may help but it is no panacea.
On the other hand, there is an occasional light–as with the hospital adjacent to our treatment program here on Cape Cod that is partnering with us, not only for comprehensive education for docs and nurses, but also a collaborative program to consult on med-surg patients who are in hospital for “other” conditions but who are clearly addicted. Consultations, joint treatment planning, staff integrations–these are all approaches that can help break down barriers and normalize this illness in the medical profession. Hope you keep going for a long, long time Joe.
I agree with Raymond, We need a holistic approach to treatment and health care. Unfortunately, our ins. companies don’t lean that way and they are driving the policy. We have too many specialists and not enough GPs and family doctors. I had wonderful health care till I got married and was pushed out into the military CHAMPUS system which operated like an HMO. I didn’t get care unless it was an emergency or I was pregnant.
We will never cure addiction (unless we become computerized droids), because all humans are predisposed to always want that feel good fix. Our social structure also promotes the “always have to feel good” personality. We must teach that it is OK to be sad, upset, and yes even sometimes depressed. A good cry is better than a lot of pills or alcohol.
Thank you Mr. Califano, again for your insight and courage. The frequency that we hear a client tie his addiction to an injury and subsequent prescription to powerful and plentiful pain medication continues to grow. Doctors don’t get that in this society people are going to play fast and loose with these powerful prescriptions and that will untimately lead to a dependency. Once cut off from the legal prescription supply, and left with a rip-roaring addiction, the next step is directly into the enormous IV heroin world that is exploding in all of our communities.
If someone is not certain the medical community has its head in the sand on this topic think of the insanity of seeing a young man who is a client in a long term substance abuse treatment program, return to that program from an emergency room visit with a prescription for percocet! One would have to surmise there was no dialogue between the doctor and the patient other than the assertion that if he took these pills his life would be okay when in reality handing powerful pills to an addicted person would do anything but make his life okay.
Response to Chairman Califano.
I couldn’t agree more. My comments come from my experience as a clinical psychologist and personal tragedies. Generally — certainly not across the board — clinicians are very poorly informed about this disease and there is not enough of an effort to education clinicians about it. In my opinion all clinicians should be required to study substance use/ abuse addiction in graduate school as part of their training — even if they are not specialists. That is definitely not the case. Even among the very knowledgeable I have never attended a conference organized by psychologists or social workers in which policy is included in the discussion and analysis. (That has been for me one of the most important aspects of CASA meetings). The attention is not to prevention or to understanding how the substances affect the pathology or mental well being of ones clients but rather how pathology leads individuals to engage in substance use. It strikes me as a limited and skewed view, not particularly useful and often inaccurate. Often, the study of addiction and substance use is not sufficiently valued; there is a kind of class structure. The work of the addiction counselors is not as highly esteem as the work of many others such as the psychologists and social workers. These attitudes affect the delivery of care to patients. How often is a patient told when they seek therapy that the clinician will discuss their conflicts but they must attend an AA meeting or see a drug counselor for the other part? I’m not debating the value of an AA meeting (although the options should be much wider), but a clinician must be able to hear the whole story and treat all parts of the problem. Sending people away simply reifies the shame and hiding. I think the shame of the disease is reflected in the entire profession — what people study, what is valued, who is valued and ultimately who is served and how.
I think that change will start to take place only after the general public sues the medical community and their own doctor for overperscrption of pain medication, for not providing medication monitoring of addicting medications, and for not insisting on chemical dependency counseling as part of their medical practice protocols. I am hopeful that we all can come to the table (doctots,lawyers, front line counselors) to brainstorm in a meaningful way to solve the above mentioned problems. Who would not want to participate in a dialogue that could save lives- the lives of their own childfren? let’s make it happen at CASA at Columbia