“Our country is gaining weight. Obesity leads to significant morbidity. Chronic joint pain and hypertension are two of the many possible disease states that can result from an individual’s overweight status. Therefore, we must do everything we can to treat diabetes.”

That paragraph is clearly illogical. Although both points being made are true, one does not follow from the other. Indeed we must treat diabetes, and diabetes has a greater prevalence among those who are overweight than among those of healthy weight. But the fact that obesity leads to great morbidity is not the reason that we need to treat diabetes. Further, our treatment of diabetes will do little to stem the tide of obesity.

“Drug and alcohol use is epidemic in this country. The use of these agents leads to enormous health and financial costs. Fires, crime, falls and motor vehicle accidents all have higher incidence among those using drugs and alcohol than among the abstinent. Therefore, we must do everything we can to treat addiction.”

I’ve paraphrased from a number of current white papers in the field, each of which was written with the best of intentions, and yet, make illogical pleas. Drug and alcohol use are related to addiction, just as being overweight is related to diabetes. In both scenarios, one side does not require medical treatment although it can lead to medical complications, while the other side does require medical attention and treatment. Yes, drug use is rampant, costly and can result in health-related disasters. And yes, addiction should be treated. But the second fact does not follow from the first. Further, and perhaps not so intuitive, prevention targeting drug use will do almost nothing in terms of reducing addictive disease prevalence.

This point is topical as we fight for parity of funding for treatment of addictive illness. If we are to make the argument for parity, we cannot have our decision-makers in government think that addictive disease, as a set of diagnoses, applies to everyone who uses addictive chemicals.

Within the excellent Blueprint for the States, published in 2006 by Join Together, the following points are made as part of the introduction, and are themselves citations from the literature:

• Between 40 percent and 80 percent of families in the child welfare system have alcohol or other drug problems, and a majority of children in foster care come from families with drug or alcohol problems.
What is an alcohol or drug problem? Are we referring here to alcoholism, to a diagnosable addictive illness, or to occasional use? The fact that the percentage is so poorly determined (40 to 80 percent) calls into question the validity of the measurement tool.
• More than one-half of all state prison inmates were under the influence of alcohol or drugs when they were arrested.
This is clearly the result of use rather than addictive illness. While some of this group may have addiction, we don’t know if it’s 5 percent or 90 percent.
• Nearly one in six state inmates committed their crimes to support a drug addiction.
This starts to answer our last question.
• Drunk driving is a major expense to the police, courts and emergency medical systems.
Some of this is due to alcoholism and some due to poor judgment on the part of those non-alcoholics who were drinking as a social activity.
• About 20 percent of acute Medicaid expenditures pay for alcohol- or drug-related medical costs.

Even here, we do not have a firm footing. Some percentage of this is for treatment of addiction itself; some percentage for treatment of addictive disease sequelae; and another percentage for treatment of substance use-related sequelae. But which is which? And one wonders if included in this are all the costs of treating the sequelae of nicotine dependence. I suspect this is excluded and that the actual percentage is far higher if one were to include all substance use-related morbidity.

All these points are quite reasonable in context, but different readers are likely to interpret the points variably, or to use the points to bolster their favored position. This is why our language must be specific, even more in this medical specialty than in any other. There are readers who think that overuse of alcohol can cause alcoholism (it can’t), just as sitting in the sun every day can cause melanoma (it can). That false assumption can misguide all the interpretations of data that follow. There are some who feel that anyone who drives drunk is an alcoholic (wrong), and therefore, believe that those seeking parity would want any such individual to receive medical treatment (also wrong).

Issues become more complex when we start to talk about prevention. Are we trying to prevent addiction, addiction-related morbidity, substance use, or substance use associated morbidity? Prevention of any one of these requires a specific approach that won’t necessarily be of any value for preventing the other three. Even greater complexity comes into play once we start to educate non-medical personnel as to how addictive disease can impact patients when they’re not using addictive substances. I’ve seen this elicit shock and surprise from legislators, some of whom believe that once a patient is abstinent, treatment for addiction is no longer necessary. Even some of our peers believe that any symptoms appearing in the absence of continued substance use must be the result of a primary psychiatric diagnosis rather than simply being representative of the addictive illness itself, thereby causing some to think the prevalence of dual disorders is far higher than it really is. But that’s a subject for another article.

This column represents Dr. Gitlow’s personal opinion and does not imply any position or policy taken by either the AMA or ASAM.

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