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It’s a disease, stupid.
Although such blunt words were never uttered, it was the clear and overarching message of a National Institutes of Health (NIH) panel on medical treatment of addiction following a 2.5-day consensus conference in Bethesda, Md., in November.
Panel chair Lewis Judd, M.D., former director of the National Institute of Mental Health and current chair of the department of psychiatry at the University of California at San Diego School of Medicine, was harshly critical of draconian restrictions on methadone. In a formal statement, Judd criticized the federal government’s role in limiting methadone availability.
"We know of no other area of medicine where the federal government intrudes so deeply and coercively into the practice of medicine," said Judd. "If extra levels of regulation were eliminated, many more physicians and pharmacies could prescribe and dispense methadone, making treatment available in many more locations than is now the case."
In an interview with National Public Radio, he characterized addiction as "a no-fault illness" to which some individuals may be vulnerable due to genetic factors. If the public, medical community, federal and state officials, and addicts and their families can be educated, it will be "enormously destigmatizing," Judd added.
The panel went further than earlier government panels in urging that restrictions be lifted so that methadone could be prescribed the same as any other narcotic. At present, the U.S. Drug Enforcement Administration controls methadone so tightly that few physicians are willing to prescribe it.
A measure of how inadequately the current complex of regulations is serving the addiction-treatment community is that of the approximately 600,000 heroin addicts in the United States, only 115,000 are in methadone maintenance. Although it is impossible to gauge fully how many addicts wish to enter treatment, there is no doubt that it is far more than currently have an opportunity to do so, the report concludes. Some states have no methadone programs, and those that do have long waiting lists.
Untreated heroin addiction costs society about $20 billion annually, the panel’s report observes. Health care costs alone have been estimated at $1.2 billion a year. In the past decade there has been a dramatic rise in the prevalence of HIV infection, hepatitis C, and antibiotic-resistant tuberculosis among intravenous heroin users. From 1991 to 1995 the annual incidence of heroin-related emergency room visits jumped from 36,000 to 76,000, with a corresponding increase in deaths from 2,300 to 4,000. Addicts not engaged in methadone treatment die at three times the rate of those in treatment.
Although a long-acting form of methadone, levo-alpha acetylmethadol (LAAM), recently became available, and other drugs, such as buprenorphine, show promise in stemming heroin use, methadone has a long track record of safety and efficacy, the report observes. The drug not only helps addicts avoid heroin, but has a correspondingly positive impact in reducing addiction-related criminality, enhancing employment and familial stability, and preventing the spread of HIV and hepatitis C.
A multiplicity of biopsychosocial variables, possibly including genetic predisposition, may spur initial heroin use, but "there is no question that once the individual is dependent on heroin, such dependence constitutes a medical disorder," the report says.
Although federal regulations are the chief barrier to methadone treatment, there is also a need for better training of health care providers including primary care physicians, psychiatrists, psychologists, nurses, social workers, and others. Concerns over methadone diversion could be met by accrediting methadone providers, the report suggests.
John Thomas Ungerleider, M.D., a member of APA’s Committee on Training and Education in Addiction Psychiatry, spoke with Psychiatric News about the NIH report.
"Everything [the NIH panel] wants to do is terrific," said Ungerleider. "It’s also part of a larger thing that’s happening. Mainstream physicians are becoming increasingly frustrated" at government officials’ interference in the practice of medicine "to the detriment of patients," he said. "Physicians are finally speaking up and saying, ‘These are our patients; we want to do what’s right for them,’ " said Ungerleider. But what is right for patients and physicians is "increasingly at odds with federal policy, [which is] largely promulgated by nonphysicians. Those who oppose this are misguided and often moralistic rather than humanistic."
The report urges the government to provide a level of funding that would permit treatment access to all who need it and asks both public and private insurers to recognize such treatment as medically necessary. An optimal approach would combine methadone maintenance with psychosocial services, including counseling, and help with housing and employment, the report concludes.