SPECIAL COMMUNICATION Drug Dependence, a Chronic Medical Illness Implications for Treatment, Insurance, and Outcomes Evaluation

MANY EXPENSIVE AND DISturbing social problems can be traced directly to drug dependence. Recent studies estimated that drug dependence costs the United States approximately $67 billion annually in crime, lost work productivity, foster care, and other social problems. These expensive effects of drugs on all social systems have been important in shaping the public view that drug dependence is primarily a social problem that requires interdiction and law enforcement rather than a health problem that requires prevention and treatment. This view is apparently shared by many physicians. Few medical schools or residency programs have an adequate required course in addiction. Most physicians fail to screen for alcohol or drug dependence during routine examinations. Many health professionals view such screening efforts as a waste of time. A survey of general practice physicians and nurses indicated that most believed no available medical or health care interventions would be “appropriate or effective in treating addiction.” In fact, 40% to 60% of patients treated for alcohol or other drug dependence return to active substance use within a year following treatment discharge. One implication is that these disappointing results confirm the suspicion that drug dependence is not a medical illness and thus is not significantly affected by health care interventions. Another possibility is that current treatment strategies and outcome expectations view drug dependence as a curable, acute condition. If drug dependence is more like a chronic illness, the appropriate standards for treatment and outcome expectations would be found among other chronic illnesses. To explore this possibility, we undertook a literature review comparing drug dependence with 3 chronic illnesses: type 2 diabetes mellitus, hypertension, and asthma. These examples were selected because they have been well studied and are widely believed to have effective treatments, although they are not yet curable. Our review searched all English-language medical and health journals in MEDLINE from 1980 to the present using the following key words: heritability, pathophysiology, diagnosis, course, treatment, compliance, ad-