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Dr. Tom McLellan: Addiction and Segregation

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Dr. Tom McLellan, Professor, Dept. of Psychiatry, and Director, Penn Center for Substance Abuse Solutions

Addiction is a disease that is hard to understand. Particularly vexing is that so many of those who so obviously need care deny the existence of a problem or the need for treatment. Those who finally enter care usually have serious, chronic addiction, many co-occurring problems and a guarded prognosis. Are these features specific to addiction or are they expectable features of any illness whose care has been systematically segregated from the rest of medicine?  

Imagine if we began to treat diabetes in a system such as we have designed for addiction. First, insurance would restrict treatment only to the “truly diabetic,” those who had lost toes or some of their vision. Prevention and early interventions so common in primary care would not be reimbursed and thus rarely practiced in such a system. Hence, most of those entering treatment would be very overweight, have multiple co-occurring physical and psychiatric problems and a guarded prognosis. Even effective treatment has limited effects on very severe cases. 

These are typically not the kinds of patients that health care professionals aspire to treat. So very soon it would be considered more convenient for these unattractive, severely affected diabetic patients to have their own special building, perhaps near the edge of the property, down by the boiler plant. These are not the kinds of treatment settings that inspire career goals in young health care professionals. There would be little interest among faculty in teaching courses about this “special condition.” In turn, funding would also be segregated through “carved out” reimbursement plans designed for these “specialty” programs. 

An important perceptual phenomenon would also take place concurrent with this segregation process. These very ill patients and the segregated, specialty treatment settings would come to define the illness of diabetes in the eyes of health care establishment and the public at large; and it would not be a favorable image. Individuals who were early in the course of diabetes would find it impossible to imagine that they had anything in common with those in treatment. This would foster denial and treatment refusal until they could literally no longer live without it.

There are two points to this exercise. First, while it is largely true that the addicted individuals currently in treatment have been in denial, are seriously and chronically affected and are difficult to treat; this may have less to do with addiction than with the segregation of the treatment system. Second, with the advent of the Parity Act and Health Care Reform this segregation will come to an end. The full spectrum of  “substance use disorders” – not just “addiction” – will be eligible for treatment. Prevention, early intervention, medications and support services will be reimbursed and will gradually become accessible through primary care providers in virtually all health care facilities and settings. These services will not be restricted to just the most severely and chronically affected; early interventions and new medications will focus on those with emerging use. It will be interesting to see how the perception of this illness and its treatment changes with this new system integration. Maybe, patients won’t have to “bottom out” before they are willing to seek treatment?

Dr. Tom McLellan
Professor, Dept. of Psychiatry, and Director, Penn Center for Substance Abuse Solutions

12 Responses to this article

  1. Avatar of crystal
    crystal / May 5, 2011 at 1:52 pm

    This article is the essence of a paper i am writing for my final in my english class. If only this message could get carried to every one in the nation, recovering addict or not. from my experience as an addict in recovery it is helpful for me to see that there is someone that sees the big picture.

  2. Avatar of Dr. Andrew Tatarsky
    Dr. Andrew Tatarsky / April 29, 2011 at 4:48 pm

    Dr. McLellan’s work continues to be at the cutting edge of new developments in the field and this piece is further evidence of that. I’d like to underscore his observation about how the segregation of the treatment of substance use problems adds to stigmatizing people with substance use problems. Viewing substance use problems on a spectrum of severity like other health issues and bringing them into the mainstream of clinical practice will do much to overcome stigma. He also is speaking to a very significant paradigm shift in the way we are looking at understanding and treating the full spectrum of substance use problems. The overwhelming percentage of people struggling with substance use problems are not chronic, low bottom, dependent users yet the field is largely set up only to treat this most severe group. Nearly 60 million Americans are estimated to bing on alcohol at least once a month! Many of these users need less intensive, non-abstinence-oriented, harm reduction interventions, at least to engage them initially. Harm reduction approaches “start where the patient is” motivatinally, accept all positive change as success and see change as occuring in small incremental steps. The journey often leads to abstinence but doesn’t require it as the initial buy in to enter treatment. These approaches are best suited to facilitating collaborative therapeutic alliances in which the patient with professional guidance can get support to determine what goals and approach will be most succsessful. Then the full range of evidence-based interventions can be considered/

  3. Avatar of Bradley Meier
    Bradley Meier / April 28, 2011 at 2:20 pm

    Thought provoking…indeed.

    Dr. McClellan has been a pioneer and has altered the course of treatment and research. He is also a very nice man. We should count our blessings to have him in a position to impact policy and the collective thought about addiction.

    All the best,

    Brad Meier

  4. Avatar of Lawrence Ferber
    Lawrence Ferber / April 28, 2011 at 8:27 am

    Dr. McClellan,
    I have been a fan of yours for years now. The research and all the amazing accomplishments of yours have inspired me to grow as a man. I did use a bit of your research when I wrote my dissertation back in 2006. I wonder if the folks on Linkedin know that about you. For me, you have been a major player in the research and I am glad to be able to read what you say on Linkedin. My name is Lawrence Ferber and I originally became involved in the field because of my fascination of the disease. It’s a pleasure to know you.
    Best,
    Lawrence

  5. Avatar of Cliff Masters
    Cliff Masters / April 27, 2011 at 5:46 pm

    while the disease metaphor may be useful for challenging the moralistic attitudes towards substance misuse do you not feel we would be better placed addressing the stigma and discrimination from a more honest perspective. While some drugs are deemed ‘bad’ and their use is penalized through law stigma will remain.

  6. perryrants / April 27, 2011 at 9:25 am

    i’m so confused. is dependence (soon to be known only as addiction) a disease like diabetes (why not cancer?) or is it a brain disorder that is not necessarily a disease? is mental illness a disease or is it a brain disorder?

  7. Avatar of Lee Rush
    Lee Rush / April 27, 2011 at 5:50 am

    Excellent article Dr. McLellan and thank you for writing it. In my experience over the past several decades in school based student assistance programs (SAPs), the incidence of substance abuse problems is clearly a pediatric phenomenon. I am hoping that we will see some kind of coverage in the Health Care Reform Act to support these early interventions.

  8. Avatar of elaine
    elaine / April 26, 2011 at 8:36 pm

    This is exactly what addiction is really like. The addicts are demonized and looked at as being “bad” or “weak” who deserve whatever happens to them. Maybe all addictions should be put in this perspective, whether it is food, gambling, shopping or anything. How would the so-called “normal” folks like being treated in such negative terms? Thank you Dr. McLellan for your efforts to help the suffering addict.

  9. Avatar of Kristi Pelegrin
    Kristi Pelegrin / April 26, 2011 at 3:36 pm

    God bless Dr. McLellan as he endeavor’s to shed light on the very real, very painful problem that recovering addicts have to find ways to overcome. The segregation in the treatment of substance abuse is most definitely responsible for a vast number of relapse’s. I have been trying to recover from and addiction to Oxy Contin (that was prescribed) for the last 7 years. It has only been w/in the last 14 months that I’ve been able to remain clean. In large part it was thanks to suboxone, however it has been a living Hell trying to find physicians that will treat patients with substance abuse disorders that I can afford – or that will accept my insurance. Every step I’ve taken in the right direction has been met head on with 2 leaps backwards. By the Grace of God I’ve been able to find the strength to avoid relapse.. Whats incredibly frustrating for me, is if I had been able to seek treatment earlier, when I first asked for help 7 years ago- and (before I lost the support from my family, my career, excellent health ins. & all of my assets) I wouldn’t have had to “hit bottom” and the odds for a successful recovery would have been so much better. It’s people like Dr. McLellan tho that give me the courage and drive to keep fighting this disease that has quite literally stolen my life.

  10. Avatar of Tosia McCormick
    Tosia McCormick / April 26, 2011 at 2:14 pm

    An excellent and eye-opening article. I have just recently begun work in a methadone clinic and see this segregation at work. However, at least part of the rationale for this model is to protect the privacy of the patients and the confidentiality of the treatment. Until substance use disorders lose their social as well as their medical stigma, routine integration into care may still have some way to go.

  11. Avatar of mrlane
    mrlane / April 30, 2011 at 7:02 am

    The brain is an organ of the body – just like the kidneys, liver, heart, etc. Any malfunction of an organ, whether we understand the mechanism fully or not, is a “disease” – and as Dr Valkov argues, addictions are a disease of the brain. Dr McLellan is Right On !!

  12. perryrants / May 10, 2011 at 11:03 am

    ok, so mental illness is a disease too. thus a brain disorder is a disease and disease can be a brain disorder. which then makes additions and mental illness a disease.

    given that, why do we treat these brain disorders/diseases with “old” fashioned paraprofessional interventions. do you want your cancer treated by someone who “had” cancer or by professional?

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