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| Healthy Lifestyles |
| Columns - From the Addiction Physician | ||||||||
| Written by Stuart Gitlow, MD | ||||||||
| Saturday, 12 July 2008 | ||||||||
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I spent some time in January attending the American Medical Association’s State Legislative Strategy Conference. A portion of that conference addressed issues that have been lumped into a Lifestyle category. This stems from the recognition that the leading causes of mortality are partially the result of choices on each individual’s part. So, one way of looking at mortality records would be to say that the leading causes of death are heart attacks and cancer. An alternative way is to say that the leading causes are tobacco use, improper diet and insufficient exercise. Healthy lifestyle advocates speak about the importance of healthy choices. An individual can choose to exercise more, to eat a better diet, and not to drink alcohol or to smoke.
We can address this topic from several perspectives. If a patient of ours smokes, are we providing preventive care — care delivered so he does not get cancer, emphysema or heart disease — or are we providing supportive care for his illness, nicotine addiction? Differentiating between these two choices dictates reimbursement and insurance coverage. Preventive care might not be covered whereas supportive care for a chronic illness might be, or vice versa. Either way, should we not be consistent about how we address this? For example, if a patient is not overweight but is also not exercising, we could provide preventive care. However, if a patient is obese and not exercising, we could provide treatment for obesity, which would include a recommendation for lifestyle alteration. Most importantly, addictive disease is not a lifestyle choice. We have spent years to ensure that the public, not to mention the healthcare system itself, recognizes addiction to be a disease state. It worries me that in the move to advocate for healthy lifestyles, our patients might find themselves being addressed as if their illness is simply the result of some bad choices. Let’s say an individual uses cocaine once a year on New Year’s Eve with friends. Some years, he doesn’t use it, while on some he does. It all depends upon who he is with that year. He has no other substance use. He never has any trouble at all with respect to his rare drug use. Until, that is, the one night that he experienced a sudden myocardial infarction and died. That individual had an unhealthy lifestyle, but no disease. Care delivered in this case would have been preventive. Another individual smokes marijuana daily. He meets all the criteria for cannabis dependence. He goes through his life in this manner until, at age 65, he dies as a passenger in an unfortunate bus accident. Treatment that was given to him for his marijuana use would not, retrospectively, have been preventive. It would, rather, have been direct treatment for his illness of cannabis addiction. The first case represents a lifestyle choice, while the second choice, although it represents a way of life, is not the result of a specific choice. Healthcare reform As I write this, the primaries are underway and we’re moving toward what should be a fascinating and complex presidential election process. Polls indicate that among Americans, in general, healthcare reform is of greater importance than the war in Iraq. It seems likely the newly elected President will have a mandate to alter the healthcare system in some significant manner. The question, of course, is how this will impact our ability to deliver treatment for addictive disease, particularly given that we have not yet been successful at achieving meaningful parity for addiction, let alone universal recognition as to how addiction differs from lifestyle choices. The very public cases of two popular celebrities and their issues with addictive substance use has certainly brought to light the public perception of whether this is choice or disease. Recognizing the disease Some years ago, the young actor, Michael J. Fox, began to suffer from effects of Parkinson’s Disease. After a period of time, Fox went public with an acknowledgment of his illness, began to advocate for research into the condition, and created a foundation designed to help advance research in the field. Wouldn’t it be nice if one of the celebrities with substance use disorder came forward and said, “Yes, I’m an addict. It would be wonderful if we could figure out how this disease gets started. I’m starting a foundation whose purpose would be to fund research into the prevention of addictive disease.” The money would not go to telling 10-year-olds not to use drugs, but rather, would go to true genetic and neurophysiologic research designed to determine how to prevent the disease. Remember that the disease is what is present once the addict stops using. Before that, you simply have someone with intoxication and associated physical sequelae. And before that, you have someone with an as-yet undetectable disease. This is the key point that we need to hammer home again and again with our elected officials. They must understand that the disease itself is different from the substance use. The two clearly go hand-in-hand, but all too many legislators believe that detox is treatment for addiction. I have yet to read or see a commentary in the popular media in which a young starlet with alcoholism is described in the same manner as she would be had she just contracted diabetes or cancer. Instead, these individuals are trotted out as being an example of unhealthy lifestyles with devastating consequences, as having made choices that continue to place them in harm’s way, as having footsteps in which we wouldn’t want our own children to follow. Unfortunately, it’s not a choice. It’s a disease that impacts 10 percent of our population, and we would expect it to impact 10 percent of our celebrity population as well. I wish it were simply a lifestyle choice issue. My work would then be very easy. I’d say something like, “Just Say No.”
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