Managing substance dependence as a chronic disease: is the glass half full or half empty?

Worldwide, alcohol use accounts for approximately 2.5 million deaths annually1 and in the United States is estimated to account for economic costs exceeding $200 billion per year.2 According to the 2011 National Survey on Drug Use Health, 52% of Americans aged 12 years or older reported alcohol use, nearly 25% reported binge drinking (≥5 drinks on 1 occasion), and 6% reported heavy drinking (binge drinking on ≥5 occasions) over the past 30 days.3 The harmful effects of alcohol on health involve nearly every organ system as well as psychiatric and social comorbidity. While less prevalent, illicit drug use is also associated with health problems (such as human immunodeficiency virus infection and overdose) and substantial health care expenditures. The 2011 National Survey on Drug Use Health estimates that approximately 9% of Americans aged 12 years or older—an estimated 22.5 million individuals—used illicit drugs during the past 30 days in the United States.3 Because individuals who use alcohol and other drugs may have substantial health problems, they interact frequently with primary care, emergency departments, and other health care settings. Although some have questioned the “disease model” of addiction, asserting that substance use is a chosen behavior andnotadisease,4 there isnodoubt thatalcoholandotherdrug use disorders are prototypical chronic diseases and should be approached as such by the health care system.5 Substanceusedisorders, likediabetes, cardiovascular disease, and other chronic diseases, are characterized by a prolongedduration, intermittent acute and chronic exacerbations, and substantial morbidity and mortality. These disorders also are influenced by genetic and environmental factors, are related tospecificpathophysiologicphenomenon,and have major psychosocial components. Like other chronic diseases, substance use disorders are also treatable. Evidence for the effectiveness of treatment for improving outcomes among hazardous and harmful drinkers and among those with alcohol or drug dependence has increased considerably in the past 50 years. Screening, brief intervention, and referral to treatment (SBIRT) has been advocated for both alcoholand drug-using medical patients.6 Systematic reviews strongly support pharmacologicmanagement of alcohol withdrawal7 and also support the use of brief interventions inprimary care tomodestly decreasedrinking.8 Similarly, evidenceexists supporting theeffectivenessofpharmacotherapy suchasnaltrexone toprevent relapse in alcoholdependent individuals, althoughtheeffect size isalsomodest.9 Pharmacological approaches to opioid dependence such as buprenorphine10 have demonstrated efficacy, and buprenorphine is available in primary care. The availability of effective treatments for substance use disorders is a prerequisite for a systematic approach to treatmentandfollow-upknownaschroniccaremanagement (CCM). Chronic caremanagement is designed to improve the quality of health care and reduce health care costs for patients with chronic diseases such as diabetes,11 cardiovascular disease,12 and comorbidmedical andpsychiatric disease.13 Chronic care management also appears to be effective in increasing smoking abstinence.14 However, CCMhas not been studiedwidely in individuals with alcohol or drug dependence. Thus, the study in this issue of JAMA by Saitz and colleagues15 evaluatingCCMvsusualprimarycare for the treatment of patientswithdependence on alcohol andother drugs (opioids or stimulants) is an important addition to the literature. The authors randomly assigned 563 individuals to the 2 treatment strategies andassessed theprimaryoutcomes—selfreported abstinence fromheavydrinking, opioids, and stimulants—at baseline and 3, 6, and 12 months along with a series of secondary outcomes including other substance use measures, hospitalization, emergency department use, and substance use–related biomarkers. In comparisonwith usual primary care,CCMhadnosignificant effect onanyof theprimary outcomes. At 12months, 44% of patients assigned to CCM reported past-30-day abstinence from heavy drinking, opioids, andstimulants comparedwith42%ofpatients in theusualprimary care group. Similarly, there were virtually no differences in the other substance use–related measures and biomarkers, quality-of-life scores, or hospital and emergency department utilization. The only exception was that CCMtreated alcohol-dependent patientswere slightly less likely to experience alcohol problems, but this difference is probably clinically unimportant. Even though the patients in the CCM group were more likely to receive addiction treatment and medications, there was no improvement in outcomes vs primary care. For clinicians who believe that CCM should have a role in substancedependence treatment, these results are likely tobe disappointing.Methodologically, thiswasanexceedinglywelldesigned study in a “real-world” group of substancedependent patients using a comprehensive CCM model that was compared with usual primary care. The outcomes were well chosen and included both substance use–specific and broader measures. The 12-month follow-up rate (98% had Related article page 1156 Opinion