Main Ideas from the Article
McLellan and others have made various conclusions from their article, “Dependence, a chronic medical illness: Implications for treatment, insurance and outcomes evaluation” printed in the Journal of American Medicine Association (2000). To start with, the generally held view that drug dependence is mainly a social problem and not a health problem has become a central area of focus as is evident from the effects of drug dependence on social systems (McLellan, 2000). Unfortunately, it has been evident that there are inadequate medical approaches to prevent and treat drug adherence. This is of great concern having found out that drug dependence is a chronic medical illness. According to evidence based on literature review, drug dependence is greatly influenced by genetic heritability, personal choice and environmental factors. It negatively affects the chemistry and functioning of the brain hence, affects one’s ability to optimally function and become a productive person in the society. Drug dependence where “nicotine, alcohol and opiate” are involved can be treated by use of effective medication but the same does not apply for stimulant or marijuana dependence (McLellan, 2000). Drug dependence ought to be treated like any other chronic disease and not as an acute illness as is the present perception and standing point. The most important strategies to factor in during the treatment of drug dependence are long-term medication management and continued monitoring.
Evidence Supporting the above Conclusions
The conclusions made above have stemmed from various evidences collected by various researchers and scholars. According to the US department of health and human services (1997), 67 billion dollars are spent by the US government on an annual basis with the aim of curbing “crime, reduced productivity in work, foster care and related social problems” due to drug dependence (US Department of Health and Human Services, 1997). It is without reasonable doubt that the costs incurred are very high and because of them, it is proved that drug dependence is primarily a social problem. As such, law enforcement and interdiction is required as opposed to prevention and treatment as opposed to prevention and treatment related to health problems. In another example, 40% to 60% of patients treated for alcohol experience relapse rates within a year after discharge from hospital. These relapse rates are the main reason behind the perception that drug dependence is not a health problem hence, health care interventions are not effective for treatment.
The Australian guidelines also consider drug/alcohol dependence as a social problem because it implies that Australians engage in the habit of drinking alcohol for the purposes of pleasure, sociability and relaxation. The reasons why people engage in the habit of drinking alcohol are not at all related to one’s health condition, they fall within a socio-cultural context since people drink as a result of peer pressure, cultural and social events, or religious observance (NHMRC, 2009). In addition, as discussed earlier on, alcohol will yield into negative social effects. On the other hand, the same guidelines still consider it to be a health problem due to its associated adverse health effects because alcohol gets into the blood and from there it disrupts normal body functioning and especially the brain (NHMRC, 2009).
Inadequate medical treatment and care is attributed to physicians’ similarly held perception that that drug dependence is not a health problem but a social problem. As a result of this, McLellan and others (2000) have indicated that there are few medical schools or residency programs that have a full and elaborate course in addiction. According to a survey as reported by Weisner & Schmidt (1993), general practicing physicians and nurses were found to have no faith in medical or health care interventions in the treatment of drug adherence.
The authors made a literature review where they compared drug dependence with 3 chronic illnesses, namely: asthma, type 2 diabetes mellitus and hypertension (McLellan, 2000). The reason for selecting these illnesses was because they have been widely and adequately studied with regard to their effective treatments regardless of the fact that they are still incurable. The review focused on all English-language medical and health journals in MEDLINE since 1980 to 2000 while using the following keywords: “heritability, pathophysiology, diagnosis, course, treatment, compliance, adherence, relapse, and reoccurrence” (McLellan, et al. 2000). Genetic influence on drug dependence was based on twin studies, where a significantly high rate of dependence on drug is realized among twins than among non-twin siblings.
In addition, there were higher rates of substance dependence among monozygotic than dizygotic twins (McLellan, et al. 2000). The following heritability estimates have been published based on genetic heritability: “0.34 for males dependent on heroin, 0.55 for males dependent on alcohol, 0.52 for females dependent on marijuana, and 0.61 for cigarette-dependent twins of both sexes” (True & Xian, 1999). In addition, Edenberg, 2007 as cited in the Australian guidelines (NHMRC, 2009) states that variation in how fast alcohol metabolism takes place among people is related to the gene variation with regard to genes that control expression of alcohol-metabolism enzymes in the liver.
Drug dependence is perceived to be a voluntary action, which is responsible for the initiation and maintenance of drug dependence. This is reinforced when genetic and cultural factors come into play (McLellan, 2000). Salt sensitivity among males is an involuntary risk factor that predisposes one to hypertension. However, the fact that all people with salt sensitivity do not develop hypertension is because of an individual’s choice and use of salt. In addition, obesity, poor stress coping mechanisms and inactivity are personal choice and environmental factors that lead to development of hypertension. The same way, a person predisposes him/herself to drug dependence based on personal choices (Svetkey, McKeown & Wilson, 1996).
My stand on the Evidence
Yes, I do agree with the evidence because it is based on peer reviewed articles from medical and health journals in MEDLINE. These articles employ empirical research and appropriate research methodologies to arrive at their conclusions. Since this review is based on studying various aspects of drug dependence in relation to chronic diseases, it ought to make use of available and past researchers. In addition, literature review is a valid process in every research process, apart from the fact that in this case it is the primary process of research as conclusions are based on secondary data. I have agreed to this evidence based on the analogy approach used.
To start with, I agree with the evidence that alcohol is both a social and health problem and not solely a health problem as perceived by the doctors. This is seen from the aetiology of the condition with regard to its causes and effects. In addition, just like any other chronic illness, where continued treatment and monitoring is required, treating alcohol/drug dependence requires the same kind of treatment hence I cannot refute the similarity between the two modes of treatment. Subsequently, I agree with the evidence present to prove that alcohol/dependence is a chronic illness that requires continued and monitored treatment. However, it is worth noting that not all drugs should be considered as chronic illness like marijuana/stimulant dependence since effective treatment is not applicable (McLellan, 2000).
Justification of Conclusions by Evidence
Well, by applying rationale to the arguments presented by the authors of the article, I think that the conclusions are justified by the evidence presented. Drug-dependence is justified by the evidence showing it as a social problem. In addition, there is evidence implying that drug/alcohol dependence is a health problem is still justified. This is because, the aetiology of a disease helps to understand the kind of condition it is. Drug/alcohol dependence is a health problem based on its reaction with the blood and the brain. In a social context, social situation influence a person with regard to taking alcohol and once a positive body reaction occurs, drug dependence results.
The influence of personal choice and environmental factors is also justified. In addition, it has proved to be a chronic medical illness when compared with other chronic medical illness based on personal and environmental factors, genetic heritability, pathophysiology and treatment. According to the evidence, it is justified to state that alcohol/drug dependence is both a health and social problem. Therefore, combined efforts of the medical professionals and social scientists are deemed imperative.
Why Doctors fail to diagnose alcohol problems
Doctors fail to diagnose alcohol problems because they pay little attention to them. As a matter of fact, physicians/doctors do not include screening for alcohol or drug dependence during their routine examinations as they see it as a waste of time (Fleming & Barry, 1991). In addition, since doctors believe that there is no kind of health care intervention that can be prescribed to treat drug dependence, then there is also no need of making the diagnosis.
Doctors believe that drug/alcohol dependence is entirely a social problem, thus alcohol diagnosis is not their priority and the reason why doctors fail to make a diagnosis of alcohol and related drug problems. In addition, this has been attributed to the high relapse rates of drug/alcohol-dependants where doctors’ efforts go to waste. As a result, they believe that making an alcohol diagnosis is of no use because it is far beyond their control. The fact that there are few medical schools to offer elaborate courses on alcohol dependence is also a reason why doctors fail to diagnose alcohol problems. This is because; alcohol/drug dependence does not gain much attention hence, is not within the doctor’s diagnosis list (McLellan, 2000).
Why doctors respond inadequately to diagnosed alcohol problems in patients
Doctors consider alcohol and related drug problems to be a social menace rather than a health menace hence, they respond inadequately to patients that they diagnose as having alcohol problems. The disappointing results of relapse after treatment do not motivate the doctors in giving adequate treatment to the drug-dependant patients. In addition, the lack of a well defined cure is a great challenge. Drug dependence patients require a lot of support especially socially and as a medical doctor dealing with prescription of treatment; it would be difficult to play both a medical and social role. Most patients face restrictions thus they get inadequate care that involves detoxification or acute stabilization only (McLellan, 2000). Most drug dependence patients are not committed to the recovery process.
Evidence that problematic drinking is partly genetically mediated
Twin studies are used to establish a genetic for drug dependence. According to Nick (Audio lecture), addiction in smoking has been associated with 70% genetics. This means that if one is addicted to a drug, it is assumed that the brother or sister of this person is at an increased risk to addiction, usually two to three times likely to get addicted to the same drug as compared with anyone else on the street. There are strong genetic components in addictive behaviour. Genes influencing the rewards pathway are the main focus. A group of alcoholics were studied and the most severely addicted were found to have the A1 version of genes influencing the reward system.
Genetic influence on drug dependence is an involuntary action under which physiologic responses determine an individual’s habit of drug dependence. Individuals who become drug dependant get extremely pleasurable initial but involuntary responses to drugs. On the other hand, those who get negative or neutral reaction at the onset are less likely to become drug dependant. It has been shown that “sons of alcohol-dependent fathers are more able to tolerate effects of alcohol and less likely to experience handovers as opposed to sons of non-alcohol-dependent fathers” in their studies through use of genes (Schuckit, 1994 and Schuckit & Smith, 1996). On the contrary, the “inherited aldehyde dehydrogenase genotype that is linked to alcohol metabolism brings about an involuntary skin flushing” in response to alcohol (Newmark, Friedlander, Thomasson, 1998). Go ahead to explain that people who are homozygous with this allele, have a negative reaction to voluntary alcohol use at the onset to the extent that there is almost no single alcoholic with such a genotype.
Evidence that problematic drinking is partly mediated by psychological factors
There is a valve in the brain that enables individuals to respond effectively to signals around the environment rewards in the environment. This takes place through the brains reward pathway. Rewards like food excite this pathway. Some chemicals often hijack this pathway and stimulate it. When someone becomes addicted to drug, the reward system gets readjusted such that it becomes difficult to function without the drug.
The brain circuitry, which is primarily involved in controlling motivated and learned behaviour, is affected by addictive drugs and this sub-sequentially affects once demeanour with regard to drugs including alcohol (Koob & Bloom, 1998). The ventral tegmental area linking the limbic cortex via the midbrain to the nucleus accumbens plays a very crucial role in drug dependence. The integration of the reward circuitry involving motivational, memory and emotional centres, collocated within the limbic system are partly involved in relapses behind drug dependence. This interconnection is responsible for the positive effects of rewards experienced, as well as for learning the signals associated with these effects and the anticipatory response required (Childress, et al. 1999).
Evidence that problematic drinking is partly mediated by social factors
Relapse rates after medication are associated with the social perspective of drug dependence. Doctors believe that if health care interventions are provided to a patient and prove not to be effective, then other confounding factors, in this case social factors, are responsible. In addition, the expensive and negative effects of drug dependence on social systems are an indication that drug dependence is a social and not a health problem (NHMRC, 2009; National Centre for Addiction and Substance Abuse at Columbia University, 1998).
Analogy between alcohol-related problems and other common chronic relapsing remitting medical problems
Unfortunately, there is no one treatment that is considered to be a reliable cure for drug dependence. Patients who keep up and adhere to the recommended regimen of “education, counselling and medication” have been successful in their path to recovery, often within a period of 6 to 12 months (National Institute on Drug Abuse, 1999). When patients continue with methadone maintenance and abstinence, which can be attained by involvement in self-help programs such as Alcoholics Anonymous, are sure ways of enhancing recovery from drug dependence. In comparison to alcohol dependence, “hypertension, diabetes and asthma” are related chronic illnesses that require the same kind of treatment characterized by continued and monitored health care throughout a patient’s life to avoid relapsing (Dekker, et al. 1993). In addition, the success towards recovery is dependent on the patients’ adherence to the medical regimen.
Lessons Learned
There are various lesions to be learned from this assignment. To start with, drug dependence does not receive the much attention it deserves especially due to its addictive nature. Despite the fact that doctors assume the nature of drug dependence been a social problem, we cannot work entirely on this. Genetics has proved to greatly influence drug dependence hence it is a health concern. Genes have also been attributed to the high relapse rates amongst drug-dependence individuals. In addition, drug dependence is a chronic medical illness as derived from the analogy with other chronic illnesses.
Another thing is that there is need to reinforce the health care interventions required for helping drug-dependant individuals. Combined effort between social scientists like psychiatrists and counsellors and medical professions is imperative in the treatment process of drug dependence. In addition to medical help, drug-dependant individuals need guidance and counselling to direct them in the right manner. This is very important because it is very clear that drug dependence is associated with more negative effects than positive ones.
References
Audio Lecture
Childress, A. R., 1999. Limbic activation during cue-induced cocaine craving. Am J Psychiatry, 156 (1), pp.11-18.
Dekker, F. W., et al., 1993. Compliance with pulmonary medication in general practice. Eur Respir J., 6, 886-890.
Fleming, M. F., & Barry, K. L., 1991. The effectiveness of alcoholism screening in an ambulatory care setting. J Stud Alcohol, 52, 33-36.
Koob, G. F., & Bloom, F. E., 1998. Cellular and molecular mechanisms of drug dependence. Science, 242, 715-723.
McLellan, T., et al. Drug Dependence, a chronic medical illness: Implications for treatment, insurance and outcomes evaluation. JAMA, 284, 1689-1695. National Centre for Addiction and Substance Abuse at Columbia University, 1998. Behind Bars: Substance Abuse and America’s Prison Population. New York, NY: National Centre for Addiction and Substance Abuse at Columbia University.
National Health and Medical Research Council, NHMRC, 2009. Australian Guidelines: To Reduce Health Risks from Drinking Alcohol. Web.
Newmark, Y. D., Friedlander, Y., & Thomasson, H. R., 1998. Association of the ADH2*2 allele with reduced alcohol consumption in Jewish men in Israel: a pilot study. J Stud Alcohol, 59, 133-139.
Schuckit, M. A. 1994. Low level of response to alcohol as a predictor of future alcoholism. Am J Psychiatry, 151, 184-189.
Schuckit, M. A., & Smith, T. L., 1996. An 8-year follow-up of 450 sons of alcoholics and controls. Arch Gen Psychiatry, 53, 202-210.
Svetkey, L. P., McKeown, S. P., & Wilson, A. F., 1996. Heritability of salt sensitivity in black Americans. Hypertension, 28, 854-858.
True, W. R., & Xian, H., 1999. Common genetic vulnerability for nicotine and alcohol dependence in men. Arch Gen Psychiatry, 56, 655-661.
US Department of Health and Human Services, 1997. Alcohol and Health: Tenth Special Report to the U.S. Congress. Washington, DC: US Dept of Health and Human Services.
Weisner, C. M., & Schmidt, L., 1993. Alcohol and drug problems among diverse health and social service populations. Am J Public Health, 83, 824-829.