An interview with the authorsPublished May 2013
Reframing Substance Abuse
Why a new outlook could pit big pharma against public health
By Joshua Brooks
Published October 24, 2012
Substance abuse is a disease according to recent announcements from policymakers and expert clinical bodies.
This year, Gil Kerlikowske, director of the Office of National Drug Control Policy and President Obama’s top drug policy advisor said that addiction “is not a moral failing on the part of the individual. It’s a chronic disease of the brain that can be treated.” Even, the American Society of Addiction Medicine officially announced that addiction is a “brain disorder.”
In general, this is a good thing.
An estimated 22.1 million Americans suffer from some form of substance-abuse disorder and most require treatment, according to the 2010 National Survey on Drug Use and Health.
But, unlike years past, policymakers in the medical establishment are finally stepping up. Medical schools have started to implement substance-abuse training programs, and the use of new and old drugs like Vivitrol, Naltrexone, Acamprosate and the Suboxone implant, are examples of a new focus on bringing substance abuse treatment into the doctor’s office.
From a public health perspective, acknowledging substance abuse as a disease implies the myriad of environmental, social, economic, demographic, and genetic factors that lead to it. This is a big win for public health.
However, it also creates a new vacuum, into which pharmaceutical companies can push their drugs in the name of disease treatment—presenting a big win for big pharma, too.
Therein lies the concern.
While certain patients desperately need help, some treatments are running the risk of simply swapping one addictive drug with another.
Researchers like Dr. Walter Ling at University of California, Los Angeles, are conducting studies to use the opioid buprenorphine and the opioid receptor antagonist naltrexone in concert to treat cocaine addiction. In the process, they risk making a patient who was addicted to cocaine dependent on two entirely new drugs. Of course, these trials are ongoing, but the approach raises red flags.
Yet, Dr. Nora Volkow, the director of the National Institute of Drug Abuse, has openly championed the use of these prescription drugs.
“You are killing two birds with one stone,” Dr. Volkow said, “giving tools to improve outcomes for the patient and giving tools to the physician, increasing the likelihood they will incorporate substance abuse disorders into their practice.”
But, while prescriptions may free addicts from relapsing and lighten the burden of withdrawal during recovery, administering drugs on the back end won’t deal with many of the structural and social determinants that lead to addiction in the first place.
What is more, the scenario provides big pharma access to a steady stream of new substance abusers. Big pharma is notorious for lobbying their own interests, using doctors effectively as drug salesmen, and engaging in shady marketing tactics. Examples abound: Purdue Pharma’s violation of labeling requirements and active persuasion to overprescribe OxyContin; GlaxoSmithKline’s $3 billion dollar payout in a civil suit for kickbacks, misbranding and other misconduct to market their drugs; and Abbott’s recent settlement for aggressive promotion of their seizure drug for off-label treatment of elderly dementia patients. These are just a few. In the past three years alone, pharma companies have paid out a total of seven billion dollars settling lawsuits, often for misconduct.
Limited resources and time to understand the underlying causes of a patient’s addiction, paired with the inevitable push by big pharma, may make doctors rely too heavily on these anti-addiction drugs—creating a situation not unlike the painkiller epidemic that we have been dealing with the past decade plus.
But, researchers and policymakers can take another route, avoiding all-out dependence on an industry known for questionable practices.
By adopting epidemiological approaches to understand the biological, psychological, and social risk factors associated with addiction, policymakers could prevent or lessen potential exposures at a societal level, without the potentially negative consequences of drug treatments.
For example, an epidemiological review of the literature on different types of substance abuse indicates several potential risk factors, including adverse family conditions, exposure to peer networks using illicit drugs, and neighborhood disadvantage (after controlling for socioeconomic status), among others. At a societal level, manipulating this information to design interventions that prevent substance abuse—in the same way we design interventions against cancer, cardiovascular disease, or depression—could have far more impact on substance abuse than any treatment on the back end. For instance, early interventions in the school system or community organizations like the Community Anti-Drug Coalition of America could be fruitful.
Erring on the side of drug-based addiction treatment in the doctor’s office means trusting in an industry that has repeatedly manipulated doctors’ prescription pads for their benefit. But, focusing more on a public health approach can promote an on-going evidence-based understanding of addiction—not only curing patients in the doctor’s office, but preventing them from ever going in.
This article has been revised to reflect the following correction:
Correction: October 31, 2012
The article stated that Naltrexone was an opioid, but it is an opioid receptor antagonist.