By DAVID M. CORDANI
Cigna CEO David Cordani on treating substance-abuse disorder like every other medical disorder
IN 1980, OUR ROADS WERE SEVEN TIMES DEADLIER than our drugs. But in 2008, drug overdoses surpassed car crashes to become the No. 1 cause of accidental death in the U.S., killing almost 50,000 Americans in 2014, the latest year on record. This epidemic is due almost entirely to the alarming rise of one class of drugs: Opioids, which include prescription painkillers and heroin, killed nearly 30,000 Americans in 2014, up from just under 10,000 in 2001. Once considered a relic of the 1970s, heroin in particular has seen a peculiar and deadly resurgence, as more patients become dependent on prescription opioid painkillers and switch to heroin when their prescriptions run out. Between 2010 and 2014, heroin overdoses tripled.
Major steps have been taken to address this epidemic. In March, the Centers for Disease Control and Prevention announced new guidelines for prescribing opioids, discouraging prescriptions that last longer than a week. Days later, the FDA put stronger warning labels on the class of drugs, pointing to the serious risks of “misuse, abuse, addiction, overdose and death.”
The focus on prevention is immensely important. We all know that prevention is more efficient than treatment, and without it, we would soon have more patients suffering from substance use than we could afford to treat.
But it isn’t enough. We also need to improve our approach to treating substance-use disorders. For other chronic diseases, such as diabetes or obesity, doctors are encouraged to provide evidence-based care, analyzing historical data to adopt what works and abandon what doesn’t. The current approach to substance-use disorder treatment, however, is based largely on the Alcoholics Anonymous 12-step model, which doesn’t take into account that 40% to 60% of substance abuse is attributable to a person’s genetic makeup. We need to look beyond support groups to more comprehensive care solutions that include therapy, medication and family support.
Additionally, long-term intensive recovery facilities have become the norm, even though there is very little evidence of their comparative effectiveness. Thirty-day inpatient programs can cost anywhere from $15,000 to $26,000, with some charging more than $100,000. Nevertheless, the rehabilitation industry, which generates $35 billion in annual revenue, wants us to believe that these long-term residential treatment programs are “best in class.”
We have the data to tell us what care should look like for substance-use disorders. The least restrictive levels of care—intensive shorter-term outpatient programs, for instance—are actually the most cost-effective: An analysis of the Veterans Affairs alcohol inpatient treatment system found 28-day and 21-day programs yield similar results, but the 28-day program is much costlier. A 2006 study published in the Journal of Occupational Health Psychology found that people who receive personalized treatment—dedicated coaching, support and education—show significant improvement in measurements of physical and mental health.
Cigna is working with the American Society of Addiction Medicine to give patients the best possible care, based on scientific evidence, not a price tag. In the future, substance-use disorders will be viewed as chronic conditions that need to be managed for a lifetime, not treated sporadically. Treatment for substance-use disorders will include only what is proved to be effective and efficient—such as shorter-term outpatient programs, personalized care and education for individuals and their families. And standardized metrics of performance will ensure that treatment centers throughout the U.S. offer consistent and quality care.
For too long, we have viewed behavioral health as separate from physical health. In order to stop this epidemic, we need to treat substance-use disorders the same way we treat other chronic illnesses.
If evidence-based treatment and performance-based reimbursement are the gold standard for treating physical illness, we need the same approach for treating substance-use disorders.
A HEROIN ADDICT’S HALLUCINOGEN?
How a Schedule I controlled substance may help fight drug cravings
FIFTEEN YEARS INTO A NATIONAL TREND of increasing overdose deaths, there is an imperative to develop better medications to treat addiction. Ibogaine, a chemical derived from the root bark of an African plant, may provide a key. In animals, a single dose of ibogaine decreases signs of opioid withdrawal and produces sustained reductions in the self-administration of heroin, morphine, cocaine, nicotine and alcohol. Effects in humans closely parallel these findings. Ibogaine is illegal in the U.S., where it has been classified as a hallucinogen since 1967, and unregulated but available in Canada and Mexico. New Zealand, South Africa and Brazil authorize the use of ibogaine by licensed medical practitioners.
In 1990, Congress mandated the National Institutes of Health to develop medications to treat addiction. The NIH undertook a program of research on ibogaine in 1991, and developed a structurally similar and potentially safer ibogaine analogue known as 18-MC. But further development of 18-MC is stalled by lack of funding. The NIH now supports the development of medications to treat addiction with less than $100 million annually, while the cost of developing a single drug to final FDA approval can exceed $1 billion. In the private sector, pharmaceutical companies are avoiding new, disruptive pharmacological paradigms and opting for the lower-risk—and lower-cost—strategy of developing “me too” versions of approved drugs.
The need for a fundamentally new pharmacological treatment for addiction has never been more urgent. Policy aimed at the private sector needs to better incentivize the financial risk of innovation. Creative, high-risk research, neglected in the pharmaceutical sector, needs substantial public funding. Improving addiction treatment has a cost. The alternative, in human and economic terms, is extravagant. Dr. Kenneth Alper is professor of psychiatry and neurology at the New York University School of Medicine.