A report last week that the University of Maryland Medical Center is one of 10 hospitals across the country this year that will begin offering new residency programs in addiction medicine is welcome news for Baltimore, which for decades has suffered from epidemic levels of drug and alcohol abuse and a violent drug trade that claims hundreds of lives every year. Estimates of the size of Baltimore’s substance abuse problem range anywhere from one in 10 to one in six city residents. No city can make progress when such a substantial portion of its residents are mentally and physically disabled by substance abuse problems.
The program at UMMC reflects a sea change of attitudes in the medical community toward the problem of drug and alcohol addiction, which was long considered mostly a problem for psychiatrists and the criminal justice system. But over the last decade medical advances and increased access to treatment have produced an array of new therapies that treat addiction as a chronic illness, not as a moral failing or purely psychological problem. The UMMC program will train physicians from other medical specialties how to diagnose and treat patients with drug and alcohol addictions using the same kind of long-term approach employed to manage diabetes, asthma, hypertension and other chronic disorders.
New pharmaceuticals such as buprenorphine have proven extremely effective in blocking addicts’ craving for heroin, cocaine and other opiates. Other recently developed drugs, such as naltrexone, produce similar blocking effects in alcoholics. Combined with individual and group counseling, and with social support services such as housing and employment assistance, addicts can reclaim their lives and become productive members of the community. Even if they relapse — nearly 40 percent of hospital admissions for substance abuse are people who have gone through treatment at least once — they can still turn their lives around with proper support and post-recovery supervision.
Over the last five years the number of people being treated for substance abuse problems in Baltimore has increased significantly. The city now has about 5,000 residential and outpatient drug treatment slots, and though some methadone programs still have waiting lists, people generally are being served far more quickly than just a few years ago. Buprenorphine, which is an alternative to methadone, can be administered in physicians’ offices, and health officials are working to expand the number of doctors who can prescribe the drug. The cost of in-patient care ranges from a few thousand dollars a month for a basic, no-frills inner-city residential program, to $20,000 a month or more for a Cadillac private treatment center like the Betty Ford Clinic.
Yet even the best treatment programs only address those patients who have already sought help for an addiction. Far less progress has been made in keeping people from becoming addicted in the first place, largely because the risk factors and behaviors most likely to lead to addiction are beyond the control of public and mental health professionals. While experts agree that a certain percentage of people may be genetically predisposed to addiction, they are also virtually unanimous in the view that environmental and social factors play an enormous role in determining who will ultimately become an addict.
Environmental contributors to addiction range from the density of liquor stores and open-air drug markets in a community to public policies such as alcohol tax rates. Many studies have shown that alcoholism rates and incidents of drunk-driving accidents decline when taxes on alcohol sales go up. Social factors that contribute to addiction include poverty, lack of education and economic opportunity, joblessness and homelessness, all of which contribute to a sense of despair and hopelessness that leads people to attempt escape through drugs or alcohol. The persistence of addiction as a medical problem can be partly attributed to the fact that these underlying environmental and social conditions remain largely unchanged over generations of city residents.
Given that the problem of addiction is unlikely to go away despite medical advances in treatment and increased access to care, how can public health officials and elected leaders reduce the toll it exacts on families and neighborhoods, or at least mitigate its effects? What is needed is a comprehensive approach to prevention and treatment that also includes early identification of symptoms and rapid intervention, followed by long-term recovery services to keep people from relapsing. Like other chronic illnesses, the earlier the problem is detected the greater the likelihood of a successful outcome.
The increase in the availability of drug treatment in Baltimore, and the advances in the understanding of addiction being made at places like UMMC, have been tremendously important. Each additional life saved from addiction is a tremendous victory, both for the individual and the community. But it is not enough. Just as we have made great strides in moving from seeing drug addiction as a criminal problem to treating it as a medical one, we need now to tackle the sociology of addiction. The best intervention of all is one that keeps people from becoming addicted in the first place.