By U. Jorn. Bloomsburg University.

Observers and practitioners o f medi­ cal care have failed to grasp the implications o f the evidence discount endep 75 mg visa. As a result buy discount endep 50 mg on-line, the burning issue of the day is national health insurance, not the end o f medicine. We have tolerated tiers of medical practice paralleling class structure and even have created classes o f medical untouchables. T heir logical exten­ sion has always been some form o f comprehensive national health insurance that would greatly expand public support of medical care while leaving the delivery system intact. The Obstacles 229 National health insurance was a m ajor issue in the 1972 presidential election, and the debate has continued in Con­ gress since then. Thus, the assault proposed against inequi­ table access to care in this country will be m ade with dollars rather than with structural reform. T he solution being ad­ vanced, despite differences in details, is to increase purchas­ ing power to a level that presumably would be relatively uniform throughout the population. But when m easured against the argum ents made here, the plans are all o f a piece. A nd failure to engage these issues will have two profound and irreversible conse­ quences. T he first is that m ajor expansion in the financing system will lock in the current system for delivery of care for the indefinite future. This is the pitfall o f the otherwise salutary means being taken to assault inequities in medical care through an expansion of purchasing power. T he issue m ust be so stated as to make it possible for those who wish to limit the scope o f the existing system to fix on that goal and not be deflected by the benefits that comprehensive health in­ surance will ostensibly provide. T he second is that underw riting the costs of medical care through a com prehensive health insurance plan will inevita­ bly result in even steeper escalations in the cost of care and a m ore disproportionate consum ption of the gross national product by medical care. Enoch Powell, based on his years of experience in adm inistering England’s health service (and leaving aside his animadversions on other subjects), has m arveled at the capacity o f patients to consume large doses 230 The Transformations of Medicine of care. T he passage of a national health insurance plan will dissolve the last consum ption constraint—the lack of uni­ form purchasing power. As a nation we will have then de­ cided to further feed an already bloated system and in so doing divert monies that could otherwise be spent to ameliorate social and environm ental conditions that have a dem onstrably greater impact on health, such as poor hous­ ing and m alnutrition. And, most tragically, we will deepen the dependency of consumers on services and providers. Because we are on the verge of putting public monies to the task that private money and health care professionals have not accomplished, the prospects for a new medicine are dim. Thus, passage o f a national health insurance plan poses a real and poignant conflict to those who wish to devise and im plem ent a system of medical care that will deal with causes, not cures, and with health rather than disease. T he failure to prom ote a new medicine means that “the future belongs to illness,” to use Peter Sedgewick’s phrase: we ju st a re going to get m ore an d m ore diseases, since o u r expectations o f health are going to becom e m ore expansive a n d sophisticated. M aybe one day th e re will be a backlash, p erh ap s at th e point w here everybody has becom e so lux­ uriantly ill. O f course, the oppor­ tunity to seek well-being is not widespread, but the resources are available and could be tapped if they were not harnessed to the causes o f war, competition, and exploitation. And those uses and misuses o f our resources m ust come to an end as well, if not through revolution then at least through natural attrition and decay. We have failed to do so because we have not understood what health is—we have been confused by an assumption that it was an alloy o f good luck and medical care. T he pursuit of health and o f well-being will then be possible, but only if our environm ent is made safe for us to live in and our social order is transform ed to foster health, rather than suppress joy. In this sense, Virchow was profoundly right: Medicine is simply a form of politics. E pilogue A D esign fo r th e F u tu re This epilogue contains some of my personal views about the medicine of the future. We do know, in broad terms, what is likely to be m ore effective, but we do not know enough. People must be given the opportunity to gain a greater understanding of their bodies, of the signals they receive. As simple and even conventional as this sounds, it is unquestionably the most im portant step. But it should also be understood that I am not proposing third-grade classes in personal hygiene. Health education should be far m ore sophisticated than that; there is m ore to health than brushing one’s teeth every day. Health education should be a major com ponent in any curriculum , particularly during the adolescent years when health habits are developed. The task is a large one; the knowledge deficit is great and will take time to over­ come. Almost every hospital has some space that could be made available for community health education programs. Both written and graphic materials could be 232 A Design for the Future 233 made available. And some o f the tools o f care, such as bandages, splints, and some medications, could be explained and distributed.

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Even for those who do have progresses generic 10 mg endep visa, forcing doctors to expend valuable insurance coverage or can pay out-of-pocket buy endep 75 mg, resources treating the more than 70 other there are no outcome data reflecting the quality conditions requiring medical attention that result of treatment providers so that patients can make from substance use and addiction, while informed decisions. We are grateful available knowledge on how to prevent risky use to Karen Carpenter-Palumbo, former director of and treat addiction. The and Voices of Recovery, Betty Ford Center, Commission includes an impressive group of National Council on Alcoholism and Drug individuals knowledgeable about the many Dependence, Inc. We are grateful for their expert and Substance Abuse Providers of New York assistance. Finally, we are grateful The project was made possible by the generous to the 176 key informants who shared their financial support of The Annenberg Foundation; insight and recommendations. The Diana, Princess of Wales Memorial Fund and The Franklin Mint; The New York Susan E. Jennie Hauser managed the bibliographic database and Jane Carlson handled administrative details. The term addiction also has been used in reference to compulsive behaviors involving eating, gambling and other activities that affect the brain’s reward system and which may develop independent of or in combination with other manifestations of addiction. This report, however, focuses only on addiction involving nicotine, alcohol and other drugs. It is estimated that more society, we do not even collect information on than 20 percent of deaths in the U. They also drive and contribute to a wide range of costly social This report documents the significant body of consequences, including crime, accidents, evidence defining and describing the disease of suicide, child neglect and abuse, family addiction and the risky use of addictive dysfunction, unplanned pregnancies and lost substances. Costs of addiction and risky populations in need of screening, intervention substance use to government alone total at least and treatment. It outlines the consequences and costs substances contribute to these consequences, of our failure to prevent risky substance use and they are very different conditions. Finally, it examines a disease and, like other diseases, it can and the profound gaps between those who need should be diagnosed and treated in the context of treatment and those who receive it, and between * the medical system, using available evidence- the services they receive and what constitutes based practices. In spite of the fact that about 80 ‡ Despite the prevalence of these conditions, the percent of Americans visited at least one enormity of the consequences that result from physician or other health care professional in them and the availability of effective solutions, screening and early intervention for risky † Treatment is defined in this report as psychosocial substance use is rare and the vast majority of and pharmaceutical therapies. Detoxification, mutual people in need of addiction treatment do not support programs, peer counseling, other support receive anything that approximates evidence- services (including religious-based counseling) and based care. And, unlike other diseases, physicians too often lack access to available,  Physicians and other medical trained and certified addiction physician professionals, who make up the smallest specialists for consultation or referral. Furthermore, whereas the main American Journal of Public Health criterion for determining whether health care July, 1919 services should be provided to patients in mainstream medicine is the principle of There is urgent need for widespread and early 14 medical necessity, patients needing education of the medical profession, addiction treatment may face stringent legislators, administrative authorities and laity eligibility criteria for treatment entry, into the facts of addiction disease… including insurance benefit restrictions, limited availability of treatment slots, long As a definite clinical entity of physical waiting lists, lack of child care and the disease, addiction is practically untaught in the school and unappreciated by the average requirement to comply with all rules and 15 medical man… treatment protocols. There simply is no other disease where appropriate medical In the light of available clinical information treatment is not provided by the health care and study and in the light of competent system and where patients instead must turn laboratory research we are forced as a to a broad range of practitioners largely profession to admit that we have not treated exempt from medical standards. Compounding the America’s tendency to frame risky use of problem, quality assurance standards that do addictive substances and addiction as the same exist focus more on administrative processes issue and as moral or social problems has than on measureable patient outcomes. The end result is that we have of available prevention, intervention and declared war on drugs rather than mounting a treatment approaches. We costs went to treating the disease of largely have punished rather than treated those 17 addiction. Spending on addiction in need of help even though treatment for a treatment disproportionately falls to the disease and accountability for behavior are not public sector. Failure to do so is a percent of the costs of addiction treatment, violation of medical ethics, a cause of untold 18 and the private share has been decreasing. A) what is offered in addiction “rehabilitation” programs has not been subject to rigorous scientific study and the existing body of evidence demonstrating principles of effective treatment has not been taken to scale or integrated effectively into many of the treatment programs operating nationwide. This is inexcusable given decades of accumulated scientific evidence attesting to the fact that addiction is a brain disease with significant behavioral components for which there are * Including any use of illicit drugs or the misuse of effective interventions and treatments. A § controlled prescription drugs, use illicit Continuum of Substance Use ** 21 drugs or engage in some combination of these forms of substance use but do not Percent of Population Age 12+ meet clinical diagnostic criteria for by Level of Substance Use* addiction. Risky users are targets for public Never No Non- Risky Addiction health efforts aimed at reducing risky use Used Current Risky Use Use Use and for health professionals’ efforts to prevent risky use from progressing to the * Includes tobacco, alcohol, illicit drugs and misuse of disease of addiction. Department of Agriculture Dietary the disease of addiction, it makes an important Guidelines for safe alcohol use are no more than one distinction between addiction and risky use of drink a day for women, no more than two drinks a addictive substances: day for men and no alcohol consumption for: (1) persons under the age of 21; (2) pregnant women; * (3) individuals who cannot restrict their drinking to  Those with the active disease of addiction are defined in this report as meeting the moderate levels; (4) individuals taking prescription or clinical diagnostic criteria for past month over-the-counter medications that can interact with alcohol; (5) individuals with certain specific medical nicotine dependence or past year alcohol conditions (e. For data analysis purposes, the national survey examined for this report defines misuse of controlled prescription medications more generally as “taking a  Risky users of addictive substances are † controlled prescription drug not prescribed for you or defined in this report as those who currently taking it in a manner not prescribed for the use tobacco products, exceed the U. Individuals Substances Act of 1970, which created a system for who have the disease of addiction but do not meet classifying illicit and prescription drugs according to diagnostic criteria for past month (nicotine) or past their medical value and their potential for misuse. In year (alcohol and other drug) addiction are not this analysis, illicit drugs include marijuana/hashish, included. Addiction Is a Brain Disease Whereas the majority of these experts provided their thoughts in the context of an Addiction is a complex brain disease with open-ended interview guide designed by 23 significant behavioral characteristics. However, very few people Risk factors for developing addiction include a with addiction actually receive adequate, 36 genetic predisposition, structural and functional effective, evidence-based treatment, and the brain vulnerabilities, psychological factors and usual approach to treatment involves brief, environmental influences. Whereas biological, episodic interventions rather than a model based psychological and environmental factors--such on long-term chronic disease management. As a as impairments in the brain’s reward circuitry, result, high rates of relapse, while comparable to compensation for trauma and mental health other chronic diseases, may be due at least in problems, easy access to addictive substances, part to inadequate or ineffective interventions 37 substance use in the family or media and peer and treatments. A factor that is particularly predictive of risk, however, is the age of first involvement with addictive substances--such as use; in 96.

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