Mark S. Gold, MD

We read with incredulity, but not much surprise, the findings of Anne Case, Ph.D., and Angus Deaton, Ph.D., in their recent article detailing increased morbidity and mortality in midlife white non-Hispanic Americans (PNAS. 2015 doi:10.1073/pnas.1518393112).

With modern medicine, pharmaceuticals, vaccines, public health, genomics, and other advances becoming the norm, assuming that health, happiness, and longevity would inevitably follow seemed logical. Needless to say, this assumption, as Dr. Case and Dr. Deaton describe, is erroneous. Still, however, we must pay particular attention to the causes.

Sociocultural trends might contribute to the overall increase in non-Hispanic white mortality in the 21st century as reported, but the factors that Dr. Case and Dr. Deaton describe are the direct result of untreated addiction substance misuse-abuse-dependence and other psychiatric illnesses. For example, the authors highlight chronic liver disease as contributing to mortality and cite alcohol as an etiology. But the ultimate cause of the illnesses and troubling mortality trends is the disease of addiction.

Many experts recognize that substance misuse and addiction constitute the nation’s most pressing public health problem, but this recognition has done little to provide trained physicians with the tools that can lead to early intervention, and treatment, a recent report shows (“Addiction Medicine: Closing the Gap Between Science and Practice,” New York: National Center on Addiction and Substance Abuse at Columbia University, 2012) – a point that we will repeatedly raise. Stereotypes in the media aside, there is indeed increased perception of drug use disproportionately afflicting “non-college whites” (“America’s New Drug Policy Landscape,” Pew Research Center, April 2014). This perception might be tied to prescription practices.

For example, fear of prescribing narcotics to some demographics, but not others, might contribute to demographic differences in the current opioid (both prescription and heroin) use and overdose epidemic. A few years ago, one study found that pharmacies in white, non-Hispanic neighborhoods were more likely to carry prescription opioids (N Engl J Med. 2000;342:1023-6), and a more recent study shows that emergency room physicians are more likely to prescribe opioids to non-Hispanic whites (JAMA. 2008;299[1]:70-8). Accordingly, new users who ultimately develop opioid use disorders are largely white, and often, the first exposure to opioids is heroin (JAMA. 2014;71[7]:821-6). Consequently, whites are more likely to experience heroin overdoses (MMWR. 2014;63[39]:849-54).

Regarding alcohol, whites also are more likely than are other racial/ethnic groups to consume alcohol, according to results of a 2012 Gallup poll and the 2013 National Survey on Drug Use and Health. Interestingly, rates of binge drinking do not vary substantially between whites, African Americans, or Hispanics, the NSDUH findings show. However, a striking finding is that non-Hispanic whites accounted for 67.5% of alcohol poisoning deaths, a recent MMWR report shows (2015 Jan 9;63[53]:1238-42).

That addiction is clearly America’s No. 1 public health problem notwithstanding, shame and stigma remain ever present. Most patients enrolled in addiction treatment today were referred by a loved one or employer, not by a diagnosing physician. We would encounter significant public outrage if physicians did not diagnose, or at least have a high clinical suspicion for diabetes or cancer, yet this unfortunate lack of consideration remains true for addiction. Were the nation’s No. 1 public health problem cardiovascular diseases, we would likely see cardiology training and research programs growing at all of the major academic medical centers. We would see medical students trained to a high level of competency in the evaluation, diagnosis, and intervention of cardiovascular disease. Physicians, even many psychiatrists trained in traditional medical schools, have more actual experience in obstetrics and gynecology than they do in addiction medicine.

While less than 5% of physicians will ever deliver a baby, medical schools mandate that 100% of students learn about reproductive anatomy in the basic sciences and delivering babies in the clinical clerkship. Nearly all physicians will encounter addiction in clinical practice, yet the basic tenets of managing a patient with addiction are largely absent or comprise an insignificant part of most medical school curricula.

Unfortunately, lack of such education leads many physicians to believe that addiction treatment is neither evidence based nor effective. However, this notion is an archaic fallacy that ignores the evidence. As an example, impaired physicians and other health care professionals, when treated in a structured setting and provided follow-up support and accountability, have a success rate of urine-test–confirmed abstinence and return to work in excess of 80% (J Subst Abuse Treat. 2009;36[2]:159-71). Obviously, the solution is implementing mandatory addiction training in medical schools and residencies, as physicians will need to understand and be able to implement the core principles of addiction medicine: evaluation, testing, diagnosis, and referral to treatment.

And even if a person is diagnosed, a significant disparity exists between coverage of addiction treatment and other health services. Recent initiatives from the Affordable Care Act have mandated that insurance companies provide substance treatment resources, but resources are vastly underused. Most single-state agencies are facilitating the education and training of more addiction counselors, but many states (40%) have not facilitated collaborations between addiction treatment with other medical programs, and nearly half of all states have not provided the infrastructure for insurance participation in addiction treatment (Health Aff. 2015;34[5]828-35). As an example, in Massachusetts, even for insured individuals, structural barriers largely related to insurance issues prevented use of ACA-funded addiction treatment for addictive disorders (Health Aff. 2012 May; 31[5]1000-8).

In addition, despite the availability of evidence-based pharmacologic and psychotherapeutic treatments, a great paucity of qualified addiction medicine physicians and addiction psychiatrists exists. This has become impossible to ignore in the midst of an overdose crisis (Psychiatr Ann. 2015;45[10]522-6). Were addiction truly respected as America’s No. 1 public health crisis, we would see a sizable increase in addiction medicine physicians and addiction psychiatrists. The White House recently offered proposals aimed at alleviating some of these concerns by expanding physician prescribing of buprenorphine and naloxone as well as education on abuse and appropriate prescribing protocols. But if addiction is going to be taken seriously as a disease, we need more physicians practicing with dedicated training in addiction medicine and addiction psychiatry.

Taken together, we cannot expect the impact of substance use, misuse, and dependence to improve without major changes. Advances in medicine continue to manifest at a very fast pace, while addiction and other psychiatric illnesses remain disparately underappreciated, ultimately slowing and even reversing progress on longevity.

Overall, the ACA has been beneficial. But health care reform that fails to provide early diagnosis, intervention, and ready and reliable access to the same range of substance abuse treatments as available to physicians is wholly incomplete, and in a sense, is not reform at all. If we fail to heed this warning, a continuation of the trends described by Professors Case and Deaton is almost a foregone conclusion.

Dr. Srivastava is a second-year psychiatry resident at Washington University in St. Louis. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also is chairman of the scientific advisory boards for RiverMend Health.

We read with incredulity, but not much surprise, the findings of Anne Case, Ph.D., and Angus Deaton, Ph.D., in their recent article detailing increased morbidity and mortality in midlife white non-Hispanic Americans (PNAS. 2015 doi:10.1073/pnas.1518393112).

With modern medicine, pharmaceuticals, vaccines, public health, genomics, and other advances becoming the norm, assuming that health, happiness, and longevity would inevitably follow seemed logical. Needless to say, this assumption, as Dr. Case and Dr. Deaton describe, is erroneous. Still, however, we must pay particular attention to the causes.

Sociocultural trends might contribute to the overall increase in non-Hispanic white mortality in the 21st century as reported, but the factors that Dr. Case and Dr. Deaton describe are the direct result of untreated addiction substance misuse-abuse-dependence and other psychiatric illnesses. For example, the authors highlight chronic liver disease as contributing to mortality and cite alcohol as an etiology. But the ultimate cause of the illnesses and troubling mortality trends is the disease of addiction.

Many experts recognize that substance misuse and addiction constitute the nation’s most pressing public health problem, but this recognition has done little to provide trained physicians with the tools that can lead to early intervention, and treatment, a recent report shows (“Addiction Medicine: Closing the Gap Between Science and Practice,” New York: National Center on Addiction and Substance Abuse at Columbia University, 2012) – a point that we will repeatedly raise. Stereotypes in the media aside, there is indeed increased perception of drug use disproportionately afflicting “non-college whites” (“America’s New Drug Policy Landscape,” Pew Research Center, April 2014). This perception might be tied to prescription practices.

For example, fear of prescribing narcotics to some demographics, but not others, might contribute to demographic differences in the current opioid (both prescription and heroin) use and overdose epidemic. A few years ago, one study found that pharmacies in white, non-Hispanic neighborhoods were more likely to carry prescription opioids (N Engl J Med. 2000;342:1023-6), and a more recent study shows that emergency room physicians are more likely to prescribe opioids to non-Hispanic whites (JAMA. 2008;299[1]:70-8). Accordingly, new users who ultimately develop opioid use disorders are largely white, and often, the first exposure to opioids is heroin (JAMA. 2014;71[7]:821-6). Consequently, whites are more likely to experience heroin overdoses (MMWR. 2014;63[39]:849-54).

Regarding alcohol, whites also are more likely than are other racial/ethnic groups to consume alcohol, according to results of a 2012 Gallup poll and the 2013 National Survey on Drug Use and Health. Interestingly, rates of binge drinking do not vary substantially between whites, African Americans, or Hispanics, the NSDUH findings show. However, a striking finding is that non-Hispanic whites accounted for 67.5% of alcohol poisoning deaths, a recent MMWR report shows (2015 Jan 9;63[53]:1238-42).

That addiction is clearly America’s No. 1 public health problem notwithstanding, shame and stigma remain ever present. Most patients enrolled in addiction treatment today were referred by a loved one or employer, not by a diagnosing physician. We would encounter significant public outrage if physicians did not diagnose, or at least have a high clinical suspicion for diabetes or cancer, yet this unfortunate lack of consideration remains true for addiction. Were the nation’s No. 1 public health problem cardiovascular diseases, we would likely see cardiology training and research programs growing at all of the major academic medical centers. We would see medical students trained to a high level of competency in the evaluation, diagnosis, and intervention of cardiovascular disease. Physicians, even many psychiatrists trained in traditional medical schools, have more actual experience in obstetrics and gynecology than they do in addiction medicine.

While less than 5% of physicians will ever deliver a baby, medical schools mandate that 100% of students learn about reproductive anatomy in the basic sciences and delivering babies in the clinical clerkship. Nearly all physicians will encounter addiction in clinical practice, yet the basic tenets of managing a patient with addiction are largely absent or comprise an insignificant part of most medical school curricula.

Unfortunately, lack of such education leads many physicians to believe that addiction treatment is neither evidence based nor effective. However, this notion is an archaic fallacy that ignores the evidence. As an example, impaired physicians and other health care professionals, when treated in a structured setting and provided follow-up support and accountability, have a success rate of urine-test–confirmed abstinence and return to work in excess of 80% (J Subst Abuse Treat. 2009;36[2]:159-71). Obviously, the solution is implementing mandatory addiction training in medical schools and residencies, as physicians will need to understand and be able to implement the core principles of addiction medicine: evaluation, testing, diagnosis, and referral to treatment.

And even if a person is diagnosed, a significant disparity exists between coverage of addiction treatment and other health services. Recent initiatives from the Affordable Care Act have mandated that insurance companies provide substance treatment resources, but resources are vastly underused. Most single-state agencies are facilitating the education and training of more addiction counselors, but many states (40%) have not facilitated collaborations between addiction treatment with other medical programs, and nearly half of all states have not provided the infrastructure for insurance participation in addiction treatment (Health Aff. 2015;34[5]828-35). As an example, in Massachusetts, even for insured individuals, structural barriers largely related to insurance issues prevented use of ACA-funded addiction treatment for addictive disorders (Health Aff. 2012 May; 31[5]1000-8).

In addition, despite the availability of evidence-based pharmacologic and psychotherapeutic treatments, a great paucity of qualified addiction medicine physicians and addiction psychiatrists exists. This has become impossible to ignore in the midst of an overdose crisis (Psychiatr Ann. 2015;45[10]522-6). Were addiction truly respected as America’s No. 1 public health crisis, we would see a sizable increase in addiction medicine physicians and addiction psychiatrists. The White House recently offered proposals aimed at alleviating some of these concerns by expanding physician prescribing of buprenorphine and naloxone as well as education on abuse and appropriate prescribing protocols. But if addiction is going to be taken seriously as a disease, we need more physicians practicing with dedicated training in addiction medicine and addiction psychiatry.

Taken together, we cannot expect the impact of substance use, misuse, and dependence to improve without major changes. Advances in medicine continue to manifest at a very fast pace, while addiction and other psychiatric illnesses remain disparately underappreciated, ultimately slowing and even reversing progress on longevity.

Overall, the ACA has been beneficial. But health care reform that fails to provide early diagnosis, intervention, and ready and reliable access to the same range of substance abuse treatments as available to physicians is wholly incomplete, and in a sense, is not reform at all. If we fail to heed this warning, a continuation of the trends described by Professors Case and Deaton is almost a foregone conclusion.

Dr. Srivastava is a second-year psychiatry resident at Washington University in St. Louis. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also is chairman of the scientific advisory boards for RiverMend Health.

We read with incredulity, but not much surprise, the findings of Anne Case, Ph.D., and Angus Deaton, Ph.D., in their recent article detailing increased morbidity and mortality in midlife white non-Hispanic Americans (PNAS. 2015 doi:10.1073/pnas.1518393112).

With modern medicine, pharmaceuticals, vaccines, public health, genomics, and other advances becoming the norm, assuming that health, happiness, and longevity would inevitably follow seemed logical. Needless to say, this assumption, as Dr. Case and Dr. Deaton describe, is erroneous. Still, however, we must pay particular attention to the causes.

Sociocultural trends might contribute to the overall increase in non-Hispanic white mortality in the 21st century as reported, but the factors that Dr. Case and Dr. Deaton describe are the direct result of untreated addiction substance misuse-abuse-dependence and other psychiatric illnesses. For example, the authors highlight chronic liver disease as contributing to mortality and cite alcohol as an etiology. But the ultimate cause of the illnesses and troubling mortality trends is the disease of addiction.

Many experts recognize that substance misuse and addiction constitute the nation’s most pressing public health problem, but this recognition has done little to provide trained physicians with the tools that can lead to early intervention, and treatment, a recent report shows (“Addiction Medicine: Closing the Gap Between Science and Practice,” New York: National Center on Addiction and Substance Abuse at Columbia University, 2012) – a point that we will repeatedly raise. Stereotypes in the media aside, there is indeed increased perception of drug use disproportionately afflicting “non-college whites” (“America’s New Drug Policy Landscape,” Pew Research Center, April 2014). This perception might be tied to prescription practices.

For example, fear of prescribing narcotics to some demographics, but not others, might contribute to demographic differences in the current opioid (both prescription and heroin) use and overdose epidemic. A few years ago, one study found that pharmacies in white, non-Hispanic neighborhoods were more likely to carry prescription opioids (N Engl J Med. 2000;342:1023-6), and a more recent study shows that emergency room physicians are more likely to prescribe opioids to non-Hispanic whites (JAMA. 2008;299[1]:70-8). Accordingly, new users who ultimately develop opioid use disorders are largely white, and often, the first exposure to opioids is heroin (JAMA. 2014;71[7]:821-6). Consequently, whites are more likely to experience heroin overdoses (MMWR. 2014;63[39]:849-54).

Regarding alcohol, whites also are more likely than are other racial/ethnic groups to consume alcohol, according to results of a 2012 Gallup poll and the 2013 National Survey on Drug Use and Health. Interestingly, rates of binge drinking do not vary substantially between whites, African Americans, or Hispanics, the NSDUH findings show. However, a striking finding is that non-Hispanic whites accounted for 67.5% of alcohol poisoning deaths, a recent MMWR report shows (2015 Jan 9;63[53]:1238-42).

That addiction is clearly America’s No. 1 public health problem notwithstanding, shame and stigma remain ever present. Most patients enrolled in addiction treatment today were referred by a loved one or employer, not by a diagnosing physician. We would encounter significant public outrage if physicians did not diagnose, or at least have a high clinical suspicion for diabetes or cancer, yet this unfortunate lack of consideration remains true for addiction. Were the nation’s No. 1 public health problem cardiovascular diseases, we would likely see cardiology training and research programs growing at all of the major academic medical centers. We would see medical students trained to a high level of competency in the evaluation, diagnosis, and intervention of cardiovascular disease. Physicians, even many psychiatrists trained in traditional medical schools, have more actual experience in obstetrics and gynecology than they do in addiction medicine.

While less than 5% of physicians will ever deliver a baby, medical schools mandate that 100% of students learn about reproductive anatomy in the basic sciences and delivering babies in the clinical clerkship. Nearly all physicians will encounter addiction in clinical practice, yet the basic tenets of managing a patient with addiction are largely absent or comprise an insignificant part of most medical school curricula.

Unfortunately, lack of such education leads many physicians to believe that addiction treatment is neither evidence based nor effective. However, this notion is an archaic fallacy that ignores the evidence. As an example, impaired physicians and other health care professionals, when treated in a structured setting and provided follow-up support and accountability, have a success rate of urine-test–confirmed abstinence and return to work in excess of 80% (J Subst Abuse Treat. 2009;36[2]:159-71). Obviously, the solution is implementing mandatory addiction training in medical schools and residencies, as physicians will need to understand and be able to implement the core principles of addiction medicine: evaluation, testing, diagnosis, and referral to treatment.

And even if a person is diagnosed, a significant disparity exists between coverage of addiction treatment and other health services. Recent initiatives from the Affordable Care Act have mandated that insurance companies provide substance treatment resources, but resources are vastly underused. Most single-state agencies are facilitating the education and training of more addiction counselors, but many states (40%) have not facilitated collaborations between addiction treatment with other medical programs, and nearly half of all states have not provided the infrastructure for insurance participation in addiction treatment (Health Aff. 2015;34[5]828-35). As an example, in Massachusetts, even for insured individuals, structural barriers largely related to insurance issues prevented use of ACA-funded addiction treatment for addictive disorders (Health Aff. 2012 May; 31[5]1000-8).

In addition, despite the availability of evidence-based pharmacologic and psychotherapeutic treatments, a great paucity of qualified addiction medicine physicians and addiction psychiatrists exists. This has become impossible to ignore in the midst of an overdose crisis (Psychiatr Ann. 2015;45[10]522-6). Were addiction truly respected as America’s No. 1 public health crisis, we would see a sizable increase in addiction medicine physicians and addiction psychiatrists. The White House recently offered proposals aimed at alleviating some of these concerns by expanding physician prescribing of buprenorphine and naloxone as well as education on abuse and appropriate prescribing protocols. But if addiction is going to be taken seriously as a disease, we need more physicians practicing with dedicated training in addiction medicine and addiction psychiatry.

Taken together, we cannot expect the impact of substance use, misuse, and dependence to improve without major changes. Advances in medicine continue to manifest at a very fast pace, while addiction and other psychiatric illnesses remain disparately underappreciated, ultimately slowing and even reversing progress on longevity.

Overall, the ACA has been beneficial. But health care reform that fails to provide early diagnosis, intervention, and ready and reliable access to the same range of substance abuse treatments as available to physicians is wholly incomplete, and in a sense, is not reform at all. If we fail to heed this warning, a continuation of the trends described by Professors Case and Deaton is almost a foregone conclusion.

Dr. Srivastava is a second-year psychiatry resident at Washington University in St. Louis. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also is chairman of the scientific advisory boards for RiverMend Health.