Dr. McClelland is Director of the Center for Substance Abuse Solutions at the University of Pennsylvania. If you've read his bio and I'm sure nearly all of you have, his is an eminent voice, it's a highly influential voice, he brings a deep humanity and also high intelligence to the whole area that we're discussing today through the maze making treatment better. Would you please welcome Dr. Tom McClelland.
Thank you very much. I especially appreciated your opening comments. I think quite thoughtful and perhaps some of what I'm going to say will be helpful as you make the kind of deliberations the United States has also been. deliberating.
So I'm going to go through these three things. I've made a terrible rookie mistake. I've made far too many slides here so I'm going to go quite fast.
You will be penalized for my mistake. But I want to go through things that I think are quite important. I'll tell you the end before I tell you the middle. I think it's a mistake to lump addiction with harmful use and early use. One policy won't fit.
I think the kinds of interventions that we've traditionally given to the most severely addicted people don't match what we now know about the science. But there are options. options, okay? So this is a very important slide. I'm going to base almost everything on this.
It's a picture of what substance use problems, everything but cigarettes, looks like in the United States of America. It's pictorial in that it shows that in the bottom of this pyramid is where, first of all, the majority of people are, and also that indicates people who either do not use at all or use very little. Very seldom, okay? Anything, alcohol, opiates, cocaine, methamphetamine, whatever, okay?
Now you'll see that wavy line there, about a third of the way up, and it's got holes in it. Well it's about that point where use has become harmful. Now that is not diagnostic. Doesn't mean that you are an addict if you are drinking or using drugs at that level.
And we honestly don't know exactly where it is, and we know that people go back and forth. But we know there's a lot of them. In the United States, there's about 60 million people whose use is harmful to themselves, to their relationship, or to their health.
This is a particular area of focus in the United States'recent health care reform. This is what is screwing up the treatment of hypertension, diabetes, chronic pain, sleep disorders, the major illnesses in the United States. to manage lower level but still harmful levels of use. Now, up at the, about two thirds of the way up there, there's a bright, crisp, dark, clear line. That is where the frequency, duration, intensity of your use meets diagnostic criteria for the most severe disorders, addiction and abuse, okay?
In the United States, there are about 25 million of those individuals, and that's a lot, but relative to what? Well, perhaps you've read the. there's a very significant epidemic of type 2 diabetes in the United States, and there is. There's about 24 million of them. So we have about the same number of people who have significant and very severe and chronic use.
Now if you're sitting in the back, you probably can't even see the pinnacle of this pyramid. That's the proportion of people that are actually getting any kind of care. It's about 2.3, 2.4 million. One tenth of those that. that have the most severe form of the disorder, but a tiny proportion of the people whose use is harming themselves and others.
Now, if you want a policy, if you want to bring just what Peter said, a value for your money and reduction of harm to your population, you cannot continue to focus entirely on that small pinnacle. Of the most chronically ill, the most severe, the most complexly affected people. You must develop, and the United States has never done this. Addiction is a segregated illness. It is separated in...
financing, it's separated in concept from almost everything else, and it has penalized the health of the United States. So this is the kind of policies that the United States is trying to develop. And it's trying to develop... in integrating it into the rest of healthcare because without that it just simply won't work.
Okay so let's talk about this group the most severely addicted. Okay what do we know about them and what do we know about them I keep talking about it in terms of other real illnesses. Why would I do that because many people think addiction is simply lawlessness simply weak will bad parenting.
whatever you want to say. Well, in studies of these real illnesses, you find that they're characterized by clear genetic heritability. You know that from twin studies. So, for example, if I say from behind this curtain is going to come twin A, he's going to have blue eyes. I'll give you a dollar if you can tell me what color twin B eyes are.
Everybody here is going to say blue. They're all blue. because eye color is 100% genetically determined.
Well, what about? Asthma, diabetes, hypertension. It's way up there.
If twin A has asthma, it's somewhere between a 35% and 70% chance that twin B also has asthma. It's not 100% because it takes into consideration things like personal choice, their culture, their family, their behavior. Very interesting, Tom. So what?
What about alcohol, opiate, and cocaine use? Almost identical. The same. level of genetic heritability.
So, I'm going to keep stressing this. Substance use is a function of availability. There's no doubt about it. It's like any other attractive commodity. Greater availability, lower price, greater access, you're going to have more users of any substance.
But addiction is far more complicated. It is at least in part, a significant part, a function of your genetic heritability. How can that possibly be, you ask?
Don't tell me that the act of picking up a pint and putting it in your mouth, that can't be genetically determined. And it isn't. But once that pint hits the inside of you, that's when the genetics take over.
OK. Addiction also is associated with brain changes. And here, for example, is a cocaine abuser. Sorry, this is a normal subject. And what you're looking at is somebody chopped your...
head off like this and you're taking a look at three different planes within your brain and suffice it to say that more yellow and more red means more more brain activity, okay? That's a good thing, all right? Well, there's a cocaine abuser 10 days after they've stopped cocaine use. Now, I am a trained scientist, so I can tell you that there's more blue in those than there is in the top, okay?
His brain ain't working good, as we say in science. All right, but it's gotta go away, right? Well, there's 100 days later, and I'm gonna tell you that there's more blue in those.
abstinence and in fact there is more return of brain function but it's not at the normal level. Will it ever get there? We don't know yet.
Okay. Implications what's so what? Well I hope you don't have 30-day treatment programs in the United States.
We do. What's that brain going to look like after 30 days? All right. Now, these changes must go away. Certainly, surely to God, they must go away.
Well, let me show you something that's perhaps difficult to see. Here is an MRI machine. And what you have, if you can't see in the back, is a person lying prostrate here with his head in this big donut magnet. And right up here on the diagonal is a screen very much like this one.
And on that screen, that individual is being shown either pictures of nature, squirrels running up a tree, or... Pictures of drug use, in this case I think it's opiates. A former opiate addict has not used in over a year.
What did you do this kind of torture for? Here's why. We wanted to know if the very sight or the sound, the people, places, and things, as the AA people talk about, will themselves produce a reinstatement of the kind of craving and brain changes that are associated with the drug itself. Now keep in mind, this is not a guy hanging out in a street corner.
This is a guy in a sterile clinical setting. So there you go. There's the two slices of the brain, and that's what the brain looks like when this individual sees a nature video.
Again, greater activity in the orbitofrontal cortex. There's what it looks like. This is a guy who's never had... who hasn't had opiates for over a year.
You show him a picture of a person using opiates, lying on his back in this sterile situation, and his brain lights up. That is not willful misconduct. It's not bad breeding. It's not poor parenting.
It's persistent brain changes that are reinstated through classical conditioning. And they affect how you can imagine treatment. will work.
Okay, so those are the points. So once you're up at the pinnacle of that pyramid, ladies and gentlemen, you're not talking about willful misconduct anymore if you ever were. You're talking about a chronic illness, and my points from now on is we've never treated addiction as though it were a chronic illness. We've treated it like it was a bad habit, okay? Now, let's talk about contemporary addiction treatment and here is the model and it is a beauty.
It is as simple as you can get. I call it a washing machine. You take a dirty old substance abuser and you put them into the treatment setting, Shady Acres treatment program and maybe that's a residential program or maybe it's an outpatient program of 20 sessions or whatever. Notice it's got nice fixed boundaries around that.
treatment program lest we spend government money in an unnecessary fashion. Okay? Treatment stops.
There's people are hugging, they're crying, and they're wishing the individual goodbye and good luck. And a guy like me comes along six months or twelve months later after treatment is over, important point, to see whether treatment has worked. It has worked if this is a non substance abusing person. It hasn't worked if he's relapsed, right?
It's as simple as that. And for decades, we've wondered what to put into the washing machine. Evidence-based practices, regulations, more money, whatever, okay?
And the assumptions are pretty straightforward. If you give this individual just the right amount or the right duration, he will have learned his lesson, he will have realized drugs are bad, and it will work. Every clinician knows that...
His or her treatment works particularly well for certain kinds of people but not others. Well, here's the embarrassing problem. When you look at studies of outcome, and Peter referred to this earlier, this is what you find, and it's not a pretty picture.
Researchers like me have failed to see differences between very brief treatments and very thick, intensive ones. Researchers like me have failed to see any difference in outcomes measured six months or 12 months after treatment stops between people who go to inpatient versus outpatient. Now if you're an insurer, if you're a government minister and you have to have a sensible way of allocating funds, which one are you going to pick?
I'm picking the cheap one. There's no evidence that the thick one, expensive one works. Every clinician knows that women need different kinds of care than men. Well, it's very difficult to see it when you look at the research literature in the substance abuse field.
Now, what could possibly account for this? Well, to talk about it, I want to first of all deputize every single member of this audience. You are right now, okay, not yet, not yet, hang on. Now I'm going to talk about another kind of treatment. So that was substance abuse.
Now let's talk about any other kind of chronic illness. Hypertension, diabetes, chronic pain, asthma, you have it, tooth decay, okay? It's usually identified, hopefully very early, in primary care, okay?
So, easy thing to do, primary care doctor slaps a blood pressure cuff around your arm, says, wow, your blood pressure's elevated. They do not rush you off to a 30-day blood pressure treatment program. They handle it in primary care.
They handle it because they've been trained to do that. There's a pharmaceutical industry that's provided medications. So lots of other things that can be done. And that's the first line. Often it doesn't work.
And when that happens, they send them to specialty care. Now, in specialty care, they address the symptoms. They reduce the severity, the intensity.
They teach self-management skills. What they do not do... ...is refer somebody to church basements for help from their peers following discharge.
That would be called malpractice. What they do is they send them back to the primary care doc. Why?
Well, because it's a chronic illness. It's a chronic illness. It's one we don't have a cure for, but you can manage. So the goal of specialty care is not cure. The goal of specialty care...
...is to get somebody to the point where it can be managed in a primary care setting. Lovely, Tom, that was really instructive, but so what? Well, these are the major points of chronic illness. By the way, here's an important one. Evaluation in chronic illness is a clinical duty.
It's a reimbursed duty. It's a responsibility. When that blood pressure cuff gets wrapped around, you are... You are simultaneously evaluating whether what you've done to that point is having an effect, but you're also using it to plan for what you'll next do.
You're using the results to manage care because maybe I mentioned these are chronic illnesses. All right. Now, now you are all deputized to be members of the United States Food and Drug Administration. We have some of the most.
Restrictive and careful and safest laws about new drug admissions of the world. Okay, so here's actually a cartoon. I was on that panel and it dawned on me in the course of my service something that I'm about to show you.
Okay, here's a kind of a kind of data that you you often see. So what is typically measured is symptom severity. Okay, so here's a gauge. This is before treatment starts, this is during treatment starts, and this is after treatment is over.
And again, being a trained scientist, I can tell you that before treatment started, and this person, what we're doing here now is we're evaluating this brand new drug for hypertension. And your goal is, your job, is to say whether we should pass it, whether we should get FDA approval, okay? So look, you can see the symptoms prior to the initiation of treatment are high. You know that because that bar is big, okay? And look what happens when treatment starts and throughout the course of treatment.
Again, I'm a trained scientist. I can tell you those bars are short. That means fewer symptoms. Blood pressure went down.
This is one kind of evidence the Food and Drug Administration accepts as evidence compared to placebo, evidence of effectiveness. But wait, as they say in the game shows, there's more. Look what happens after you take the treatment away. Look at that. The symptoms come back.
And once again, Food and Drug Administration in the United States of America says that too is evidence for the effectiveness. of this new medication. So, members of the panel, do we approve this medication?
You bet. Absolutely. Good drug. This is going to be great. Next drug.
Now many of you will notice a similarity between this and the other cartoon, but there's a critical distinction. This is a new medication for cocaine addiction. This is a new treatment procedure for marijuana addiction or alcohol, whatever.
But look, the data are exactly the same. So, what do you think? Should we simply approve this?
Hearty response you New Zealanders have. You know there's a trick and the answer is hell no we're not going to approve this. Are you kidding me?
Are you not listening? Don't you see that six months following treatment termination the symptoms have returned almost to the point where they were before treatment started? Oh, you were focusing during the course of treatment.
No, no, no, we never do that. In the addiction field, never. We act like we have a cure.
We've been treating addiction, and I have been evaluating it as though we have a cure. And you know what? We ain't got no cure. And we may have, guys like me, may have really underestimated in a very important way the true effects of treatment. First of all, because of the model under which it's delivered, and second of all, the model under which it's evaluated.
And maybe that's why we have these kinds of conclusions. Because I can tell you that if you give a very short hypertension treatment or a very intensive hypertension treatment, followed by stopping that hypertensive treatment, you're not going to see a difference six months later. Okay?
Something to think about. All right, wise guy. What would you do? What do you Yanks do over there in the United States?
Well, as I say, we've been screwing this up pretty regularly for a long time and it's been a mistake. One of the things that we failed to do is see just how prevalent substance use problems. Now I'm down on that pyramid. I'm not up at the top anymore. I'm not talking about addiction.
I'm talking about harmful use levels. This is data from the Kaiser. Permanente Health System.
And what you're seeing is over representation of people with alcohol and other drug users in every one of the chronic illnesses that are being treated. And in fact, it's now clear that we commissioned a number of systematic reviews, not by some psychologist that works in addiction, but by People who are experts in each of these chronic illnesses, it's now clear that particularly alcohol, but to a lesser extent other substance use problems, compromise, complicate the diagnosis, the management, the costs, and the outcomes of every one of those illnesses. Take breast cancer, for example. In the United States, most doctors pay no attention to alcohol use among breast cancer patients. Well, here are a couple of facts.
One, the amount, frequency, duration of your alcohol use is a better predictor of what, if you're a woman, a better predictor of whether you're going to get breast cancer than the number of cigarettes that you smoke. With the exception of one genetic combination, it's a better predictor than your genes. And two, once you have breast cancer, any amount of alcohol accelerates tumor growth.
So the failure to... to counsel women and to bring that into play as you're treating breast cancer means worse breast cancer outcomes, greater costs, more suffering. So, for this group of people, we're not talking about the top here, down here, clearly the United States has now finally seen the light.
And we, in the new healthcare reform, for the very first time, we have a primary care benefit for the treatment of substance use disorders. I'm going to skip a lot of slides here, so I'm going to summarize a lot of this. We have never in the United States had a benefit for substance use disorders, only for addiction. And the difference is really quite important. Imagine, for example, if we had the same kind of a benefit in diabetes.
And... under the view that you want a husband, you know, scarce health dollars, it's quite reasonable to say we'll only treat real diabetes, you know, when someone has lost a digit or gone blind. That's when we'll give them treatment, and we'll give them specialty care treatment. That's the benefit, the insurance benefit in the United States.
And very soon, I guarantee you, people would say, you know, those... Terribly fat, terribly in denial, patients really need their own kind of treatment and it ought to be not part of the hospital. It ought to be down there by the boiler room maybe, across the parking lot.
No responsible professor was going to tell his best medical student, you should go into diabetes young man, there's real future there. It won't happen and that's what's happened in the addiction field. Well, the reason I bring it up is because it's going to be undone under healthcare reform. Under healthcare reform, it's the first time in my lifetime that physicians will be paid to do preventive, early intervention, and office-based treatments. So put differently for those who are more commercially, there's now a market for teaching physicians something.
There's a market among drug companies to make medications. Or- the specialty care field you have 13,000 programs in the United States but only about 40 percent of them even have a physician. So there ain't no market for a pharmaceutical firm to invent a drug that's going to help manage cocaine dependence. Well now they're going to be 550,000 primary care doctors that are going to be in this market.
Okay? It's going to be a very different situation. I'm going to just go through A number of this and screening and brief intervention is one of the, you must know about that in New Zealand, actually work has been done here I know.
Here's Medicaid costs in Washington State. These are for people who are coming in to standard treatment in hospitals in Washington State and they're diagnosed as having not addiction but harmful substance use, mostly alcohol. And one year later, after a 15-minute screening and brief intervention session, these are the dollars that were used, $4,000 per patient per year savings.
And this has now been replicated. So this is now not just fair. It's not just equitable for the illness of substance use disorders.
It is a big favor to general health. health care. We're helping through the substance, it can truly be said that substance use services are adding to the general benefit and the reduced costs of mainstream medicine. Okay, now let's go back up to our old friends up at the top of the pyramid, those with the most severe complex chronic conditions.
Is there anything that could work? Is there anything that's out there that matches what we now know about the science of this disorder. Its chronicity, its complexity, the brain changes.
And the answer is, yeah, we got something. But unfortunately you have to be a physician or an airline pilot or a lawyer to receive this kind of treatment in the United States. Once again, it's a segregated form of treatment and it's called, for physicians, called the physician health plans. The prevalence of addiction in physicians is exactly the same and even higher than it is in their general public.
About 12% of physicians end up with alcohol or other substance use problems, okay? But they don't get 30 days of treatment at Betty Ford. They don't get six outpatient sessions and some group.
They get five years of care. And it goes like this. An addicted physician is identified by his colleagues, and he's offered a choice.
Look, we want you to sign up to this physician health plan, and if so, any charges against you, any kind of wrongdoing that might be alleged, will be held in suspension. If you complete the treatment, you're fine. If you don't, we will go forward. And there are several phases to it.
First is a comprehensive evaluation and a contract. The physician says, yeah, I'm going to go along with this. I'm going to do what you ask.
So once again, as Peter says, this is for a population of people that are unaware and, frankly, resistant to care. But nonetheless, they get this. Then they have standard care that you or I might get.
in a residential substance abuse treatment program, usually 30 to 60 days, followed by A continued outpatient treatment. At this point they're able to go back and practice medicine, but during that period they have to continue to attend AA. A Caduceus Society is the medical society for recovering physicians.
They're expected to get family therapy and they are monitored every single week, sometimes multiple times in a week, with urine drug screens, 28 panel urine drug screens. And at points during the course of their normal workday, somebody may come and say, hey, let's go have a cup of coffee and please fill this little cup up, okay? So they're monitored continuously.
And here's the results. We did a study. I had never, I'd been skeptical that this was different.
So we did, with the help of the physician health plans, we did a prospective study. Retrospectively, we started in 2007, went backwards and got all patients who came into care in 16 treatment programs and followed them over the course of the next five years with their records. And 57% of them did complete this full regimen of care. Another 15% actually had relapsed.
But Instead of throwing them out, they increased the intensity and frequency of care, and they were still being monitored. And about 28% either quit the practice of medicine on their own, retired, or 22 died and some, frankly, absconded. So that's what the results look like. But here's something rather startling.
This is for all patients here. Over the course of ensuing five years, 78% didn't have a single positive urine. I don't mean at a single point in time 78% were clean. I mean that throughout the five-year period, 78% never had any evidence of drug use.
From the urines. or from the reports of their families or from the reports of their colleagues. That's pretty doggone good.
Well what about the people that slipped, people that actually did reuse? As I said, we didn't or they didn't throw them out of their jobs. They instead increased the intensity of treatment and only 26% of them ever had a second positive urine throughout that five-year period.
There's revoked licenses and that seems to be appropriate. So in conclusion, in the United States. We think we've been thinking about this the wrong way. Treatment of substance abuse is one of the most recent illnesses treated, and we've had a bad model. It's been the bad habit, you need to learn your lesson model.
Send them to some place that is separately financed, separately administered, separately run. Expect that they will get equal treatment. They don't.
And they're going to learn their lesson, and they'll never use drugs again. That hasn't worked well. We now believe it's a chronic illness. Once you're addicted, it's a chronic illness, and it can be, should be managed like every other chronic illness. And that means full involvement of family and the individual and the medical system.
Bring all the resources to bear. But more, it means that you now have the obligation to prevent and intervene early, especially in healthcare settings. where substance use disorders are being identified, and doctors are going to be paid to do that. And the model is the patient-centered medical home, exactly the same model that is now used for the management of other chronic illnesses.
So I'm sorry if I've gone over my time. I hope it gives you something to think about. I think it's a very exciting time in the United States.
I think for the first time. in my lifetime, we're going to see the kind of care that I hope my grandsons get, because we haven't had that. So thank you very much for your time, and I guess we wait until after the next speaker, right, for questions.
Thank you, Tom. Thank you.