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.
Dr. A. Benjamin Srivastava (left) and Dr. Mark S. Gold
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.