April 22, 2004 - Medscape Medical News (US Web) Top U.S. Physicians, Lawyers Tackle National Drug Policy A Newsmaker Interview With David C. Lewis, MD By Laurie Barclay, MD

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Editor's Note: Prominent U.S. physicians and lawyers have joined together in a nonpartisan organization, Physicians and Lawyers for National Drug Policy (PLNDP), to advocate for a public health approach to federal and state substance abuse policies.

Since its inception in 1997, the group has believed that drug and alcohol policies must be based on evidence rather than on politics, that prevention and treatment are more cost-effective than incarceration, and that substance abuse should be afforded equal footing with other chronic, relapsing conditions in terms of access to care and insurance coverage. The revised and expanded group, now incorporating members from the legal profession, met on April 20 at the National Press Club in Washington, D.C., to discuss these and other issues, including the need for widespread alcohol screening in trauma centers and emergency rooms.

To learn more about PLNDP's agenda, Medscape's Laurie Barclay interviewed David C. Lewis, MD, a member of the board of directors of the revamped group and a founder of the original group. Dr. Lewis is a professor of medicine in community health and a professor of alcohol and addiction studies at Brown University in Providence, Rhode Island.

Medscape: What was the impetus behind the creation of PLNDP in 1997 and its recent revision and expansion?

Dr. Lewis: The creation of PLNDP in 1997 was really an expression of historical frustration, because the leadership of medicine for almost a century had not been directly involved in the fashioning of drug policy. There were physicians during some periods of that time who were involved, but basically it had become a criminal justice enterprise primarily. When the leadership gathered for the first time in 1997, they struck quite a moderate and bipartisan tone saying that they wanted to really apply evidence in evaluating drug policy, whether it be criminal justice approaches or medical and public health approaches. But they obviously were looking for an increase in the attention we pay to public health approaches and medical approaches, which in fact meant an expansion of treatment in a major way, both in and out of the criminal justice system. So that was really the impetus that led to our formation.

In our first meeting on a hot July day in the summer of 1997 and in two meetings at the Aspen Institute, which were extremely well attended both by the core physician leadership group and by other leaders in law and business, we set the groundwork for a consensus, which we followed in the ensuing years.

I think that we did help turn more public support and private support toward treatment and lessened the discrimination toward addicts and the incarceration of nonviolent addicts. Polls in 1997 showed the public would just as soon send somebody to jail for their alcoholism or drug addiction as send them to treatment, and by the time we finished that had changed, and I hope that we made a contribution to that change.

The new PLNDP group really came out of a discussion that we had with business, law, medicine and other health professionals. It became clear that we would strengthen our message and be able to analyze the issues the policy insures better if we had a combined effort with the legal profession. So this has been in the cards for some time. It has been discussed for at least two years as part of our group, and now we have made a more formal organization with a board of directors and a leadership council and two leading individuals, George Lundberg on the medical side and Professor Richard Bonnie on the law side.

Medscape: Why does the PLNDP feel that medical and public health approaches will be more effective than the criminal justice system and interdiction in reducing illegal drugs?

Dr. Lewis: From the evidence, that's what we ought to be doing. If you're talking about what to do about nonviolent addicts who need treatment, quite obviously you can show that it's both the humane and cost-effective way to provide treatment for them. There are a number of options people have now for treatment, including diversion from the criminal justice system through something like drug courts and through other court procedures, but we felt that medical and public health approaches were really underutilized compared to other approaches. We did a cost analysis of the cost of keeping somebody in prison for a year, which was upwards of $30,000, versus the cost of treatment, which ranged from something like $6,000 to something like $12,000 a year.

Medscape: What specific medical and public health approaches does the PLNDP recommend, and what would be the cost and funding base for these programs?

Dr. Lewis: We haven't chosen specific projects yet; that will come out of a meeting with the leadership council and the new board of directors. We certainly take a clear position about what we think addiction is. Understanding that addiction is a disease does not absolve the addicted individual of responsibility for their behavior, but their addiction should be given strong weight in the mitigation of punishment and as a basis of diversion from the criminal justice system. So that's really the law statement part of our group.

Sending people to prison does not in itself help them recover, and the collateral consequence is that a criminal record creates enormous barriers to effective recovery. I think it's fair to say that is an overall perspective of our law people and our medical people. Drug policy should reflect the public health approach to prevention and treatment of substance abuse and should avoid excessive reliance on disproportionate punishment. The United States should embrace an evidence-based, long-term strategy for controlling what is and will continue to be an endemic social problem, taking into account the cost and benefits of every policy instrument deployed.

Part of this exercise in forming this group was to review a report from the National Research Council (2001), Informing America's Policy on Illegal Drugs: What We Don't Know Keeps Hurting Us, on the effectiveness of our current national drug policy - a report that really pointed out how little of the policy is based on evidence. This report has influenced particular principles that we're going to talk about when we launch the group.

Medscape: What effects would there be from shifting funds away from drug enforcement through the criminal justice system?

Dr. Lewis: You would save money and be effective in preventing crime. One of the encouraging things about the treatment of alcoholism and drug addiction, particularly if it's treated early, is that it's a very effective crime preventer. Generally speaking, an investment of maybe $2,000 in one year in treatment offsets about $19,000 the following year in criminal justice costs. One of the biggest cost offsets and benefits from treatment is decreased crime, and that's very clear from a lot of different studies. There's actually a famous study in California talking about how $7 are saved for California tax payers for every $1 invested in drug treatment. Most of those $7 are actually saved from reduced crime, which happens almost immediately after the person enters treatment. You don't have to wait years and years to see that benefit.

Medscape: Does the PLNDP advocate changes in criminal law pertaining to possession, use, and trafficking in illegal drugs?

Dr. Lewis: We haven't advocated any specific changes in law; because that will depend on the leadership council and the board of directors and a council of advisors, which we're setting up for a meeting this fall. We're still straightening out the priorities we have in terms of what we ought to address early on, but whatever we do take up it will be entirely consistent with the statement of principles that I just referred to. If you have this discussion with me or with other leaders from the group in October, we could be very specific about the particular issues we're going to pursue.

Medscape: In what ways does the PLNDP hope to reduce regulation of addiction treatment programs, and what effects would this have?

Dr. Lewis: One of the consensus statements from the original group about excessive federal regulation referred mostly to methadone maintenance, which is uniquely regulated. It's the most regulated drug in the United States. Physicians are not free to prescribe it to addicts; there's all kinds of heavy duty regulation, and it's resulted in fairly large clinics as an option for people receiving methadone maintenance. That needs to change. One of the changes that has happened is an introduction of another maintenance drug, buprenorphine, which can be used in primary care and private practice settings. But that too is accompanied by too much regulation limiting the number of addicts that each practice can treat.

Medscape: If more insurers cover substance abuse treatment on an equal footing to that of diabetes, hypertension, and other chronic diseases, what effect will that have on overall insurance costs?

Dr. Lewis: Like the initial PLNDP project, we're going to want insurance benefits for addictive disease, and we're going to want them for a lot of good reasons. First, it's cost-effective; second, it's the right thing to do; and third, treatment is as effective as it is for diabetes, hypertension, and asthma. An article in The Journal of the American Medical Association shows that treatment outcomes for addiction are equal to those for other chronic diseases.

The problem with insurance is self-evident: insurance companies will simply say it costs too much to insure something. They will also say they don't want any mandates. That's understandable; as an industry, of course they don't want any mandates. But the interesting thing about the cost is how minimal the additional cost would be for insuring alcoholism and other addictions. That is interesting compared to some of the cost of the other chronic diseases and even the cost of mental illness, which has more obligatory inpatient care. So the annual increase for full parity for substance abuse treatment is estimated at about a $5 increase in insurance premiums a year to cover this.

But insurance companies are in a bind, because we don't have a systematic healthcare system in this country, and people can shift insurance companies. Insurers are always worried about whether they can enlarge their good-risk patients and decrease their bad-risk patients, so in our health system we penalize people with chronic disease in terms of insurance. It's unfortunate, but we can't do anything about it. Even so, accepting the system we have, fortunately the costs are really minimal compared to what the benefits are - just the offset in the cost of other diseases and other conditions that could be prevented and other medical and surgical costs and hospitalizations that could be prevented by early intervention for addiction treatment.

The amount of injuries that go with alcoholism alone are astronomical in terms of the cost, and alcoholism is in fact the leading cause of decreased productivity of all the chronic diseases in the business world. So if you look at that it makes no economic sense for these conditions not to be fully covered, but I think the insurance industry unfortunately has a reflex reaction - that's a mandate and we don't want it. Even if it were a mandate, it's a mandate we should have, and it's not going to raise premiums enough to make a difference in terms of the broadly insured public. But it will make a difference to thousands and thousands of people with these diseases.

Disclosure: One PLNDP member, George Lundberg, MD, is editor-in-chief emeritus of Medscape and editor of Medscape General Medicine (www.medgenmed.com).

Reviewed by Gary D. Vogin, MD