Economics of addiction and health reform

Like many people Robert Downey Jr. is an addict.

Addiction is a frighteningly common disease, and for an addict so is relapse. When a wealthy person relapses, they may go to an expensive treatment facility, like Promises in Malibu. Such facilities can cost $1,000 per day. Cheap, if they work, and if you can afford it.

For most of us, those are two big ifs which tell us a lot about medical economics. Even "middle-class" drug treatment can cost $7,500. And it doesn't always work.

Insurers have learned to tread carefully here. Public and private policies involving addiction are stringent. But, as they say, Alcoholics Anonymous is free. If you're ready to quit, AA and other self-help groups can work as well as the most expensive hospital.

Bankole Johnson of the University of Virginia believes rehab doesn't really work at all. (Picture from the University of Virginia.)

He calls addiction a "disease of the brain" and is in trials on a combination of Topiromate (an anti-convulsant sold as Topamax) and Ordansetron (used to treat severe nausea including that from chemotherapy) that might effect a chemical cure.

Supporters of rehab say Johnson is wrong, that rehab works. The point to a National Institutes of Health study of Oxford Houses, and a 2006 study in Alcoholism, showing it to be cost-effective.

Many addicts who have achieved remission, like Downey, say nothing worked until they "hit bottom," that is until their condition became so bad that their minds changed, and they came to accept what rehab was offering. But not everyone does. Addicts can die of their addictions.

Addicts can also be addicted to anything, not just drugs like heroin, alcohol and nicotine. There are food addicts, video game addicts, sex addicts, exercise addicts, and people addicted to danger. Each addiction carries a cost, each has a process for addicts to "come down," each has a success or failure rate.

With mental health now given parity with physical health in health reform, these economic questions become more important. They also echo questions we face in physical health.

1. How much treatment can we afford from a common pool?
2. What types of treatment should be covered from that pool?
3. To what extent should patients be able to decide on their course of treatment?
4. If we find a chemical "cure," like the one Dr. Johnson is working on, do we go to that first?
5. No matter the cost?
6. Can we make people get treatment?
7. Can we refuse treatment, especially in people who have relapsed several times?

All the questions we have regarding physical health, and health reform, are seen in stark relief when we talk about addiction. Questions of cost vs. efficacy. Questions of success vs. failure. Questions of compliance vs. non-compliance.

These questions are important for those who opposed health reform and continue to oppose it. Rich people can afford Passages, poor ones cannot. We can't give everyone Passages from a common pool, public or private. So how much should we give them?

Reform opponents have a simple answer. Nothing. Get the treatment you can afford, or shut up and die. Given the low cost of self-help groups like AA, that is a more compelling argument for addiction than it is for, say, cancer.

But in the end it is the same question, and it's one which, thanks to health reform, we now need to face directly.

This post was originally published on Smartplanet.com