If you use drugs and get sick, society will spend thousands of dollars on you. If you abuse drugs and want to get straight, society will spend pennies. This is a sad conclusion of our study published several months ago in the Journal of the American Medical Association.
We found that in 1988 alone at Johns Hopkins Hospital, charges for 983 patients who were intravenous drug users totaled between $6 million and $10 million. Most of the money was spent treating complications; little was aimed at reversing addiction.
One physician recalled the case of a man who came to the emergency room and wanted to get into a treatment program; all she could do was put him on a long waiting list. Later that evening, as she drove home, she saw him wandering the streets and guessed that a drug connection was more likely than a treatment connection. Yet, if he suffered a heart infection as a result of drug use, we could have hospitalized him, at great expense to taxpayers.
This reactive mode is characteristic of our health care system, which spends billions of dollars to treat people in the late stages of their disease and comparatively little on preventing it.
Although intravenous drug abuse gets more attention, alcohol abuse has been -- and continues to be -- a bigger problem. A 1990 report by the Centers for Disease Control estimates that alcoholism is directly responsible for as many as one in 20 deaths annually. Another study from our hospital, published in 1989, documented alcoholism as a complicating factor in about 25 percent of all hospitalized patients. The figures at other hospitals are even higher.
In fact, last year the National Institute on Alcohol Abuse and Alcoholism estimated the costs of alcoholism nationwide to the society at $117 billion annually.
Given these statistics, you might think that hordes of physicians would be developing strategies for prevention or more effective treatment. If so, you'd be wrong. Only one of the 387 clinical fellows training at Johns Hopkins is specializing in substance abuse.
Why? Imagine you are a graduating medical student saddled with an average debt of $42,374. Would you choose a low-prestige career serving patients who are difficult and sometimes physically and verbally abusive, where the system of care is so disorganized that you see mostly treatment failures and few successes, and where you are paid comparatively little? It's not surprising that many who get involved often do so for personal reasons. The fact is that more of our best minds are needed to solve what many Americans believe to be the nation's chief domestic problem.
To rectify the problem, here's some advice for those who make drug policy:
Institute loan-forgiveness programs for doctors, nurses, psychologists, counselors, social workers and others who want to get involved in combatting drug abuse, and fund more programs to train leaders in the field.
Encourage the development of comprehensive treatment programs that reduce the barriers between disciplines.
Change incentives that pay handsomely for care of secondary complications and little for primary care or prevention.
Persuade key representatives of the judicial, educational and health care systems to join forces with local residents who feel the impact of drug abuse every day.
Most important, improve the care of high-risk women of childbearing age, and establish systems to help the children of addicts, who have a greater likelihood of developing drug dependence. Prevention means caring about their home lives, education, jobs and housing, as well as supporting the community activists who are trying to drive out the pushers.
It also means acknowledging the link between intravenous drug abuse and the use of other drugs -- some of which are legal. The relationship of alcohol and tobacco to heroin, cocaine and other drugs has been well-documented. In a survey of 71 drug abuse patients at Hopkins, 87 percent used cocaine, 83 percent heroin, 80 percent smoked cigarettes and 63 percent abused alcohol. This polydrug abuse makes them more difficult to treat and illustrates the need to treat addictions as related, not separate, entities.
If drug abuse responded to slogans, billboards and bumper stickers, we'd be home free. It doesn't. We need to start transferring some of the millions being spent at the wrong end of the disease cycle to prevent further abuse, as well as helping those who are addicted to get off drugs.
Simplistic, you say, since we can't just walk away from existing patients whose treatment bills continue to pile up. True enough. Major shifts will require a comprehensive overhaul of health care financing, now under serious consideration.
Meanwhile, we can start parallel prevention programs for drug abuse and AIDS, which is increasingly associated with it. Why not pay for residential treatment for the poor? It has been shown to be effective for the affluent. To accomplish this, we could shift some of the drug war money from military operations to treatment.
But to do all this, we need new money, despite the looming deficit. Too often, we're told that we can't do what we agree ought to be done because of "the bottom line." Thus, we have no money to increase spending for the homeless or to repair our nation's crumbling infrastructure.
I'm not arguing against spending money to bolster emerging Eastern European democracies or to pay for other services deemed essential, such as "drawing a line in the sand" in the Mideast. But why not apply the same urgency to domestic issues? Why spend billions abroad to protect "the American way of life" when it is being eroded from within?
Peter E. Dans is associate professor of medicine at Johns Hopkins University School of Medicine in Baltimore.