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A Minute With Dr Hancur: Spring 2006

"It's Drugs, Stupid!" This was the title of a New York Times magazine article written in 1995 by Joseph Califano, former Secretary of Health, Education and Welfare under Lyndon Johnson. In it, he compels us to pay greater attention to how drugs contribute to our societal problems, including healthcare. It was seen as an important piece because Califano had no preordained agenda. Rather, he was speaking from his observations as the former head of a large government agency entrusted with the welfare of American citizens.

For the past 30 years, I have taught a course on substance abuse at the University of Rhode Island. In the 1970's, it was titled "Social and Psychological Aspects of Alcoholism". It morphed in the 1980's to the "Alcohol Troubled Person" and then finally to its current title, "The Substance Troubled Person". What happened over the years was an expansion of our awareness about "addictions" to include a wide variety of drugs. During that same period, the previously separated alcohol and "drug" treatment systems merged into a more uniform "substance abuse" system.

The common denominator across all of the substances in the new system was their ability to alter the consciousness of the user. Despite that progress in understanding the essence of abuse, the treatment system continued to ignore tobacco / cigarettes as a true substance of abuse even though there was near universal awareness that it, too, alters consciousness. In fact, if it were not for pressure from other sectors of society, namely the courts and legislatures, the current restrictions on tobacco use which are so widely accepted today would not have happened if they had depended upon action from either the substance abuse treatment system or mainstream healthcare. In addition, most smoking cessation programs reside outside of the substance abuse treatment system, even though tobacco (nicotein) is at least the second most abused drug in the world.

With the advent of casinos across America in the past decade, problem gambling has risen in stature as a legitimate focus of clinical attention and, for the most part, substance abuse providers are regarded as the experts in the treatment of this problem. This is appropriate as the behavior of problem gamblers and the behavior of substance abusers is often quite similar, as is the treatment approach.

Including gambling in the area of "substance abuse" does pose some difficult questions, however, as gambling is a behavior, not a drug. Some of the presumptions about the genesis and essence of drug problems are challenged by the inclusion of a "substance" that does not have direct biochemical effects, specific to its class. Nevertheless, the commonality between gamblers and substance abusers in terms of seeking behaviors and difficulties achieving abstinence are nearly identical. Also, the comorbidity of gambling and substance abuse presents a compelling argument that the same basic mechanisms are in play.

I believe that seeing the commonality among all substances of abuse is a positive development and that including tobacco / cigarettes and problem gambling is also a good move. Hopefully, you agree with me so far. The proposal I really want you to consider however is a further expansion of substance of abuse to include "food". Once we get past the requirement that the substance / behavior has to have direct and specific biochemical effects, as we have done with gambling, then food qualifies. It clearly and powerfully can alter consciousness for large numbers of people and does so to their detriment, even to the point of death.

In the United States, food is actually the number one substance of abuse when measured in healthcare dollars. This is an astounding fact when you realized that smoking accounts for more than 400,000 deaths per year and cost more than $75 billion per year in direct medical expenses, according to the Centers for Disease Control and Prevention. With food, as with tobacco/ cigarettes and alcohol, mainstream healthcare has failed to address the problem effectively, in my opinion. True, there is more attention being paid to the issue. But I know of no one who believes that the problem is being addressed adequately. Diabetes, hypertension, arthritis, orthopedic problems, gastric distress, hypercholesterolemia, etc., etc., etc. can all be viewed as symptoms of a larger substance abuse problem, namely, food.

My thesis here is that problems with food are behavioral health problems and we, as behavioral health providers, should be dealing with them. We would think of ourselves as negligent if we sat across from patients who were pulling their hair out or scratching their arms until they bled or smelled of alcohol and we did not bring that behavior to the patient's attention. I submit that it is just as negligent if we do not address equally obvious problems with food. Treatment approaches that view problems with food as amenable to quick, episodic interventions will fail as certainly as approaches that allow the problem drinker to have a "couple" or the gambler to only bet the office pool.

Mainstream healthcare, including behavioral healthcare, and mainstream health insurance have not done enough to support efforts to deal with food. Blue Cross and Blue Shield of Rhode Island has attempted to change that in a number of important ways. One is its new Health and Wellness Institute which will provide tools and support to help individuals accelerate behavior change that improve their health. BCBSRI is also helping to initiate change by facilitating the integration of primary care and Behavioral Health. As these initiatives go forward, we are depending upon you, the behavioral health provider, to do your part to resolve the number one healthcare problem in America – substance abuse – and that includes alcohol, tobacco and food.

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