The new guidelines for the Mental Health Parity Act (MPHA) went into effect on January 1, 2010, arriving not a moment too soon. Federal law now requires that insurers who cover mental health or addiction treatment must do so equally with the coverage they provide for medical and surgical ailments.
State and federal governments in the United States currently spend more than $15 billion per year, and insurers at least another $5 billion per year, on substance-abuse services for some four million people, but researchers estimate that some twenty million Americans who could benefit from treatment are not getting it. As the psychologist Peter Levine notes, "The costs in human suffering, family disintegration, and lost productivity are staggering." Not to provide treatment is to condemn people to a lifetime of misery and, with distressing frequency, to untimely death.
The MPHA implicitly recognizes that addiction is a mental health issue and that its consequences can be as debilitating as that of any chronic, severe physical illness--in fact, physical illness is often the outcome of untreated addiction. HIV, Hepatitis C, multiple infections of body organs from liver to heart to brain are the frequent consequences of injection drug use, just as lung cancer and chronic lung disease follow from nicotine addiction and cirrhosis of the liver and many other diseases occur in the wake of chronic alcoholism. So any distinction between addiction and physical illness is artificial.
It is also clear that addiction itself is a disease of the brain. Through new imaging methods we've been able to glimpse the human brain in action under the immediate influence of drugs and after long-term drug use. The findings are abnormal, and they get more abnormal with chronic use. Those who study addiction agree that on the basic physiological level, addiction represents "a different state of the brain," in the words of physician and researcher Charles O'Brien. The addicted brain just doesn't function normally, any more than a diseased heart functions normally. The central dilemma is that this dysfunctional organ now has to make a decision to heal itself. It can rarely do so without expert help and compassionate support.
Addiction, contrary to popular opinion, is not a simple matter of a poor lifestyle "choices," bad decisions, or moral failure. Large scale population studies have shown that most severely addicted people suffered extreme adversity in childhood--neglect, abuse, trauma that most of us cannot even imagine. The brain is shaped by such influences. The brain circuits that later become implicated in addiction are potentiated to do so by what happens in early childhood. As a physician working with a highly addicted population at a residential harm reduction center, I can report, for example, that among my female patients there is not one who was not sexually abused in childhood--as were many of the men.
Finally, there is a close link between addiction and mental health problems, since all addictions are ill-fated attempts at self-medication. What conditions do people self-medicate? Post-Traumatic Stress Disorder, for example, with opiates and other drugs; ADHD, with stimulants. Depression, anxiety, social phobias are also among the mental health disorders people try to soothe through drug use.
The updated guidelines to the Mental Health Parity Act will not have universal reach, nor will it be the final answer to the many gaps in addiction treatment in the U.S., But it is an important step in the right direction.