Vig Subramanian

Hidden Costs, Dirty Lies, and The Illusion of Choice: The Worst of American Healthcare

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by Vignesh Subramanian, April 12, 2022

The headlines are the same every year, and have been so for the last half-century: U.S. Health Care Ranked Worst in the Developed World (TIME, 2014); US health spending twice other countries’ with worse results (Reuters, 2018); U.S. health-care system ranks last among 11 high-income countries (Washington Post, 2021). The United States spends more on health care expenditures – both as a proportion of its gross domestic product and on a per capita basis – than any other developed nation, with annual accelerated growth rates in health spending exceeding those of OECD counterparts (Tikkanen and Abrams, Schneider). It is increasingly being understood that the U.S.’s outlier status is the result of higher prices and cost barriers rather than comparatively greater service utilization, with higher payments to hospitals and physicians as well as administrative overheads largely driving the outsized differences in spending (Kurani and Cox). Exactly how egregious the bills sent to American patients can be, however, is hidden in the fine print – an abusive doctrine formulated by medical bureaucracies and providers alike to obscure the truth about how far they are willing to go for profit.

Among the most obvious and decried examples of deceptive charging practices by providers are the various forms of surprise billing that often follow already costly care. Patients who unknowingly receive treatment from physicians who are not in their insurance network are prime targets for additional charges that may amount to tens of thousands of dollars (Kliff and Sanger-Katz). These patients typically do not choose the treating doctors themselves and are not made aware in advance of their out-of-network statuses (usually because of the urgency of required treatment or the availability of specialized providers, as is the case with emergency care or complex surgeries); some may have even sought care at an in-network hospital or urgent care center, reasonably assuming that these facilities employed providers that were similarly covered by their insurance. Nevertheless, these patients end up faced with the prospect of their insurance company refusing to pay an out-of-network balance bill, while collection agencies abandon good-faith protocols as they move to seize debt (Weber). Surprise billing often involves high initial reimbursements demanded by providers, procedures intentionally being redirected to more expensive ‘affiliated’ or ‘consolidated’ sites, and separate facility fees being tacked on; it can also affect non-emergency routine or scheduled care, making the issue a common woe for patients who cannot ‘shop’ for more affordable provider options while under any degree of duress.

The contributions of such bills to soaring healthcare spending cannot be overstated, but represent just the tip of a larger iceberg of unnecessary and inexplicable costs to the average American patient. Surprise bills would not be possible if not for deliberate schemes characterized by so-called “chargemasters” – the comprehensive, hospital-specific compendiums of all services said hospitals may charge for – to keep the realized costs of care hidden until after delivery. Such measures work to withhold, clutter, or bury procedure price lists from or on hospitals’ public sites and web search queries, while selectively publishing ‘starting point’ and ‘prospective’ rates far below those used for Medicare reimbursements and private insurance payments with little basis in market transactions (McGinty). They quietly tuck arbitrarily applied fees, such as those for basic consultation, testing, and diagnostic procedures (e.g. blood draws) or for care that was ‘seriously considered’ or ‘activated’ but not ultimately provided (e.g. trauma response fees), into final bills without patient notification (Gold and Kliff). They enshrine refusals to bring sticker prices for the use of certain technologies (e.g. MRIs) or operative procedures (e.g. hip replacements) in line with those of lower-tier doctor’s offices or otherwise justify or address variation and make comparison feasible across emergency departments, trauma centers, and surgery centers in a given geographic area (Pflanzer). Hospital systems are even willing to charge patients for minimal labor costs (fees charged to new mothers who have just given birth for “skin-to-skin contact” with their newborns are an infamous example), for basic health products like over-the-counter pharmaceuticals, toiletries, and first aid supplies that cost far less at neighboring pharmacies, and for services supporting other parts of the continuum of care at exorbitant levels (e.g. transport services like ambulance rides, despite the fact that EMS crews themselves are not reimbursed for patients not transported to emergency rooms) (Earl, Reed). Collectively, these ‘grab-every-last-dollar’ tactics take gross advantage of the necessity of critical care to bleed American patients dry, making every step into treating facilities as financially punishing as possible while denying them even the fundamental privilege of foresight to predict the final bill.

In a legitimately free market – indeed, of the kind defenders of the U.S. healthcare model contend it is and must remain – the ‘consumer’ is assumed to be able to make choices of free will, with the most accurate information possible on the prices of the goods and services available to them. This premise holds that such informed decisions will in turn guarantee a higher quality of service provided, improving consumer satisfaction while reducing costs as providers compete in a ‘race to the bottom.’ Yet neither that transparency of information nor that freedom of choice are available for U.S. healthcare’s consumer, the American patient. Deliberate and disingenuous attempts by hospital associations and physicians’ groups to bury costs and coerce acceptance of their terms instead take options away from the average American while triggering even more adverse reactions from elsewhere in the market. Insurers, supposedly the representatives of patients’ financial interests, have felt compelled to respond to providers’ effective price gouging by abruptly terminating physician contracts and leaving marketplaces (leaving many patients out in the cold with smaller networks), or else by secretly negotiating with hospitals to establish ‘adjusted payment rates’ and so-called “anti-steering clauses” (long-term agreements to avoid moving policyholders to other providers with lower costs), all without providing adequate notice to policyholders (Miller, Allen, Mathews). Governmental interventions, meanwhile, leave a lot to be desired in substance; recently enacted federal legislation that bans surprise billing and mandates that out-of-network cost sharing must match in-network provider rates, for example, only covers emergency services (and even then does not cover ground ambulances), meaning surprise billing is still possible in a large range of healthcare settings (Mensik). Other promulgated rules requiring hospitals to post price lists and insurers to inform members of discounted rates upfront fail to establish guidelines on making the provided information decipherable, while coming under sustained legal assault by healthcare and business groups seeking to shield their dealings from public view (Chiwaya and Kimelman, Weixel).

The hidden costs and false illusions of choice of service perpetuated by U.S. healthcare providers amount to a dirty lie – one that paints the patient’s inability to find affordable care as a personal failing rather than a carefully constructed outcome. The American system is not broken, but rather working perfectly as designed: to maximize profits by harassing and charging patients to the point of bankruptcy, by any and all means. It is despicable that those means have come to include openly deceiving patients about the true value of costs incurred, rendering them less willing consumers and more cash cows on which any number of charges may be whimsically levied. As our white coat-adorned saviors in operating rooms and I.C.U.s become existential threats to the pocketbook, it becomes extraordinarily difficult not to ask the question: was I, the patient, really the priority?

Works Cited

Allen, Marshall. “Why Your Health Insurer Doesn’t Care About Your Big Bills.” ProPublica, 25 May 2018, propublica.org/article/why-your-health-insurer-does-not-care-about-your-big-bills. 

Chiwaya, Nigel, and Jeremia Kimelman. “You Can Now Get Your Hospital’s Price List. Good Luck Making Sense of It.” NBC News, 15 Jan. 2019, nbcnews.com/news/us-news/hospital-price-list-chargemaster-rules-trump-mandate-2019-n959006.

Earl, Jennifer. “Doula Explains Why Hospital Charged Parents $39 to Hold Newborn in Viral Post.” CBS News, 13 Oct. 2016, cbsnews.com/news/doula-explains-why-hospital-charged-parents-39-to-hold-newborn-baby-in-viral-post/.

Gold, Jenny, and Sarah Kliff. “ER Bills: A Baby Was Treated with a Nap and a Bottle of Formula. His Parents Received an $18,000 Bill.” Vox, 28 June 2018, vox.com/2018/6/28/17506232/emergency-room-bill-fees-health-insurance-baby.

Kliff, Sarah, and Margot Sanger-Katz. “Surprise Medical Bills Cost Americans Millions. Congress Finally Banned Most of Them.” The New York Times, 21 Dec. 2020, nytimes.com/2020/12/20/upshot/surprise-medical-bills-congress-ban.html.

Kurani, Nisha, and Cynthia Cox. “What Drives Health Spending in the U.S. Compared to Other Countries.” Health Spending, 20 July 2021, healthsystemtracker.org/brief/what-drives-health-spending-in-the-u-s-compared-to-other-countries/

Mathews, Anna Wilde. “Behind Your Rising Health-Care Bills: Secret Hospital Deals That Squelch Competition.” The Wall Street Journal, 3 Oct. 2018, wsj.com/articles/behind-your-rising-health-care-bills-secret-hospital-deals-that-squelch-competition-1537281963.

McGinty, Tom, et al. “Hospitals Hide Pricing Data From Search Results.” The Wall Street Journal, 22 Mar. 2021, wsj.com/articles/hospitals-hide-pricing-data-from-search-results-11616405402.

Mensik, Hailey. “Ground Ambulances, Excluded from Surprise Billing Ban, to Get Scrutiny from Federal Committee.” Healthcare Dive, 22 Nov. 2021, healthcaredive.com/news/federal-committee-ground-ambulances-no-surprises-act/610451/.

Miller, Andy. “Patients Are Getting Stuck out-of-Network Due to Rifts between Insurers and Hospitals.” Fortune, 16 Nov. 2021, fortune.com/2021/11/16/out-of-network-insurance-companies-health-care-systems-hospitals-contracts/.

Pflanzer, Lydia Ramsey. “The Cost of an MRI Can Vary by Thousands of Dollars Depending on Where You Go.” Business Insider, 28 Mar. 2017, businessinsider.com/how-much-an-mri-costs-by-state-2017-3.

Reed, Tina. “Ambulance Rides Are Getting a Lot More Expensive.” Axios, 22 Feb. 2022, axios.com/ambulance-rides-are-getting-a-lot-more-expensive-cee897fe-63b7-4412-aa67-718109773e79.html.

Schneider, Eric C., et al. “Mirror, Mirror 2021: Reflecting Poorly | Health Care in the U.S. Compared to Other High-Income Countries.” Improving Health Care Quality, Commonwealth Fund, 4 Aug. 2021, commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly.

Tikkanen, Roosa, and Melinda K. Abrams. “U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes?” U.S. Health Care from a Global Perspective, 2019, Commonwealth Fund, 30 Jan. 2020, commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019.

Weber, Lauren. “Patients Stuck With Bills After Insurers Don’t Pay As Promised.” Kaiser Health News, USA Today, 11 Feb. 2020, khn.org/news/prior-authorization-revoked-patients-stuck-with-bills-after-insurers-dont-pay-as-promised/.

Weixel, Nathaniel. “New Trump Policy Will Force Insurers to Disclose Prices up Front.” The Hill, 29 Oct. 2020, thehill.com/policy/healthcare/523328-new-trump-policy-will-force-insurers-to-disclose-prices-upfront/.

Today’s Crisis Standards of Care: A Death Knell for the Less-Abled

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by Vignesh Subramanian, December 3, 2021

As of November 2021, nine U.S. states – Alaska, Idaho, Montana, Washington, Colorado, Wyoming, New Mexico, Utah and Arizona – have either officially activated statewide crisis standards of care or have been on the brink of declaring their activation. The news comes as several more states, including the southern bloc of Georgia, Kentucky, Mississippi, Arkansas, and Texas, have warned that I.C.U.s are rapidly approaching capacity (Knowles). Amid waves of largely unvaccinated COVID-19 patients besieging weary hospitals, authorities have attempted to ease this burden by hastily formulating policies that will decide the relative value of human life during public health crises for decades to come. But what does all of this mean?

Crisis standards of care institute substantial changes to the delivery of healthcare services amid pervasive or catastrophic disasters, with the understanding that standard levels or quality of care can no longer be wholly provided to patient populations. In the United States, activation of these standards is formally declared by state governments and directly alters the evaluation criteria on which decisions about triage, transfers, and use of scarce resources are made. The criteria are far-reaching but vary immensely; some incorporate ‘inclusion criteria’– encouraging treatment of patients in good standing following assessments of their major organ health, life expectancy, and the order of the first-come/first-serve basis — while others also incorporate ‘exclusion criteria’– rejecting critical care for patients with low likelihood of immediate survival or poor ‘quality of life,’ or those patients for whom it is assumed that increased sustenance will not substantially provide significant benefit (Auriemma). 

Physicians’ use of this last-resort discretion can be frightening; beyond the more expected measures of postponed elective, cosmetic, and nonurgent surgeries and longer wait times in general, patients are often subject to crucial decisions made on mere whims. Physicians can send patients home to rely on inadequate in-home medical equipment, transfer them to hospice care or other centers without the appropriate specialized facilities, and even remove them from life support entirely, all over their objections. Universal ‘do-not-resuscitate’ and ‘do-not-intubate’ orders are applied as blanket protocols to all patients in cardiac or respiratory arrest if insufficient staff are available, even without consideration of patient statuses on a case-by-case basis. Ventilators are given to those who are most likely to restore their normal breathing function, nearly defeating the purpose of the devices; ambulances are not guaranteed upon emergency calls; and patients may even be denied admittance into a hospital to begin with (Chin and Harris). As the systemic capacity to treat large patient volumes shrinks, so too does sympathy for those whose lives are simply deemed worth less.

Do not resuscitate (DNR) order — A written order from a physician, issued at a patient’s request, instructing healthcare providers not to perform any form of cardiopulmonary resuscitation (CPR) – including chest compressions, cardiac drugs, or placement of a breathing tube – on the patient should respiratory or cardiac arrest occur.

(Breu and Herzig)

Do not intubate (DNI) order — A written order from a physician, issued at a patient’s request, instructing healthcare providers not to place a breathing tube to assist the patient’s breathing should respiratory or cardiac arrest occur. Unlike a DNR, a DNI still allows providers to administer chest compressions and cardiac drugs as necessary.

(Breu and Herzig)

It is therefore not surprising that crisis standards of care amount to a death knell for the less-abled. Already, reports are being made of elderly patients and those with disabilities receiving subjective evaluations of their ‘quality of life’ from their physicians in violation of civil right statutes, being denied care at hospitals without resource shortages due to mere anticipation of capacity being reached, and being pressured — especially in the cases of patients with intellectual disabilities, and in the absence of caregivers — to sign off on advance directives they do not understand. Despite their relative inability to accurately predict the long-term survival probability of patients with disabilities, or whether or not such patients will require use of greater treatment resources, many doctors and lawmakers continue to place ableist judgement above sound scientific knowledge. Of the twenty-nine U.S. states that issued crisis standards of care guidelines before or at the start of the COVID-19 pandemic, the vast majority did not include language prohibiting discrimination against elderly or disabled patients in the provision of critical care, and few used their administrative processes to close such loopholes. Some state plans actually explicitly prioritize younger patients and those without comorbidities, while others prohibit people with specific disabilities from being offered life-sustaining ventilation support or throw discretion to hospital policy (Cleveland Manchanda). Such fragmentation of standards forces the current array of disability rights groups engaged in litigation against these hospitals to base their petitions on tort law claims rather than righteous grounds of disability discrimination, leaving patients at the mercy of an indifferent medical bureaucracy.

Ableist — The quality of being prejudiced or discriminatory against individuals with disabilities.

(Neilson)

It is inexcusable that demonstrably false stereotypes about the ‘quality of life’ experienced by a patient with disabilities or old age are allowed to dictate the quality of care they receive. While the U.S. has made tangible progress towards extricating such biases from medical practice — one could certainly point to the Americans with Disabilities Act, Title VI of the 1964 Civil Rights Act, Section 504 of the Rehabilitation Act, and Section 1557 of the Affordable Care Act (DOJ, HHS) as prominent examples — those gains have evidently not been fully incorporated into the healthcare pathway. Even during a public health crisis, acute episodes of illness must not determine the relative value of a patient’s life simply because providers are under duress. Instead, moments such as these call for the best of physicians’ work ethic and equity in screening criteria and treatment allocation decisions.

Works Cited

“A Guide to Disability Rights Laws.” Civil Rights Division, U.S. Department of Justice (DOJ), Feb. 2020, https://www.ada.gov/cguide.htm#anchor64984.

Auriemma, Catherine L., et al. “Eliminating Categorical Exclusion Criteria in Crisis Standards of Care Frameworks.” American Journal of Bioethics, 18 May 2020, https://www.tandfonline.com/doi/full/10.1080/15265161.2020.1764141.

Breu, Anthony C., and Shoshana J. Herzig. “Differentiating DNI from DNR: Combating Code Status Conflation.” Journal of Hospital Medicine, Oct. 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5240781/.

Chin, Natalie M., and Jasmine Harris. “Examining How Crisis Standards of Care May Lead to Intersectional Medical Discrimination Against COVID-19 Patients.” Center for Public Representation, UC Davis School of Law, Feb. 2021, https://www.centerforpublicrep.org/wp-content/uploads/FINAL-Intersectional-Guide-Crisis-Care-PDF.pdf.

Cleveland Manchanda, Emily C., et al. “Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity amidst COVID-19.” Journal of Racial and Ethnic Health Disparities, Aug. 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425256/.

Knowles, Hannah. “Hospitals Overwhelmed by Covid Are Turning to ‘Crisis Standards of Care.’ What Does That Mean?” The Washington Post, 23 Sept. 2021, https://www.washingtonpost.com/health/2021/09/22/crisis-standards-of-care/.

Neilson, Shane. “Ableism in the Medical Profession.” Canadian Medical Association Journal, Joule Inc., 14 Apr. 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162445/.

“Section 1557 of the Patient Protection and Affordable Care Act.” Office for Civil Rights, U.S. Department of Health and Human Services (HHS), 27 Oct. 2021, https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html.

Addiction and Brain Disease: Intertwined but Not One and the Same

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by Vignesh Subramanian, October 18, 2021

Today, nearly every major medical organization in the United States defines drug addiction as a primary brain disease – a progressive, relapsing disorder driven not by choice, but rather by neural dysfunction. From patient advocacy organizations like the American Medical Association and the American Society of Addiction Medicine to top research organizations like the National Institutes of Health and the National Institute on Drug Abuse, this characterization of compulsive substance misuse is believed to effectively counter stigmatization of treatment while still accounting for biological and psychological realities. Yet if one is to evaluate other possible classifications and the present state of diagnostic protocols in fair measure, it could be reasonably asserted that a discussion is still to be had about the addict’s role in their own entrapment. The degree to which addiction may be considered a chronic illness is therefore contingent on not just the relativity of its prognosis, but also on what physicians believe to be appropriate recourse. 

The scientific tenets of addiction agreed on by psychologists, neurobiologists, and practitioners alike are key to judging the applicability of the brain disease model. Unwarranted assumptions about either the appositeness of a standard of comparison or a propensity for self-domestication can derail precedents set and determinations previously made by the discipline in question. It is fair to accept the medical discipline’s rhetoric on the need for restrictiveness in exposition, defining “chronic illness” as controllable but hitherto incurable conditions often identifiable by long periods of latency and protracted clinical course [3].

Proponents and opponents of the brain disease model also concur on the neurochemistry behind addiction. It starts with unregulated surges of the neurotransmitter dopamine in response to drug consumption occurring in the basal ganglia, the area of the brain tasked with executive functions that, among other behavior, enable learning from the ‘reward’ of brief ecstasy [5]. An affinity for a substance leading to increased use will cause neural circuits to adapt by restructuring receptors, by scaling back sensitivity to the drug’s effects – requiring more consumption to attain the same euphoric “high” – and by increasing tolerance of the substance as this subconscious demand is satisfied, completing the cycle [8]. The patient eventually develops dependence (inability to function without the substance) and dysphoria (a state of unease in the drug’s absence), fomenting cravings that prioritize reducing pain over experiencing pleasure [11]. The cycle is ultimately difficult to break, for reasons that demonstrate the true interplay of biology and behaviorism: parallel remodeling of the extended amygdala – tasked with controlling responses to stress – and the prefrontal cortex, which manages decision making, drives the user to form associations between increased consumption and decreased stress, causing inhibitory pathways to shut down as short-term reward is favored and sought after [5].

At no point in this slippery slope beyond the first ‘gateway’ use is the chemical compulsion of a drug resistible or reversible; indeed, the same reward circuits that drive addiction account for most human physiological needs, including reproductive activities [2]. In that regard, addiction is not just subconscious, but natural, solely dangerous in excess; patients of more socially sanctioned chronic illnesses – diabetes, heart disease, skin cancer – are victims of similar bet-hedging, whether it be by consumption of processed carbohydrates and meats, lack of exercise, or even sun exposure. Opponents of the brain disease model argue that the problem is initial awareness of risk: addicts must understand that intoxication is a precursor of worse to come, and addiction has a spectrum of severity, making accurate diagnosis difficult if not impossible [4]. With no physical measures of identifying mental health disorders (such as objective lab tests using biomarkers) yet deployed in medical practice, physicians must rely on neuropsychological assessments and dissociated imaging scans to compare a patient’s cognitive impairment with normal executive function and processing abilities. Such measures have found that neural changes associated with addiction matched those of “deep habits, Pavlovian learning, and prefrontal disengagement”, but did not match the “development-learning orientations” of various mental illnesses [1]. In other words, addiction stimulates synaptic pruning and neuroplasticity (the ability of neurons in the brain to change connections and reorganize) just as a conventionally developed brain does, but in atypical patterns poorly reflecting normal maturation and psychological tendencies. This information only sharpens the question of whether addiction is truly an aberration of the mind’s development or simply a collection of varying and even rectifiable effects elicited by the drug itself; to put it metaphorically, would a stabbing through the heart be considered cardiovascular illness? The concept of placing addiction on par with the likes of Alzheimer’s and Parkinson’s disease – surrounded by questions of whether all manipulated neuroplasticity is pathogenic, whether addicts can be responsible for consciously committed actions, and what even constitutes a problem with the brain – is thus far from conclusive. 

Acceptance – or lack thereof – of substance addiction as a brain disease has had and will continue to have wide-ranging implications for patient protections under law and avenues of treatment. Distinguishing between the public perceptions of users’ behavior and the intimate worldviews of addicts as shaped by their battles for recovery help sustain the idea that addiction medicine can be entirely recontextualized into being a centerpiece of public health. For example, even if addiction is not to be considered a disease of the brain, its contribution to the later development of chronic illnesses such as lung disease, stroke and HIV/AIDS makes addiction treatment itself a form of preventative medicine rather than rehabilitation alone [10]. Conversely, if classification of addiction as a brain disease remains the status quo, it might justify dependence as a ‘side effect’ of self-medication started because of lack of access to care, much the way it is for some substances with addictive potential – like selective serotonin reuptake inhibitors (SSRIs) and opiates – that are used and abused as antidepressants and for pain management, respectively [2][7]. As is clearly evident, proponents and opponents of the brain disease model ultimately do not disagree on the facts of addiction, but simply emphasize different contexts that, when taken to their conclusions, have different implications for diagnosis and stigmatization; both camps have proven willing, however, to oversee an explosion of medicalization that address those biological and psychological realities [6]. Today, trained physicians can administer pharmaceutical agonists and antagonists in clinics and other outpatient settings; the importance of psychosocial therapy, monitoring and follow-up in addiction treatment has been amplified; and the establishment of drug courts and diversion and harm reduction programs attests to the idea that drug consumption is not inherently a moral failing and that natural reactions to its effects can be less painfully anticipated and controlled [9]. 

Addiction is a convoluted condition: it has an onset influenced by environmental conditions but no infection agent, has little known pathological prognosis but a tendency to run in families, and displays outward behavioral changes but is not anatomically degenerative. A disease model that assumes partial responsibility on the part of the addict but recognizes the extent to which addiction rewires the brain is perhaps the best road on which to pursue a patient freedom-centric means of battling dependency and decay.

Works Cited

  1. Lewis, Mark. “Addiction and the Brain: Development, Not Disease.” Neuroethics, vol. 10, 2017, pp. 7–18, doi:10.1007/s12152-016-9293-4.
  2. Hammer, Rachel, et al. “Addiction: Current Criticism of the Brain Disease Paradigm.” AJOB Neuroscience Journal, vol. 4, no. 3, 2013, pp. 27–32. doi:10.1080/21507740.2013.796328.
  3. “Is Addiction a Disease?” Partnership to End Addiction, July 2020, drugfree.org/article/is-addiction-a-disease.
  4. Levy, Neil. “Addiction is not a brain disease (and it matters).” Frontiers in Psychiatry, vol. 4, no. 24, 2013. doi:10.3389/fpsyt.2013.00024.
  5. United States, Department of Health and Human Services. “The Neurobiology of Substance Use, Misuse, and Addiction.” The Surgeon General’s Report, 2016. addiction.surgeongeneral.gov/sites/default/files/chapter-2-neurobiology.pdf.
  6. NIDA. “Preventing Drug Misuse and Addiction: The Best Strategy.” National Institute on Drug Abuse, 10 July 2020, http://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/preventing-drug-misuse-addiction-best-strategy.
  7. Satel, Sally, and Scott O. Lilienfeld. “Addiction and the Brain-Disease Fallacy.” Frontiers in Psychiatry, vol. 4, no. 141, 2014. doi:10.3389/fpsyt.2013.00141.
  8. “The Science of Drug Use and Addiction: The Basics.” National Institute of Drug Abuse, 25 June 2020, http://www.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basics.
  9. Smith, David E. “The Evolution of Addiction Medicine as a Medical Specialty.” AMA Journal of Ethics, vol. 13, no. 12, 2011, pp. 900–905. doi:10.1001/virtualmentor.2011.13.12.mhst1-1112.