It is not the stuff that medical students' dreams are made of, an area of medicine in which there is little glamor, few dramatic interventions, and, by definition, no cures. Yet the management of chronic disease will increasingly and relentlessly consume more of the health care system's time and resources. Worldwide, the number of people with chronic diseases is growing as the population ages. The evidence suggests that chronic diseases are managed poorly, which is a shame as patients miss out on effective drug treatments and they and their caregivers are denied psychological and social support. This issue is devoted to the many issues used by chronic diseases.
In an Op-Ed on p 76, John Roberts points out that there are 90 million Americans with chronic diseases who spend more than 60% of the country's health budget. Could he, as a physician do more good, he wonders, by setting up community weight loss programs instead of prescribing antihypertensive drugs? In their Op-Ed on p 78, George A Bray and Jennie Macdiarmid echo the call for more preventative measures against chronic disease. There are at least 250 million people who are obese world-wide, yet many countries do not classify obesity as a chronic disease, although it is a major risk factor for diabetes mellitus, gallbladder disease, coronary heart disease, and some forms of cancer. An international obesity management strategy is needed, the authors argue, to provide national guidelines and public education programs.
Many patients with chronic diseases suffer pain, often as a result of peripheral tissue or nerve damage. According to guidelines from the AMA's Council on Scientific Affairs, a subgroup of patients with noncancer pain may benefit from the long-term use of opioids. The risk of drug misuse by patients is small but doctors are still frightened to prescribe opioids for noncancer patients (and even those with cancer) in case of criticism or even legal sanctions. There is, however, insufficient evidence to indicate exactly which patients are most likely to benefit.
The evidence is also scanty for the treatment of chronic prostatitis, a condition that affects about 9% of men at any one time (p 98). Symptoms include lower back or perineal pain and can be severely debilitating. Yet the evidence for well established treatments, such as antibiotics, alpha blockers, and transurethral resection, is inconclusive; few randomized controlled studies have been done. The treatment of back pain can now be supported by research evidence, but typically physicians are slow to change their practice (p 121). Although good evidence shows that bed rest does not improve outcome but that exercise does, physicians are reluctant to suggest the latter, perhaps because it sounds less sympathetic.
Dementia is one of the most cruel of the chronic diseases and for all the recent advances in drug treatment, there is no cure. On p 115, Ruth O'Hara and colleagues review recent findings on Alzheimer's disease and discuss treatment options. There are 4 million people in the US with dementia, a disease that lasts about 7 to 10 years and devastates individuals and families. Research efforts are directed at looking at attacking the amount of β amyloid and understanding the genetic background of the disease. As with many chronic diseases, there are likely to be other, psychosocial risk factors.
The very definition of a chronic disease is a social phenomenon. On p 130, Jean Scandlyn explains the differences between acute and chronic disease and says that while AIDS is now a chronic disease in the Western world where resources are available for drug therapy, it remains an acute disease in the developing world where such treatments are unaffordable. One of the side effects of having a chronic disease is that it carries a stigma: reactions from strangers to a person who is HIV positive are unpredictable. As Scandlyn says, “In some respects the uncertainty of chronic illness is as difficult to live with as the knowledge that you will soon die.”
Laurice M Compagno seems to have turned that uncertainty into a positive force in her life. On p 138, she talks about how thalassemia has shaped her personality, making her determined and giving her the desire to be the “best person that I can be.” Her family has understandably been stressed by her illness, but one of the major stressors has been the insurance companies, who almost stopped her attending graduate school because her HMO would not cover her treatment if she studied out of state. Compagno argues that physicians alone cannot manage thalassemia. Like all chronic diseases, it needs a multidisciplinary team approach to improve the quality of life for patients and their families.