Friday, December 4, 2009

Transforming Treatment for Addictions in America

On October 31, I left NIH and and returned to St. Paul-Minneapolis, MN to rejoin my family. I'd like to share what my next project is: Transforming Treatment for Addictions in America. Of course it sounds grandiose, and perhaps it is. (If so, I'm sure I'd be the last to recognize it.) However, I think that the time is right for transformative change in this field, and that given the right effort and some luck, it could actually happen very rapidly.

Here's why. First, nearly everyone agrees that the current system of care is not meeting anyone's needs very well. Many people have difficulty obtaining access to treatment. Treatment is often of low quality and effectiveness yet can be very expensive. Treatment centers are able to offer just about whatever they want, regardless of whether there is scientific research or expert consensus concerning effectiveness. For example, at licensed treatment programs around the country, you could get hypnosis, yoga, meditation, treatment with nutritional supplements (which the program sells), treatment based on brain scans, and equine therapy (riding horses). It is almost certain that the treatment recommendation will be whatever that program offers, and there seems to be no felt ethical obligation to educate consumers about alternative treatments that may have better efficacy. Programs may offer seven days of treatment or six months. Thus, consumers are often confused about how to decide about where to go and what treatment is effective.

Second, consumers do not have any meaningful choice in the type of treatment available (except for the flaky stuff.) With the exception of methadone and Suboxone maintenance, more than 90% of US treatment programs offer group counseling and referral to AA. Period. Consumers don't like our programs, thus the majority have to be coerced into treatment. I often ask people what it would take to make them walk into a rehab program tomorrow and the nearly universal answer is: I'd have to have no other choice. Unfortunately, too many providers have become complacent, not needing to provide good customer service because their clients have no choice but to comply. Most importantly, there is very little access to newer treatments that are based on solid scientific studies. Every time I have had a national media interview in the press, I have received calls and emails from patients and families: where can I find a doctor to prescribe these medications [for alcohol dependence] that you were talking about?

Third, there has been a revolution in understanding of substance use and addiction that has radically altered our view of the spectrum of substance use and associated problems. This new understanding has significant implications for configuring a system of care. We now have the knowledge and tools to offer risk reduction and individualized treatment for a much broader group of people than ever before. Most people who drink more than is medically advisable have relatively mild dependence and remain highly functional. They have a much better prognosis than the more severely affected people who enter rehab programs. They can respond to less intensive and more discreet treatment if it were made available, and the only way to do that is through the existing system of health care. In the future, most people who develop alcohol dependence will go to their primary care doctor or psychiatrist and receive medications and brief behavioral support. This is the way we treat depression now, and although it's not perfect it has made treatment more accessible, affordable and attractive. Those with severe, recurrent disorders require care that is set up to manage the addiction and the co-existing health conditions over years to decades, not weeks or months. Chronic care management by physicians, nurses, and other professionals is needed and makes more sense than expecting a few weeks of group counseling to induce permanent recovery. The prognosis is much better than most people think, but it often takes several years to finally achieve recovery.

I am in the process of forming an initiative to transform treatment for addictions in America in the next five years. It is called the ALATYR Initiative. In the coming weeks, I will be describing this in detail, and sharing our progress.

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