Friday, December 4, 2009

What's Needed to Transform the Treatment System?


Today I heard a presentation by Tom McLellan, PhD, the Deputy Director of ONDCP, outlining the priorities of the Obama administration concerning “demand reduction,” i.e. prevention and treatment. Dr. McLellan and those he works with are to be commended for developing a thoughtful and comprehensive approach. You can read more about it here: http://www.whitehousedrugpolicy.gov/policy/demand_iwg.html

At the same time, I have some concerns about their approach. My overarching concern is that it may not fundamentally alter the care system in the country but instead attempt to incrementally improve the existing one. I think the existing one, based on a now outmoded idea, is so flawed that it cannot be sufficiently improved. Instead, we need to move in a more transformative way, offering a completely new way of thinking about and treating substance use disorders.

One particular concern is that their approach seems unlikely to close the largest treatment gap there is: the people lying between at-risk users (the target of SBIRT) and people with severe, chronic or recurring dependence (the target of traditional treatment programs.) Between lie all the people with mild to moderate dependence who remain highly functional even though they are concerned and are struggling with their use. They primarily have symptoms of compulsive use: using larger amounts and for longer times, persistent desire to quit/down and being unable to do so, and using despite psychological or physical symptoms caused/exacerbated by use, such as hangover or insomnia. Serious functional impairment only occurs in a relatively small minority of users. For this group, addiction is seldom a chronic disease. This is demonstrably so for alcohol dependence. I suspect the same is true for other substances (especially cannabis) but the proportions may vary (there may be fewer functional cocaine, meth or opioid users relative to functionally impaired addicts.) These functional dependent persons are the people who “do not perceive a need for treatment.” I strongly believe, however, that there is an interaction between perceived need for treatment and what that treatment is or is perceived to be. Don’t you think if treatment for alcohol dependence meant going to your primary care doctor or psychiatrist and receiving a medication and brief behavioral support that it would change perceptions about “need” for treatment?

The only way I can see to offer this group attractive, accessible, affordable care is through existing healthcare and mental healthcare systems. In ONDCP’s approach, treatment still seemed to be something that occurs in special places and that is done by special people (i.e., in rehab or opioid treatment programs.)

Finally, we need a robust medical addiction specialty sector to make any of this happen, and we need to define and disseminate a model of medical/psychiatric treatment for addiction. (By “medical” I mean a biopsychosocial approach, not just medication.) For example, most treatment for depression is done by non-psychiatrists, but I think that few doctors would try to treat depression if they didn’t have a psychiatrist to refer the difficult cases. Similarly, I think it is essential that there be sufficient, well-trained addiction psychiatry and addiction medicine physicians available to provide the chronic care management for complex, chronic disorders.

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