Wednesday, February 10, 2010

The future of addiction treatment

I'm just back from ICTAB, the International Conference on Treatment of Addictive Behaviors, held each year in Santa Fe, NM. Established by Bill Miller, this is the 12th annual conference. As you might expect, the participants are devotees or at admirers of Motivational Interviewing, the set of techniques that Dr. Miller and colleagues developed at the University of New Mexico. Dr. Miller has retired (although he was at the meeting and very present) and now Barbara McCrady, PhD, is the Director of the Center for Alcoholism, Substance Abuse and Addiction (CASAA) at UNM. Terri Moyers, PhD, was the organizer for the conference, held at the ElDorado Hotel. 

I found many kindred spirits there, professionals who had been working for years to provide scientifically based treatment for addictions. Treatment that provided highly professional, individualized treatment in an environment of respect, confidentiality and consumer choice. But so far, there's been nothing to bring them together to advocate for a comprehensive, accessible and affordable alternative to existing rehab programs. There were many senior scientists there as well. People who had been working for decades to improve the outcome of addiction treatment, to understand the basis of it, and to justify the expense of treatment. And they were excited too. They have seen their hard-won research findings sit on the shelf, not being implemented by treatment programs, not available to consumers. 

More than ever, this meeting energized me and strengthened my commitment to change the way we do business in the treatment of substance use conditions. I really think the time is ripe for change. And I am beginning to understand the power of people coming together in a common goal. There is a groundswell building that includes scientists, treatment professionals, payers, health care organizations, county, state and federal health care organizations, employers, family members, and most of all, people suffering from addiction, who desperately want access to new therapies and approaches, flexibility, professionalism, and better outcomes. I don't know a single person who believes the current system of care serves anyone very well. The time for change is now.

A caveat: sometimes, in my enthusiasm for change, I may be perceived as putting down addiction counselors and others who are currently providing treatment, or as saying that current treatments are ineffective. I know how dedicated treatment providers are, and how much they want their clients to respond and have better lives. But most are working within a framework that is 50 years old and that does not incorporate current scientific understanding of addiction and its treatment. Change may be disruptive for some providers, especially those who have been working in the field the longest. There must be sensitivity to those concerns. But we also cannot let those concerns override the need to provide the best treatment, grounded in science, to people who need it. I think there are ways to make the transition work.

I also agree that there are several approaches to behavioral treatment that are approximately equally effective if delivered skillfully. I use them myself and have experienced how helpful they are to me (helping to provide care) and to my patients and families. My concern is that those treatments, delivered individually by skillful, well-trained therapists (as is the case in the studies) are not available to most people. And, most current rehab programs don't offer that quality of therapy. The studies published by Tom McLellan, currently Deputy Director for Demand Reduction at the White House Office of Drug Control Policy (ONDCP) found that more than 90% of rehab programs in the US offer group counseling and AA, and nothing else. Together the research budgets for the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) amount to almost $2B per year. It's time the American taxpayer had access to the fruits of this investment.

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