Tuesday, February 19, 2013

What's Wrong With Addiction Treatment in America?

Since Jane Brody quoted me in her column in the New York Times, I've been inundated with calls, emails and other inquiries. Here are some themes, impressions and stories that help illustrate the gaps and barriers to receiving up to date, consumer-friendly, addiction treatment.

1. "He's been through treatment program after treatment program. None of them worked! And we still don't really feel he's had a good evaluation or any continuity of treatment."

This has been a very consistent experience reported by families of someone with an addictive disorder. There is a profound sense of being out there alone, in sharp contrast to having a relative with colon cancer. There is a great sense of fragmentation of care, as well as inconsistent opinions and recommendations. Because "programs" are arbitrarily time-limited, they have no ongoing responsibility of the care of their patients, unlike other medical specialities. How would you like it if your oncologist only saw you for 8 weeks, and then treatment ended? And once "the program" has ended, there is no care, no one to help you manage an out-of-control situation. And it's worse when "the program" is in a distant location. What is learned in an artificial, low-stress environment and now access to alcohol or drugs does not translate well when you get back home. The stacks of bills, the crying baby, the leaking roof, and the liquor store around the corner make it pretty difficult. Addiction is best treated like other disorders, with people living in their own communities, learning how to stay sober there, with everything that's going on.

2. "I (or my loved one) is in (or about to begin) a treatment program for drug X. But they don't seem to have the kind of treatments you talk about. Where can I get that kind of treatment?"

Many people I talk to are trying to figure out what type of treatment or treatment facility is going to be best for their particular problem. And they don't know where to get reliable information. Much of the information, practices and pronouncements are not supported by scientific studies, but that doesn't stop treatment programs from asserting them anyway. So the marketplace is confusing, not unlike walking through a market with each vendor hawking her wares. Testimonials and outrageous claims abound! Literally fantastic outcomes are assured! That's right! Step right up and submit your payment now! You won't be sorry! We promised 100% success if you do exactly as we tell you and you really want to succeed!

(So if you fail... well...it's your fault. Sorry.)

We need an ethic of professionalism in addiction treatment that at least reduces that type of selling of services. We need to embrace an ethic of adhering to scientific findings, and changing our beliefs when the facts change. We need to foster the humility to care, even though our treatments are only partially effective, and in some cases totally ineffective. We can't abandon our patients because we cannot change the course of their illness. Do you really think they want to die? They don't! But they and we are helpless in the face of their brain dysregulation. As is true with so many human ailments: cancer, heart disease, stroke, diabetes, depression, arthritis, multiple sclerosis. As our understanding of these diseases advances, through scientific research, our tools for preventing and treating them will improve. But it will cost a lot and take a long time. But our only hope is to support it. Research on addictions and their treatment.


  1. I couldn't agree with you more. The time issue is one which is of particular interest. I find some who would benefit from relatively short interventions to combat their substance abuse being forced into long-term programs, and those who have been addicted for years being promised a "cure" in 21 days. Neither makes any sense.

    It also leads to inconclusive evidence regarding out-comes. I find many patients do well with highly structured and manualised CBT programs in the short to medium term, but require a more individual psychodynamic approach to cope long-term. If we are not engaged with our patients for the long-term, how are we able to gauge the course of disease?

    I also believe your comment about community based "real world" interventions is very valid. There are some who benefit from inpatient in a protected setting, but this is not an end in itself, and treatment should continue once the patient has returned to their (usually sick) system.

    "We need to foster the humility to care, even though our treatments are only partially effective, and in some cases totally ineffective. We can't abandon our patients because we cannot change the course of their illness." - that has to be my quote of the month. Brilliantly said, sir.

  2. This has been an ongoing issue for more than 30 years now. In 1980 Bill Miller and I published a then comprehensive review of the treatment outcome literature for alcohol problems. Back then we found a substantial disconnect between what works based on research and what was being done in treatment. This continues to this day.

    Tom McLellan has written extensively on how the substance abuse treatment system is broken in the U.S. When it comes to healthcare, substance abuse treatment providers are the least well trained, most poorly educated, are paid the lowest of healthcare providers and have the highest rate of turnover, 50% annually.

    This picture is improving but slowly. The coming integration of behavioral health in primary care that is starting to happen promises real improvement in how clients are screened for and referred to more effective treatments. Including brief, focused treatments that are provided by the behavioral health specialists in primary care themselves.

  3. One of the stupidest actions I have seen taken by many treatment facilities is to discharge someone from treatment for the mere relapse in the drug of the patient’s choice, after all that is the reason that they do come for treatment, trying to stop such behavior.

    Treatment facilities have justified their behavior from "the patient obviously has not reach bottom yet", "the patient is not motivated enough", and a long list of other rational for which they have never done any scientific studies... When they have nothing to base it on they can conjure anything they want to justify their authority.

    This discharge of patients from treatment because 3 month down in treatment the patient relapse, I see it kin to being a schizophrenic and "what,... you are hallucinating? OUT OF THE HOSPITAL".... What about a cancer patient, if they get worse the doctors kick them out of treatment, the hospital, the hospice they have gone to have a dignifying death?

    Isn't this patient abandonement? a very questionlable code of ethics violation.

    While the federal government attempts to encourage patients to stay in treatment, facilities do their best to work against patients well being and

    In essense most treatment facilities are harm producers and not about health and medical treatment.


Comments are welcome.