By Christopher Kennedy Lawford
August 29, 2012
It shouldn’t be much of a surprise to anyone in recovery from addiction that our nation’s treatment programs could use a lot of upgrading. If you’ve been through the addiction ringer, as I have, you’ve probably glimpsed if not experienced the good, the bad and the ugly of treatment facilities and what they have to offer.
So it was with a mixture of relief and trepidation that I greeted the release of a major 5-year national study titled, “Addiction Medicine: Closing the Gap between Science and Practice,” examining whether treatment has been effective or not.
My relief came from knowing the source of this study—the National Center on Addiction and Substance Abuse at Columbia University, founded in 1992 by Joseph A. Califano, the former U.S. Secretary of Health, Education and Welfare. I’ve known Joe for many years and I have nothing but the highest respect for him and the research institute that he created.
My concerns about this or any generic study of addiction treatment effectiveness revolves around the nature of the disease and the treatment industry, and the diverse methods and standards used. Is it possible to produce a practical set of findings about effectiveness that take into account all of the various approaches to treating alcohol and drug abuse? Let’s consider some of the highlights in this huge 587-page report:
() “Addiction treatment facilities and programs are not adequately regulated or held accountable for providing treatment consistent with medical standards and proven treatment practices.” That is certainly a sweeping declaration, but the study backs it up with a survey of the states that found a widely uneven terrain for treatment standards: 14 states with no licensing or certification for addiction counselors, 14 states requiring only a high school diploma to treat addiction, etc. In other words, depending on the state where you live, you may or may not receive adequate care from qualified personnel for your substance problem.
() “Only about 1 in 10 people who need treatment for addiction involving alcohol or other drugs receive it. Of those who do receive treatment, most do not receive anything that approximates evidence-based care.” What is evidence-based care? It’s a test of a method’s effectiveness in treating alcohol or drug dependency by using peer-reviewed studies published in science journals. Usually the findings of one study have been replicated many times by subsequent studies. A good example is Cognitive Behavioral Therapy, a process that has been repeatedly tested and found to be useful in treatment. Many other methods that are used and touted by some treatment facilities fail the evidence-based standard for assessing value.
A friend of mine and an expert in the field, Alexandre B. Laudet, Ph.D., Director of the Center for the Study of Addictions and Recovery in New York, made an important point that was largely overlooked in the study: “There is a ‘denial gap’ whereby the vast majority of folks not getting treatment are not seeking it because they don’t feel they need help. While it’s true that 90% of people who need help don’t get it in a given year, it’s not because treatment isn’t available, or because the treatment is necessarily bad. It’s probably because we as a society have done a very poor job at making ‘recovery’ attractive. Society continues to treat addiction like a crime or a moral failing, rather than as a chronic brain disease.”
Another major finding of the study confirmed something that was already clear to me and many others in the recovery field. Doctors may routinely screen their patients for such things as high blood pressure, but “they rarely screen for risky substance use or signs of addiction.” Instead, physicians usually stay fixated on the long list of health problems that result from addiction, ranging from accidents to heart disease and cancer. About 95 cents of every health dollar spent by government at all levels (around $468 billion annually spent on addiction and risky substance use behaviors) goes to pay for the consequences of addiction and only 2 cents go to prevention and treatment. This myopic attention span represents a lost opportunity for the medical field to erect a first line of detection to get at the root causes of what overburdens our health care delivery system and raises health care costs.
President Obama’s Affordable Care Act will help to remedy this situation by enlisting the medical system, via physician contact with patients, as a front line addiction detection screen.
Taken together, this report competently identifies the major gaps in addiction treatment and points to a series of public policy proposals for reforming how the system treats America’s most neglected and misunderstood disease. This means we have a monumental education campaign ahead of us.
That campaign in the public realm needs to start with changing citizen attitudes about the causes of addiction and how to treat it. We must show there is a brain disease cause while emphasizing the need for personal accountability in seeking treatment, It will take time, but we can close the gap between what science now knows about addiction and what the public thinks it knows.