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How Can This Still Go on in Addiction Treatment? Some Things Never Change or Seem to Change So Slowly

It’s been more than five years since I did the research for Inside Rehab and more than 15 years since I wrote Sober for Good. And although there’s been some change for the better in the field of substance use disorder (SUD) treatment and recovery, it continues to amaze me that so many practices continue in the field that shouldn’t.

Following are just some of them:

  • We tell people with substance use disorders that they have a disease, and then continue to punish them when they “fail.”

For instance, clients are regularly kicked out of treatment and sober living facilities when they exhibit the very “symptoms” (using alcohol and other drugs) that brought them to treatment. The criminal justice system gives lip service to understanding “the disease” and co-occurring mental health problems, but dishes out punishment, often creating a revolving door of incarceration (with little or no professional help) – release, repeat behavior, and reincarceration.

Just recently a young woman with a long history of severe alcohol and mental health problems committed her first drunk-driving offense. She shared that, at her hearing, the prosecuting attorney blew off her successful pre-hearing efforts to stay sober and seek professional treatment. He laughed at her attorney’s attempts to lower her charges and said, ”Great that she did all these things, but she needs to be punished” – with a threat to increase her jail sentence above and beyond what’s customary.

In addiction historian and writer William L. White’s latest blog titled, Who Profits From Addiction/Recovery Stigma?, one of the groups he names is the “criminal justice industrial complex.”

He said: “The twentieth century stigmatization, demedicalization, and intensified criminalization of drug problems created the largest expansion of the criminal justice system in American and world history… Any suggestion that drug users deserve compassion and care rather than punishment and control threatens to transfer billions of dollars in cultural resources to other social institutions – a move that those with vested interests in the status quo must aggressively resist to protect their own personal and institutional interests.

  • “Most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat the disease, and most of those providing addiction care are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to provide the full range of effective treatments.”

The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia) issued this statement in 2012 as part of its comprehensive report on the state of U.S. addiction treatment, and I see little sign that this has changed.  The authors analyzed state and federal governments’ and professional associations’ licensing and certification requirements for treatment providers and found not only that most medical professionals are inadequately trained about addiction, but that most of the people providing addiction care are not “equipped with the knowledge, skills or credentials necessary to provide the full range of effective treatments.”

…substance use disorders are commonly accompanied by mental health disorders, and people with these problems are among the most difficult for our health and mental health care system to treat.-Anne FletcherIn examining minimum state requirements for becoming an addiction counselor, they found that most states didn’t even require a minimum of a bachelor’s degree to become credentialed. The minimum degree in many states was a high school diploma, GED, or associate’s degree. (They also have to subsequently take some addiction-related courses and have a good number of clinical hours, but again no degree is required. It’s largely an apprenticeship-type arrangement.) Six states required no degree at all.

To get a sense of whether this has changed, I checked the certification agency for addiction counselors in the state of New York, which has one of the largest numbers of drug and alcohol treatment facilities and clients in the country. It remains a state requiring only a high school diploma or GED as a minimum credential. This is hard to believe when substance use disorders are commonly accompanied by mental health disorders, and people with these problems are among the most difficult for our health and mental health care system to treat. Yet we’re placing their care in the hands of many undertrained individuals. For any other mental health problem/profession, a minimum of a master’s degree is required.

  • Although the notion of “cross addiction” – that is, that people who recover from one addiction are at particularly high risk of picking up a new addiction – has been challenged, individuals new to recovery are commonly given warnings to the contrary.

For instance, someone addicted to alcohol may be told he or she can never take a painkiller or smoke marijuana – if they do, it’s considered a relapse, a warning that can become a self-fulfilling prophecy for a person’s drug of choice. (In other words, someone who had an alcohol use disorder takes a painkiller, decides she’s relapsed, and then figures she may as well drink because she “blew it.”) Or a person in recovery may be warned about “exercise addiction” when, in fact, it’s a healthy substitution for old unhealthy behaviors. Not long ago, a large study published in JAMA Psychiatry showed that after 3 years, people who overcame a SUD were about half as likely to develop a new one as another group who did not overcome their SUD.

  • Many people don’t know that it’s not legal for the criminal justice system to require people to attend AA/NA or 12-step-based addiction treatment programs unless they’re also offered a secular alternative.

That’s because multiple federal courts of appeal ruled that the AA/NA tenets are religious in nature. Although offenders can still be court-ordered to attend support groups, secular alternatives must be offered as well. Yet offenders are regularly ordered to attend 12-step meetings without alternatives. And often there are no alternatives in a given community, so clients are ostensibly forced to go to a 12-step group unless the legal system will accept attendance at an on-line alternative meeting.

  • Few people receive evidence-based guidance when their loved ones have a substance use disorder.

Given its more than two decades of scientific backing, it’s difficult to understand how few SUD treatment facilities use or have even heard about the approach for families that has the most research support: The Community Reinforcement and Family Training or CRAFT approach. (When I visited treatment programs for Inside Rehab, only 1 of the 15 was using CRAFT.)

CRAFT has been found to be far more effective than the “psycho educational family weeks” that are popular at rehabs and than Al-Anon, the support group that many rehabs encourage family members to join. In multiple randomized controlled trials, compared to traditional interventions in which families confront a loved one, CRAFT has also been shown to be far more effective at engaging the person in treatment. The communications skills it teaches can also be helpful for people whose loved ones are in treatment.

  • Evidence-based treatment is still slow to work its way into what goes on in substance use disorder programs, and practices that go on are often not in the client’s best interest.

In a recent NY Times profile of renowned addiction psychiatrist, Mark Willenbring, MD by Gabrielle Glaser, the state of the situation was well captured with Willenbring’s quote:

“When we publish studies in our field, nobody who is running these [addiction] centers reads them. If it counters what they already know, they discount them… In the addiction world, the knee-jerk response is typically, ‘We know what to do.’ And when that doesn’t work, we blame patients if they fail.”

Despite the fact that clients often know what’s in their best interest, a loved one of mine who recently went to a renowned residential program was repeatedly told when she questioned any practices, “We’re the best in the world; we know what we’re doing. Don’t question us.” Upon arrival, she was asked what her treatment goals were, but they were nowhere to be seen on her treatment plan – in other words, her counselor apparently decided what her plan and goals would be. Yet it’s known that outcomes are better when clients are involved in decision-making and have choices.

  • Although we have multiple medications that can help people with particular SUDs, they are used far too infrequently.

The latest edition of the large national survey of drug and alcohol treatment programs that’s conducted each year (NSSATS) – which asks the vast majority of U.S. addiction treatment facilities (just over 14,000 of them) about their practices – revealed that the vast majority did not report offering any of the three FDA-approved medications for treating alcohol use disorders (AUD.)

When it comes to opioid use disorders, long-term maintenance treatment is recognized as the treatment of choice to prevent cravings and health problems and to decrease relapse and death rates.-Anne FletcherWhen it comes to opioid use disorders, long-term maintenance treatment is recognized as the treatment of choice to prevent cravings and health problems and to decrease relapse and death rates. However, data on adults with private insurance (the most common form of health care coverage in the U.S.) from the 2010 to 2014 Truven Health Analytics MarketScan® Commercial Claims and Encounters Database* show that 40 percent of patients did not receive any follow-up services within 30 days following an opioid-related hospitalization. Within 30 days of discharge for an opioid-related hospitalization, just 6.0 percent of patients received medications only, and about 43 percent received therapy only. Only about 11 percent received both medication and a therapeutic service within 30 days following hospitalization.

At a large local general medical clinic with multiple subspecialties, there is one psychiatrist who prescribes buprenorphine (Suboxone.) This doctor has been certified to do so for about 18 months and has yet to have a patient referred for this purpose. (She is limited to seeing patients only within this one clinic.) As Christine Vestal points out in an excellent Stateline article titled, “Few Doctors are Willing, Able to Prescribe Powerful Anti-Addiction Drugs,” “Most doctors with a license to prescribe buprenorphine seldom – if ever – use it.”

*The MarketScan Database captures all billed services, including prescription drugs, outpatient services, and inpatient services.
  • Although most people with drug and alcohol use disorders also have mental health problems or what’s known as co-occurring disorders, the latter are often not addressed at all or adequately at drug and alcohol programs  – even at ones that recognize themselves as “dual diagnosis.”

According to the 2013 National Survey on Drug Use and Health, fewer than 8 percent of people with co-occurring mental illness and substance use disorders received treatment for both conditions, with more than half receiving no treatment at all.  (Several years earlier, the figures were the same.)

With serious mental illness, about 13 percent received both types of care. But that doesn’t mean the care was integrated – that is, assistance for both conditions in one setting, during the course of the same treatment episode, and by the same team of clinicians. This kind of care is associated with lower costs, reduced substance use, increased abstinence odds, improved psychiatric symptoms, and better quality of life.

In short, we still have a long way to go to get substance use disorder treatment on par with that of other health conditions.

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