My Wish List for Substance Use Disorder Treatment

One of my favorite blogs is ConscienHealth by Ted Kyle, R.Ph., M.B.A. – a former pharmaceutical company executive who now works with experts and organizations to advance evidence-based prevention and treatment approaches to health and obesity. Not only is the blog fascinating as it keeps me up-to-date about obesity and weight management – my field of early training and clinical work, as well as the topic to which five of my books are devoted – but it’s striking how often his insights concerning weight-related issues ring true for substance use disorders.

Consider his “Obesity Wish List for 2015,” which includes better access to care (because we consistently deny individuals such access, despite the arsenal of treatments and clinicians available); evidence-based prevention (greatly needed because obesity is so resistant to treatment and we need rigorous evidence for prevention interventions that work); genuine, competitive innovation to cure obesity (while small weight losses help, Kyle argues that we’ve got to deal with obesity “with the same vigor applied to pursuing cancer 40 years ago”; and no more shaming of overweight people (although increasingly recognized, the counterproductive “shame and blame” response to obesity is still very present.)

When I read Kyle’s list, I thought, “This sounds just like what I’d wish for when it comes to substance use disorders.” It then brought to mind a list of “greatest concerns about substance use disorder (SUD) treatment” I started soon after Inside Rehab was published. So taking Kyle’s lead, I decided to turn these around, to come up with the following personal 2015 wish list for the treatment of substance use disorders (SUDs):

• Better disseminate and apply approaches shown to be effective, at the same time relying less on ineffective approaches.

Most addiction treatment facilities say they are using evidence-based treatment – and they are to some extent. However, studies suggest that most programs use such approaches minimally. It’s time to lay off the educational films and lectures such as 12-step lectures and ones reminding people of how alcohol and drugs have “hijacked” their brains. Programs also need to step up to the plate when it comes to using addiction medications…-Anne FletcherDozens of studies show they’re ineffective for addiction treatment. Clients would benefit more from learning skills to move forward in building productive lives, reconstructing their thinking, and working on relationships and interpersonal skills. Programs also need to step up to the plate when it comes to using addiction medications – only a small percentage offer any of the three FDA-approved medications for treating alcohol use disorders. (See “What Medications Can Help You Get Sober?”) My next article will address rehabs’ failure to use medications for opioid addiction, which are among the best tools we have to help people maintain recovery.

• Provide care that’s truly individualized – based on the client’s input, personal choices, past experiences, connection with counselors (therapeutic alliance), and multiple needs (not just addiction); collaboration with previous and current providers; and family communication (if the client feels comfortable with that.)

Websites for treatment programs usually say their care is geared to the individual, but I repeatedly heard about “cookie cutter” approaches. That meant worksheets that were the same for everyone, 12-step emphasis for all (even though most people fail to attend meetings over time), repetitive treatment for individuals returning to care when their SUDs reoccurred, limited input from clients (even though they often have wisdom about their needs), and hours upon hours of group treatment (with very little one-on-one therapy) – even when paying upwards of thirty thousand dollars a month for rehab.

• Offer evidence-based skills for significant others to help them facilitate treatment for loved ones with SUDs, communicate in more effective ways, set boundaries, and care for themselves.

Although the scientifically supported Community and Reinforcement Approach (CRAFT) has been available for decades, very few treatment facilities use it. Rather than the traditional approach of telling loved ones to go to Al-Anon, that you can’t change another person, and that you need to “detach with love,” CRAFT teaches people how to take steps to move loved ones toward treatment, reinforce sobriety, communication skills that help bring about behavior change in loved ones with SUDs, and ways to enhance their own happiness. The approaches are now well described in two books, Get Your Loved One Sober and Beyond Addiction: How Science and Kindness Can Help People Change.

• Address the needs of the far greater number of people with substance problems that are not “severe.”

Considering alcohol problems, only 1 percent of adults have a chronic or recurrent and severe alcohol use disorder in any one year, while another 4 percent of adults have an alcohol use disorder that’s in the “mild” to “moderate” category. Yet another 25 percent of adults in any given year meet guidelines for being “at-risk” drinkers who are at risk for developing an alcohol use disorder. (“At-risk” drinking for a woman is considered having more than three drinks on any day or more than seven drinks per week; for a man, it’s considered no more than four drinks per day or fourteen drinks per week.)

We need more health care professionals (who need not be addiction experts) trained in a relatively simple science-based approach called ‘brief intervention’ to help at-risk drinkers.-Anne Fletcher

Most addiction treatment programs and support groups (such as AA) are designed to meet the needs of people with severe SUDs, and individuals in the other categories often feel they have no place to turn. We need more health care professionals (who need not be addiction experts) trained in a relatively simple science-based approach called “brief intervention” to help at-risk drinkers. (The Institute for Research, Education, and Training in Addictions [IRETA] is a great resource regarding such approaches.) And individuals with mild to moderate alcohol problems can often benefit from seeking one-on-one help from a mental health professional, psychiatrist, or other physician who has expertise in treating SUDs.

• Provide integrated treatment for people with co-occurring substance use and mental health disorders.

Research suggests that the most effective way to treat people with both kinds of problems is through integrated services – that is, services that provide mental health and substance use disorder services at the same time – with both of them seen as “primary,” with one or more clinicians or a team that has expertise with both disorders, and in one setting. It’s time to stop making a priori decisions about the need to “treat the addiction as primary,” as I found to be the case at some rehabs as I did the research for my book. Institute of Medicine recommendations for implementing quality care for individuals with co-occurring disorders clearly state that all types of disorders should be treated as “primary” and that “no program, patient, type of disorder, or approach to treatment is considered more important than others.”

When a program touts itself as ‘co-occurring’ or ‘dual diagnosis,’ consumers have a right and a need to know exactly what that means and what care clients will be getting.-Anne Fletcher

When a program touts itself as “co-occurring” or “dual diagnosis,” consumers have a right and a need to know exactly what that means and what care clients will be getting. Unfortunately, these terms tell people nothing, according to Dartmouth Medical School’s Mark McGovern, Ph.D., a psychologist and leading expert on co-occurring disorders who is spearheading a national effort to improve care for people with both SUDs and mental disorders. He said, “We really don’t know what programs mean when they call themselves this… There’s a disconnect between what programs say they provide and what clients report happening when they receive treatment.” (See here for more about Dr. McGovern’s interests, and Inside Rehab’s chapter, “When It’s Not ‘Just’ a Drug or Alcohol Problem” provides a great deal of information about how to find care for people with co-occurring disorders.)

• When an SUD is severe, treat it the same way we treat other chronic disorders such as diabetes, perhaps for a lifetime, recognizing that severity of symptoms typically waxes and wanes and that treatment intensity needs to be stepped up or stepped down accordingly.

This includes moving away from time-limited treatment periods to ones that are individualized according to client need, ideally with no end dates and with opportunities to remain involved with providers for whatever amount of time they need. They should not be required join a “program” that requires having to start all over again and need to be able to have continuity with providers who helped them in the past. Finally, treatment providers need to communicate with one another – a problem in traditional medical settings as well as substance use disorder and mental health settings. SUD treatment providers can best do their jobs and clients’ best interests are served when communication and collaboration occurs among clients’ mental health professionals, primary care physicians, social services agencies, and from one level of addiction treatment to the next – for instance as clients transition from residential to outpatient settings and then become integrated in home communities.

I’m well aware that each one of these wishes is a tall order. Many of the experts I’ve gotten to know during the ten years I’ve been researching, writing, and now working in this field have dedicated their careers and campaigning for decades to bring about such changes, yet we still have a long way to go. One can wish, can’t she?

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