Wednesday, July 25, 2012

Broken Treatment: How the Addiction Industry is Failing its Clients

It’s not medical. It's not psychiatric. What is it?

1. Most clinicians who treat addicted patients are counselors, not physicians; thus they cannot prescribe medication and they generally don’t “believe” in the use of medication for addictive disorders.

2. Most patients have medical insurance that excludes or severely limits treatment of addictive disorders, so payment for service is not good. This situation may change in the near future with the advent of healthcare reform in the United States.

So writes Dr. Charles O’Brien of the University of Pennyslvania Perelman School of Medicine, in a recent article for The Dana Foundation’s website.  In his article—“If Addictions Can Be Treated, Why Aren’t They?”—Dr. O’Brien asks a basic question: “Why are most patients not even given a trial of medication in most respected treatment programs?”

Even though pharmaceutical companies have throttled back on their interest in anti-craving drugs in recent years, there are, in fact, a few medications recognized by the FDA, primarily for use in the treatment of alcoholism. But they are not much in favor, and O’Brien believes he knows why:

The answer seems to be that there is a bias among treatment professionals, perhaps passed down from past generations when addictions were not understood to be a disease. Medically trained personnel are minimally involved in the addiction treatment system and most medical schools teach very little about addiction so most physicians are unaware of effective medications or how to use them.

What is on offer at most addiction treatment facilities is not actual rehabilitation, but rather short-term detoxification. And what we’ve learned from neuroscience is that taking away the drug is only stage one. The addiction remains, the reward and memory systems still operating erratically. We understand some of this circuitry better than at any time in history, but the concrete effects of these insights at the level of the community treatment clinic have been small to nonexistent. Money, of course, is part of it, since addiction has only recently, and sporadically, gotten the attention of funding agencies in the public health community. 

Health journalist Maia Szalavitz, writing at Time Healthland concurs: “Unlike most known diseases, the treatment of addiction is not based on scientific evidence nor is it required to be provided by people with any medical education—let alone actual physicians—according to a new report.” The report in question, from Columbia University’s National Center on Addiction and Substance Abuse (CASA), notes that most people are shoehorned into a standardized approach built around the 12 Step model of Alcoholics Anonymous. “The dominance of the 12-step approach,” writes Szalavitz, “also leads to a widespread opposition to change based on medical evidence, particularly the use of medications like methadone or buprenorphine to treat opioid addictions—maintenance treatments that data have show to be most effective.”

  Szalavitz also believes she knows why, and her thinking is similar to O’Brien’s. “Other medications that are known to treat alcohol and drug addiction, such as naltrexone, are also underutilized,” she writes, “while philosophical opposition to the medicalization of care slows uptake.”

There is a straightforward reason for considering the use of medication in the treatment of addiction: strong suggestions of recognizable genetic differences between those who respond to a given medication, and those who don’t. As O’Brien explains, a prospective study now in progress will be looking to see if alcoholics with a specific opioid receptor variant show a better outcome on naltrexone than those with the standard gene for that opioid receptor. And if they do, the FDA may allow a labeling change “stating that alcoholics with this genotype can be expected to have a superior response to naltrexone.”

But that won’t be happening tomorrow. In the meantime, we are stuck with the addiction treatment industry as it is. “The [CASA] report notes that only 10% of people with substance-use problems seek help for them,” Szalavitz concludes. “Given its findings about the shortcomings of the treatment system, that’s hardly surprising.”

Photo Credit: Creative Commons


Anonymous said...

Thanks for the post. It is a pretty interesting topic. My opinion varies greatly from what I gather while reading this article. I got clean and sober with the help of a sober living that is based around the principles of 12 step programs. It may be true that medical treatments to alcohol and drug addiction play second fiddle to the various 12 step programs. I am of the belief that the physical craving for drugs and alcohol is only a symptom to a much greater problem. Using drugs like suboxone may help with the physical craving experienced by an addict but does little to attack the root of the problem. Who is to say that the addict on suboxone doesn't return to their drug of choice once reality resumes? There is a reason that the individual turned to the drug in the first place! If that reason is not addressed than there is no chance for a happy and serene life. Maybe a combination of therapy and drug detoxification would work...but 12 step programs work! They offer a great outline for living for recovering addicts and alcoholics. I don't mean to be controversial or anything it just saddens me to see people trying to put a band aid ver a very serious problem. I went to a sober living called New Life House. There I learned how to live a clean and sober life. I now live without drugs and alcohol and I am a very happy, successful person. I no longer crave drugs and I am a better person!

Tetyana said...

Great post! I think a lot of this is true for eating disorders as well (and I'm sure many other things, as well, though I don't know to what extent).

Particularly the whole notion of treatment being really a detoxification (or, a break from habit, but not really actual treatment). That is why relapse is so common - after treatment, you are back in the same situations, same triggers.

And I think there's a sense that these problems are somehow not legitimate, not neurobiological but cultural or social (which is perplexing to me.. everything that affects behaviour has a neurobiological basis). That, people can just snap out of it if they really wanted it or recover, if they really wanted it.

The 12-step program is also used to treat EDs, as I've found out recently, which I find ridiculous, but that's my own personal opinion.

There is very little evidence-based treatment for EDs.. astonishingly little. I don't know how it compares to addictions, though. But, I do feel EDs and addictions often overlap in these areas... left out and forgotten by a large portion of the medical community, unfortunately.

Maybe I'm wrong. I hope I'm wrong, but that's the sense I get.

Dirk Hanson said...

I'm not as familiar with treatment centers for eating disorder, but I'm not surprised to hear that the same problems are found there. Thanks for your comments.

Hannah F said...

I always love your insights Dirk. I'm passing this along to colleagues of mine who are preparing (as I am) to enter the addiction counseling field.

Dirk Hanson said...

Hey thanks!

Mark Kastleman said...

It just doesn't make sense to me to take drugs for an addiction of drugs. They might take the addiction of the abused drugs away, but the addiction of the prescribed medication will begin. The root of the problem, which is "addiction" doesn't get treated. Only the specific drug is treated.

Dirk Hanson said...

Medications for addiction are not necessarily addictive themselves.

Anonymous said...

Thank you for this.
My attempt to detox from synthetic cannabinoids and heavy kratom use (~.5 oz/day) was flatly rejected by my local detox facilities based on insurance. What was especially galling was the fact that they did not even offer an out-of-pocket alternative. I can afford it and would be willing to pay, but nothing. I was basically told they couldn't help me unless I was addicted to real drugs.

I guess I'll hit them up when I develop a heroin relapse. :\

Anonymous said...

This again just goes to show every person in addiction is uniques which is why each individual has their own individual treatment plan. Addiction itself is so truely unique its not medicine vs 12 steps there's so much more to recovery. I am in recovery 4 years sober and have not utilized treatment, 12 steps, or modern medicine. Each addiction is so different and has its own story and these are things that we need to remember. Modern medicine needs to work hand in hand with addiction counselors so that the person is treated as a whole. Its all about educating professionals to give an understanding of the disease itself. Without education, knowledge and understanding can cannot work together as a whole from professionals to individuals to communities to a our nation, to defeat this disease.

Jen Smith said...

I've seen a few addicted people helped through medications but I've seen many screwed up by prescribed meds and thrown deeper into the perils of the disease.

I don't judge anyone's decision or use of medication but believe it's a very scary proposition. I'm grateful to have a med free recovery of many years.

Dirk Hanson said...

I'm grateful for your recovery, too. I'm also grateful that addiction medications exist for those who need them. And their very existence helps continue to nudge treatment away from its Freudian underpinnings.

denise krochta said...

This is a very frustrating part of the addiction/recovery process for me to present to my audience on my radio show. I try to present all that is "out there" that is logical without any bias. I see a lot of controversy about the new vs the traditional treatment models as well as the "black and white" of all 12 step vs therapy, meds, and other kinds of support. To me, I think it is important for people to realize that, as with all things in life, all people are unique and one thing that works for one person doesn't necessarily work for someone else. I think it is important for people to be knowledgeable about what is available so they can have choices, not just one thing that is the standard. It is quite an evolving field, isn't it?

Dirk Hanson said...

Absolutely true, Denise. If we've learned anything, it's that there is no "one size fits all" treatment approach. Hopefully we will get better with the treatment match thing, so we can figure out, for example, who is likely to benefit from anti-craving medication.

Christina Dansby said...

Some of us still believe that there is a magic pill for every treatment, able to cure us completely. But those of use who have the courage to delve deeper into the subject, sooner or later will reach the conclusion that the cure is in themeselves, or at least that they can help their genreal condition just by changing their way of thinking.

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