Addiction Rehab: Everything is Broken

Down the rabbit hole in search of effective treatment.

When I first began researching drugs and addiction years ago, a Seattle doctor told me something memorable. “It’s as if you had cancer,” she said, “and your doctor’s sole method of treatment consisted of putting you in a weekly self-help group.”

I’ve got nothing against weekly self-help groups, to be sure. But as Ivan Oransky, executive editor of Reuters Health and a blogger at Retraction Watch, told me as recently as least year, addiction treatment appeared to be “all selling and self-diagnosis. They’re selling you on the fact that you need to be treated.”

In his introduction to Inside Rehab by Anne M. Fletcher (pictured), treatment specialist and former deputy drug czar A. Thomas McLellan writes that the book is “filled with disturbing accounts of seriously addicted people getting very limited care at exhaustive costs and with uncertain results...”

A common notion about addiction treatment facilities, or rehabs, is they are commonly called, is that they are staffed by professional social workers, certified counselors, and family psychologists, as well as addiction specialists. However: “Of the twenty-one states that specify minimum educational requirements for program or clinical directors of rehabs, only eight require a master’s degree and just six require credentialing as an addiction counselor,” writes Fletcher. Neuroscience journalist Maia Szalavitz, who writes for Time Healthland and specializes in addiction and rehab, told Fletcher that “the addiction field has been about as effectively regulated as banking before the economic crisis in many states.” According to Tom McLellan, counselor and director turnover in addiction treatment programs is “higher than in fast-food restaurants.”

In the United States, where for-profit treatment is prevalent, money does not buy access to superior treatment. Fletcher, author of several self-help books on weight loss and alcoholism, doggedly documents what she learns from visiting treatment facilities and interviewing current and former staff and clients. One difficulty with a book of this kind, based primarily on first-hand accounts, is that the same treatment program can offer vastly contrasting experiences from one client to another. And Fletcher, no fan of the 12 Steps, wants AA and NA to account for themselves in a way those volunteer institutions were never designed to accomplish.

But let’s just say it: Addiction treatment in America is a disaster. Addicts get better despite the treatment industry as often as they get better because of it. How did it all go wrong? Part of the answer is that addiction, like depression, tuberculosis, and other chronic conditions, is a segregated illness, as McLellan explains in his introduction. Traditionally, chronic conditions like alcoholism “were not recognized as medical illnesses, and have only recently been taught in most medical schools and treated by physicians. They were seen as ‘lifestyle problems’ and care was typically provided by concerned, committed individuals or institutions not well connected to mainstream health care.”

For treatment of alcoholism and drug addiction, the work has historically fallen to addicts themselves, due to discrimination, segregation, and stigmatization. This prevailing condition is still seen today in many group treatment programs, which are often administered in large part by former addicts with little or no formal training, rather than medical or psychological professionals. Addiction, as the author’s husband wryly remarked, “is the only disease for which having it makes you an expert.”

Which brings up a central point: Where are all the M.D.s? Doctors aren’t helping, either, when they fail to screen for risky drinking or drug use, or when they automatically refer addicts rather than treating them.

If Christopher Kennedy Lawford’s new book, Recover to Live, is the pretty picture, then Fletcher’s Inside Rehab is the gritty picture, in which most addicts who recover don’t go to treatment, 28 days is not long enough to accomplish anything but detox, group counseling is not always the best way to treat addiction, the 12 Steps are not always essential to recovery, specialty drugs are often needed to treat drug addiction, and, perhaps the most troubling of all, most addiction programs do not offer state-of-the-art approaches to treatment that have been shown to be effective in scientific studies.

What clients get, for the most part, is “group, group, and more group,” Fletcher writes. And in many cases of residential or outpatient rehab, “the clients did most of the therapy.” The scientific evidence suggests that some addicts do better with an emphasis on individual counseling, rather than the constant reliance on group work that traditional rehabs have to offer. As one counselor put it: “If I made an appointment to see a therapist because I was depressed, would I be told I have to do a program with everyone else?”

Monthly residential treatment can easily cost $25,000 or more. But public, government funded rehab centers, which presumably have less incentive to treat clients like money, are frequently full. And since these programs run the bulk of prison-related treatment in this country, addicts often stand a better chance of getting into these less expensive programs if they commit a crime.

Even if you manage to get in, rehab rules all too often seem arbitrary and punitive: Recreational reading materials, musical instruments, cell phones, and computers are frequently not permitted. And there is a strong tendency to insist that use equals abuse in every circumstance. Rehab management—the business of what happens after formal treatment ends—is largely neglected in the treatment sphere.

Fletcher rails against the disease model, but mostly in response to how she believes this concept is presented by AA/NA. Like other critics, she dwells on the idea that the disease tag serves as a crutch and an excuse, rather than as an extremely empowering notion for many addicts. In fact, the disease model, as addiction scientists understand it, is seriously underrepresented in the treatment field. Too many mental health professionals continue to insist that “all you need to do is get to the bottom of the problem and the need to use substances to cope, will dissipate,” said an M.D. specializing in addiction. “However, there is absolutely no evidence that this approach works for people who are addicted to alcohol or drugs… The primary-secondary issue is moot and an artifact of the bifurcation of the treatment delivery system.”

A significant number of rehabs still oppose medication-assisted treatment, Fletcher makes clear. Hazelden made news recently for dropping its long-standing opposition to buprenorphrine as a maintenance drug for opiate addicts during treatment. Richard Saitz of Boston University’s School of Medicine says in the book that if addiction were viewed like other health problems, “patients addicted to opioids who are not offered the opportunity to be on maintenance medications would sue their providers and win.”

According to Dr. Mark Willenbring, former director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA): “No one wants to say, ‘Treatment as we’ve been doing it probably isn’t as effective as we thought, and we need more basic research to really come up with new tools. In the meantime let’s do what we can to help suffering people in the most cost effective way and strive to not harm them.’”