One Thing Obamacare Can’t Fix: Bad Addiction Treatment

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Correction appended, March 26, 2014.

After weeks spent offering up increasingly desperate excuses for the glitchy rollout of Obamacare’s insurance exchanges, Health and Human Services Secretary Kathleen Sebelius seemed elated to change the subject, at least for a moment, when last week she announced regulations that will mean that almost all Americans with health insurance will be fully covered for the treatment of mental illness, including addiction, at least as well as they’re covered for physical diseases. The regulations were trumpeted as part of the President’s plans for curbing gun violence, but they have enormous implications for untreated addiction, which alone costs the nation $420 billion a year, mostly in health care, criminal justice and lost productivity.

(MORE: Viewpoint: We Need to Rethink Rehab)

The new rules are comprehensive, but it’s impossible to know how they’ll be interpreted, monitored and policed. Treating mental illness isn’t easy or cheap, and treating addiction can be even more complex. Research has shown that addicts who drop out of treatment before 90 days have relapse rates similar to those who stay in treatment only a day or two. After 90 days, however, relapse rates drop steadily the longer they stay in treatment. Few physical illnesses require three-plus months in the hospital. Even after a long stint in an inpatient or outpatient program, most addicts require aftercare that may continue for one to many years. Will insurance now pay for those who need long-term stays in sober-living houses or outpatient programs? What if they relapse, which is common for sufferers of this chronic illness? Will insurance pay for another three-month stint? And another? Will they cover addiction medications like methadone or buprenorphine, even though some patients must stay on them for years or even a lifetime (just as some must stay on blood-pressure medication or insulin throughout their lives)?

Those in the addiction-treatment field as well as addicts and their families know well that these rules are long overdue. Three hundred and fifty people die every day because they never got the addiction treatment they needed. Drug abuse kills more Americans than any other nonnatural cause. But even full insurance coverage can’t pay for good treatment — if it doesn’t exist.

According to Thomas McLellen, a psychologist and professor of psychiatry at the University of Pennsylvania and founder and Executive Director of the Treatment Research Institute, 90% who enter addiction-treatment programs in the U.S. don’t receive evidence-based treatment. Instead, they mostly get “treatments” rooted in the view that addicts are weak, narcissistic and iniquitous, and therefore, if ever they’ll stop their destructive and self-destructive behavior, they must pray, atone for their sins and accept that they’re powerless over their addiction — hardly a medical approach to treating disease. Many current programs actually reject scientific evidence. For example, they prohibit the use of addiction medications, even though they’ve been shown to be more effective treating some addictions (specifically, the range of opiates like Oxycontin to heroin) than anything else.

Not only do few programs offer treatments that work, but many have no qualified staff. Seriously ill patients may never see an M.D. As a result of the abysmal system, only 1 in 10 addicts ever gets any treatment whatsoever. Of those who do, few get well. After treatment, when addicts relapse — even when they relapse and die — they’re blamed. They (or their surviving family members) are told that they were too weak, weren’t committed enough to staying sober or didn’t pray hard enough, when in fact, they never received proper care.

(MORE: Make the Next Drug Czar a Doctor)

As important as it is that insurance fully covers addiction care, the money will be wasted if the treatment system isn’t rebuilt from scratch. What will it require? Scientists have identified best practices to treat addiction — a menu of behavioral, pharmacological and psychological treatments. Insurance plans must only pay for programs that offer them. These treatments must be practiced by experts trained in addiction medicine. In addition, practitioners and programs must be monitored and their licenses and accreditations periodically reviewed — just as doctors and hospitals are. There must be full accountability. If there is, programs will either adapt and offer evidence-based treatment practiced by qualified professionals, or they’ll go out of business. Only then will Sebelius’ regulations do what they’re intended to do: lower crime and heath care costs, increase productivity and save lives.

Correction: The original version of this story contained an incorrect citation for the assertion that 90% of those who enter addiction-treatment programs in the U.S. don’t receive evidence-based treatment. That estimate is from Thomas McLellen, a psychologist and professor of psychiatry at the University of Pennsylvania and founder and Executive Director of the Treatment Research Institute.

11 comments
JenniferBonin
JenniferBonin

I had to cringe a bit at this article.  Yes, I firmly agree that evidence-based medicine is needed to help treat addiction.  And yes, absolutely, there's a lot of hooey out there today, run by well-meaning people who sincerely believe that one can "pray" or "talk" the problem away without any messy medications or doctors' visits.  I suppose it's possible that that helps some, but I can't help but think that an intermediate response, between the "medicine only" of this article and "pray/talk only" that the article so clearly derides, is most likely to help more people.

The fact is, modern medicine CAN help.  Part of addiction IS physical, and that needs to be addressed.  But part of addiction is also mental/emotional, and THAT needs to be addressed too.  Some people might find the mental/emotional structure they need in God, which is fine.  Others may find it in AA or a similar talk group.  That's great, too.  And obviously, a tough but supportive family and friends matters hugely.  This article seems to ignore all of that.  Which, to me, seems just as offensive and ignorant is when others ignore the benefits that appropriate medical treatment can provide for addiction sufferers.  Why don't we just all work together, guys, hey?

banana2013
banana2013

Clearly this article was written by someone who has little comprehension of the disease of addiction. The use of substitute medications such as methadone and buprenorphine are simply band aids that allow the individual to continue to get high. Both of these substances have a worse withdrawal than the opioid that the individual was originally using. This issue is spiritual in nature and therefore, it is applicable that the solution be likewise. Hiding behind statistical data from influenced populations is convenient to get one's point across, but no one can effectively dispute the millions of addicts that have recovered through the twelve steps of A. A. which is spiritual in nature.

PhilBroyles
PhilBroyles

While I agree with the overall tone of the article and advocate for evidence based treatments and funding for programs that work and defunding those that don't,  I think statements like this are misleading and show a bias towards the medical model and against everything else; "Ninety percent of those who enter addiction-treatment programs in the U.S. don’t receive evidence-based treatment." 

This statistic is one that I find difficult to accept knowing that I was trained in evidence based practice, used them in every position and program I worked for the last 12 years and use today in the program I'm director of. 


And just because someone has a four year degree or advanced  medical degree doesn't mean they are more capable of delivering evidence based treatment than someone with an addiction specific training background and less years of formal education. 

The call for evidence based practice has been a result of and  led by the consumer movements and who are often characterized as "paraprofessionals".

Evidence based practices include peer support models and other natural supports that are independent of the elitism of higher education and the medical professions.  


Read more: David Sheff: Obamacare Needs to Overhaul Addiction Treatment | TIME.com http://ideas.time.com/2013/11/13/one-thing-obamacare-cant-fix-bad-addiction-treatment/#ixzz2ms2uAYrx

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ShamsAci

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hartleichter
hartleichter

While I do agree with David about the current state of affairs in addiction treatment and the lack of a consistent model to help those afflicted, I find the veiled resentment against 12 Step a little disconcerting. For years the medical community postured that AA or 12 Step had no quantifiable evidence that its model of self help had a viable place in the scientific community.  Well, its now beginning to look like a SEGMENT of the medical community 'pshaws' some evidence to advance their own agenda.

I would like to point out two studies; one that surfaced as Project MATCH which basically states that AA members in long term service, i.e., pro-actively helping others do succeed in long term recovery as a result and another published recently

( http://psychcentral.com/news/2013/11/15/spirituality-improves-outcomes-for-teens-in-rehab/62071.html ) that appears to have a significant impact on the Recovery Rates of teenagers. For the most part, a large part, I do agree with Mr. Sheff. I would ask that he lay off the finger pointing, veiled or other-wise and stick to the positive aspects of his views based on its own merits than to denigrate another to make his point look good. A point that he may well have to share within the spiritual realm of recovery as well as the scientific realm. 

Hart

ClaireSaenz
ClaireSaenz

JeffT:  Where is the evidence that "any successful treatment model today includes AA after treatment."?  



JeffT
JeffT

Drug and alcohol addiction is extremely hard to treat because the addict has to be willing to change the way that they think. I hope that your comment about atonement of one's sins and the admission of powerlessness is not a slam on Alcoholics Anonymous. Any successful treatment model today includes A.A. after treatment. The admission of powerlessness helps the addict ask for help which is a crucial step in recovery because it is a major change in the addicts mind. For years the self absorbed addict is the one calling all the shots. And eventually the addict has to clean up the wreckage from the past so as not to use those memories in a self defeating process. Science and treatment therapies can help the body recover, but the mind is obviously a different and more complex problem. Living in MN, I know all about the different treatment programs. There is one program that is having better results by doing away with therapy and getting back to the basics of A.A. But my experienced opinion is that no matter what the treatment, success rates will always be low because of the nature of the disease. A good question to ask would be, "what causes people to turn to drugs and alcohol to enjoy life only to find that they become addicted to these substances and cannot live without them." And the insurance companies are asking: "if this disease is so hard to treat and the success rate is so small, why do we keep paying for treatment?" Better addiction medicine will not make much difference, it will just cost more.

annemfletcher
annemfletcher

Spot on, David Sheff! From the outset, the Obama administration has emphasized the need for evidence-based medical care and it's time that this crosses over to addiction treatment. The "solution" when someone has a drug or alcohol problem always seems to be "go to treatment/rehab." But few ask about what goes on there and whether the approaches are scientifically supported. Many programs say they're using such approaches, but in reality they're not, or they're using them in ineffectual ways by poorly trained staff. (More than half of states don't require a 4-year college degree to become credentialed as an addiction counselor.) It's time that we all demand change. 

Anne Fletcher, MS, Author of Inside Rehab

Truth_Seeker
Truth_Seeker

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lordelvis
lordelvis

I have none - but a comment.  I hated AA, hated it.  Especially when forced to attend.  The program I mentioned - the majority of our after care is over the phone.  Yes there is nightly meetings - non mandatory.  We also use group email support.  Schick Shadel provides the phone system for us, 5 weekly meetings are "organized" and the remainder are patient organized/sponsored.   Aftercare is essential for a period of time after treatment.  I also think some people need it more than others so it needs to be part of any successful program.  I also think the patient/person must be free to chose to be there not forced.  The AA model has and does work for many people.  I am not one of them.  Schick Shadel uses many topics in their aftercare meetings - it is not the same all the time, it flows and changes with science and the needs of the patience.  What I love most......I never ever have to say "Hi I am ....and I am a alcoholic".  I am not.  I am me, and I am a NON USER, not a loser.

Support_Counselor
Support_Counselor

@annemfletcher The amount of time in college/study does not always equate to being an expert in any field. In order to work at a drug and alcohol treatment facility, a person needs an education in addiction and recovery. There are many ways to achieve that, one of which includes attaining the CADC which focuses ONLY on addiction recovery. A 4-year college degree will require classes that have little or nothing to do with addiction or recovery in most cases. So are you saying that ANYONE with a 4-year degree is better than someone trained with a CADC which takes anywhere from 2-3 years to attain but which focuses only on the addiction and recovery process and which, consequently, amounts to more training in the subject than an average student with a bachelor degree would receive? And what do you mean by "many programs"? Can you please give us some statistics rather than a generalized and subjective phrase? Thank you!