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.

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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.

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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.