I wrote a paper about this topic some time ago, but thought I would post a more parsimonnious version of the top ten reasons treatment fails patients. The point is not to suggest that treatment is always ineffective, just that we have a long way to go to optimizing it for those who struggle.

• Treatment focuses on select objects of addiction and does not address the entire package of addictive behavior (see previous post).
• Treatment time is way too short – often lasting days or a few months, instead of years like other chronic medical conditions.
• Treatment relies heavily on group therapy, an abstinence-based approach, and use of 12-step principles instead of indivdiualizing treatment to patients needs and using a wide range of evidence-based practices.
• Underlying mental health, trauma,  and developmental deficitis/constrictions go unaddressed or undertreated.
• Use of medications specifically approved by the FDA to treat addictions, including naltrexone, acamprosate, buprenorphine, and methadone, are underutilized in treatment.
• Treatment overly focuses on the pathological side of the equation, and does not encourage interventions based on positive psychology and creativity.
• Treatment programs forget they are running a business, and that patients really are customers, even when they are mandated to treatment. What would treatment be like if funding was based on outcomes specific to customer satisfaction?
• Too much emphasis is placed on stage models of treatment when there is a much stronger base of evidence for universal processes of change.
• Treatment programs see less than 10 percent of those in need of help. How can programs better align themselves with the needs of thier community and broaden the use of their resources to help a greater number of people (i.e., population-based medicine).
• Treatment often remains disconnected from other important healthcare and community stakeholders. Disconnects between crimminal justice, primary care medicine, policy makers, and others mean many people fall through the cracks and ultimately fail treatment.

Perhaps you can add a few to the list?

Addiction comes in packages – not the type of packages you want on your birthday or for Christmas, but packages that develop over periods of time and involve excessive behavior with more than one object of addiction. Rarely in my clinical work and research have I experienced patients that struggle with only one addiction. If you abuse methamphetamine or cocaine, chances are good you have struggled with out-of-control sexual behavior. If you gamble, chances are good you also drink or smoke. If you use drugs of any kind, you likely drink and use cannabis as well.

And of course the packages usually include a lot of other issues as well: mental health problems (trauma, depression), physical health problems (chronic pain, diabetes, hypertension), and a wide range of psychosocial problems (relationships, debt, unemployment, legal problems). When we combine all the issues with addiction what we see clinically is a complex mess. What makes treatment so difficult is really understanding how all the issues interact with each other, and where to start with intervention. Many who receive treatment from a private practice clincian rely on what happens in just one hour out of 168 in a given week. Not much time to intervene when so many issues are present.

One of the best descriptions of the “packages” is a chapter written by Patrick Carnes, Robert Murray, and Louis Charpentier titled “Addiction Interaction Disorder” found in the Handbook of Addictive Disorders: a Practical Guide to Diagnosis and Treatment, edited by Robert Coombs (2004). In the chapter, the authors define 11 dimensions in which different addictions interact with each other. For example, masking occurs when “an addict uses one addiction to cover up for another, perhaps more substantive addiction.” Such is the case when a patient says “I did all those sexual things because I was high on methamphetamine.”

The key point of all of this:  to successfully intervene it is necessary to address the package of addictive behavior, and the co-occurring issues that go alone with the addictions as well. We must move away from treatments and interventions that focus exclusively on specific objects of addiction, and learn to think systemically about all of the various issues causing problems. This is why I am not a fan of certifications focused exlusively on drugs, gambling, or sex. What we need are clinicians who can treat the entire package.