Addiction treatment system 14 years later….still in need of an overhaul
This past week The National Center on Addiction and Substance Abuse at Columbia University released a scathing report of our addiction treatment system: Addiction Medicine: Closing the Gap between Science and Practice. While the report says nothing new, it does a nice job of summarizing the fact that we have made little progress since the Institute of Medicine released Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment on January 1, 1998. Here we are, 14 years later, and well, where are we now?
The new report points out these grim statistics:
- 15.9% (40.3 million) of US age 12 and older struggle with addiction to alcohol and drugs (the number is higher if we factor in behavioral addictions such as gambling, sex, food, and online activities)
- 31.7% (80.4 million) of US age 12 and older, while not addicted to anything, engages in risky use of substances that threaten health and safety (again, this number is higher if behavioral addictions are included)
- 89.1% of those who meet criteria for addiction involving alcohol and drugs (not including nicotine) receive no treatment
- Of those who do get treatment, about 50% come from criminal justice (only 5.7% are referred from primary care medicine)
- Over 50% of those who go to treatment drop out
- Addiction and risky substance use costs our society an estimated 468 billion each year
Not good! I will admit I was a bit depressed reading through the report, but not surprised. Addiction is a problem still very much misunderstood. Take for example this huge 573 page report, that constrains the definition of addiction to substances. How can we possibly make progress evolving our treatment system if we continue to narrowly define addiction. It is not just to substances that people become enslaved, but to food, gambling, sex, and many online behaviors. We now have neuroimaging studies providing empirical support that the brain is an equal opportunity organ that does not care what stimulates it, so long as dopamine provides a nice reward that keeps us coming back for more. In a great book on overeating, cleverly titled, The End of Overeating, by David Kessler (which I plan to blog about soon), he makes the point that animals will work almost as hard for food as they will for cocaine. So, back to my point. How can we make progress in this field when we continue to slice up the addiction problem, and fail to understand that it is not about the objects per se, but the relationships that a person has with these objects – all of these objects?
Accurately defining the problem would be a start, because we could then start building systems of care that leverage interventions for a wide range of chronic conditions, including addiction. But even agreement on a broad definition will likely not be enough. We need big system changes to make big progress. The CASA report provides a list of recommendations for improvement, including:
- Increasing screening and referral in primary care medicine
- Improve training on addiction in medical schools
- Establish national accreditation standards for all addiction treatment facilities and programs
- Educate non-health professionals about addiction, screening, and referral (dentists, teachers, legal staff, welfare, etc.)
- Require adherence to use of evidence-based treatments
- Expand addiction treatment workforce
- Implement more national public health campaigns
It is a list, but hardly a gutsy one or even close to what needs to be done if we are to make big progress. What would my list look like? Here are my top four suggestions:
- National Institute on Addiction (NIA): While integrating NIDA and NIAAA into one organization next year is progress, I would like to see an institute called the National Institute on Addiction that puts the emphasis on understanding the relationships people have with all objects of addiction, not just alcohol and drugs. While I know these agencies have invested resources in gambling and food, the money is scant compared to what is spent on substances. One of the primary goals of this organization would be to get all stakeholders (researchers, treatment providers, public) on the same page about how we should define addiction.
- Leverage the Internet: Over 80 percent of the US population has access to high-speed internet, which means that we have the potential to reach the 90 percent who don’t get care. I am not saying this is easy, but there is a saying in marketing that you go where the customers are – and they are online.
- Stop criminalizing addiction and treat those who do end up behind bars: The vast majority of folks behind bars suffer from addiction and most don’t get treatment. This needs to change. Because most will get out, why not use their time while in prison to treat their addiction, educate them, and provide them something to live for when they get out? I know, this costs too much money. See my last point.
- Invest in families/prevention: Addiction is primarily a problem born out of adolescence. Most who develop addictions begin their journey before the age of 15. We need to devote significant resources to helping families flourish. We need programs that help people developmentally obtain the capacities they need for optimal mental health, for intimacy, parenting, and getting along with each other.
What would be on your list?