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?
Tags: addiction, cost of treatment, education, public policy, roots of addiction, Treatment
The addiction/alcoholism information contained here is incredibly accurate & insightful. Looking specifically at the “recommendations for improvement” above, I can only imaging how my addiction might have been positively intervened upon early on prior to developing the actual addiction.
Your list is very insightful and shows promise. I’d say my list would be very similar. Although, as we all know cost will always play the biggest factor in our health care options.
I feel that educating families would be a huge plus. Coming from a family that has members who have struggled with Alcohol addiction their entire life I never really put food or object addiction into the same importance. I guess that’s my own ignorance. It just always seemed to me that since alcohol and drug abuse can end with such damaging health outcomes that they were worse. I get why addiction should be categorized as a whole.
The statistic are pretty astonishing and I hope that people will wake up and start working toward a better solution.
This article was truly inspiring. I have a few very close people in my life that have and still are struggling with addictions. I have learned that once you have an addiction to something, whether it be drugs or sex or gambling, you will always have that addiction. It is not a crime to have an addiction, but sometimes being on that high and exciting moment can cause you to do something criminal. I believe treatment works, maybe not right away but in the end it works. Locking someone behind bars doesn’t. It only makes them angry and when they are let out can cause more criminal actions.
Thank you for sharing this, as it is something I will constantly refer to.
I am studying the war on drugs in a college criminology course on crime control strategies and I am particularly interested prevention of teen drug and alcohol abuse. I think your point about investing in families and prevention is extremely vital. Reaching kids in their adolescence by giving them honest, useful, and scientific information is so important. Kids need to know the difference between use and abuse and by teaching them the legal and physical consequences they can begin to make important decisions that will keep them safe during times when they are pressured.
The Columbia University report you mentioned is very startling, because it shows where we lack in our resources. I reviewed your list of possible solutions and wanted to elaborate on a couple of them. Early drug and alcohol education for our youth is paramount. Unfortunately, this education may happen once a year in a single grade from programs such as Drug Resistance and Education (D.A.R.E.) or in a onetime health class. Does this onetime education work? In my opinion, it does not! Drug and alcohol education should be continuous throughout the school year. The brains of our young people need the information repeatedly, so it can be imprinted. I understand that they come from different family situations and a variety of ethnic and socioeconomic backgrounds. However, our schools can still provide them the mental tools to make informed and good decisions.
As you mentioned, we do need to stop criminalizing addiction. The recent Bureau of Justice Statistics (2011) reported that over the past three years, the U.S. prisoner population has slowly decreased. In addition, the same report explained that 51% of the federal prisoners incarcerated were for drug offenses. This problem needs reform. Many courts throughout our country are implementing alternative sanctioning methods called intensive supervision programs that require substance abuse treatment. Judges, prosecutors, defense bar, and law enforcement actually help encourage offenders to succeed. Numerous studies and reports suggest that these programs are successful in reducing recidivism. As we head into the future, I hope these programs pick up momentum. They may help reduce the costs of incarceration without treatment and help offenders with addiction issues be productive members of society.
References
Bureau of Justice, Correctional Populations in the United States, 2011. Retrieved from http://bjs.ojp.usdoj.gov/content/pub/pdf/p10.pdf
It seems like addiction is treated very narrowly, indeed. I think the most important of the solutions is investing in families. This is especially important when dealing with addicted parents or abusive homes in general. This is often such an important piece of an addict’s history. Chances are that they grew up in a bad home, or their parents had the same problems that they wind up having. It’s interesting how that works. I do think that addiction is treated kind of coldly. We are treating the substance addiction, but not getting to the root of the problem. By doing this, the person in treatment could just turn to another substance, or as you mentioned something that isn’t even a substance. If all they’ve ever known is unstable, unhealthy relationships, they can just transfer that to something else, even if they stop abusing the substance they were being treated for in the first place. This doesn’t seem like an effective way to treat addiction at all.
What stood out for me was the section, Stop criminalizing addiction and treat those who do end up behind bars. I think one of the biggest issues with our society is our inability to deal with problems. Most addicts are viewed as either criminals or as someone who is sick, while they view themselves as a person who is going through a rough time. Our society is so quick to place labels on people, and to criminalize people for actions that we fail to realize that we are stripping these people of their humanity. If you break something that’s already broken, how can you expect it to be fixed? There is no quick fix for addiction, and what works for one person may not work for another. Telling addicts that they are criminals or monsters, strips them of their humanity and makes it difficult for them to face reality.
After reading this article, I found the effort for trying to fix the problem of addiction seemed promising. Addiction is a major issue in this country and not just with alcohol and drugs. What I found astonishing was the fact almost 90% of addiction patients are not treated and 50% of who do receive treatment decide to give up and drop out. The four points you stated I agree with. Criminalizing addicted individuals I feel does not help the cause and would make things worse on that individual. It is important to get a sense of the relationship of the person and the object and to get treatment for them. Family care and trust group is beneficially effective on a positive standpoint, because it shows the support to the person with the addiction and maybe they would be willing to fight and get rid of the addiction. Families are very important. Also, I feel reaching over the internet is a good marketing tool to help with addiction. Each day internet access is growing and lot of things are done online now and electronically. Reaching out to addicted people would be smart to start online. I really enjoyed this article and opened my eyes.
Researchers and scientists clearly know where they want to go to help addiction, but as of right now they feel far from that. There are the little steps they are taking in order to help addicts, but there is so much more to those small steps. People aren’t really looking at the big picture. While reading this blog, I was completely shocked by these facts:
? 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
It’s so unfortunate that a whopping 89.1% of addicts receive no treatment at all. After reading Tweak, I learned that addicts will constantly turn down the help from friends and family members who are trying to get them into treatment. This 89.1% of addicts who aren’t receiving treatment are either because they are constantly denying the help or they have pushed away all their loved ones who were willing to help or they just won’t put themselves in treatment. Then once addicts do receive treatment, 50% dropout! The process is just too difficult and long for some people. Nic Sheff constantly talked about how he wanted to give up and use again, and at some points he did, but at least he went back into treatment after he relapsed.
Dr. Fitzgerald has only 4 suggestions to improve addiction, but these 4 suggestions would extremely help the issue. I really agree with his suggestion about investing in families. We know that addiction can start a lot of the time from families and home life. It would really help the addiction situation by creating programs for families to really focus on getting along and maintaining strong mental health. I think this is the most important of Dr. Fitzgerald’s 4 suggestions. We need to focus on stopping addiction from the very start.
I also agree with your list, It is very insightful, especially about criminalizing addiction. I read an article a while back about a person who is incarcerated for grand theft auto who had never done drugs before but started to abuse the substance while imprisoned. My question is should they also educate about prevention in prison? Also a question about the NIA, do you believe the reason why money is scant for food and gambling addiction compared to alcohol and drugs is due to the fact of harm to one’s body? and higher death rates?
Great, thanks!
Good questions! Yes, prevention in prison makes a lot of sense to me. On your second question, no, I don’t think it relates to body harm because obesity is among the most costly public health problems of our time. I think it goes back to the historical roots of understanding addiction through the lens of substances. Despite everything we know today, behavioral addictions remain the stepchild of substance abuse disorders, and this must change if we are to be successful at helping those who struggle, in my opinion
J