What Is Addiction Treatment?

Cross-posted from djmitchellauthor.com.

How is addiction treated in this country? There’s no single answer. There isn’t even a standard for what makes treatment successful. Some measure years of abstinence. Some seek moderation, but don’t consider abstinence to be part of recovery. Others seek temporary reduction in use through incarceration, or simply a reduction in socially unacceptable behavior.

One reason for this is confusion about the nature of substance abuse. Science recognizes three categories: the risky user, the physically dependent person, and the addict who returns to the substance repeatedly even after being separated from it. Medicine, on the other hand, used to recognize the first two categories. But the DSM-V, the latest version, combines all substance abuse under the single label, “Substance Use Disorder.”

Another reason is the disconnect between science and medicine on the one hand, and public policy on the other. For example, the largest single “treatment” provider for drug users is the prison system. More than half a million nonviolent drug offenders are incarcerated, at a cost to the taxpayers of around $15 billion per year. While there are some drug treatment programs in some prisons, the majority of inmates do not receive drug treatment. The National Institute of Health cites public desire for retribution rather than rehabilitation as a major barrier to drug treatment in prisons.

The amount spent on incarceration pales in comparison to the $30 billion or more spent annually on treatment facilities. In 2017, over 4 million Americans received treatment in a variety of settings. Of these, 2.5 million attended a treatment facility, residential or outpatient. Others may have received help from doctors, psychologists, or Twelve Step programs. Of the treatment facilities, 53% received government funding, meaning they are prohibited from using any spiritual or religious approach, including the Twelve Steps.

A more startling statistic is that of the 20 million Americans who needed treatment in 2017, only 12% received it at a treatment facility. Another 7% received treatment at non-specialty facilities. Still, 81% of those who needed treatment didn’t get it. The most common reason, cited by 41%, was lack of insurance coverage.

Some 10% of treatment facilities provided Medication Assisted Therapy (MAT), in which physical dependence on heroin or other opiods are treated with methadone or buprenorphine– long-acting opioids that are much harder to quit after long-term use. Of these, 95% still offered methadone, while 65% offered a choice between the two substitutes. There was no indication of how many facilities used these replacements for detoxification only, and how many used ongoing maintenance. (I’ll post another time about the nightmare of “methadone maintenance.”)

So what does all this tell us? First, most Americans who need help for substance abuse don’t get it.

Second, there’s a wide variety of approaches to treatment. Some, like prison, embrace the belief that if you punish someone enough, they will somehow magically change. Others, like substitution therapy, seek to reduce the criminal and health effects of addiction, but do not seek to actually treat addiction. Still others seek to return the sufferer to “social” use. Those that do seek abstinence measure it in various ways: abstinence for the duration of the program, or at 90 days, or at a year, or at 5 years.

A study of veterans in Twelve Step programs found that 70% of those who participated for a period of months were still abstinent at 16 years. In contrast, some treatment facilities that don’t use the Steps have abstinence rates around 10% at one year.

The most successful treatment approaches, at least for those who suffer from true addiction, seek total abstinence and a changes way of living. As noted in my previous post, it’s not enough to just get someone off drugs. Addiction is a way of life, a purpose for living, and a moral framework. For treatment to be successful, these old ways of being have to be replaced with new ways of being.

To be successful, treatment does not focus on moving away from drugs, but toward a suitable new way of life.

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