“If you build it, they will come” doesn’t apply just to a baseball stadium in a cornfield. I believe that the same principle will work for creating affordable, effective treatment for addiction in the United States.
Despite well-meaning rhetoric and funding from sources both public and private, the U.S. has an appalling dearth of person-centered care for the millions of Americans living with addiction, the biggest public health crisis of our time.
I have worked in the recovery field for more than 30 years. I have seen individuals with addiction recover because they got the care they needed. Sadly, they are the minority, since our country does not have the treatment and recovery support infrastructure it so desperately needs. Five years of sustained recovery from substance use is the benchmark: 85% of people who achieve that remain in recovery for life. So it makes no sense to me that we aren’t designing our care systems around this goal.
According to the National Institute on Drug Abuse, treatment “for less than 90 days is of limited effectiveness, and treatment lasting significantly longer is recommend for maintaining positive outcomes.”
But few Americans get anywhere near 90 days of care. Within the confines of existing insurance networks, short-term treatment of 28 days or less is all that most Americans are offered — if they can get any help at all. This ultimately reflects the soft bigotry of low expectations: an inadequate care system designed to deliver less than what people need because we still moralize addiction and do not value people who have substance use disorders.
Here’s my vision for what substance use treatment should look like: Generally, it starts with a minimum of 90 days in a professionally staffed, licensed program providing evidence-based care. For some, but not all, this would be a residential program. It should also include the establishment of recovery centers in every community — places where people in recovery can support each other. A viable treatment system would also include ongoing peer support services for individuals and families affected by addiction for at least five years that help sustain recovery.
Consider a young woman with an addiction problem. Getting help for her is hard to do. In Pennsylvania, where I live and work, 11 adolescent treatment facilities have been shuttered over the last decade even as overdose has become a leading cause of death for young people in the state.
I envision a system in which she could access residential care without delays or intricate authorization processes, stay there for the time she needs, then return to the community to participate in age-appropriate treatment and education. She would attend a high school designed to provide a safe, recovery-oriented environment that would include alternative peer groups that support the social and recreational needs of youths in recovery. Once she is ready for college, this young person could attend a school with a collegiate recovery program, which is set up to provide support for students in recovery nestled in the larger academic community.
By achieving recovery with help from a system like this, she would avoid the medical, social, and criminal costs that come with addiction, not to mention experience the benefits of recovery. This is what we all want for our own families, and it is what we should expect from our care systems.
An adult with an addiction also needs 90 days of evidence-based care in a professionally staffed, licensed program. This should be the minimum standard for treatment offered by every insurance policy in the nation; they also need to include family services. Treatment must address the individual’s co-occurring medical, psychiatric, relational, and other needs in a holistic fashion.
Care should include services to help individuals reorient themselves to living in recovery with the support they need to heal. The services needed generally diminish in intensity over time based on an individual’s needs.
In the event of a relapse, more intensive services should be resumed without arbitrary limits from insurers.
People in early recovery should have access to active recovery resources like the one in my community, Sync Recovery Community, where I once was a volunteer. It provides opportunities to hike, bowl, kayak, and develop new social connections with others in recovery, which is critically important.
Once an individual achieves stable recovery, she or he should still be provided with an annual recovery check-up at least through the five-year mark, when the research tells us that return to active addiction is unlikely.
Addiction is pervasive, and help is elusive. It is past time to make recovery pervasive so we can protect our family members, friends, neighbors, and countrymen from the corrosive impact of addiction. It would cost a fraction of what not helping people costs us.
According to the U.S. Surgeon General, the cost of not helping individuals with opioid addictions was around $440 billion. The cost also includes lost productivity, as well as addiction-related costs associated with the criminal justice, health care, and human service systems.
Roughly 40% of people who have substance abuse problems also have mental health issues, yet fewer than half receive treatment for either disorder. Closing this treatment gap and spending money to help people recover would save both money and lives.
Sadly, even when individuals find treatment today, they often experience significant barriers to entry, including complicated insurance requirements, high out-of-pocket costs, and out-of-network providers that can make treatment unaffordable for most people. This status quo continues despite increasing evidence of its inadequacy: study after study has revealed that very short term care is minimally effective.
Many policy makers, and even many Americans, see people with addictions as “those people.” But they are really our people and, given the proper treatment and support, recovery is the likely outcome for them.
William Stauffer is the executive director of the Pennsylvania Recovery Organizations Alliance and an adjunct faculty member at Misericordia University in Dallas, Pennsylvania.
Fran try Antabuse. It works.
My alcoholic daughter has tried both Antabuse and monthly shots of Naltrexone… she quit both.
Currently she’s on 4-5 medications, two of them are for her alcoholic seizures, one an antidepressant, another is a mood stabilizer, and one for nerve pain Gabapentine (spelling might be wrong).
Naltrexone helped her cravings alittle, but it also allowed her to drink way more without feeling drunk, doctors warned her many times she wouldn’t live another year because of the amount of alcohol she consumed on a daily basis while taking naltrexone.
It’s very hard to keep her on her current medications, she’s bi-polar, some days she’s into getting better, some days she doesn’t care, other days she wants to be pharmaceutical free and lucky during those days someone has been with her to call 911 during her seizures. Everyday/ every hour is different with her and her moods, that’s one of the reasons we had her treated with the Naltrexone monthly shot.
Rehabs (30-120 days) don’t help, treat or cure addiction. If anything, the addiction comes back worse than before.
How do I know? I have a 25 year old alcoholic Daughter she has been in rehabs, and withdrawal clinics since she was 17. We estimate she’s been to 20-25 different rehabs, several of them repeatedly. One year she continually spent 365 days in several different withdrawal centers and rehabs.
Her behavior and addiction has only changed for the worse. She now sees herself as a victim and nobody understands.
For only 20k a week sit around in a hot tub and be cured from your addiction. Cliffsidemalibu
What’s your evidence that PRO-Ais a trade association?
I saw a tweet from a medical provider that characterized PRO-A as a treatment provider.
Recovery organizationa can mean a lot of things. I don’t know much about them or their funding, but they say the provide no services and I haven’t seen any evidence that they are a trade group.
Where is this coming from?
I agree it’s difficult to know what PRO-A is exactly, and the name is potentially misleading. There is no obvious list of members, directors, or contributors. The mission sounds benevolent and inclusive. But from some of the published initiatives, and certainly from this article, it is clear that the principals have fixed views regarding treatment and monitoring for recovery, not supported here by any credible scientific evidence. The recovery industry is rife with conflicts, and the corrupting influence of money is ever present. One certainly cannot rely on the published edicts of governmental agencies that are revolving doors for industry.
The likelihood of the author’s objectivity on the issue of optimal treatment duration is vanishingly small, given his position as Executive Director of a trade association of recovery centers, each member of which of course profits from every additional patient day over what is currently covered by insurance.
The justification given for his statement “treatment “for less than 90 days is of limited effectiveness, and treatment lasting significantly longer is recommend for maintaining positive outcomes.” is a bald assertion put forth by NIDA operatives in their 2018 book, Principles of Drug Addiction Treatment. That book in turn was written by a number of people representing the drug treatment industry, and it was unsupported by evidence. In fact, the only published scientific study analyzing these Principles (Pearson, et al J Subst Abuse Treat. 2012 Jul; 43(1): 1–11, doi: 10.1016/j.jsat.2011.10.005) concluded that “meta-regression of 230 studies indicated that studies in which clients participated in treatment 12 weeks or more had virtually the same drug use outcomes as those with participation of less than 12 weeks. ”
I’m surprised STAT didn’t consider this significant conflict of interest before it published this piece.
What’s your evidence that PRO-Ais a trade association?
I saw a tweet from a medical provider that characterized PRO-A as a treatment provider.
Recovery organizationa can mean a lot of things. I don’t know much about them or their funding, but they say the provide no services and I haven’t seen any evidence that they are a trade group.
Where is this coming from?
I looked at their 990. Most revenue is from government grants. The rest is from a recovery institute (which I assume relates to the provision of recovery coaching classes), and a conference.
He’s basically arguing for recovery management (at the individual level) and recovery-oriented systems of care (at the systems level).
If you’re interested in evidence for that model, see here: http://www.williamwhitepapers.com/pr/2008RecoveryManagementMonograph.pdf
Dr Andrew –
Addiction is a chronic medical condition and longer term care is generally more effective and there is a body of research showing the efficacy of moving beyond acute, short term care. I share a link here to a posting by the American Society of Addiction Medicine (ASAM) on the long term care model . The work of Dr Dupont has been very influential to me and may be worth looking at. As an FYI, PRO-A is not a trade association as another poster identified. Also insurance in America largely does not pay for recovery support services. I understand some of the skepticism about our care system due to profit motivated interest groups and things like patient brokering which we want tougher laws to be put in place and enforced so there groups stop preying on vulnerable people. This article is sincerely what I see as the best path forward to helping people with substance use disorders – I personally have seen far too much devastation caused by addiction even as I have seen people get into recovery and do remarkable things with their lives. I do appreciate your feedback and this response is intended to be respectful. ASAM link: https://www.asam.org/resources/publications/magazine/read/article/2015/12/13/setting-a-new-standard-for-treatment-with-five-year-recovery
Bill Stauffer,
Your comment is clearly well intended and respectful. However, the author you cite, RL DuPont, for long profited from, and is a notorious apologist for the drug treatment/testing industry. As a founder of NIDA, he was strongly supportive of a program that incarcerated children (STRAIGHT, INC) based on his same antiquated beliefs about substance use (he was Nixon’s Drug Czar). One of his coauthors, AT McLellan, has recently been sued for fraud in connection with a rehab from which his recovering son had profited mightily. (ATMcL was Obama’s Drug czar at the time). The common theme is, as so often the case, $$$$.
I am also well aware of ASAM, which is heavily funded by these industries.
The paper you cite as dispositive is based on statistically flawed research, and was initially rejected for publication. Not sure how they finally managed to get it out. The same dataset, however, has been repeatedly churned in order to generate the same conclusion, in support of exorbitant, restrictive and long term treatment and promoting the supposed superiority of such and even more inordinately prolonged monitoring. This study and its spawn is also most likely the basis for both ASAM’s position and NIDA’s (both RLD and ATM were NIDA leaders) regarding long term treatment and monitoring.
These regimens are both very profitable, but there is no real evidence that either is actually effective. However, many intelligent but non-scientifically oriented people such as yourself have been convinced that it is.
It does appear that Pennsylvania Recovery Organizations Alliance is not a typical trade association. I’m still not clear on exactly who it represents. But even if it should somehow be pure advocacy for recoverings, it seems clear that insurance coverage for long term treatment is an aspiration. I personally don’t believe insurers should be paying for something that is not proven, any more than individuals. Nor should non-insured individuals be forced into paying for same, as happens in some professions.
However, thanks for your thoughtful input.
An addict chooses to go down the pathway of substance abuse. It is a one way street. Once an addict always an addict. It’s not my fault it’s their fault. Sorry.
You’re right, Glenn, but what does that suggest as a way for us to respond?
I think it’s clear that we have to treat addicts anyway, like we treat the damages to failed suicides or crash injuries in drag racers.
We even have to treat gunshot injuries that bank robbers incur while resisting arrest.
But why do they turn into that one-way street in the first place?
Surely they do not think to themselves, “Hey! I have a good idea! I will make myself into a hopeless addict and live a life of shame, suffering, crime, and degradation until I die, which will be “soon.” What a great plan!”
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But anyway, since no treatment works in the first place, what if we stop enriching fake treatment facilities and just skip that part.
We can use the money wasted on fake treatments to maintain the addict’s drug use (and stop economic crime) and give the addict social support (and reduce some of the other consequences of the addiction).
For example, addicts may need someone to pay their rent, to buy them food and clothes, to pay their cable TV bill, and so on.
This plan would be far far cheaper than paying for fake cures — while simultaneously paying the social costs of the unmitigated addiction too.
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One problem with this kind of “harm mitigation” is that it apparently makes addiction spread.
At least, that is the reason, I understand, that the UK stopped their program of issuing free heroin to addicts.
Apparently making addiction seem to be “consequence-free” (or even an economic opportunity) is not a great way to discourage new users from starting up.
I’m not convinced of the “once an addict, always an addict” curse–at least not for alcoholism. I self-treated for my alcoholism with Naltrexone over about two weeks (couldn’t quit on my own)–and always take one pill an hour before drinking (yep–I can still drink, but now in moderation). New Year’s Eve I didn’t even finish the 12 ounce beer I nursed for four hours. No interest. No desire. No drunk. No futher treatment. “Clean” for four years.
If 85% of those who do not relapse within 5 years continue to be drug-free, what percent of addicts reach that benchmark?
If 5% of addicts stay in recovery for 5 years, and only 85% of those remain drug-free, then only about 4% of addicts benefit from addiction care.
Perhaps it should be acknowledged that the overwhelming majority of addicts will not recover no matter what we do.
What if we moved to a vastly cheaper program of “harm mitigation”?
Anyway, I am not seeing any attention to prevention.
I have never understood what outcome a person anticipated in the few minutes before committing the first act of becoming an addict.
Shortly they are incurable addicts, racking up arrests, poverty, degradation, diseases … and all the other consequences of drug addiction.
What did they think was going to happen?
Anyone can tell that in 6 months after you addict yourself, you will be breaking into your grandmother’s home to steal her TV and dead husband’s wedding ring.
So why do people even start?
Let’s work to prevent it.
Treatment after the fact clearly does not work.
If we could take the money spent on incarcerations, health care costs, law enforcement costs, etc. that it costs society due to the lack of availability of good treatment, and a full continuity of care, it wouldn’t be costing us the money it does now on the aforementioned areas. Swap them out; we’re doing it backwards.
Can someone tell me where this statistic comes from please and thank you.
“Five years of sustained recovery from substance use is the benchmark: 85% of people who achieve that remain in recovery for life.”
I’m pretty sure there’s more than one, but here’s one: https://www.ncbi.nlm.nih.gov/m/pubmed/17986709/
great article!
sadly, the revolving door that some ‘relapse’ facilities are involved in today are about $, lattes & keep coming back programs designed for their benefit..
ive seen some good facilities, bought out by big $ & they’ve turned into recovery drive-thru’s…
right here in northeastern penna…
government can help, but politicians are so very often about themselves and their own power…
eg our present governor touts help for addiction….
while the lt gov touts listening sessions to make marijuana legal…
its twisted…
in my opinion