Monday, February 25, 2013

What's Wrong With Addiction Treatment in America?

What's Wrong With Addiction Treatment in America?

From Dr. Mark Willenbring MD Substace Matter.

Since Jane Brody quoted me in her column in the New York Times, I've been inundated with calls, emails and other inquiries. Here are some themes, impressions and stories that help illustrate the gaps and barriers to receiving up to date, consumer-friendly, addiction treatment.

1. "He's been through treatment program after treatment program. None of them worked! And we still don't really feel he's had a good evaluation or any continuity of treatment."

This has been a very consistent experience reported by families of someone with an addictive disorder. There is a profound sense of being out there alone, in sharp contrast to having a relative with colon cancer. There is a great sense of fragmentation of care, as well as inconsistent opinions and recommendations. Because "programs" are arbitrarily time-limited, they have no ongoing responsibility of the care of their patients, unlike other medical specialities. How would you like it if your oncologist only saw you for 8 weeks, and then treatment ended? And once "the program" has ended, there is no care, no one to help you manage an out-of-control situation. And it's worse when "the program" is in a distant location. What is learned in an artificial, low-stress environment and now access to alcohol or drugs does not translate well when you get back home. The stacks of bills, the crying baby, the leaking roof, and the liquor store around the corner make it pretty difficult. Addiction is best treated like other disorders, with people living in their own communities, learning how to stay sober there, with everything that's going on.

2. "I (or my loved one) is in (or about to begin) a treatment program for drug X. But they don't seem to have the kind of treatments you talk about. Where can I get that kind of treatment?"

Many people I talk to are trying to figure out what type of treatment or treatment facility is going to be best for their particular problem. And they don't know where to get reliable information. Much of the information, practices and pronouncements are not supported by scientific studies, but that doesn't stop treatment programs from asserting them anyway. So the marketplace is confusing, not unlike walking through a market with each vendor hawking her wares. Testimonials and outrageous claims abound! Literally fantastic outcomes are assured! That's right! Step right up and submit your payment now! You won't be sorry! We promised 100% success if you do exactly as we tell you and you really want to succeed!

(So if you fail...'s your fault. Sorry.)

We need an ethic of professionalism in addiction treatment that at least reduces that type of selling of services. We need to embrace an ethic of adhering to scientific findings, and changing our beliefs when the facts change. We need to foster the humility to care, even though our treatments are only partially effective, and in some cases totally ineffective. We can't abandon our patients because we cannot change the course of their illness. Do you really think they want to die? They don't! But they and we are helpless in the face of their brain dysregulation. As is true with so many human ailments: cancer, heart disease, stroke, diabetes, depression, arthritis, multiple sclerosis. As our understanding of these diseases advances, through scientific research, our tools for preventing and treating them will improve. But it will cost a lot and take a long time. But our only hope is to support it. Research on addictions and their treatment.

Fresh NEWS in Florida SB 808 and HR735

I received the news from the Florida Medical Association:

The Florida Medical Association on the syringe exchange legislation proposed for the 2013 legislation session. The bills are HB 735 by Rep. Mark Pafford and SB 808 by Sen. Gwen Margolis. At this point, session officially begins next Tuesday. The House and Senate bills received their committees of reference last week. Unfortunately, both received 4 committee assignments each which isn’t a great sign but not totally unsuspected either. The main hurdle at this point is getting the bills heard in their first committees of reference.

Email Gwen Margolis
and  Mark Pafford

Thanks them let them know that substance use treatment requires quality assurance like expected of all other medical services.

My response:

I have a grave concern, which I would like to see how it can be incoporated in the bill. That is need for quality assurance. It is unfortunately but substantial number of professionals in social science has been ignoring both ethics and appropriate medical protocol and best practice. Often taking upon them to create policies and practices that is inconsistent with the best interest of their clients or patients, mostly for their own convenience.

As you may know by now, that has been a great concern of late Dave Purchase who just passed away, and numerous professionals associated with the harm reduction practice. We are all very concern to assure scientifically based practices which has been ignored by the Substance Use Disorder treatment community. This professionals seem to think that they do not need to follow the same scientific standards expect of all other medical fields. You might have received from NASEN documents associated with science and best practice. If you do not have them, I can provide them to you as they have given me the courtesy of sending me copies.

As you might know, syringe exchange will only but one service. This could be the opening to health system to a disfranchised population that we have been everything but ignoring, discriminate, stigmatized and even acted with bigotry. I assert that this manner of acting toward these individuals is consistent with racism.  Perhaps this is the reason that we are not making much head way with appropriate treatment of this population.

I am concern for patient’s safety and rights, and to tell you the truth neither the State of Florida Depatment of Children and Family who are suppose to license the facilities nor the treatment  facilities seem to be joyfully oblivious to the needs of this type of patients. Their professional behavior is more consistent with self-preservation and convenience than patient’s needs.

What we call substance abuse residential "treatment" today is only so by long term declaration, and is not supported by quantitative empirical research. As far as I Know it is neither effective and I suspect (without any data) that it causes relapse and possibly other bad habit. I like to avoid stating patients safety and syringe exchange program by people who have political and funding sources but not the require appropriate medical skills to provide quality assurance work. Unfortunately, having an education and a license is not guaranteeing it.

I also have copies of a draft of a bill that is being worked in North Carolina. As far as I can tell me and
have been the only two underground clean syringe programs in South Florida and doing our best at providing safe syringe and information.

I will look for the bills and see what suggestion or respond further.