Posts Tagged ‘addiction treatment’

Finding a Better Way to Treat Addiction

In my previous blog, I mentioned a great new resource that CASA has published about the condition of addiction treatment in this country. The book, “Addiction Treatment: Closing the Gap between Science and Practice,” is available for free as a download at

I’ve been reading this document in detail, finding facts that support what I see in the real world of treatment. In the U.S., our approach toward funding of addiction treatment is exactly backwards. We spend a relatively small amount on prevention and treatment of the actual disease of addiction, but billions on the constellation of medical issues caused by addiction.

Most addiction-related medical expenses are paid for from public funds. In fact, over ten percent of all federal, state, and local government dollars are spent on risky substance use and addiction problems. Sadly, over 95% of this money is spent on the consequences of drug use and abuse. Only 2% is spent on treatment or prevention.

Untreated addiction costs mightily. People with untreated addiction incur more health care costs than nearly any other group. An estimated one third of all costs from inpatient medical treatment are related to substance abuse and addiction. Untreated addicts (I include alcohol addicts with drug addicts) go to the hospital more often, are admitted for longer than people without addiction, and require more expensive heath care than hospitalized non-addicts. The complications these people suffer could be from underlying poor physical health and lack of regular preventive healthcare, but most of the cost is incurred treating the medical problems directly caused by addiction and risky substance use.

That data is consistent with my experiences when I worked in primary care. I always felt like I was slapping Band-Aids on gaping wounds when I treated people with alcohol or other drug addictions. I never felt like I was treating the real problem, and I wasn’t, as this report so eloquently indicates. My practice had a handful of “frequent fliers” who came to the ER several times per month with the same addition- related illnesses, over and over. I admitted one patient to the hospital at least twenty times over four years for the treatment of alcoholic gastritis. Each hospital visit lasted four or five days until he was well enough to go home and drink again. Another patient was admitted about every two months after he got pancreatitis from another bout of binge drinking. This went on for years.

This was in the early 1990’s, in my former life as a doctor of Internal Medicine. I didn’t know what to do with these people. They frustrated me. Maybe I told these patients to go to Alcoholics Anonymous, and probably I asked the social worker to arrange inpatient treatment if possible. But I didn’t have the knowledge or tools to really help these people, and instead only did what I was trained to do: treat the medical problems caused by addiction.

In my Internal Medicine residency, I admitted many patients to the hospital for endocarditis (infected heart valve) contracted from IV heroin use. Each time, this required six month of intravenous antibiotics. Back then we kept such patients in the hospital the whole time. You can imagine the cost of a six week hospital stay, not that these addicts had any money to pay. Just a fraction of that amount could have paid for treatment at a methadone clinic, the most effective way to treat heroin addiction, and prevent dozens of medical problems. But I never referred them to the methadone clinic available in that city. I didn’t know anything about methadone or the medical-assisted treatment of opioid addiction, and apparently my attending physicians, responsible for my training, didn’t know about it either. It was a shame, because in those years, the late 1980’s, we were making new diagnoses of HIV almost daily among IV drug users. Since then, a study showed a patient using IV heroin drops his risk of contracting HIV by more than threefold if he enrolls in a methadone clinic.

Family members of people with untreated addiction have higher health costs, too. Families of people with addiction have 30% higher health care costs than families with no addicted member. I presume that’s from the stress of living and dealing with a loved one in active addiction. Often family members are so caught up in trying to control the chaos caused by active addiction that they don’t take time for routine health visits.

The costs of untreated addiction aren’t only financial. Addiction and risky drug use are the leading causes of preventable deaths in the U.S. Around 2.9 million people died in 2009, and well over a half million of these deaths were attributable to tobacco, alcohol, and other drugs. Overdose deaths alone have increased five-fold since 1990.

We know addiction is a chronic disease, yet we spend far less on it than other chronic diseases.

For example, the CASA report says that in the U.S., around 26 million people have diabetes, and we spend nearly 44 billion dollars per year to treat these patients. Similarly, just over 19 million have cancer, and we spend over 87 billion for treatment of that disease. In the U.S., 27 million people have heart disease, and we spend 107 billion dollars on treatment.

But when it comes to addiction, we spend only 28 billion to treat the estimated 40.3 million people with addiction, including nicotine. Most of the money we do spend is paid by public insurance. For other chronic diseases, about 56% of medical expenses are covered by private payers, meaning private insurance or self-pay. But for addiction treatment, only 21% of expenses are paid from private insurance or self-pay. This suggests that private insurance companies aren’t adequately covering the expense of addiction treatment. Indeed, patients being treated with private insurance for addiction are three to six times less likely to get specialty addiction treatment than those with public insurance such as Medicaid or Medicare.

In the U.S., we don’t treat addiction as the public health problem that it is. Some people still don’t believe it’s an illness but rather a moral failing. Doctors aren’t educated about addiction is medical school or residencies, and we often have an attitude of therapeutic nihilism, feeling that addiction treatment doesn’t work and it’s hopeless to try.

Families and medical professionals often expect addiction to behave like an acute illness. We may mistakenly think addiction should be resolved with a single treatment episode. If that episode fails, it means treatment is worthless. Families want to put their addicted loved one into a 28-day treatment program and expect them to be fixed forever when they get out. They’re disappointed and angry if their loved one relapses.

This reminds me of an elderly man I treated for high blood pressure many years ago. I gave him a month’s prescription of blood pressure medication, and when he came back, his blood pressure was good. I was pleased, and I wanted to keep him on the medication. He was angry. He said he was going to find another doctor. He thought the one prescription should have cured his high blood pressure so that he would never have to take pills again, and was disappointed with my treatment.

If we keep our same attitude toward addiction treatment, we are doomed to be as disappointed as my patient with high blood pressure. Addiction behaves like a chronic disease, with period of remission and episodes of relapse.

We have a lot of work to do. As this CASA publication shows, we have to change public attitudes with scientific information and do a much better job of training physicians and other health care providers. We should pay for evidence-based, high-quality addiction treatment, rather than spend billions on the medical problems caused by addiction as we are now doing.

Books for Addiction Counselors and other interested parties:

Here’s my list of favorite addiction-related books. Some are more traditional textbooks, and some were written more for entertainment, but all of these have helped me understand addiction and its treatment better. I highly recommend them all.

Principles of Addiction Medicine, ed. by Ries et. al.,  for the American Society of Addiction Medicine

            It’s expensive, but worth it. It contains comprehensive information about the whole field. If you’re going to work in this field for any length of time, you should buy it. And read it. It’s a mighty tome, and big enough to cause hernias if you lift it the wrong way, at 1408 pages. Get the 2009 4th edition.

Substance Abuse : A Comprehensive Textbook, by Lowinson et. al.

 Published by the American Psychiatric Association, it gives information about addiction from the psychiatrist’s perspective. More heavy lifting, at 1200 pages. This book may function better as a reference. Obviously, the information covered overlaps with information in Principles of Addiction Medicine. (But the latter is the better book, in my opinion) There’s also a distillation of information contained in a paperback version: Substance Abuse Handbook, by Ruiz, which is half the size at 500+ pages.

Addiction Treatment: Science and Policy for the Twenty-first Century, edited by Henningfield

            This is a small book packed with up-to-date information. If you don’t have much time to read (and I pity you) then this is one of the best books to stay informed. The book is divided into small chapters, written by different people who are experts on the given topic. It even gives space to minority opinions, like the chapter written by Stanton Peele. Once again, he describes in detail how apples are different than oranges. Yeah, I know, doesn’t seem worth discussing to me either. But that’s a short chapter.

High Society: How Substance Abuse Ravages American and What to Do About It, by Joseph Califano

            This book is packed with information and well-written enough to hold anyone’s attention. The book does a great job of describing the current U.S. situation with drug abuse and addiction. Critics of the book may say the book overstates the severity of addiction in the U.S., but sadly, I don’t it does. He cites extensive references, so go check them out yourself if you doubt what you read.

Rethinking Substance Abuse: What the Science Shows, and What We Should Do about It, edited by William Miller and Kathleen Carroll

            This book gives the latest update on which treatments are evidence-based, and discusses why these treatments aren’t being used to their fullest.  In this country, there is a gap between what we know to be the best kinds of treatments for addiction, and the treatments that are actually delivered. If you read this book, you’ll be better able to recognize which treatments we should be using. Some might find this book a little dry. The sections are written by people who know what they’re talking about.           

Addiction and Grace, by Gerald May

            This is still my all-time favorite. A small book, it talks about the nature of addiction, and the spiritual aspects of addiction and recovery. It describes the behaviors addictions can cause. It points out how all of us have addictions to varying degrees, which the author calls attachments. These attachments may not be to drugs, but they can be to activities, people, or behaviors.

Motivational Interviewing, by William Miller

            This book, along with Stages of Change by Prochaska and DiClemente describe the nuts & bolts of the motivational interviewing techniques. It goes into great detail about how MI is done, and points out the underlying reasons why this method works. Many people think they already “do” motivational interviewing, and they may – but reading this book will help you do it better. This method really works well with chronically angry clients.

Women Under the Influence, by the National Center on Addiction and Substance Abuse (CASA)

            Probably the most extensively researched and annotated book describing addiction in women. Not only is the book itself interesting and educational, it has dozens of useful references. Be sure and check out CASA’s other books, most of which can be downloaded for free from their website: “You’ve Got Drugs,” about controlled substances access via the internet, “Shoveling Up,” about the cost of addiction to society, and “Under the rug” about how addiction is under diagnosed in some groups.

 I could go on and on, but this is a start….

Oh. Of course. I need to mention my all-time, number one favorite book of all time: Pain Pill Addiction: A Prescription for Hope, by me. It’s at the publisher’s now, and I am hoping it will be out by early September.