I was talking this evening with my distinguished friend and former Delaware News Journal reporter, Adam Taylor. I work as a counselor in an abstinence-based outpatient treatment facility; Adam now works in PR for a company that uses medication-assisted treatment modalities. We were discussing the state of substance use treatment in light of the new opiate/heroin epidemic. With a median age of 50, we remember when heroin was mostly confined to the inner cities, and also when drug treatment and recovery were dominated by abstinence-based, 12-step philosophy. We also remember a time when young people were not dropping like flies.
The times they are a-changing. Our regime-toppling and nation-building in the middle east has resulted in the unregulated distribution of literally tons of heroin. Combine this with a prescription-palooza back home, and you have the makings of a junkie apocalypse. Heroin is the new marijuana; except Poppy is far more enchanting than her cousin Mary Jane, and far more deadly. Our treatment system has been woefully unprepared. Insurance companies mete out inpatient treatment a week at a time and often implement “fail first” requirements for admission. Treatment facilities, increasingly cash cows for large healthcare corporations, not only refuse to disclose success rates but in fact have no standardized way to measure them; instead they cite sparkling testimonials from alumni on their Facebook pages as evidence of their efficacy. Recovery housing remains largely unregulated and unsafe. The entire system seems to want to put the kibosh on the mounting evidence that what we are doing is simply not working.
The nearly century-old dogmatic conception of addiction dictates that, regardless of the drug, the affliction and the addict remains the same. One only needs to read David Sheff, Marc Lewis, and others to understand that different drugs have different effects on the brain, and different prognoses for recovery. The age of onset has shifted as well. My friend Adam writes:
Recovery for these young addicts requires a uniquely difficult path. Heroin is a powerful drug, with a particularly hard bottom that comes quickly for the addict. While some alcoholics can function for decades before they finally seek help in their 50s or 60s, defeated heroin addicts are walking into rehabilitation centers in droves in their teens or early 20s.
On the whole, what the treatment and recovery communities are finding is that this new wave of addiction is not responding well to the traditional models. It’s not that the disease model, the 12-step paradigm, and abstinence-based treatment are wrong or flawed…they have been very successful in their own right. However, the one-size-fits-all prescription for addiction that still prevails across the nation is faltering and failing under these very different conditions. I know there are those who will say, “I/my friend recovered using abstinence…”-yes, you did, they did, and so did I. But by and large, the system is performing very poorly. We can, and must, expect and demand better outcomes.
Up until recently, SUD has been an anomalous malady which, while enjoying medical status in legislation and funding, somehow defies the usual protocol for medical treatment. When treatments for other chronic illnesses are ineffective, providers try new and different methods. Professionals who refuse to embrace more effective treatments are either left by the wayside or held liable for malpractice. Success and recovery rates are published with supporting empirical evidence. New medications are used without shame or stigma. No one tells the diabetic he is not truly in recovery because he uses insulin. Yet, somehow, our treatment of substance use disorders remains mired in the last century.
One thing that we have known for years is that a length-of-stay approaching 90 days has the best outcome. Insurance companies and managed care, of course, have other ideas, and so we have tried to find other ways to keep clients engaged in treatment, whether it be outpatient, alumni groups, or even online support. The idea of post-treatment engagement is greatly facilitated by the reduction of stigma, which has historically had people skulking away from treatment like a bad one-night stand.
The other thing that has been known for some time but is just now starting to become generally accepted is that substance use is manifested in manifold ways and at diverse levels of severity. This seems to be the hardest part for us to embrace; the idea of treatment diversity; the basic idea that we cannot treat everyone the same way, and that there is no panacea. The utopian extension of this concept is the complete individualization of services, which in its purest form may be impractical. This entails not only treating people differently based on their disorders, but also having different styles and approaches to treatment, based on the individual experience of the disorder.
One of my favorite conceptualizations of substance use disorders is the developmental/learning model. Human behavior is often studied in developmental terms, and so it makes a lot of sense to view SUD in this way. Many people who have recovered from substance use disorders have simply grown out of them; they may not have undergone treatment, may not have utilized traditonal support groups, and may not even consider themselves as being “in recovery”. Those who have succeeded via the traditional route also seem to share the common factor of personal development, either coincidentally or through a structured process such as the Twelve Steps. For young addicts facing tangible challenges to developmental growth, spiritual development is premature and can often seem either forced or contrived. Often, young heroin addicts simply do not live long enough to truly benefit from the traditional methods.
Increasingly, treatment modalities are focused on keeping the person alive and healthy until they can either find the motivation to change, or until their natural stage of development is more conducive to recovery. Of course, these modalities do not consist of passive waiting. Motivational counseling techniques are increasing in popularity as evidence of their efficacy mounts, and counselors now possess a wider range of skills than those which comprised the old confrontational, problem-focused approach. In a developmental/learning model, empowerment and strength-building are essential, and the name of the game is solutions. Rather than an approach which holds that “no human power” can be effective, these strategies focus on building autonomy and self-efficacy; the hallmarks of lasting change. Still, there are many who cling stubbornly to the old ways, often valuing dogma over best practice. I worked for a treatment facility in which the lead counselor scoffed at motivational interviewing as ineffective compared to the agency’s 12-step, confrontational style. She was once overheard saying, “The other halfway house makes them scrub the bathrooms with toothbrushes; we don’t do that, so I guess we’re pretty motivational.”
The Office of National Drug Control Policy of the White House has been holding webinars and discussing the addiction epidemic. At the end of June this year, there was one for parents, and my friend Cindy sent me these bullet points:
- Recognize that prevention has to start in middle school
- Mandate Prescriber education nationally
- Naloxone access expansion
- Reduction of opiate prescriptions
- Increase access to treatment and facilities for long term recovery
- Medical assisted treatment (MAT) to be the standard of care
- Recognize the stigma attached to substance use–change our language, integrate care in primary care offices, and barriers to ongoing care such as criminal records and the impact on other things like housing, jobs etc
- Working with international partners to diminish source of drugs ( Mexico, etc)
When I went to the White House website to follow up, I found all kinds of writing about Motivational Interviewing. The future of substance use treatment is clear and has been laid out for us. How long will it take, and how many more have to die, before we read the writing on the wall?