As an independent researcher, professor, and clinical officer in many venues for more than forty years, I am an insider who has grown to love struggling addicts and I invite you to face with me some of the elephants living in our rooms. First, let me be clear in that I am not implying that those who dedicated their lives to the treatment of addiction are anything less than unsung heroes. This is a field that has evolved driven by dedication and caring with little support from mainstream medicine. What I am saying is that many have been throwing darts with blindfolds on from a questionable foundation.
Imagine the following scenario: The test results are back, you need heart surgery. Because the disease is progressive the operation should take place in the next few weeks. What are your options? You can fully trust your physician and schedule your operation. You can see another doctor for comparable results. You can easily access the credentials of your treatment providers. You can easily find outcomes for the hospital, your surgeon, and your diagnosis. Finally, you can access research or articles about the most progressive treatment available, and if you are totally thorough, you can compare costs of treatment. This rarely exists in drug addiction treatment.
A while back a close family member requested inpatient treatment for her addiction. After forty-eight years in the field you would believe this would be an easy task for me—it was anything but. As a scientist and clinician I am able to access much of what is proposed to define quality of care. I pride myself on being on top of the research and know many of the treatment centers that have good reputations. That said, I had no method to determine which program would best suit my family member and no method of determining quality of care related to outcomes. Comparable data was not available, so I chose a place that met the minimum standards I have set for care. A lay person seeking treatment for a loved one is simply lost in the woods and could more easily access information about a vehicle they would like to purchase than reliable information regarding treatment.
The Early Years
In what I am calling the “early years” of drug treatment, 1960 to 1990, treatment was at best an interpretation of the road to recovery viewed through the myopic lens of one or more individuals by virtue of “having been there.” Pseudoscience presented under the mantel of science was common. Syndromes were described in detail with little evidence that they existed in the real world other than by anecdotal information. The roots of these early programs were represented by two major tracks: those with drug addiction and those with alcoholism. Alcohol and drug addiction were viewed as disparate challenges in separate government agencies and treatment centers to include separate wards in psychiatric hospitals.
The fellowship of Alcoholics Anonymous (AA) by this time had become well established in the US. For some treatment programs, AA quickly became the basis for what was called “Twelve Step” treatment programs. AA is an international, mutual-aid fellowship founded in 1935 by Bill Wilson and Dr. Bob Smith in Akron, Ohio. AA’s stated “primary purpose” is to help alcoholics “. . . stay sober and help other alcoholics to achieve sobriety” (AA Grapevine, 2013). With other early members, Bill Wilson and Bob Smith developed AA’s Twelve Step program of spiritual and character development. AA’s initial Twelve Traditions were introduced in 1946 to help the fellowship be stable and unified while disengaged from outside issues and influences. The Traditions recommend that members remain anonymous in public media, altruistically help other alcoholics, and that AA groups avoid official affiliations with other organizations. They also advise against dogma and coercive hierarchies. Subsequent fellowships such as Narcotics Anonymous (NA) have adopted and adapted the Twelve Steps and the Twelve Traditions to their respective primary purposes (Gross, 2010).
The Twelve Step treatment programs were faced with a dilemma presented by these Traditions and in particular Tradition eight of AA: “Alcoholics Anonymous should remain forever nonprofessional, but our service centers may employ special workers” (AA Grapevine, 1952). Some viewed these Twelve Step treatment programs as violating the traditions of AA. In addition, Twelve Step work and AA meetings on the campus of treatment programs gave fuel to these concerns. In the appendices of the Big Book, Bill Wilson wrote, “Alcoholics Anonymous should remain forever nonprofessional. We define professionalism as the occupation of counseling alcoholics for fees or hire. But we may employ alcoholics where they are going to perform those services for which we may have to engage non-alcoholics. Such special services may be well recompensed. But our usual AA ‘Twelfth Step’ work is never to be paid for” (AA, 2001). Some of these concerns remain today, particularly in treatment programs that do not employ a professionally credentialed and licensed staff. It is difficult to convince payers to reimburse treatment programs that primarily rely on services which can be easily found in the community and are not supported by mainstream behavioral health science.
The Synanon organization, initially a drug rehabilitation program, was founded by Charles E. “Chuck” Dederich Sr., in 1958 in Santa Monica, California. By the early 1960s, Synanon had also become an alternative community, attracting people with its emphasis on living a self-examined life, as aided by group truth-telling sessions that came to be known as the “Synanon Game” (Yablonsky, 1965). According to an article in Mother Jones, “Synanon was discredited in the late 1970s and 1980s as its violent record was exposed” and it shut down permanently in 1991 (Szalavitz, 2007). It has been called “. . . one of the most dangerous and violent cults America had ever seen” (Novak, 2014). As the story goes, Chuck went to his doctor, who informed him he must stop smoking. When he returned to the facility he informed all that smoking was no longer permitted and about 50 percent of the residents left the program the next morning (Yablonsky, 1965). Many of these folks returned to their hometowns, some with sustained recovery from heroin, and proceeded to open treatment centers known as “Therapeutic Communities” (TCs) to treat drug addiction.
In the early TCs one of the rewards for completing the program was to “get your wings,” which meant going out with a staff member and getting drunk. At the early TC conferences, a hospitality suite filled with expensive liquor was commonplace. I experienced the above personally as a member in an early TC.
Third-party payers began to pay for treatment based on arbitrary standards designed to protect the bottom line, such as two twenty-eight-day treatments in a lifetime separated by thirty days. Although the disease concept of addiction was taking hold, there was little evidence that treatment was supported by science. The field was not at all unified and even respected leaders could not agree on whether addiction was a disease. These third-party payers (such as large insurance companies) began to pay for treatment, which resulted in significant growth in the treatment industry. Runaway costs without outcome data in part resulted in the managed care correction, which took the treatment community by storm. The Health Maintenance Organization Act of 1973 directly promoted the development of HMOs. In the 1980s, the prospective payment system (PPS) for Medicare was introduced to curtail health care costs in hospitals. Hospitals were reimbursed a predetermined amount for each diagnostic-related group (DRG). DRGs were intended to motivate hospitals to increase efficiency and minimize unnecessary spending, as they would only be reimbursed a set amount for each diagnostic category (Meyer, Rybowski, Eichler, 1997)*. DRGs were viewed by providers as arbitrary and capricious. Many inpatient programs were forced to close their doors, while others scaled back their systems to comply with DRG reimbursement. The major problem here was that the standards for care set by insurance companies were as arbitrary as the treatment itself, only this time with an eye on curbing the runaway cost of treatment.
The Middle Years
These years—1990 to 2010—were filled with great revelations, almost all based on intuition. We began to hear, with great authority from treatment providers, terms like “dry drunk syndrome,” “enabler,” “codependency,” “mentally ill chemical abuser,” and others. Vernon E. Johnson published I’ll Quit Tomorrow: A Practical Guide to Alcoholism Treatment (1990), which spurred the growth of an intervention profession based on what some believed were less than ethical meetings where patients were tricked into coming to a meeting with family and friends to be confronted regarding their alleged addiction. This diagnosis was often made by poorly trained individuals, sometimes even before meeting patients and as a result of conversations with loved ones. Desperate families paid high prices under the threat that their loved ones would die without these interventions.
Treatment programs rebounded fueled by celebrity deaths and a growing belief that addiction is a disease. Today most agree that addiction is a disease and rather than rely on scientific diagnosis, default to what is called the “biopsychosocial model” of assessment. What we do know is that if this is a disease, the medical community has not invested much in either research or treatment.
The American Society of Addiction Medicine (ASAM) Patient Placement Criteria, first published in 1991, provides a common language to help the field develop a broader understanding of the continuum of care. The second edition (PPC-2) was published in 1996 and a revised second edition (ASAM PPC-2R) was published April 2001. Although this was a major step in the right direction, it did very little in developing applied standards of care other than admission requirements for levels of care based on patient severity (Mee-Lee, Shulman, Fishman, Gastfriend, & Griffiths, 2001).
The DSM-IV provided more confusion than science and categorized users as either being an “abuser” or “dependent” (APA, 2000). As a result, many treatment programs relied on these designations to determine who had the disease and who was just making bad decisions as the severity continuum was basically ignored.
Based on the increasing need to demonstrate program efficacy facing Health Care Reform and Parity, many addiction treatment programs and payers have developed a renewed interest in program efficacy. The new ASAM Criteria (third edition) which is incredibly comprehensive, some might say to the extent that easy use becomes problematic, offers a mixture of science, anecdotal information, and intuition (Mee-Lee, Shulman, Fishman, Gastfriend, & Miller, 2014). That said, the ASAM Criteria represents the most efficacious treatment standards the field has to offer. The DSM-5 (APA, 2013), which has little application to treatment, appears to be more political than scientific and the severity continuum for addiction is represented by a numbers game (i.e., how many symptoms does one have rather than including the severity of these symptoms; Frances, 2013). Even with significant advances in neuroscience we have limited data that demonstrates that these sciences make a difference in the long-term recovery of patients.
Recent attempts to provide quality care include systems such as “value-based purchasing.” In the health care industry, pay for performance (P4P) is also known as value-based purchasing, the concept of which “. . . is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. This strategy can be contrasted with more limited efforts to negotiate price discounts, which reduce costs but do little to ensure that quality of care is improved” (Meyer, Rybowski, & Eichler, 1997). Although this is a good start and programs are rewarded for outcomes, there is little evidence of correlation between these outcomes and the efficacy of treatment. In other words, outcomes do not necessarily indicate that the treatment is of high quality and there is little effort to aggregate data so that outcomes may inform treatment in the future.
Another approach to defining quality, evidence-based models, may arguably be a significant step above care based on intuition and dogma. At the same time, questions of generalizability and lack of individualized attention to care plague this approach. As Norman G. Hoffmann, PhD, suggests, “Evidence-based treatments utilize a treatment model documented to be effective in controlled clinical research with no guarantee that it will work in clinical practice” (2012).
Given all of this, what about the research? There has been no lack of scholarly research emanating from prestigious universities such as Rutgers, Brown, and Yale, and Texas Christian University, among others. As early as 1970, the Drug Abuse Treatment Information Project (DATIP)—led by George Nash, PhD, and myself—began collecting outcomes on some of the very early treatment programs in the United States. In 1972 a national evaluation of treatment effectiveness based on outcomes titled the Drug Abuse Reporting Program (DARP) developed extensive outcome data along with post-treatment follow-up outcome studies on recovery evidence (Simpson & Sells, 1982). Dr. Hoffmann developed the Comprehensive Assessment and Treatment Outcome Research (CATOR) in 1980, the aggregate databases totaling over seventy-five thousand adults and eleven thousand adolescents. Project MATCH began in 1989 in the United States and was sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The project was an eight-year, multisite, $27-million investigation that studied which types of alcoholics respond best to which forms of treatment. Project MATCH studied whether treatment should be uniform or assigned to patients based on specific needs and characteristics. The programs were administered by psychotherapists and, although Twelve Step methods were incorporated into the therapy, actual AA meetings were not included (Project MATCH Research Group, 1997). Through several generations outcomes research in addiction continued to progress, with perhaps the Addiction Severity Index (ASI) being the most widely recognized (McLellan, Luborsky, Woody, & O’Brien, 1980).
Yet, with so many volumes of data collected over more than forty years, we are hard pressed to cite outcomes research that has actually informed treatment. Clearly, treatment for addiction has evolved very slowly compared to the advances in medical science as many programs cling to theories and practices that continue to be unsupported by science.
The bottom line is, when hard pressed, few treatment programs could scientifically defend their clinical systems or even know the impact of clinical practices on long-term recovery. Some providers refer to practices that have been included in treatment, such as CBT, as evidence that the program provides evidence-based treatment. This is a quantum leap, as few programs know the impact of these practices on long-term recovery.
Today the addiction field does not have a shared lexicon—if you are not a believer, just ask three different therapists what “recovery” means. There is little comparable data and we are challenged to find reliable outcome data that meets standards of scientific rigor. Baselines and benchmarks are elusive, and standards of care based on available certifications by accreditation bodies such as Commission on Accreditation of Rehabilitation Facilities (CARF) read more like boarding house requirements than the reflection of clinical efficacy.
What is Needed?
First and foremost is the need for research that informs care. Esoteric journal articles that add little to quality of care are rarely useful unless you are in an environment that requires publications to survive. As I read through volumes of research in peer-reviewed journals it is a rare instance to actually find conclusions that directly inform care. Outcomes that only promote treatment add to the confusion and lack of credibility. In addition, outcomes that simply measure utilization serve payers more than science and do not result in best clinical practices. Journals that are dedicated to informing practice based on research are sorely needed. We need to move beyond the reliance on SAMHSA’s evidence-based models of the past that have been plagued with issues of replicability, and in my opinion have done little to inform best practices in addiction treatment.
Here is a good example of what may happen when relying on cookie-cutter models rather than those that have scientific underpinnings. I remember working in the Middle East where I was contracted to evaluate a large treatment program for women. These folks paid $500,000 for an American evidence-based model of care where inpatient treatment lasted on average two years. At the end of my review I met with the board of directors and told them I had good news and not such good news. I informed them they could now treat four times as many women for the same investment by changing the program to six months rather than two years. They immediately recoiled and asked how they could do such a thing after spending $500,000 on the program. I informed them since they had no idea what happened to the women after two years, they may as well treat four times as many women for six months with the same apparent outcomes. This program needed to be supported by outcomes research that informed care based on cultural considerations.
Since there appears to be some consensus that addiction is a chronic relapsing brain disease, perhaps we can begin to guide treatment utilizing the same system that informs medical treatment. My prediction is that unless this happens there will be a major correction, much more severe than the managed care correction of the 1980s, and addiction treatment will eventually be absorbed as a legitimate specialty in the psychiatric community. We cannot continue to call this a disease and treat it with fifty-year-old practices that are not supported by science. Peer-to-peer support should have a greater role in early engagement and continuing care combined with treatment that is science driven. Treatment centers need to reevaluate clinical practices as they may not be poised to meet the needs of the addicted population moving forward.
As in the past, unless treatment providers and researchers band together to build the bridge from bench to trench, treatment will be dictated by utilization rather than clinical outcomes and at best the field will fall back into a managed care environment plagued by a crisis of credibility.
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