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KICKING THE HABIT

We Know What Works

So when will we break the cycle of failed treatment?

In an average year, this is Dane County: 426,000 people, sparkling lakes, a stable economy, churches, synagogues and mosques, top-ranked public schools, family farms, arts and music, lovely parks, countless festivals and more high school graduates and restaurants per capita than just about anywhere else in the nation.

And, in the same average year, this is Dane County on drugs: 33,290 people in need of drug treatment, 2,900 driving under the influence arrests, 2,600 liquor law violations, 1,400 controlled substances arrests, 895 liquor-licensed taverns and stores, 125 deaths related to alcohol and other drug abuse ( AODA ), 30 state-certified treatment programs, 25 drug treatment center beds, four drug-related homicides, one methadone clinic, one women-only drug treatment center, zero tolerance in schools, zero in-patient treatment centers for teen-agers, zero chance, still, that we're taking any of this seriously enough.

"I think too many people in our society are naive about how significant the drug issue is," says Lieutenant Bill Housley of the Dane County Narcotics and Gangs Task Force.  "Substance abuse problems drive a very, very high percentage - I would put it in the area of 60 to 70 percent - of other societal ills, from domestic abuse to neighborhood problems to thefts, robberies, you name it, all the way up to homicides."

The State Bureau of Substance Abuse estimates that 10 out of every 100 people - 10.4 percent - are in deep AODA trouble.  In Dane County, that trans lates to the aforementioned 33,290 adults.  Half those people, the bureau says, are already addicted to one or more drugs.  The other half are well on their way.

Their problems are with alcohol - still the most used, abused and addicted-to drug in Wisconsin - and other drugs ( hence the increasingly familiar AODA acronym ), including cocaine, methamphetamines, Ecstasy, heroin and other opiates, and all manner of prescription medication.  Marijuana, while not necessarily addictive, makes the AODA list by being the second-most abused drug in the state.  Marijuana possession arrests in Dane County increased 445 percent from 1989 to 1999

To be clear, experts say, not everyone who abuses a drug will become addicted.  But substantial numbers of people progress from use to abuse, and many of them become addicted.  All are in dire need of comprehensive and sustained treatment, yet only 1 in 10 is receiving anything that even comes close.  Primary care physicians, for example, routinely miss addiction-related symptoms.  Local clinics are so backlogged that people wait for weeks or even months for treatment.  Ground-breaking research hasn't yet been integrated into standard treatment practices.  The amount of treatment offered specifically for women or teens falls far short of meeting the demand for it.  Adequate health insurance coverage for addiction treatment is a blue-moon exception rather than the everyday rule.

To do better than treating one out of every 10 addicts - and there's an awful lot riding on whether we can - we're going to have to rethink pretty much everything we thought we knew about drug addiction.

Big surprise: It's not working

If you were a drug addict in the 1980s, the treatment industry wants you to know - sorry! - that those confrontational, shame-inducing, one-size-fits-all behavior modification programs it prescribed back then were, ultimately, about as effective as a good leeching.  Of course, this is not news to your loved ones, who eventually tired of watching you fail to kick your habit and threw up their hands and walked away.  But now everyone knows what went wrong.  Your problem, it turns out, was as much medical as it was behavioral, and you needed help that you weren't getting in treatment.

"We used to think a drug was a drug was a drug, and we used to have the same treatment plan for virtually everyone," says Mike Florek, longtime director of Tellurian drug treatment programs in Madison.  "It was basically 'be abstinent and deal with denial.' And we never used to accept people on medications in our programs.  Now we've found that there is so much more involved in the recovery process, that each individual is different, that phar-macological approaches are often valuable.  We know so much more about how to help people with addiction disorders."

Then came the 1990s.  If you were a drug addict during that decade, the judges and politicians who sent a million of you to prison in order to fight the war on drugs would like you to know that - their mistake! - drugs are cheaper and more plentiful than ever and the rate of addiction to them may have actually increased.  Perhaps it seemed like a good plan at the time - if treatment didn't work then incarceration surely would - but now even President George W.  Bush is rethinking the notion of mandatory prison sentences.  It turns out that your problem was as much medical as it was criminal, and you needed help that you weren't getting in prison.

And if you're a drug addict today, the scientists who are researching the effects of various mind-bending chemicals on the brain would like you to know that their studies prove what you and your despairing family and your "just say no" insurance company and even our collective and frustrated citizenry have always suspected to be true.  Your problem is as severe and complex and - you guessed it - as medical as anyone could ever have dreamed.

"Hundreds, at least, of profound, very clear neurochemical changes in the brain are associated with addiction," says Ann Kelly, chair of the University of Wisconsin-Madison neuroscience department.  "And the parts of the brain that are affected are the parts that are important for normal function: decision making, cognition and emotion.  You start to walk a little on thin ice when you say, 'This is what causes addiction,' because people who take drugs also cause addiction, you know? But the current thinking based on research is now that once a person has gone down the path of severe addiction he or she has, unfortunately, very little control over certain feelings, emotions and urges."

So if you're a drug addict today, we'll state the ever-increasing obvious: You're up against it.  The latest studies show that your problem is biological and twice as hereditary as heart disease.  It's also possible you were predisposed to addiction from the very beginning.  And you've exacerbated things beyond measure by ingesting drugs that have fundamentally altered the way your brain works.  For a long time, certainly.  Forever, possibly.  Scientists have proved that your brain can go months, maybe years, without a drug and then suddenly flare into a relapse at the slightest provocation.  A couple of weeks in an 80s-style self-help program isn't going to change that.  Nor will a couple of years in prison.

We'd ask you what you're going to do about it, except that the studies have been pouring in for the past few years to show that the non-addicts are in just as deep as you are.  In fact, everyone in our com-munity has a stake - one larger than yours, in some ways - in making sure that, this time, the help you really need is the help you actually get.

What it costs: a sampling

In fact, experts are sounding an increasingly insistent alarm about the staggering financial costs of addiction.  According to a national study done in the early 1990s, for example, nearly one-third of all Medicare and Medicaid payments are spent not on treatment of addiction but on treatment of its accompanying medical complications, including liver disease, heart disease, gastrointestinal problems, high blood pressure and, for purposes of this statistic alone, smoking-induced emphysema and lung cancer.

Another study from the late 1990s, shows that 13 percent of the overall budget of every state in the nation is used to deal with the problems that drug addiction causes in health, corrections, public safety, child welfare and other services that depend on state funding.  The Centers for Disease Control data show that alcoholism alone costs Wisconsin in excess of $1.5 billion annually.

A host of other studies, though, bring the cash implications into the starkest relief.  They demonstrate one remarkable fact: Anywhere from $7 to $12 in medical care, corrections administration, education funding and social spending is recovered from every dollar invested in addiction treatment.  In light of this, our current policies on drug treatment seem like the fiscal equivalent of bailing water into a sinking boat.

Redefine it, then fix it

Past failures, current advances, a smoldering crisis.  Our best hope, say experts, is to redefine addiction, wholesale.

"We need to consider addiction like any other chronic illness," says Michael M.  Miller, M.D., medical director and manager of the NewStart treatment center at Meriter Hospital and secretary of the American Society of Addiction Medicine.  "We need to provide insurance benefits for chronic disease management and build our treatment-delivery systems around chronic disease models.  If we do that, we have a chance of significantly reducing the prevalence of addiction in our citizens, and this will be a cost-saving intervention in the end."

Miller is talking about a couple of things here.  One is the Research to Practice Initiative, a statewide attempt to get the latest developments in addiction treatment into the hands of the providers who work with addicts.

The other is parity, a legislative mandate that would require insurers and managed care providers to treat addiction the same as asthma and diabetes and any other medical condition.  Thirty-four states have already passed mental health parity laws which, for all practical purposes, reclassify addiction disorders from behavior problems to medical conditions.  The American Society of Managed Care Professionals and the American Society of Addiction Medicine have jointly endorsed parity, as have many other medical organizations.

A parity bill, SB-157, was introduced by state Senator Mary Panzer ( R-West Bend ) last year and has passed in the Senate but not in the Assembly.  Wisconsin insurers, then, still operate under a 1976 state mandate that requires them to provide up to $7,000 per year in mental health services.  The way this amount is divided up generally leaves enough for three weeks of outpatient - or one week of inpatient - addiction treatment.

That's a fraction of what physicians and treatment providers now say should be the gold standard of addiction treatment: after comprehensive assessment, detoxing and perhaps a short inpatient stay, addicts should receive at least a year and preferably more of regular outpatient counseling, group therapy and involvement with a support group such as AA, psychotherapy as indicated, along with appropriate anti-craving and mood-stabilizing medication, or both, and help with co-occurring problems such as mental illness and family dysfunction.  Such treatment, they say, should be available on demand.  And refresher courses - think of it as booster treatment - would be musts for addicts who relapse.  Treatment of substance abusers would have its own variation on these themes, designed to help abusers manage their problems back into responsible use or abstinence.

Routinely providing less, according to Mike Bohn, M.D., an addiction specialist who serves on the UW clinical faculty and consults for the State Bureau of Substance Abuse and WPS Insurance, is like treating a cancer patient with only half the recommended course of chemotherapy.

"And what you do, then," he explains, "is you select out those people who are least successful with treatment.  And they then have recurrent problems.  And they cost a lot of money."

Some of the barriers to parity are obvious.  Addiction has behavioral and psychological components to it that other chronic diseases don't.  Diabetes and asthma do not, for example, drive any percentage of crime, let alone more than half of it.  Also, opponents of parity fear that it could bureaucratize the aspects of treatment that are working, and institutionalize some that aren't.  It's also a tough sell as an insurance add-on in a year during which employers, who decide what's covered under employee health plans, are facing premium increases that approach 30 percent.

Insurance groups, for their part, are reluctant to take a step that would increase their upfront costs, especially when it is government spending that stands to recoup a lot of the investment.  And corrections officials aren't anxious to have to fund comprehensive screening and treatment for the addiction disorders and abuse problems that, according to all estimates, plague the majority of their inmates.

Despite all that, though, observers say the biggest obstacle to medicalizing addiction isn't the lack of parity.  It's the depth of the stigma.  Stigma is what keeps non-addicts seated on their hands and prevents addicts and those in recovery from speaking up.  It is, says Miller, "the primary driver of our current situation."

Bohn agrees.  "People overcome cancer and they proudly wear a T-shirt saying it," he says.  "Addiction is the only illness that has a recovery group that by definition is anonymous.  It is that stigmatizing.

Shangri-la County

A few local efforts are beginning to shine through.  "Dane County really is Shangri-la when it comes to drug treatment," says one observer.  Alcohol was decriminalized by state statute in the 1970s, for example, meaning that someone incapacitated by alcohol goes to a medically supervised de-tox facility to recover and not to a drunk tank to "sleep it off." That's standard operating procedure here, but many other counties lag a quarter-century behind the law, and a jail cell is still their venue of choice.

There's the Dane County Drug Treatment Court, the only such program in the state, where the Honorable Stuart Schwartz has since presided over 100-plus people who've exchanged drug-related jail time for extensive treatment.  A recent follow-up survey shows that people who complete the program backslide 22 percent of the time, compared with the national recidivism average of 56 percent.

We have one of the few women-specific treatment centers here, the ARC Center for Women and Children.  "Women have family, social and abuse issues that men often don't," says Flo Hilliard, the project director for the Wisconsin Women's Education Network on Addiction and Recovery.  "They have much higher co-occurring rates of depression.  And there's been lots of research that has shown that women do much better if they have treatment services that are sensitive to their special needs."

A more sweeping attempt at reform was undertaken late last year when Dane County Executive Kathleen Falk tabbed $1 million of the county's capital budget for a facility for jail inmates with abuse problems and addiction disorders.  "Too many people in our jail are there because they abuse alcohol or other drugs," she said in her December announcement, "and too many are released without having changed that destructive behavior." Helping them, she predicts, will reduce jail overcrowding and recidivism and will better protect the public.

Addiction is not a curable disease.  That consensus has been reached.  It's not, after all, resolvable with antibiotics or surgery.  That it's a weakness of character or a moral failing or a criminal flaw was long assumed and has, in fact, driven much of the public policy and private opinion on addiction treatment.  But the sheer numbers and diversity of people who become addicted - and who make it into recovery - defy such easy judgment.  Science and experience have shown us what addiction is not.  Now comes the important part: deciding what, exactly, it is.

Mary Feingold is a contributing writer to Madison Magazine.