Pubdate: Wed, 08 Apr 2015
Source: Tahoe Daily Tribune (South Lake Tahoe, CA)
Column: Mental Health Matters
Copyright: 2015 Swift Communications
Author: Andrew Whyman
Note: Incline Village resident Andrew Whyman, MD, is a clinical and 
forensic psychiatrist. His column focuses on drugs, mental health and 
substance abuse in an effort to raise better awareness.


The seeds of a health care revolution in drug and alcohol treatment 
are just starting to germinate. The outcome is far from certain, but, 
with billions on the table, an epic battle is percolating.

Let's start with the convoluted back story. A hundred-plus years ago, 
drug and alcohol problems were generally viewed as moral weakness 
and/or personality defect confined to working class Caucasians or 
ethnic minorities. Alcohol and drug use was legal in America.

Then, the temperance movement produced alcohol Prohibition in 1920.

America's drive to establish international prominence led Theodore 
Roosevelt's Administration to orchestrate the International Opium 
Convention of 1912, the first international drug control treaty.

Fallacious and racist stereotypes about certain groups who used drugs 
- - i.e. Chinese, Blacks, Mexicans going on murderous rampages, 
compromising the virtues of San Francisco society matrons, or 
engaging in herculean sexual feats - led to the gradual 
criminalization of drug use (See "Drugs, Society and Human Behavior 
"by Carl Hart and Charles Kgir).

None of this was based on science or factual data about the negative 
impact of drugs on society. All of it reflected the culture and 
politics of the time ("The American Disease: Origins of Narcotic 
Control," David Musto, M.D., 1973).

When a small group of physicians was arrested by the federal 
government for prescribing opiates to treat addiction, doctors 
withdrew from the drug treatment enterprise entirely.

After Prohibition was repealed, government expanded the laws 
criminalizing drug possession (See "Drugs: America's Holy War" by 
Arthur Benavie). Lengthy prison sentences for drug possession became 
the norm, and eventually included "life mandatory minimums," i.e. a 
life sentence with no chance of parole.

Jail and prison populations exploded, as did state and federal 
budgets to feed the cost of these laws.

Medical research about addiction was discouraged and evidence-driven 
treatment resources were few. Academic medical centers rarely 
provided either inpatient or outpatient treatment programs.

Given the paucity of medical care and evidence driven treatment, 
non-medical providers of care filled the vacuum. Alcoholics Anonymous 
and its derivative 12-step programs became the norm and the 
predominant treatment model.

Thousands of private residential treatment programs opened around the 
country owned by entrepreneurs and staffed by former addicts (See 
"Inside Rehab" by Anne Fletcher, 2013).

In more recent years, a host of factors has altered the treatment landscape.

As jails and prisons filled to capacity and beyond due in no small 
part to the addict population, both the financial and social costs of 
incarceration accelerated.

Recidivism of released prisoners was enormous. Rates of substance 
abuse and addiction showed no signs of lessening.

The criminal enterprise of illegal drug manufacture and sales 
continued to be highly profitable and immune to American-driven 
military efforts around the globe to eradicate drugs at their source.

The "War on Drugs" commencing in the 1970s was increasingly seen as a failure.

Overlapping with these factors, biological research produced an 
understanding of changes in brain chemistry associated with 
addiction. The field of Addiction Medicine gained credibility and confidence.

Scientific papers began to show the usefulness of medications in 
treating opiate addiction and alcoholism. These findings contradicted 
central tenants of 12-step programs in the private and the criminal 
justice systems of treatment.

Comprehensive surveys of the drug rehabilitation industry 
demonstrated that most residential treatment programs failed to 
provide effective care ("The Sober Truth: Debunking the Bad Science 
Behind 12-step Programs and the Rehab Industry," Lance Dodes, M.D., 
and "Handbook of Alcoholism Treatment Approaches").

An overview of the central failings of the 12-step model of treatment 
just appeared in the April 2015 issue of the Atlantic Magazine.

Detailed studies exposed the meager qualifications of most 
"counselors" in the drug treatment industry.

A damning 2012 report by the National Center on Addiction and 
Substance Abuse at Columbia University compared the current state of 
addiction medicine to general medicine 100 years ago. It notes that 
many states do not require licensing or certification of addiction 
counselors, that patients see a "broad range of practitioners largely 
exempt from medical standard."

Each of these data threads, woven together, leads to the conclusion 
that, with rare exception, the drug treatment industry is a failed 
therapeutic enterprise, one that promises much, at substantial cost, 
while achieving precious little.

Now, add the Mental Health Parity and Addiction Equity Act. And the 
Affordable Care Act providing insurance coverage to millions while 
requiring improved efficiencies and treatment outcomes.

These initiatives should threaten the future viability of the present 
drug treatment industry by requiring markedly enhanced professional 
qualifications for providers and scientific metrics showing that 
treatment works. Of course, with billions at stake, you never know. 
- ---
MAP posted-by: Jay Bergstrom