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Mental Health Matters: Drug treatment industry a failed therapeutic enterprise

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After Prohibition was repealed, government expanded the laws criminalizing drug possession (See “Drugs: America’s Holy War” by Arthur Benavie).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.

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. He can be reached for comment at adwhyman143@gmail.com.


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