Viewpoint: We Need to Rethink Rehab
Our current treatment system for addiction is unnavigable, unregulated and unsuccessful. It needs an overhaul
When my son Nic became addicted to methamphetamine and other drugs, I was panicked, overwhelmed and desperate to save his life but had no idea what to do. I’d heard about rehab, where you send people with drug problems, but I soon learned that there’s no standard definition of it; instead it’s a generic word for a wide variety of treatments, including some that are outrageous. Past-life therapy? Exorcism? Tough-love programs in which patients are made to scrub bathroom tiles with a toothbrush or cut grass with scissors? Even in more-typical rehabilitation programs, patients are not seen by licensed practitioners — no doctors or psychologists — only self-anointed “experts” with no training or credentials, unless you count their own recoveries from addiction to heroin, alcohol or other drugs.
I chose a rehab center for Nic that was recommended by a friend who had sent her son there. The program lasted 28 days, after which he relapsed. Over the next six years, he was admitted to six residential treatment programs and four outpatient programs. He would do better for a while, but then relapse. Each relapse was crushing. I thought he might die.
Every year in the U.S., 120,000 people die of addiction. That’s 350 a day.
I’ve already written about my experience with Nic, but for my new book, Clean, I wanted to understand why so many suffer and die. So I undertook an investigation of the treatment system that so often fails. I learned that no one actually knows how often treatment works, but an oft-quoted number of those who abstain from using for a year after rehab is 30%. Even that figure is probably high. “The therapeutic community claims a 30% success rate, but they only count people who complete the program,” according to Joseph A. Califano Jr., founder of the National Center on Addiction and Substance Abuse and a former U.S. Secretary of Health, Education and Welfare. “Seventy to eighty percent drop out in three to six months.” Over the course of my research, I did hear one statistic that I trusted. Father John Hardin, chair of the board of trustees at St. Anthony’s, a social-services foundation with an addiction-recovery program in San Francisco, told me, “Success for us is that a person hasn’t died.”
The treatment system fails because it’s rooted in an entrenched, inaccurate view that addicts are morally bereft and weak. If they weren’t, the belief goes, they’d stop using when drugs began to negatively impact their lives. Most treatment centers in the U.S. are based on an archaic philosophy that’s rooted in the 12-step model of recovery. These programs have saved countless lives, but they don’t work for a majority of people who try them. It’s not a fault in the program itself. Its founder, Bill Wilson, wrote, “These are but suggestions.” But many rehabs require them. This is particularly problematic for teenagers and young adults, the very people most susceptible to addiction. Twelve-step programs require people to accept their powerlessness and turn their lives over to God or another higher power. Many adolescents question religion, and in general teenagers aren’t going to turn their lives over to anyone.
In many 12-step-based programs, patients are berated and yelled at if they don’t “surrender” and practice the steps. They’re warned — in some cases, threatened — that if they don’t, they’ll relapse and die. It can become a self-fulfilling prophecy. Addicts don’t think they can be treated if they don’t embrace the program, and so they give up on the idea that they can be helped. They do relapse. Some die. When they do, they’re blamed. Blaming the victims is convenient for those who treated them, because it absolves them of accountability. They can take credit when their patients get well, but they take no responsibility when they don’t. But the bigger problem with 12 steps is that a growing body of evidence has proved that addiction isn’t a choice subject to willpower but a brain disease that’s chronic, progressive and often fatal.
Though they aren’t available to many people who need them, there are alternatives to 12-step-based treatments that can improve an addict’s prognosis. These treatments don’t rely on best guesses or tradition. Rather than require contrition and prayer, they use therapies that have proved effective in clinical trials, including cognitive-behavioral therapy designed to train addicts to recognize and interrupt the cues that trigger the relapse mechanism; motivational interviewing, a therapy approach widely used to treat many psychological disorders that helps addicts engage in treatment; contingency management, which essentially rewards addicts for clean time; and psychopharmacology.
Absurdly, the latter remains controversial in the addiction-treatment community, with some factions claiming that you don’t treat drug problems with drugs. But you do, at least in many cases. One of the most effective interventions for opiate addictions is medication, including the opiate agonists and partial agonists methadone and Suboxone. These drugs have proved so effective that Steve Shoptaw, an addiction specialist and psychologist in the department of family medicine at UCLA, says, “I won’t treat opiate addicts unless they take Suboxone.” Most researchers agree that no single therapy is appropriate for every addict. Often they’re used in concert. An effective treatment regimen may include AA, but only for those patients who are open to it.
Currently there’s a chasm between these and other evidence-based treatments (EBTs) and rehab programs. Every day addicts fall into it, and many never make it out. Most people in need find themselves in the same frustrating position I was in when I was desperate and overwhelmed, shopping for programs and doing the best I could to navigate an unnavigable system that’s also largely unregulated. In many states, anyone can open a rehab program — no licenses or accreditation are required.
This is slowly changing. More people are being educated about the fact that addiction is a disease and therefore requires treatments based on the medical model. The more consumers are educated and demand EBT, the more the billion-dollar rehab industry will adapt and offer it. That is, the industry will adapt or it will die and be replaced. In the meantime, those who need treatment must do the best they can to find programs that offer EBT. The place to start is by receiving an assessment from a psychologist or psychiatrist who is trained in addiction medicine. Even finding these professionals can be a challenge, but the American Society of Addiction Medicine maintains a directory that is available online. A competent doctor can determine the severity of addiction and the presence or lack of co-occurring psychological disorders and prescribe the next step. It may include a brief intervention, therapy, psychopharmacology, an inpatient or outpatient program that offers quality care or a combination of these things.
Meanwhile, the National Institute on Drug Abuse is funding the Treatment Research Institute in Philadelphia, directed by Tom McLellen, the former deputy director of the Office of National Drug Control Policy, to create and test a science-based method of rating treatment quality and determining the likelihood of favorable outcomes of treatment programs. Working with consultants from Consumer Reports, the Treatment Research Institute hopes to create a guide that will help those who need treatment and raise standards in the industry. Another hopeful development is the founding of an organization that could be for addiction what the American Cancer Society is for cancer, called Brian’s Wish to End Addiction. In addition to supporting treatment research, the organization will also launch education and other prevention campaigns and lobby for policy so that, for example, insurance will adequately cover addiction treatment.
After a hellish decade, my son got and stayed sober. His current treatment regimen includes regular sessions with a psychiatrist who sees him for his addiction and co-occurring bipolar disorder and depression. He’s been in recovery now for five years. But of the nation’s 20 million addicts, only 10% will ever receive treatment. And the majority of those who do will be failed by the existing system. Nic is one of the lucky ones. I’m one of the lucky ones. But this should not be about luck.