Michael Boyle, University of Wisconsin
Perhaps the time has come to design and implement a new system to address substance use illnesses housed within the mainstream medical system.
Ironically, the medical field was a major factor in the development of the specialty alcoholism and drug addiction systems. In 1956 the American Medical Association defined alcoholism as a disease and declared an end to a common policy that barred alcoholics from admission to general hospitals. The results were not impressive, with continuing indifference or refusal of the medical profession to provide treatment beyond detoxification; detox was rarely available among alcoholics taken to jail. There were few treatment options except those provided in state psychiatric hospitals and in a few treatment units in community hospitals.
Additionally, when the medical profession did address substance use problems, some of the approaches, including the use of prefrontal lobotomies, were horrific. Medical attitudes toward alcoholics were evident in the provision of both mandatory and voluntary sterilization based on concepts of eugenics. “Voluntary” sterilization in state psychiatric hospitals was often required as a condition for discharge. It is not surprising that distrust for the medical profession existed among persons in recovery from drug or alcohol problems.
Thus, by the mid-20th century, approaches for treating alcoholism and drug addiction were developed for the most part independently of the medical profession.
The residential approach for treating alcoholism was developed by Pioneer House and then by Hazelden in the late 1940’s. This became known as the Minnesota Model with a 28-day length of stay. The conceptual belief that evolved was that alcoholism had physical, psychological, social, and spiritual dimensions. Alcoholics Anonymous (AA) served as the foundation of the treatment approach, requiring participation in AA and completion of the first several of the 12 steps. The staffing usually included a substantial number of people in recovery. Eventually, this approach spread nationwide.
For drug addiction, a very different treatment evolved in California within an organization called Synanon in the late 1950’s, becoming known as the Therapeutic Community (TC). This approach embraced the concept that drug addiction resulted from character flaws that developed from being immersed in an addiction subculture. The TC strategy assumed that the existing character had to be broken down and then rebuilt through confrontation with and pressure from the members of the staff and TC. This was envisioned as a long-term process, often consisting of one to three years of residential treatment. Ironically, many of the early TCs were focused solely on drug addiction and viewed use of alcohol as a privilege to be earned by the participants.
The Minnesota Model and Therapeutic Community approaches still have a major presence in the substance use treatment field today, although 28-day treatment is increasingly rare (with most care delivered on an outpatient basis) and TCs have changed, becoming less confrontational today. Both models were based on the beliefs and experiences of their founders and alumni, as little research on effective treatments existed in the 1940s and 1950s.
Decades after the founding of the substance use treatment systems that exist today, several reasons support the idea of general healthcare assuming responsibility for the treatment of alcohol and other substance use disorders.
This change may come about by default since overall, specialty addiction treatment organizations are poorly prepared to participate in the changes required under the Affordable Care Act (ACA). These changes include the delivery of evidence- based treatments, use of electronic health records, and participation in electronic health information exchanges. The research team known as NIATx based at the University of Wisconsin developed a Health Reform Readiness Index to measure the preparedness of addiction treatment organizations to implement the ACA (Molfenter et al., 2013). The index covered 13 domains of organizational readiness with each being rated on a 4-point scale:
• 0 – needs to begin
• 1 – early stages
• 2 – on the way
• 3 – advanced
Representatives of 276 treatment organizations completed the index. The mean scores indicated most providers were in the early stages of developing and implementing changes. For example, the mean score for use of evidence-based treatments was 1.14; 1.12 for using administration information technologies, and .44 for use of patient health technologies. Catching up to the requirements of the new healthcare system mandated by the ACA will be extremely challenging for many of these organizations. Lack of resources, particularly in the publicly-funded sector, currently affects the ability of these organizations to attract and retain highly skilled clinical staff and medical professionals as well as to purchase and implement the technologies that are needed in a modern healthcare system.
With the implementation of ACA, the demand for the treatment of substance use illnesses is projected to increase, largely because of increased insurance coverage through Medicaid. Expansion of treatment participation by members of the medical profession may assist in meeting this demand. Further, if such an increased medical presence occurs, some of the projected 90% of people who currently have alcohol or drug use problems but do not access treatment may be more likely to accept care in a medical setting rather than a specialized addiction treatment program.
Medications are now available for the treatment of alcohol or opiate use problems. Yet, most specialty alcohol and drug treatment organizations do not employ or have arrangements with medical providers who can or will prescribe and monitor the use of these medications. If the medical profession assumes greater responsibility for addressing substance use disorders (SUDs), the use of medications will surely increase, as that is the principal modality for the treatment of all other illnesses. While the medication options for the treatment of SUDs are currently limited, dozens of potential new medications are in development or being tested in research trials. When found effective, these new medications are likely to be more rapidly adopted by medical professionals than has shown to be the case in the specialty care system with a low level of medical presence. Further, for what is largely improbable within the current specialty care system, advances in personalized medicine research may allow physicians to select medications that are likely to be most effective based on a patient’s genetic makeup.
Relatively painless and safe detoxification, whether provided in inpatient or outpatient settings, requires medical monitoring and utilization of appropriate medications. To illustrate what occurs without medical involvement, many specialty treatment providers provide detoxification without medication. Such treatment is frequently referred to “social setting” detoxification. The term sounds nice but in reality it means going “cold turkey” and suffering the side effects of withdrawal. In the not too distant future, people may look back at this practice as barbaric.
Despite over 15 years of research identifying the need for a disease management or continuing care approach to addressing substance use illnesses that are chronic in nature, the predominant models still use an acute approach to treatment and rapid discharge with little ongoing post-treatment monitoring or support. Whether this would improve with greater medical involvement is unknown.
General medicine is supposed to be oriented toward ongoing care of patients, and a major goal of the ACA is to increase this involvement. Even patients with no significant healthcare problems are scheduled for annual physical checkups while patients with chronic conditions such as diabetes and hypertension may have their physician appointments scheduled much more frequently depending on their response to treatment. This orientation would greatly facilitate the addressing SUDs as ongoing conditions that require monitoring.
Recent research on the use of technologies delivered through computers, smart phones and tablets are demonstrating positive outcomes in all areas of medical care. These technologies can be used for both treatment and recovery support for those with substance use disorders. The medical field is oriented to the repeated introduction of new technology in contrast to the significant staff resistance to innovation that has often been found in specialty SUD treatment programs.
If general medicine assumes responsibility for treating substance use illnesses, it is important that the best psychosocial approaches be incorporated. Professionals such as psychologists and social workers who are highly trained in evidence-based cognitive behavior treatments need to be part of the treatment teams. In fact, the experience of using behavioral change techniques for substance use problems may lead to the adoption of these practices to address other healthcare conditions. Patients should also be encouraged to join and attend mutual aid groups. Voluntary attendance in mutual aid has been shown to increase positive outcomes.
It is time for the head and body of the treatment of SUDs to be reconnected, and the medical field offers the best opportunity for a rapid transformation to occur. Lack of resources, adherence to tradition, and resistance to changes directed toward the decades- old model of community-based substance use treatment make it unlikely that the current structures can adapt to the changing demands that will occur with continuing implementation of the ACA.