By Laura Hilgers - May 19, 2018
Ms. Hilgers (@Lhilgers)has written about having a child with an addiction and is a is a freelance journalist
Two years ago, I spent a week in Houston helping my stepbrother while he underwent treatment for Stage 4 lymphoma at the University of Texas MD Anderson Cancer Center. I sat with him while a nurse cleaned his chemo port and made records of her work, to keep his medical team updated. I accompanied him for the blood tests that determined his readiness for the next treatment. I stayed by his bed as his stem cells were harvested for a transplant, one of the cutting-edge, evidence-based therapies that ultimately saved his life.
Around the same time, I was helping my 22-year-old daughter, who struggled with alcohol and drug addiction. The contrast between the two experiences was stark. While my stepbrother received a doctor’s diagnosis, underwent a clearly defined treatment protocol and had his expenses covered by insurance, there was no road map for my daughter. She had gone undiagnosed for several years, despite my reaching out to her health care providers, who either minimized my concerns or weren’t sure what to do.
I had to hire an expensive interventionist — a professional who helps families find appropriate care and runs interventions — to find names of treatment centers. I spent weeks calling programs, asking questions and waiting to learn what insurance would cover. Finally, after my daughter agreed to treatment and we paid all costs up front, I sent her to a 45-day Arizona inpatient program, praying it would work.
Addiction, like cancer, is a complex disease that requires a multipronged approach. It also affects 1.5 times as many people as those with all cancers combined, and it was pivotal in causing some 64,000 overdose deaths in 2016 alone. It makes no sense that what is fast becoming our greatest health care crisis is still dealt with mostly outside the mainstream medical system.
According to a 2016 surgeon general’s report, 10 percent of the 21 million Americans with substance-use disorders will receive treatment. This is in part because there are no national standards of care for treating addiction, and the $35 billion rehab industry is regulated piecemeal, state by state. While many treatment programs offer excellent care, others are motivated by profit and engage in practices such as patient brokering (in which hefty sums are paid to those who refer an addict to a program) and charging insurers exorbitant fees.
On average, medical schools in the United States devote 12 hours to substance abuse, and little of that on diagnosing or treating the condition. Many doctors also struggle to get reimbursed for providing this care.
Addiction treatment has a long, fraught history. In the 19th and early 20th centuries, when addiction was, for the most part, considered a moral failing, people sought cures in asylums and “inebriate homes.” They also relied on doctors, who sometimes prescribed opiates to help morphine addicts slowly withdraw.
But with the passage of the Harrison Narcotics Tax Act of 1914, and several Supreme Court decisions, the government began to prosecute these doctors. William L. White’s book “Slaying the Dragon: The History of Addiction Treatment and Recovery in America” reports that more than 25,000 physicians were indicted between 1914 and 1938. Some 3,000 were jailed. “The practical effect of such enforcement,” wrote Mr. White, “was that physicians stopped treating addicted patients.”
Our understanding of addiction is different now. The surgeon general’s report defines it as a “chronic neurological disorder” and outlines evidence-based treatments. These include drugs like methadone and buprenorphine; individual and group counseling; step-down services after residential treatment; mutual aid groups like Alcoholics Anonymous; and long-term, coordinated care that includes recovery coaches.
Unfortunately, much of this knowledge isn’t being applied in doctors’ offices or even many treatment centers. “There’s a wealth of literature collected over many decades, along with a robust medical evidence base, showing what works and what doesn’t,” Dr. Anna Lembke, chief of the Stanford University Addiction Medicine Dual Diagnosis Clinic, told me. “Treatment for addiction works, on par with treatment for other chronic relapsing disorders. So, it’s not really that there’s no road map. It’s that the road map has not been recognized or embraced by the house of medicine.”
Dr. Lembke would like for a person afflicted with addiction to be able to arrive in an emergency room or a doctor’s office and find a protocol in place for immediate treatment, just as my stepbrother experienced with lymphoma. “That’s what we don’t have,” she said. “We have very high-end, and very expensive care, which is good care for those who can afford it, and then we have everybody else pretty much, for whom there’s limited care.”
Efforts are underway to create this much-needed change. The advocacy group Facing Addiction, along with the health care consulting firm Leavitt Partners, has assembled a team of experts and industry leaders to promote care models that help patients achieve long-term recovery and reward providers based on how well patients hit “recovery-linked performance measures.”
Another organization, Shatterproof, is working with 16 health insurers, which collectively cover 248 million people, to adopt national principles of care, including universal screening, access to medications and continuing long-term outpatient care. Gary Mendell, Shatterproof’s chief executive, believes that once private insurers recognize these standards and create financial incentives to meet them, the rest of the health care system will follow. It would be good if that included Medicaid and Medicare, which cover 69 percent of Americans’ addiction treatment.
The staggering economics of the opioid epidemic may be what forces our system to change. According to the nonprofit group FAIR Health, which draws on data from more than 21 billion privately billed health care claims, “Professional charges and allowed amounts for services for patients diagnosed with opioid abuse or dependence rose more than 1,000 percent from 2011 to 2015.” This increase, partly the result of addiction treatment coverage mandated by the Affordable Care Act, may spur health care systems to create their own treatment centers.
Cost-effective health care providers like Kaiser Permanente and the Department of Veterans Affairs have been doing this for years, and at least one other major provider, Massachusetts General Hospital, recently integrated substance-use disorder care into its system. Another bright spot is the federal prison system, which offers a residential drug abuse program, typically lasting nine months, in 76 locations.
There is a risk, of course, in urging the very medical system that helped create the opioid epidemic to treat it. “What we don’t want to do is go from OxyContin pill mills to buprenorphine pill mills,” Dr. Lembke said. “I think the way to try to avoid that difficulty or disastrous unintended consequence is to really carefully and judiciously prescribe.”
It’s a risk we may have to take. Evidence-based research should not be perishing in peer-reviewed journals while people are dying or struggling to find effective care. The millions of people still suffering from addiction, and those in recovery, deserve the same level of gold-standard care that saved my stepbrother and my daughter, both of whom are now in remission.