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The Irrationality of Addiction Treatment

The most cursory review of the history of addiction treatment reveals a long tradition of inadvertent harm in the name of help (iatrogenic illness). Such treatment insults span bleeding, purging, and toxic, mercury-laden medicines in the 18th century. They include the fraudulent boxed and bottled home cures and the use of cocaine to treat morphine addiction in the 19thcentury. And they encompass the oft-lethal withdrawal procedures, prefrontal lobotomies, electro- and chemo-convulsive therapies, prolonged institutionalizations, and the harmful use of stimulants, sedatives, and anti-psychotic medications to treat addiction in the early to mid 20th century.

It is easy to look back with condescension on these and other equally harmful practices and ask in the most self-righteous of tones, “What the hell were they thinking?!” But one must ask what future historians will say of the current era of addiction treatment. Will they find similarly harmful practices? Will they, like us, ask, “What the hell were they thinking back then?” As a historian of addiction treatment, the one thing I can assure you is that such practices are difficult to quickly identify within one’s own era—even in eras in which addiction treatment has wrapped itself in the mantle of science.

Harm can result from deviations in clinical and ethical standards of practice within addiction treatment, but what about irrational, potentially harmful elements within mainstream addiction treatment that we do not see because of their very pervasiveness? The following practices are ones I suspect will be judged harshly by future addiction treatment historians.

Staffing Addiction is one of the few medical disorders treated in settings in which no physicians or other medical personnel are employed or in which those being “treated” only rarely interact with such personnel. Medical personnel make up only 19% of the addiction treatment workforce and even when present, they are rarely and only superficially involved in treatment planning or treatment of co-occurring medical and psychiatric conditions, nor are they the key decision makers in admission and discharge decisions.

Motivational Screening Addiction is one of the few disorders in which one is granted or denied access to care based on the degree of motivation to be treated. In the treatment of other medical disorders requiring lifestyle changes (e.g., diabetes, heart disease, etc.), motivation for change is viewed as an outcome of the service process, not a precondition for admission to care.

Staging of Clinical Interventions If one looks at the clinical ingredients of the dominant models of inpatient/residential rehab of the past half century, two ingredients are striking: 1) daily staff lectures on varying aspects of addiction, treatment, and recovery, and 2) individual and group therapies that require disclosure of highly personal information (e.g., past and present patterns of abandonment, loss, victimization, predation, and a detailed accounting of  emotional distress)–information often elicited in the mid-late 20th century via “therapeutic confrontation”). Didactic lectures (one of the most ineffective teaching methods) assume a level of comprehension, capacity for personal applicability, and memory at the very time most patients are at the peak of addiction-induced deterioration of cognitive functioning. The individual and group therapies assume that such “emotional work” must and can be achieved in the earliest stages of recovery. Ironically, these same activities may have far greater value in later stages of recovery–months or years beyond the involvement of addiction professionals.  The absence of stage-dependent clinical and non-clinical recovery support interventions and the history of confrontation as a clinical tool within addiction treatment will be deeply puzzling to future historians.

Medication Access Addiction treatment is unique in the denial of access to medication that can reduce the risk of premature death on the grounds of treatment philosophy. For example, 28% of treatment admissions in the U.S. are for opioid use disorder, but less than 10% receive medication-assisted opioid therapy. Only a small percentage of addiction treatment programs offer a full spectrum of FDA-approved medications for the treatment of substance use disorders.

Therapeutic Alliance / Retention Of the more than 1.4 million annual addiction treatment admissions, only 43% successfully complete treatment. Treatment adherence is an issue in the treatment of many disorders, but the fact that less than half of people admitted to addiction treatment successfully complete that course of treatment is extremely troubling as is the additional fact that those failing to complete treatment are not routinely provided assertive follow-up after their disengagement from treatment.

Administrative Discharge Addiction treatment is unique in the medical arena for its practice of “kicking” people out of treatment for exhibiting the primary symptom of the disorder for which you have been admitted for care. With other disorders, such symptom expression is confirmation of the diagnosis or a signal that refinements or alternative methods of treatment are needed. People undergoing addiction treatment may also be kicked out of treatment for behavior unrelated to the disorder (e.g., minor rule violations or pursuing a romantic relationship with another patient). More than 100,000 people each year are administratively discharged from addiction treatment—7.1% of all discharges.

Graduation Many addiction treatment programs provide a “graduation” ceremony marking “discharge” from treatment and termination of the service relationship after brief recovery stabilization and at a time of high risk for addiction recurrence. There is no counterpart to this ritual in the treatment of other complex, chronic medical disorders.

Post-treatment Monitoring / Support There is a high risk of resumption of drug use and related problems in the weeks and months following discharge from addiction treatment, and recovery is not fully stabilized until 4-5 years of continuous recovery. Others with medical disorders that have such patterns of vulnerability (e.g., patients treated for cancer, heart disease, diabetes, or asthma) are afforded assertive and sustained post-treatment monitoring, support, and if and when needed, early re-intervention. Such sustained recovery management is not a routine component of addiction treatment in the U.S. although efforts are underway to extend addiction treatment from acute models of care to models of sustained recovery management.

Treatment Recycling Addiction treatment is one of the few areas of medicine in which people are repeatedly recycled through the same treatment regime that previously failed to generate sustainable symptom remission. At present, 58% of people admitted to addiction treatment have one or more prior treatment admissions. In other areas of medicine, symptom recurrence following treatment is indicative of a refinement or alternative method of treatment.

Nicotine Addiction People with substance use disorders present to addiction treatment with high rates of concurrent nicotine addiction, and smoking is a major factor in the disease burden of people in recovery from other addictions. People treated for SUDs are more likely to die following treatment from nicotine-related illnesses than from the drugs for which they were admitted for treatment. Smoking cessation enhances recovery outcomes for other SUDs. (See HERE for review of studies.) In spite of these facts, addiction treatment has not historically viewed smoking within the rubric of addiction or cessation of smoking within the rubric of recovery. The era of enabling nicotine addiction in addiction treatment and the slow pace of integrating smoking cessation as an element of addiction treatment and recovery support will leave historians of the future questioning the sources of this conceptual blindness.

Participation in addiction treatment can elevate recovery outcomes and countless individuals and families owe their very lives to addiction treatment. That fact does not preclude the presence of irrational elements within the design of addiction treatment that will leave future historians asking, “What the hell were they thinking?”