Substance-abuse rehabilitation programs: moving toward evidence-based treatments

Most people know someone who has “been through rehab” have a general sense of what the game is about: a stay of a month or so in a dedicated facility in the company of other addicts and alcoholics, introduction to “The Twelve Steps,” and a recommendation to follow up after discharge with Alcoholics (or Narcotics) Anonymous meetings, individual or group counseling, and–if required by a judge, employer, or state licensing board–regular urine testing.
What many do not know, despite frequently confronting first-hand the return to using by friends or family members, is that in the end, the vast majority people who go through these programs go back to drinking and drugging just as energetically and destructively as before, if not worse.
Now, some states–most notably Oregon–are taking a hard look at the traditional rehab model along with the fact that $15 billion in government funds was spent last year on treating four million people, and demanding that treatment centers not only become more accountable in terms of post-treatment follow-up of those who use their services, but also adapt their standard treatments–usually meted out by certified drug and alcohol counselors in the absence of medical doctors and consisting largely of videos, lectures, and confrontation-based group talk sessions–in accordance with what research has deemed most effective.

[V]ery few rehabilitation programs have the evidence to show that they are effective. The resort-and-spa private clinics generally do not allow outside researchers to verify their published success rates. The publicly supported programs spend their scarce resources on patient care, not costly studies.
And the field has no standard guidelines. Each program has its own philosophy; so, for that matter, do individual counselors. No one knows which approach is best for which patient, because these programs rarely if ever track clients closely after they graduate. Even Alcoholics Anonymous, the best known of all the substance-abuse programs, does not publish data on its participants’ success rate.
In 2003 the Oregon Legislature mandated that rehabilitation programs receiving state funds use evidence-based practices — techniques that have proved effective in studies … When practiced faithfully, evidence-based therapies give users their best chance to break a habit. Among the therapies are prescription drugs like naltrexone, for alcohol dependence, and buprenorphine, for addiction to narcotics, which studies find can help people kick their habits.
Psychotherapy techniques in which people learn to expect and tolerate restless or low moods are also on the list. So is cognitive behavior therapy, in which addicts learn to question assumptions that reinforce their habits (like “I’ll never make friends who don’t do drugs”) and to engage their nondrug activities and creative interests.

The problem, of course, is training and hiring people who can administer these “high-end” therapies. Most programs cannot afford to keep a medical doctor on the payroll; many lack full-time nurses. This means, among other things, no prescription drugs. For years, Alcoholics Anonymous as a whole deplored the use of any psychoactive medications whatsoever, and even today one can attend a meeting and listen to at least a few old-timers querulously dismiss the idea that medications aimed at treating bipolar disorder even SSRI’s are of use, claiming instead that the idea is to wean oneself of all mood-altering chemicals. Then, many of these people, after their third cup of coffee within an hour, head outside for a smoke.
There is also the fact that AA is upheld as a gold standard, and even a necessity, when in fact there is no reason to believe some people do not do just as well or better using other means.

For some addicts, a standard program may not help at all, according to Anne Fletcher, who for her book “Sober For Good” interviewed 222 men and women who had been clean for at least five years. “A lot of these people overcame an alcohol problem on their own, or with the help of an individual therapist,” Ms. Fletcher said.

I know people with serious, long-term drinking problems who have in fact quit altogether without even setting foot in a meeting. Some use prescription drugs, therapists, or both; some simply have had enough and are sufficiently motivated to stop for whatever reason that they put the plug in the jug and never look back. On the other hand, many find AA to be a lifeline, and make it their primary social peer group, with many of them trusting in God to keep them sober. While those crediting the supernatural with their sobriety are in error, if their belief in the idea does the trick, it’s hard to find fault with their stance; pleasantly deluded is preferable to drunk and despondent (or dead)–but this is simply not an approach everyone has the constitution to put in play.
In Delaware, another state that is strongly seeking accountability, data has begun to roll in.

In 2001 the Delaware Division of Substance Abuse and Mental Health began giving treatment programs incentives, or bonuses, if they met certain benchmarks. The clinics could earn a bonus of up to 5 percent, for instance, if they kept a high percentage of addicts coming in at least weekly and ensured that those clients met their own goals, as measured both by clean urine tests and how well they functioned in everyday life, in school, at work, at home.
By 2006, the state’s rehabilitation programs were operating at 95 percent capacity, up from 50 percent in 2001; and 70 percent of patients were attending regular treatment sessions, up from 53 percent, according to an analysis of the policy published last summer in the journal Health Policy.

The issue here is that every “case” of addiction is unique. That sounds like a cliche, and it is, but consider the fact that drug and alcohol problems plainly exist along a severity gradient, are rooted in different causative factors in different people (the self-medicating bipolar or depressed person versus the psychologically “normal” person turned narcotics addict thanks to chronic-pain issues), and exist in people with wildly different attitudes toward “spirituality,” group versus individual counseling, medications, self-help settings, and much more.
The bottom line is that people with substance-abuse problems need to believe their life is worth living sober, warts and all, before they stand a chance in hell of remaining clean. Given a spark of motivation and hope, from whatever source, the most abject gutter-drunk can dry out and stay dry. But then take someone with an objectively less severe clinical addiction who couldn’t care less what becomes of her, and the most comprehensive treatment and monitoring in the world, short of literal incarceration, will not be sufficient to see her remain sober for long.

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