The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia) released a report on addictions today that is remarkably comprehensive and even more remarkably honest in portraying the virtually utter failure to identify and effectively treat addiction in the U.S.
The report, titled "Addiction Medicine: Closing the Gap Between Science and Practice," starts with the premise that addiction is a disease. Addiction is not recreational drug use or risky behaviors (like adolescent binge drinking or buying drugs on the street). They focus on abuse and dependence on alcohol, legal and illicit drugs, and tobacco. While the authors recognize a group of addictive/compulsive behaviors, they are not covered in this report.
CASA Columbia is a renowned research center on addiction. For the past five years it brought together a team of addiction, public health and judicial experts, universities, medical centers, and other mainstream officials under the direction of Drew E. Altman, Ph.D., president and chief executive officer of the Kaiser Family Foundation, to study and survey the field of addiction in order to give us a landscape report of such precision and breadth. Scientific literature was reviewed, extensive surveys were conducted (throughout the U.S. and an in-depth survey in New York State), leading researchers and experts were interviewed, focus groups were held, and state and federal licensing, certification and accreditation rules and regulations were examined. Care was taken to hold to high standards of analysis and evidence. In short, this is one tome we ignore at our own peril.
Their definition of addiction is alcohol and drug (including tobacco) abuse (compulsive use despite clear harm to relationships, work and physical health) and dependence (where the body experiences withdrawal when blood levels of a substance drop).
Their definition of treatment is that of psychological and social therapies (like motivational interviewing/motivational enhancement therapy, cognitive behavioral therapy -- CBT -- provided individually and in groups, the often highly-effective but controversial contingency management approaches that reward abstinence, and family therapies) and medications used to treat additions (like naltrexone, nicotine replacement and buprenorphine -- see here and here). They do not include detoxification (typically repetitive, expensive, and often medically-unnecessary interventions that are generally ineffective in promoting recovery), peer- and religious-based counseling, emergency room and prison/jail services. Don't bother to pick up this 573-page report (more than half of which is appendices and references) if you believe addiction is a failure of will, a form of moral turpitude, or habits where people should "just get over it" (though some future campaign should try to change your mind).
The consequences of untreated addiction, and its predecessor risky alcohol and drug use, are chilling. The report concludes that:
"Risky substance use and addiction constitute the largest preventable public health problems and the leading causes of preventable death (emphasis mine) in the U.S. Of the nearly 2.5 million deaths in 2009, an estimated minimum of 578,819 were attributable to tobacco, alcohol or other drugs."
The report also estimates the costs of addiction and risky substance use behaviors to government coffers alone to exceed $468 billion annually. Yet, and here is the most important finding of all, only one in 10 people with addiction to alcohol and/or drugs report receiving any treatment -- at all. Can you imagine that measure of neglect were the conditions heart or lung disease, cancer(s), asthma, diabetes, tuberculosis, or stroke and other diseases of the brain?
Tobacco use is the leading preventable cause of death and disability in this country. But the catastrophic effects of addiction do not stop there: The report considers car crashes, where 40 percent of fatalities involve someone under the influence; the five-fold increase in prescription drug overdose deaths since 1990, where OD fatalities exceed traffic accidents; increased risk of heart and lung diseases, cancer and sexually-transmitted diseases; and parental substance abuse, which increases the risk of their children performing poorly in school and developing conduct and trauma disorders, asthma, ADHD, depression and, of course, addiction itself. Family dysfunction warrants particular notation, since addiction produces financial and legal problems (property and violent crimes) and increases domestic violence, child abuse, unplanned pregnancies, and motor vehicle accidents.
The report is exhaustive in the ways it considers legal and illicit drugs, alcohol, and tobacco. Each section is clear, compelling and exceptionally well-supported with tables and references. A thorough analysis of why we are at this deeply troubling state of neglect examines how addiction has been systematically omitted from medical care, how treatment providers are terribly undertrained to deliver a range of proven treatments, how treatment programs are not sufficiently held accountable for delivering evidence-based practices, and how private insurance payers have eluded the provision of adequate benefits and defaulted payment to the public sector. But what we need to know far beyond the inescapable evidence of how big and bad the problems are is what can be done?
The opening recommendation is a page out of every good textbook of public health. Start by detecting a problem that is -- by inattention or aversion -- kept out of sight. We do not deal with what we do not confront. More than 80 million people (!) in this country ages 12 and older abusively engage in substance use without meeting criteria for addiction (defined above) and represent an exceptional opportunity to intervene early and effectively, yet this is not happening. Simple screening tests for alcohol, drugs and tobacco exist and can be made standard practice throughout medical care (and in educational and counseling settings). SBIRT -- Screening, Brief Intervention and Referral for Treatment -- is a recognized, proven and even reimbursed medical procedure that awaits general use despite the consequences of not using it.
The report offers a set of treatment recommendations and asserts importantly that comprehensive treatment (combining psychosocial and pharmacological interventions) is generally better than reliance on one approach alone. There is an abundance of information on treatment, beginning with stabilization of the disease and continuing on to acute care with therapy and medications. The authors provide critically-important and urgently-needed information about how chronic disease management techniques extant throughout medicine today need to be applied to addiction. Nutrition and exercise are woven into the treatment approaches. AA, NA, SMART and other longstanding and effective recovery programs find their way into the report as "support services," revealing its particularly medical and judicial framework.
One finding that may pertain to readers of this post, or people they know, is that public attitudes about the causes of addiction "... are out of sync with the science." Their survey work reveals that one-third of Americans still regard addiction as a "... lack of willpower or self-control." We can be our own worst enemy, and local and national efforts to change minds and hearts are needed.
Further recommendations are framed as major sections on how to close the science-to-practice gap (to make happen in everyday practice what we know from science that works): commencing a national public education campaign, mandating program adherence to proven practices, establishing quality improvement tools and procedures to steadily and progressively improve program performance, insurance reform, and organizing federal oversight into one agency on addiction.
There is so much more in the report that this summary cannot cover. Among the findings readers may also want to take guidance from are on special populations (from youth to the elderly, and including veterans, pregnant women and those with co-occurring medical and mental health disorders), on parity legislation and the do-or-die role of funding prevention and services, and on education and practice standards. The report serves both as a call to action and an encyclopedic warehouse of information.
The CASA Columbia report's strengths are its veracity, clarity and credibility, the last based on the excellent science they summarize and the caliber of the report's authors. A shortcoming is that it was developed by experts in medicine, addictions, public health and jurisprudence; as a result, it does not report on the emerging and abundantly-used field of complementary and alternative approaches to addiction "treatment" (such as yoga and acupuncture) nor dedicate much report real estate to 12-step and related recovery models. Nor does the report consider how making legal substances more expensive and more difficult to get could be used as means of controlling youth drinking and other compulsive habits, though CASA Columbia did consider these interventions last year in a report on adolescent substance abuse (see here and here).
Practitioners, policy makers, educators and responsible citizens should more than consider "Addiction Medicine: Closing the Gap Between Science and Practice." It needs to become an agenda for action. Not doing so will mean that this country would have decided to continue to neglect its most prevalent, destructive and costly of diseases.
The Huffington Post soon will be publishing a series on alternatives to 12-step and medication-assisted recovery. Readers will have an opportunity to comment and debate on the topics covered.
Lloyd I. Sederer, MD
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
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