I would like to lay out a road map for the next few posts. I would like to write about several issues that relate in some way to the ‘disease theory of addiction.’ I want to explain why addiction is best considered a ‘disease;’ something that most people who work in the addiction field consider to be a fact, not a theory.
From there I would like to point out the differences in how society views addiction, compared to other diseases. Finally, I want to present what I see as the fundamental flaw in how we treat addiction. To give a preview of that discussion, my concern about the treatment of addiction is that while many people CALL addiction a disease, few medical professionals or societies actually TREAT it that way.
What I write will anger a few readers. I don’t WANT to make people angry at me; I just don’t see any way to present these ideas without causing anger. The obvious solution to that dilemma is to simply write about something else. But that hardly seems like the right thing to do. Opioid dependence is, after all, the most critical health epidemic in my lifetime— if being critical relates to the years of lives lost to the disease.
I see young people dying all around me. I’m not imagining the deaths; I have read the obituaries, talked to grieving parents, and even testified in court in some cases, I read front-page news stories from across the country, each describing the high number of deaths in their readership areas. Are other people seeing this?! If so, where is the outrage? In Wisconsin we had 70,000 protesters this weekend—both sides combined—over the issue of collective bargaining rights by public employees. The State Capital was packed with screaming teachers. Even the President weighed in on that issue. But thousands of young people die in their parents’ basements, and we have no outrage?!
Before taking me to the woodshed, I ask that people who work in the traditional treatment industry give some thought to the success rate of their programs for treating opioid dependence. I realize that hard data is hard to come by for many reasons. People who do well may not want to keep in touch with treatment centers that they associate with a part of their lives that they would like to forget. People who do poorly are even harder to follow, whether they leave after several days of bad withdrawal, get kicked out for coming up ‘dirty’ in a urine test, or graduate with honors, but relapse on the way back to their home towns.
And there is no way to measure the largest group who fail treatment; people who need treatment but who never find the nerve, money, or desperation to show up!
I think I understand the philosophy of those who treat addiction, and why they feel that they are doing a pretty good job treating opioid dependence. And this gets us to the first major difference in how addiction is treated, compared to the treatment of other diseases.
When organized medicine evaluates the efficacy of a treatment, there is usually an expectation of success. If the success rate for treating cancer was below 10%, for example, there would be few cancer centers bragging about their treatment programs! When I worked as an anesthesiologist, I took hundreds of children to the operating room—always with the assumption that every single person would do well. Any sign of failure- an unplanned hospital admission for prolonged nausea or a chipped tooth, not to mention heart failure or brain damage, resulted in formal peer review hearings and possible sanctions against the physician.
But with addiction treatment, the opposite is true. The general assumption is that treatment is a good thing—whether or not it works. And consciously or unconsciously, many who work in the addiction treatment industry compare their success rates not with an ideal standard of 100% cures, but instead against ‘utter failure.’
Patients who do well are the exception, especially if all of the suffering addicts who viewed the program’s advertisements are included in the mix. Those who work in the industry dodge responsibility for bad outcomes, blaming the patient in those cases. That is a convenient way to make bad numbers more palatable—but it is an exceptional and unique perspective upon which to consider the success rate of treatment programs for a given disease.
In other words, compared to doing nothing at all, residential treatment is probably a good thing. But if the success rate for residential treatment of opioid dependence were compared against the outcome for treating any other illness using any other course of treatment, the work of residential centers would stand out as abysmal failure. When the cost is added in, the industry appears ripe for an investigation by federal authorities. After all, there are few areas in medicine where a patient pays tens of thousands of dollars for treatments in which the usual outcome is utter failure.
See? I told you I’d make you angry.
There are many things to write or wonder about. When and why did organized medicine abdicate responsibility for treating the disease of addiction? Is medicine in a position to take that responsibility back? Can the programs now treating addiction the ‘old fashioned way’ change their expectations and demand better outcomes??
Last year I was invited (I still don’t know by whom) to DC to attend the NIDA/SAMHSA summit on treating opioid dependence with buprenorphine. The biggest surprise, as I heard the President’s drug policy advisor speak about resources, was the absence of any mention of residential treatment. It was clear that there are some in world of organized medicine who are prepared to add ‘addiction’ to the list of diseases where they will ‘first do no harm.’
If you don’t see the differences in how the disease of opioid dependence (code 304.00) is treated compared to other diseases, then stay tuned—I have a few things I’d like to show you.
Photo by OnBeeKenoBee, available under a Creative Commons attribution license.
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Last reviewed: 21 Feb 2011