POV: Let’s Get Serious about Treating Addiction
A blueprint for ending a medical and social scandal
Every few years, the media report an epidemic of heroin overdose deaths, often after a celebrity like Philip Seymour Hoffman dies and sets off the spark. This time the spike in deaths—which is real—is being attributed to heroin mixed with fentanyl. Attention will fade, but the deaths will continue. We wring our hands about overdoses, but do little to make effective treatment widely available. Our continuing refusal to prevent and treat addiction is a medical and social scandal.
A perfect example of our terrible policies happened to me yesterday. A homeless and unemployed stranger stopped me on the street to ask for $8.25 for a train ticket to get to a halfway house in Attleboro, where he had been on a waiting list for two months. He got a call that morning; there was a bed, but he had to get there. He asked for help at a nearby drug treatment referral program, but was turned down because he needed to go outside Boston. Maybe the guy was giving me a clever hustle, but I think he was telling the absurd truth of his situation.
Here are the policy changes I believe we must make to end this scandal:
- Complete the transition to individual insurance. About 98 percent of Massachusetts residents are eligible for health insurance that includes coverage for addiction treatment. Individuals with severe addiction and mental illness need significant assistance in getting and staying enrolled, so insurance coverage must come with care advocates who will help consumers who may be homeless, unemployed, and socially isolated.
- Integrate addiction, mental illness, and medical treatment around individuals with severe addiction. Telling a patient who is unemployed, homeless, addicted, and mentally ill to go someplace else or to wait weeks for an appointment is malpractice, because the providers know it will not work. We should force consolidation of addiction treatment, mental illness, and medical care providers to coordinate and take care of the most severely ill patients in one place.
- Increase insurance payment rates for addiction treatment to a level that meets providers’ costs, draws in new responsible providers, and pays for the required coordination. Very low Medicaid and private insurance payment rates create and perpetuate the shortage of quality treatment.
- Reward longer stays in treatment and stop using providers that are unable to successfully retain patients in treatment long enough for it to be effective. Longer time in treatment, inpatient or outpatient, improves outcomes. Research shows that drug treatment for less than 90 days is generally not effective, but very few public or private insurance programs authorize that much treatment now.
- Require hospitals, health centers, HMOs, and other primary providers, as a condition of their participation in Medicaid and public employee health programs, to demonstrate that they diagnose all patients with alcohol and drug disease and that they have a clinically sound program that gets individuals the care they need. Today, almost all the major health providers in the commonwealth refuse to provide addiction treatment at any appropriate scale even though many of their patients would have better clinical outcomes if they got treatment.
- Stop the revolving door at detoxification programs. Current policy and reimbursement get the patient out the door as soon as he or she is “medically stable,” whether or not the person is connected to, or ready to, enter real addiction treatment. The vast majority of people who leave detox without directly entering and staying in treatment quickly relapse.
- Stop arresting people for nonviolent drug offenses and stop putting people back in jail or prison for nonviolent probation violations, which are often related to drug addiction. Our current policies ruin thousands of young lives. Addiction is a disease, not a crime. Drug court programs are fine, but they touch only a tiny proportion of the people in the criminal justice system who need treatment. Empty and close a few jails and we will have plenty of money to help people get and stay healthy.
David L. Rosenbloom is a School of Public Health professor of health policy and management and a former commissioner of health and hospitals for the city of Boston. He can be reached at email@example.com Comments