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POV: Let’s Get Serious about Treating Addiction

A blueprint for ending a medical and social scandal

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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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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 drosenbloom@bu.edu.

13 Comments

13 Comments on POV: Let’s Get Serious about Treating Addiction

  • david on 03.21.2014 at 7:49 am

    This blueprint looks like a good start to reduce drug addiction. How about the USA Government as well as state government do more to prevent illegal trade/import of illicit drugs?? If there are no or much reduced illegal drugs coming in, then there would be no drug problem.

    • Montana Resident on 03.21.2014 at 9:44 am

      In a country as large as the US, there will always be points of entry for illegal drugs, no matter how much funding we give the DEA and other enforcement agencies. I think it would be more efficient to try and affect the demand side rather than the supply side of the equation.

  • Thank You Kitty on 03.21.2014 at 8:13 am

    Some proposals that sound worthy of consideration. Why undermine them with the old canard that “addiction is a disease”? Who is actually helped by this evasive label? Measles is a disease. Leukemia is a disease. ALS is a disease. Polio is a disease. If you can’t see the fundamental difference between these maladies and the destructive overuse of drugs, you might be part of the problem rather than the solution.

  • Robert on 03.21.2014 at 8:33 am

    Treatment for addiction in the US is a joke. Google Ibogaine – a veritable cure for addiction with wild success. And it’s illegal in the US, while methadone and subutex continue to be distributed to millions. The US govt has no desire to help addicts> Addiction treatment is big business, why would we ever want to cure it?

  • Andrew Coate on 03.21.2014 at 9:32 am

    I absolutely agree. We do need to get way, way better at offering addiction services and not criminalizing non-violent drug offenses.

    But your touching story of the guy who just needs $8.25 to get to Attleboro? Total hustle. He’s well known to folks in the area who actually work with those populations. That guy has been around for years and years with a hardly-changing story. If you offer to take him to South Station and buy the commuter rail ticket he flips out.

    Other ones he commonly uses:
    -Needs money to get a new ID card
    -Needs money to visit his daughter
    -Needs money for clothes for job interview

    • Thank You Kitty on 03.21.2014 at 5:46 pm

      With me it was “I need $16 for the rest of a bus ticket home to pick up my daughter in Connecticut.” A couple of months later the same guy was on the same block and I overheard him asking for $19 because he had to get home to Portland. In another city someone cam up to me saying, “I just need $22″ to pay off my auto repair bill so that I can take my father to get his heart medicine. No one else can take him, and I have to get my car.”

      In case people haven’t been hit up with this sort of con, the narrative method used by the hustler is to combine a request for a specific amount of money (round figures are not used) along with a specific need that is always heart-tugging.

  • Baffled on 03.21.2014 at 9:55 am

    Most definately if you honestly believe what you are trying to convince us of then you are indeed part of the problem. The government should do a better job of controlling the import of illegal drugs but they should also stop wasting millions on methadone and other wasteful programs and pushimg of legal drugs to treat a helpless cause. Addiction is NOT a disease. It is a a persons free choice to cross the line and the comsequences are clear. I am tired of the excuses people make and labels they want to put on everything. People are fat because they take in more calories than they burn and addictd are addictd because they chose that life. Unless there is a rare case of someone unwillingly being forced to take drugs and in that case, the help is well deserved.

    • Some choices are made with misinformation, or no information. on 03.21.2014 at 11:36 am

      While I agree that the choice of picking up a drug (or overeating and becoming fat) is NOT a disease, actually being addicted to something IS a disease. It is a biological state of helplessness, where your choices are ruled by a chemical imbalance in the body. It’s like needing coffee, or food, or sleep, but several orders of magnitude worse.

      And some people start drug use because they have awful lives to begin with. Because the system is so corrupt that one can’t get out of poverty even if they did their absolute best. Some start because it was forced upon them by others. Some were teens and they made this mistake and they didn’t know they couldn’t come back from it. That last one is probably the most likely situation, and you can’t possibly think you should let someone ruin their lives over one mistake they made when they were 13 and going through a tough time.

    • Danna on 03.29.2014 at 3:41 pm

      Baffled, from your comments, you obviously have no long term firsthand knowledge of addiction. Read the NIDA research; learn about brain plasticity. Watch your own loved one struggle with everything he has to quit, and watch that brain hijacking in progress, then get some medical education and come back and tell me how this is not a disease. I’m a nurse who has worked in psychiatry, as well as the mother of a heroin addict. I can tell you without a doubt from firsthand personal as well as professional experience that there’s a disease process at work. Uninformed, naïve judgments are the worst of all. Learn your subject before you offhandedly stigmatize and judge. Sure, the initial choice to use, is exactly that….a poor choice. And like many other DISEASES, addiction has behavioral components. The difference with addiction is that self righteous, heartless, judgmental bigots stigmatize and criminalize an entire population of people who are suffering. If you eat a horrible diet and give yourself cancer, we’ll race for a cure, but we’d rather walk over the lifeless bodies of addicts lying in our streets, than to provide them with effective treatment. It’s disgusting and it must change.

  • Woah on 03.21.2014 at 12:28 pm

    First and foremost addiction is a disease. Second education is a large factor that people don’t speak about. As someone who got sober while at BU if I had been given identifying information on alcoholism and addiction perhaps I could have saved myself a few years of abuse. This is a crippling disease that ruins people.

  • Dan Merrigan on 03.21.2014 at 12:44 pm

    Policies for more comprehensive and integrated behavioral health treatment and recovery services are needed for all and especially for adolescents in need. It is not an even playing field. The circumstances and conditions of one’s life play into decisions about picking up a drug. Substance use disorders typically begin during adolescence and young adulthood. Most adults with dependence started using under the age of 18, half under the age of 15. The scope of the problem is concerning: 1.8 million teens need treatment, only 1 in 16 actually receive treatment and for those who get treatment less than half are retained for 90 days. Currently, juvenile courts of our country have become the leading service delivery system for children and youth with substance abuse problems, not by choice, but by necessity. Substance abuse in the young leads to crime, but it also leads to much more. Costs to society include property damage, the consequences of drunk driving, violent behavior, and other public safety issues. Collateral effects include poor school performance, truancy, disciplinary actions, and a general erosion of the educational development of these youth, making them less employable, less productive as future employees and adult citizens. As parents of a new generation, they will pass their habits of abuse to their children, infecting them with the potential for the same disease. Many juvenile substance abusers go without treatment. Substance abuse among our young is not only a juvenile justice issue, nor is it only a public health issue. Substance abuse and the issues associated with it strike at the underpinnings of our society. Failure to provide services hurts everyone.

  • Danna on 03.29.2014 at 2:59 pm

    How about add “don’t kick people out of rehab, (even outpatient treatment, seriously?!? for relapsing. Every disease has a behavioral component to it including addiction. The relapse rate for behaviors that complicate or exacerbate disease such as diabetes, asthma and heart disease happen at the same as addiction relapse. The difference is, physicians don’t fire their diabetic patients for refusing to give up cake! My son has been kicked out of rehab in the past because of relapse and several times again when insurance decided not to pay. The lack of effective treatment is DIRECTLY responsible for him, and so many like him, ending up living on the street. And then we have the absurd nerve to blame people, marginalize and criminalize people for suffering the symptoms of a chronic disease which our system fails to treat. My son has internalized the stigma, and thinks he’s useless, worthless and a failure. But the truth is, my son hasn’t failed, but the system certainy has failed him.

  • Alyssa on 07.10.2014 at 6:11 am

    It does not matter if it’s a disease or not a disease, and continuing to tell people they have a disease is the continued excuse I here from those in recovery programs. I see the same people come to rehab leave rehab and come back again in a few moths. They have been doing this for years. Once one is physically detox it becomes a decision. This requires being uncomfortable, requires will power and a stronger desire to stay clean and sober NO MATTER WHAT. You stay clean and sober because you want it that bad and do not look for excuses or use life excuses to go back and pick up. To say that longer rehab would change the results is not true, it’s not the rehab it is the individual. I see people all the time who have been in an out of 3-6-9 month rehabs numerous times or many years and can’t or won’t stay clean and sober. I also know people who wanted it so bad and were willing to put a lot of effort and deal with the pain that they cause during their use and the struggles of getting back on their feet as well as just dealing with life in general who attended an IOP or simply had enough of the lifestyle that remain clean and sober under very difficult circumstances.
    The problem I see is that we have made it much to easy to keep relapsing and blaming the “disease” for a decision someone made to give in to feeling uncomfortable and things not going their way or happening quick enough for them. Just because you get clean and sober does not mean life will be easy it still requires effort if you want to make your life happen.
    It’s a lot of work on some days that pays off in the end.
    If an individual want to be clean and sober then they need to decide that is how they live your life now and in the future.
    Who cares if it’s a disease people should get over that word. You have control of it as long as you don’t pick it up unlike most diseases.

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