This past week The National Center on Addiction and Substance Abuse at Columbia University released a scathing report of our addiction treatment system: Addiction Medicine: Closing the Gap between Science and Practice.
While the report says nothing new, it does a nice job of summarizing the fact that we have made little progress since the Institute of Medicine released Bridging the Gap Between Practice and Research on January 1, 1998.
Here we are, 14 years later. Where are we now?
Reported Addiction Statistics:
- 40.3 million struggle with addiction to alcohol and drugs
- 80.4 million while not addicted to anything, engage in risky use of substances
- 89.1% of those who meet criteria for addiction involving alcohol and drugs (not including nicotine) receive no treatment
- Of those who do get treatment, about 50% come from criminal justice (only 5.7% are referred from primary care)
- Over 50% of those who go to treatment drop out
- Addiction and risky substance use costs our society an estimated $468 billion each year
Note: The 1st and 2nd points refer to of US age 12 and older. The numbers do not factor in behavioral addictions such as gambling, sex, food, and online activities. If they did the numbers would be higher.
How to Make Progress?
I will admit I was a bit depressed reading through the report, but not surprised. Addiction is a problem still very much misunderstood. Take for example this report, that constrains the definition of addiction to substances.
How can we possibly make progress evolving our treatment system if we continue to narrowly define addiction. It is not just to substances that people become enslaved, but to food, gambling, sex, and many online behaviors.In a great book on overeating, cleverly titled,
We now have neuroimaging studies providing empirical support that the brain is an equal opportunity organ that does not care what stimulates it, so long as dopamine provides a nice reward that keeps us coming back for more. The End of Overeating: Taking Control of the Insatiable American Appetite, by David Kessler, he makes the point that animals will work almost as hard for food as they will for cocaine.
How can we make progress in this field when we continue to slice up the addiction problem, and fail to understand that it is not about the objects per se, but the relationship that a person has with these objects – all of these objects?
Accurately defining the problem would be a start, because we could then start building systems of care that leverage interventions for a wide range of chronic conditions, including addiction. But even agreement on a broad definition will likely not be enough. We need big system changes to make big progress.
CASA Report Recommendations:
- Increasing screening and referral in primary care medicine
- Improve training on addiction in medical schools
- Establish national accreditation standards for all addiction treatment facilities and programs
- Educate non-health professionals about addiction, screening, and referral (dentists, teachers, legal staff, welfare, etc.)
- Require adherence to use of evidence-based treatments
- Expand addiction treatment workforce
- Implement more national public health campaigns
It is a list, but hardly a gutsy one or even close to what needs to be done if we are to make big progress.
My Top 4 Recommendations
#1 National Institute on Addiction (NIA)
While integrating NIDA and NIAAA into one organization next year is progress, I would like to see an institute called the National Institute on Addiction that puts the emphasis on understanding the relationships people have with all objects of addiction, not just alcohol and drugs.
While I know these agencies have invested resources in gambling and food, the money is scant compared to what is spent on substances. One of the primary goals of this organization would be to get all stakeholders (researchers, treatment providers, public) on the same page about how we should define addiction.
#2 Leverage the Internet
Over 80% of the US population has access to high-speed internet, which means that we have the potential to reach the 90% who don’t get care. I am not saying this is easy, but there is a saying in marketing that you go where the customers are – and they are online.
#3 Stop Criminalizing Addiction and Treat Those in Prison
The vast majority of folks behind bars suffer from addiction and most don’t get treatment. This needs to change. Because most will get out, why not use their time while in prison to treat their addiction, educate them, and provide them something to live for when they get out? I know, this costs too much money. See my last point.
#4 Invest in Families
Addiction is primarily a problem born out of adolescence. Most who develop addictions begin their journey before the age of 15. We need to devote significant resources to helping families flourish. We need programs that help people developmentally obtain the capacities they need for optimal mental health, for intimacy, parenting, and getting along with each other.
What would be on your list?