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Old Habits

Medicalization is the hot new thing in drug treatment. Just like in 1970.

Ibhinc.Org
Dr. Robert Dupont
Joseph Kohl
Kurt Schmoke

By Edward Ericson Jr. | Posted 7/28/2010

Second of a four-part series.

Read part 1, part 3, and part 4.

Page 5 of 5.   1  2  3  4  5  

Even as research into new and better treatment techniques gets disseminated, the long-term outcomes studies that early drug treatment advocates (and even President Nixon) envisioned are still rare. One problem is that each state has a different way of measuring drug treatment outcomes--and sometimes counties do as well.

A potential solution is the National Outcome Measures, an effort by the National Association of State Alcohol and Drug Abuse Directors (NASADAD) to implement a uniform measurement and data gathering system.

Originally scheduled for completion in 2007, the project remains unfinished.

"It's sorely lacking, 'cause so much has happened since then," NASADAD Executive Director Robert Morrison says, citing the passage of health care reform, the implementation of expanding Medicaid as a principle payer for drug treatment, and several state health reform efforts that required close attention from NASADAD's staff. The work done on the project so far constitutes "an important first step," he says, "[but] you put your finger on an important issue, which is now what? Are you using the [data] to improve service delivery?"

Morrison's characterization of National Outcome Measures suggests that improving service to addicts is not the first priority. "What we wanted to do was learn, how can we continue to tell our story," he says. "Policy makers were asking--what are the outcomes we are getting from the dollars we are allocating to you?"

In other words, National Outcome Measures is pitched to justify drug treatment expenditures to sometimes skeptical lawmakers.

Morrison says that 70 to 80 percent of the $21 billion spent on drug treatment is "public money," but that figure is dwarfed by the costs of addiction, which his staff economist estimates at $243 billion for alcohol and $181 billion for illicit drugs. Thus the benefit of treatment--even the imperfect methods now employed--far outweighs the costs, he says. And so the treatment providers' goal is to keep people with substance abuse disorders in treatment for as long as possible.

"The whole view of treatment is changing to a recovery-oriented model," says Bill Rusinko, a long-time research statistician with the Maryland Department of Health and Mental Hygiene. "The addict is seen like someone with high blood pressure or diabetes. They're basically going to be treated forever in some way or another, and never reach the point where we can say, 'You're cured and can stop seeing a doctor.'"

This idea is still controversial, even among bSAS board members. "People say that addiction is a chronic disease, so when people relapse it's not the fault of the treatment providers, and that [the providers] should not be held responsible for the behavior of people when they leave treatment," says Robert Embry, head of the non-profit Abell Foundation and a bSAS board member. "There are some who disagree, and I enthusiastically put myself in the category of people who disagree with that.

"In providing public money for drug treatment, we ought to know, within certain modalities, and within certain sub-groups of addicts, that we're having more beneficial effect on people when they get out of treatment than with other modalities," Embry says, "because we don't have unlimited money."

Yet, even as the industry welcomes the prospect of substantially increased funding--thanks to the 2008 Mental Health Parity and Addiction Equity Act, the most recent national health reform bill and the expansion of the state-run Primary Adult Care (PAC) program to cover more drug treatment services ("Cleaning Up," Feature, June 23)--the prospect of better long-term outcomes data seems to be fading.

"I think you can make improvements if there were money to follow people long-term . . . on a monthly or quarterly basis, just call them and reconnect them to the system," says Dr. Robert Schwartz, a bSAS board member and medical director at the non-profit Friends Research Institute. But "if you don't have money to pay for basic treatment, that seems like a luxury."

Schwartz suggests that concerns about drug treatment efficacy are misplaced--and maybe even reflect the stigma that still clings to addiction itself. "In some ways drug treatment outcomes monitoring is better than for most [other chronic medical] conditions," he says. Medications for opiate addiction are very effective, Schwartz says, citing methadone and buprenorphine, the latest medicinal heroin treatment, as are therapeutic communities.

Like a more modest version of Robert DuPont in 1971, Schwartz sees the problem in terms of volume and scale. "The idea with drug treatment is to have a public health outcome for a city, or a state, or for a nation," Schwartz says. "To have a public health outcome you have to--if you know you have an effective treatment--get as many people as possible into treatment."

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More from Edward Ericson Jr.

Room for Improvement (7/14/2010)
Celebrated crime control measure actually a flop, former chief reveals

Shelling Out (7/7/2010)
Mortgage broker goes bankrupt, seeks mortgage modification as taxpayers face mounting bailout bills

Cleaning Up (6/23/2010)
Federal money is expanding drug treatment in Baltimore--and causing providers headaches.

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