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Old Habits

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

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 1 of 5.   1  2  3  4  5  

Six months ago, U.S. Secretary of Health and Human Services Kathleen Sebelius gave a speech in Towson, heralding a revolution.

"There are a lot of changes happening right now that could have a big impact on behavioral health," Sebelius told anacof mental health professionals at Sheppard Pratt Health System. "Parity, health insurance reform, the growing popularity of integrated care models, an increased focus on prevention, huge gains in our understanding of the science behind mental illness and substance abuse."

"Parity" means that mental health care can no longer be discouraged by health insurers, who for years have argued for their right to charge more to cover treatment of mental disorders than for physical ailments. Since July 1, interim regulations require insurers to make a "good faith compliance effort" to follow the law--the Mental Health Parity and Addiction Equity Act--forbidding the practice.

"If 10 or 20 million Americans were walking around with open wounds, we'd call it a national crisis," Sebelius continued, according to a transcript of her speech. "But because mental illnesses and addictions can be harder to see, we don't feel the same urgency. And yet, the costs of mental illness are right there in front of us. Thirty-two thousand Americans commit suicide each year. People with mental illness make up half of the 700,000 homeless people in America. People with substance abuse disorders account make up four out of five prisoners. The National Academies estimate that mental illness in Americans under 25 alone costs our country almost $250 billion a year."

In Sebelius' model, which is pervasive in drug treatment circles, ending up in prison is just one unfortunate symptom of substance abuse disorder. It is part of a new paradigm called the Recovery Oriented System of Care (ROSC), which seeks to integrate drug and mental health treatment into the larger medical care system, reduce the social stigma associated with these disorders, and "normalize" addiction treatment. In the ROSC model, drug addiction is really no different from other chronic ailments such as diabetes or heart disease.

But this model glosses over differences in the way various medical conditions manifest themselves, and in the way treatment outcomes are measured. People with diabetes and heart disease seldom break into homes to steal electronics or push over grandma to snatch her purse. People with substance abuse disorder routinely do these things, even while receiving treatment for their disease.

And by the industry's current measures, treatment is considered successful if the patient commits fewer crimes than usual during the "treatment episode."

As drug addiction has become "substance abuse disorder" and understood by medical professionals to be a chronic condition, the drug treatment industry has moved its goal posts. The old system was based on short-term treatment leading to abstinence; the new system is usually predicated on open-ended treatment leading to reduced days of drug use, with the main goal being more drug treatment. This is the model set to be fully and indiscriminately funded by Medicaid and private insurance as part of the Sebelius-led final push to "medicalize" drug treatment.

As the history of drug treatment shows, the medical model was present at the beginning. What has long been missing is the scientific rigor and clear-eyed analysis of the kinds of long-term outcomes studies that, in other branches of medicine, bring improved care. As the Baltimore Substance Abuse System (bSAS) celebrates its 20 anniversary and burnishes its reputation as a national model for addiction treatment, the treatment industry's evolution is worth reviewing.

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

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