Principles for Improving US Treatment for Problematic Addictive Behavior
by Tom Horvath, Ph.D., ABPP
How can the United States improve addiction treatment?
The ultimate goal of support for overcoming problematic addictive behavior is to improve individual health and well-being while reducing societal costs associated with the behavior. Several countries (e.g., Portugal, Switzerland, the Netherlands) are much more effective than the US in providing this support, which can include professional services (treatment) as well as a variety of non-professional and informal support.
Calling for Change in US Addiction Treatment
In the US a rational, medical and psychological approach would improve a system that has been overly influenced by the punitive aspects of drug prohibition and the diversity-suppressing dominance of the 12-step spiritual approach (which has been of limited effectiveness and limited appeal despite its near universality in the treatment system). The two most important changes to make in the US, therefore, are to decriminalize or legalize all substance use, and to promote a diverse set of recovery supports.
However, even without these changes, which might require considerable time, some improvements could occur now. The following principles, based on the best available medical and psychological evidence, are focused specifically on what is needed in the US treatment system. If we imagined this system as already established, we would see that it emphasizes:
* Natural Addiction Recovery: Treatment views itself as an adjunct to the natural recovery process, because natural recovery is the primary general route of recovery.
* Individual Responsibility: Treatment has a primary focus on maintaining the engagement of the individual in the change process, and supporting improved coping, because ultimately it is the individual who manages his or her own recovery.
* Rapid and Ongoing Access to Addiction Treatment: Treatment is readily and rapidly accessible in multiple formats, with minimal commitment required initially and ongoing access available, because motivation to change can be fleeting.
* Multiple Pathways: Multiple pathways of change are supported without prejudice, because no approach to treatment or recovery is effective for everyone, and no approach appeals to everyone.
* Social Connection: Treatment supports re-engagement in the human community, and provides a temporary recovery community if needed, because human connection is the most powerful antidote to problematic addictive behavior.
* Family Involvement: CRAFT (Community Reinforcement and Family Training) is readily available, because even when the individual is unmotivated for change the family typically is motivated, and willing to learn how to reinforce desired changes.
* Evidence-based Practice: The foundation of treatment services is evidence-based treatment as modified by individual motivation and clinical judgment.
* Medication Assisted Treatment: Medication assisted treatment (MAT), as a specific evidence-based practice, is readily available, because it clearly supports long-term success. In a country in which substance use was decriminalized or legalized, individuals might simply be maintained on some substances (e.g., heroin), until they were ready to stop, as is done now with great success in Switzerland.
*Services for Co-occurring Conditions: Treatment is organized in the expectation that most of the treatment-seeking population has co-occurring psychiatric disorders, or subclinical manifestations of them, as well as a range of life problems that need to be included in a comprehensive treatment plan.
* Qualified Addiction Treatment Staff: High-level professionals (appropriately trained medical staff, and masters or doctoral level mental health providers) are the primary treatment providers, because they are also equipped to address co-occurring conditions using evidence-based treatments suitable for these conditions.
* Psychiatric Care: Psychiatric medication is readily available, because of the level of co-occurring conditions.
* Stepped Care: Providers focus on increasing utilization (to improve the entire population), encouraging the lowest level of care possible (because lower levels of care can be equally effective), providing the shortest length of service possible (because shorter care can be equally effective), and providing ready access to continuing care (because continued focus on change supports continued success). The treatment system is not fee-for-service oriented, because that orientation works against stepped care.
*Cost effectiveness: Services not traditionally reimbursed under current fee-for-service insurance plans (e.g., sober living, recovery coaching, employment assistance, telephone sessions, drop-in groups) are included with or instead of treatment in order to reduce set-backs and promote long-term outcomes.
* Secondary Prevention: Health care providers are supported in referring individuals who might not otherwise seek treatment.
* Tertiary Prevention: High expenditure individuals are identified and managed from a cost-effectiveness perspective.
* Incentivizing Payment Method: Population based payment (capitation or an accountable care organization) or bundled payments, rather than fee for service, incentivize providers to align with the principles stated here.
*Meaningful Documentation: Documentation meets the standard necessary to support effective treatment, which may be a lower standard than is required to support the adversarial utilization reviews under fee-for-service insurance reimbursement.
* Ongoing Research: Ongoing data collection and analysis occurs because 1) treatment needs to be adapted to various populations and environments, 2) the most cost-effective co-pay structures, if any, need to determined, and 3) the most cost-effective level of investment in treatment needs to determined based on medical cost offset. My prediction is that good treatment, which is sometimes expensive in the short-term, is highly cost-effective in the long term, because of reductions, for instance, in fetal alcohol syndrome, infections such as HIV and Hepatitis C) and physical and emotional trauma, all of which are very costly over time.
Although the US treatment system is far from operating in the manner just described, some providers, such as Practical Recovery, employ these principles to the extent we are legally free to do so. Although major changes to society’s views about problematic addictive behavior will be needed for drug prohibition to end and support for change to become diverse, for those seeking genuinely helpful treatment it is available now, if one is willing to look for it.