[NYAPRS Enews] NYT: In Wake of Parity, Focus on Evidence Based Substance Abuse Treatment

[Matt Canuteson]

The Evidence Gap: Drug Rehabilitation or Revolving Door? 

By Benedict Carey   New York Times  December 23, 2008

 

ROSEBURG, Ore. - Their first love might be the rum or vodka or gin and
juice that is going around the bonfire. Or maybe the smoke, the potent
marijuana that grows in the misted hills here like moss on a wet stone.

 

But it hardly matters. Here as elsewhere in the country, some users
start early, fall fast and in their reckless prime can swallow, snort,
inject or smoke anything available, from crystal meth to prescription
pills to heroin and ecstasy. And treatment, if they get it at all, can
seem like a joke. 

 

"After the first couple of times I went through, they basically told me
that there was nothing they could do," said Angella, a 17-year-old from
the central Oregon city of Bend, who by freshman year in high school was
drinking hard liquor every day, smoking pot and sampling a variety of
harder drugs. "They were like, 'Uh, I don't think so.' "

 

She tried residential programs twice, living away from home for three
months each time. In those, she learned how dangerous her habit was, how
much pain it was causing others in her life. She worked on strengthening
her relationship with her grandparents, with whom she lived. For two
months or so afterward she stayed clean. 

 

"Then I went right back," Angella said in an interview. "After a while,
you know, you just start missing your friends."

 

Every year, state and federal governments spend more than $15 billion,
and insurers at least $5 billion more, on substance-abuse treatment
services for some four million people. That amount may soon increase
sharply: last year, Congress passed the mental health parity law, which
for the first time includes addiction treatment under a federal law
requiring that insurers cover mental and physical ailments at equal
levels. 

 

Many clinics across the county have waiting lists, and researchers
estimate that some 20 million Americans who could benefit from treatment
do not get it.

 

Yet very few rehabilitation programs have the evidence to show that they
are effective. The resort-and-spa private clinics generally do not allow
outside researchers to verify their published success rates. The
publicly supported programs spend their scarce resources on patient
care, not costly studies. 

 

And the field has no standard guidelines. Each program has its own
philosophy; so, for that matter, do individual counselors. No one knows
which approach is best for which patient, because these programs rarely
if ever track clients closely after they graduate. Even Alcoholics
Anonymous, the best known of all the substance-abuse programs, does not
publish data on its participants' success rate.

 

"What we have in this country is a washing-machine model of addiction
treatment," said A. Thomas McClellan, chief executive of the nonprofit
Treatment Research Institute, based in Philadelphia. "You go to Shady
Acres for 30 days, or to some clinic for 60 visits or 60 doses, whatever
it is. And then you're discharged and everyone's crying and hugging and
feeling proud - and you're supposed to be cured."

 

He added: "It doesn't really matter if you're a movie star going to some
resort by the sea or a homeless person. The system doesn't work well for
what for many people is a chronic, recurring problem."

 

In recent years state governments, which cover most of the bill for
addiction services, have become increasingly concerned, and some,
including Delaware, North Carolina, and Oregon, have sought ways to make
the programs more accountable. The experience of Oregon, which has taken
the most direct and aggressive action, illustrates both the promise and
perils of trying to inject science into addiction treatment.

 

Evidence-Based Treatments

In 2003 the Oregon Legislature mandated that rehabilitation programs
receiving state funds use evidence-based practices - techniques that
have proved effective in studies. The law, phased in over several years,
was aimed at improving services so that addicts like Angella would not
be doomed to a lifetime of rehab, repeating the same kinds of counseling
that had failed them in the past - or landing in worse trouble.

 

"You can get through a lot of programs just by faking it," said Jennifer
Hatton, 25, of Myrtle Creek, Ore., a longtime drinker and drug user who
quit two years ago, but only after going to jail and facing the prospect
of losing her children. "That's what did it for me - my kids - and I
wish it didn't have to come to that."

 

When practiced faithfully, evidence-based therapies give users their
best chance to break a habit. Among the therapies are prescription drugs
like naltrexone, for alcohol dependence, and buprenorphine, for
addiction to narcotics, which studies find can help people kick their
habits. 

 

Another is called the motivational interview, a method intended to
harden clients' commitment upon entering treatment. In M.I., as it is
known, the counselor, through skilled questioning, has the addict
explain why he or she has a problem, and why it is important to quit,
and set goals. Studies find that when clients mark their path in this
way - instead of hearing the lecture from a counselor, as in many
traditional programs - they stay in treatment longer. 

 

Psychotherapy techniques in which people learn to expect and tolerate
restless or low moods are also on the list. So is cognitive behavior
therapy, in which addicts learn to question assumptions that reinforce
their habits (like "I'll never make friends who don't do drugs") and to
engage their nondrug activities and creative interests. 

 

For Angella, this kind of counseling made a difference. She spent
several months in a program run by Adapt, an addiction treatment center
here in Roseburg, a small city about 175 miles south of Portland.

 

In treatment, she said, she learned how to "just be with, and feel" bad
moods without turning to drink or drugs; and to throw herself into
creative projects like collage and painting. The program has helped her
reconnect with her father and to enroll in college beginning in January.

 

"I want to be a teacher, and someone at the program is advising me on
that," she said in an interview. "That's the plan, to just move out and
away from my old life."

 

A friend of hers in the program, Alex, a 16-year-old from Roseburg, said
that the therapy helped him monitor his own emotional ups and downs,
without being swept away by them. The counselors "are always asking
about our stress level, our anger, so you become more aware and have a
better idea what to do with it," he said.

 

Almost 54 percent of Oregon's $94 million budget for addiction treatment
services now goes to programs that deploy evidence-based techniques,
according to a state report completed last month. The estimated rate
before the mandate was 25 to 30 percent. The state has not yet analyzed
the impact of this change on clients.

 

"Before the mandate, most programs had some evidence-based practices,
and since then there has been a lot more interest and awareness of
them," said Traci Rieckmann, a public health researcher at Oregon Health
and Science University, who is following the policy implementation with
support from the Robert Wood Johnson Foundation and the National
Institutes of Health. 

 

Culture Clash

Yet interest and awareness may not translate into good practice, and Dr.
Rieckmann says it is not at all clear how many rehabilitation programs
claiming to use evidence-based techniques actually do so faithfully.
About 400 programs receive state money, and most of them are small,
rural outfits that are already stretched to provide counseling, to say
nothing of paying for extensive training.

 

"You're talking about therapies, like cognitive behavior therapy, that
take time to learn," said John Gardin, the behavioral health and
research director at Adapt in Roseburg, who travels the country to teach
the skills. "Most places don't have a person like me to do that
training, so they're getting two to three days of training, if that; and
that's just not enough time to get it."

 

In studies looking at hundreds of programs nationwide, researchers have
found a similar gap between what programs may want to do and what
they're able to do. "For instance, most programs don't have an M.D. on
staff," said Aaron Johnson, a sociologist at the University of Georgia
who has led many of the studies. "Without that, of course, you can't
prescribe any medications."

 

Tim Hartnett, the executive director of a Portland treatment program
called CODA Inc., which does its own research on patient outcomes, said
that the mandate had raised the level of conversation statewide, but
that true reform would mean "an integrated system that tracks clients as
they move from residential to outpatient treatment, and that defines
clear targets" for what a person should expect from each kind of
program. 

 

"Our goal at CODA is to create a system of care that uses evidence-based
practices at just the right dose and just the right time," Mr. Hartnett
said. "As with many chronic diseases, figuring out dosage and timing are
critical."

 

For some addicts, a standard program may not help at all, according to
Anne Fletcher, who for her book "Sober For Good" interviewed 222 men and
women who had been clean for at least five years. "A lot of these people
overcame an alcohol problem on their own, or with the help of an
individual therapist," Ms. Fletcher said. 

 

To complicate matters in Oregon, the state mandate has stirred a kind of
culture clash between those who want reform - academic researchers,
state officials - and veteran counselors working in the trenches, many
of whom have beaten addictions of their own and do not appreciate
outsiders telling them how to do their jobs. 

 

"I'm a counselor, and I'd be defensive, too: 'What do you mean, all this
stuff I've been doing my entire life is wrong?' " said Brian Serna,
director of outpatient services at Adapt, who has traveled the state to
monitor the use of scientific practices. "So the challenge is to build a
bridge between what the science says is effective and what people are
already doing."

 

One way to do that, some experts now believe, is to combine
evidence-based practice with "practice-based evidence" - the results
that programs and counselors themselves can document, based on their own
work. In 2001 the Delaware Division of Substance Abuse and Mental Health
began giving treatment programs incentives, or bonuses, if they met
certain benchmarks. The clinics could earn a bonus of up to 5 percent,
for instance, if they kept a high percentage of addicts coming in at
least weekly and ensured that those clients met their own goals, as
measured both by clean urine tests and how well they functioned in
everyday life, in school, at work, at home.

 

By 2006, the state's rehabilitation programs were operating at 95
percent capacity, up from 50 percent in 2001; and 70 percent of patients
were attending regular treatment sessions, up from 53 percent, according
to an analysis of the policy published last summer in the journal Health
Policy. 

 

"We basically gave them a list of evidence-based practices and told them
to pick the ones they wanted to use," said Jack Kemp, former director of
substance abuse services for Delaware, in an interview. "It was up to
them to decide what to use."

 

For those who are trying not to use, it doesn't much matter how rehab
services are improved - only that it happens in time. "Honestly, you
just don't care how or why something works for you," said Ms. Hatton,
the 25-year-old from Myrtle Creek, Ore. "Just that it does."

 

http://www.nytimes.com/2008/12/23/health/23reha.html?hp?8dpc

 

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