For most of the 20th century, addiction has been viewed as the result of poor choices, lack of personal responsibility, moral failure or even criminal behavior. These attitudes have coincided with the U.S. government-led "war on drugs" that has for years punished drug users with jail time. Making matters worse, treatment options vary wildly from one location to another, with no standardization across the rehab industry.
"Behavioral health, and especially addiction, have long been the stepchild of healthcare," said Harry Nelson, founder of the Los Angeles-based American Addiction Treatment Association, which helps treatment facilities maintain compliance on a wide range of issues. "There's been this system of very high-end places where people with money can go to dry out, and very primitive resources for the poor."
But the professional and public understanding of addiction has begun to evolve, albeit slowly. The American Medical Association officially recognized alcoholism as a disease as far back as 1952. "It wasn't until 2000 that the idea of treating all addiction like a chronic medical condition was proposed," though, said Tony Mele, PsyD, chief clinical officer of Sovereign Health Group, a residential rehabilitation treatment company based in San Clemente.
Recently, regulations that are part of the Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act have been a major catalyst in moving addiction treatment toward an evidence- and medical-based approach. "Over the last 10 to 15 years, the field of addiction medicine has been changing and becoming more of a legitimate science, with much less emphasis on old beliefs that addiction is a moral failing," said Betsy Spier, a psychotherapist and addiction specialist who teaches at UCLA Extension's Alcohol and Drug Abuse Counseling Certificate program.
And just as doctors have standards of care for how they treat chronic diseases such as cancer and diabetes, this new medical model means addiction treatment requires its own standards of care, a term that has gained ground amid a push for insurance companies to pay for addiction treatment, Spier said.
When the insurance company pays, there's an expectation that inpatient and outpatient rehab centers treat addiction based on the medical model, she said. These insurance constraints often mandate that treatment centers now employ staff who are either licensed as psychotherapists or certified as chemical dependency counselors.
The medical model and behavioral health
For treatment centers like Sovereign Health, where Mele is chief clinical officer, following a medical approach means doing more than simply helping patients stop using drugs and alcohol. It means addressing the underlying behavioral health issues that many addicts face.
"We've recognized that certain emotional characteristics — like depression, ADHD or a history of trauma or abuse — often co-occur with addiction," Mele said. "Substance abuse is a way to self-medicate and ease emotional pain."
According to the National Institute of Mental Health, in 2014, 20.2 million adults in the U.S. had a substance use disorder and 7.9 million were dealing with both substance use disorder and mental illness. That suggests nearly 40 percent of all addicts are suffering from underlying behavioral health issues that may contribute to their addiction.
"Once you start treating the psychopathology, the addiction gets treated as well," said Tonmoy Sharma, CEO and founder of Sovereign Health.
As a dual-diagnosis center, Sovereign Health treats both addiction and behavioral health issues. Sharma recalled an experience with a patient who arrived at Sovereign after years going in and out of various treatment programs without success: "When he came to us for the first time, our clinician did a cognitive assessment and determined that he had undiagnosed ADHD. He had been self-medicating for years. Why didn't someone pick that up before he got to this point?"
12-step programs: just one piece of the puzzle
Founded in 1935, Alcoholics Anonymous was the original 12-step program. Over the years, it has become the dominant model for addiction treatment in the United States. While programs like Alcoholics Anonymous or SMART Recovery do help some people, they aren't equipped to address underlying behavioral health issues.
"Most addiction treatment is built around a quasi-religious 12-step model," American Addiction Treatment Association founder Nelson said. "There certainly is value in talking with others who share your experience, but if the underlying issue is depression, all the substance abuse support in the world won't work."
Mele said that while 12-step programs and others like them have a role in the changing addiction treatment landscape, they should be used in the same way as support groups for other chronic medical conditions. He said support groups are useful in a wide range of situations, anything from dealing with a life-altering medical condition such as cancer to the difficulties of serving as a caregiver to a loved one with dementia. Twelve-step programs for addicts are no exception.
However, one of the flaws Mele sees in 12-step programs is the focus on teaching addicts to avoid triggers: people, places and things that make them feel tempted to use drugs or alcohol. "We can't avoid triggers," he said. "Rather than teach [addicts] how to avoid, we should teach them how to deal with triggers or train the brain to respond to triggers in a different way."
This type of thinking could improve addiction treatment as treatment centers begin to follow medical-based approaches not only to treat patients but also to measure their progress.
"Sovereign's approach is to measure patient responsiveness to sensory triggers and cues," Mele said. "We do this by measuring the brain's responsiveness to smells, sounds and visual alcohol or drug cues."
Industrywide innovation, experimentation and research on par with that of medical conditions like heart disease and diabetes can continue to pave the way for better treatment.
"The best programs are doing a significant level of intake assessment to see what works, and that's intensive and expensive," Nelson said. "Personalized care, addressing behavioral health issues and a better understanding of genetics will make it easier to get people the support they need."
What should addiction treatment look like?
The addiction treatment and recovery field is in the midst of a major transition. The American Society of Addiction Medicine, a national professional society representing physicians, clinicians and other professionals, adopted its Standards of Care for the Addiction Specialist Physician in 2014, aiming to establish a road map for high-quality addiction care.
"ASAM's contributions have been significant," Nelson said. "But they are mostly focused on physicians and detoxing and don't really address what outpatient treatment is supposed to look like."
As standards of care are developed for outpatient treatment, especially with regard to new insurance requirements, the overall quality and availability of care around the country should improve.
"Treatment centers now employ staff that have been schooled in the science of addiction and are able to give their clients more tools with which to handle their sobriety when they complete treatment," UCLA Extension psychotherapist and addiction specialist Spier said. "Because more and more clients suffer from mental health issues other than addiction, having trained psychotherapists helps the clients navigate their substance use and their mental disorders simultaneously."
But there's also the risk that the industry could try to establish a one-size-fits-all approach rather than embracing the personalized-care approach that has become a cornerstone of fields such as cancer treatment.
"Treatment centers that use a variety of methods are more effective than those with a cookie-cutter model of all clients going to the same group and having the same therapy and going to the same meetings," Spier said. "Clients do the best with a variety of modalities and many individual sessions as well as group activities."
Mele believes there are two vital components of dual-diagnosis programs that are missing in many treatment facilities. "The first is the ability to assess cognitive and personality functioning," he said. "The second is knowledgeable and competent staff trained in the treatment of mental health conditions. It is especially concerning that many dual-diagnosis recovery programs don't have staff trained in the treatment of long-standing and well-entrenched personality characteristics that have either led to the addiction or have maintained it."
Ultimately, treatment centers need to offer robust services for both addiction and mental health issues. And those need to take a variety of forms, from one-on-one counseling and group therapy to medication-based treatments for mental health issues.
They also need reliable methods by which to evaluate patients. Assessments should start when patients first arrive and identify each one's unique needs and reasons for addiction.
Finally, systems should be put in place that accurately measure progress through the program and follow up with the patients for years down the road.
"We need to measure how good treatment is or isn't," Sovereign Health CEO Sharma said. "Most [addiction treatment specialists] accept that substance abuse is a brain disease, but they rarely measure brain function. Without measurement-based care, millions will continue to endure ineffective treatment.
"That's why we need to set these standards. We feel the time is long overdue to embrace this concept and live up to the standard of other medical specialties."