Note: This article was authored by a colleague of ours who is a medical doctor for exclusive publication here, as the doctor felt that this was an important issue to be discussed in terms of medical liability and patient safety.
Substance abuse and dependence are epidemic in the United States
The federal government funds a number of programs in the “War on Drugs.” Sadly, these programs have not resulted in positive change. The National Institute on Drug Abuse reported in January of 2014 that approximately 23.9 percent of all Americans over the age of 12 years had used illicit drugs or abused a prescribed medication, including pain relievers, stimulants or tranquilizers. There has been an increase from 8.3 percent of the population known to have abused drugs in 2002. Federal officials attribute the increase to a rise in marijuana consumption, which is the most widely abused illegal drug. Use of cocaine has decreased, and the use of methamphetamine has remained approximately the same as in 2007.
Most people first use drugs during adolescence or teenagers, beginning with marijuana in approximately 50% of cases. Prescription pain medications are a rising problem in this population, and younger teenagers tend to use inhalants. Although drug use is highest in the group ranging in age from 18 to 20 years, drug use is increasing among people aged fifty and above, probably due to the baby boomer generation, who widely used drugs previously.
Alcohol is another mood-altering substance, albeit legal, to which many Americans turn and may become dependent or use alcohol abusively. Tobacco, the most addictive of all substances due to its rapid delivery to the brain, has declined in popularity.
What is “substance use disorder?”
Substance use disorder is the new term used in the fifth revision of the Diagnostic and Statistical Manual of Psychiatry to encompass abuse and dependence upon mood altering substances. Alcohol dependence or problems related to alcohol affect 17.7 million Americans, or almost 7% of the population. There has been a sharp increase in the rate of marijuana dependence within the past few years.
What is abuse and what is dependence?
The criteria by which a diagnosis of substance abuse or dependence are made met very strict criteria in the previous issue of the DSM-IV. However, the definition of substance use disorder has broadened the scope of use or experimentation to classification as a disorder under which many Americans might qualify.
Previous versions of the psychiatric Diagnostic and Statistical Manual have defined substance abuse as a maladaptive pattern of substance use leading to significant impairment or distress in one or more of the following areas within a 12 month period: failure to perform obligations at work, school or home, recurrent use in physically hazardous situations (DUI), recurrent legal problems due to use of a substance, continued use despite social and interpersonal problems. For substance abuse, the criteria of substance dependence have not been met.
Substance dependence is defined by tolerance, which refers to an increased amount of the substance to become intoxicated or to have the desired effect, with a diminished effect when using the same amount of the substance. Other characteristics of dependence include withdrawal, frequent unsuccessful efforts to control use of the substance, reduction of activities because of substance use, spending a great deal of time to obtain the substance, and continuing use despite physical or mental health problems exacerbated by the substance.
What is substance use disorder?
Substance use disorder includes a continuum from abuse to dependence as part of one process, designated mild,, moderate or severe. There are 11 criteria, and in order to be classified with mild substance use disorder, the patient must meet two criteria. For moderate SUD, the patient must meet 4 of 11 criteria, and for severe SUD, patients must meet 7 or more of the criteria. The criteria make it easier to diagnose a patient with a substance related disorder.
What is the American Society of Addiction Medicine?
The American Society of Addiction Medicine is a specialty that is NOT recognized by the American Board of Medical Specialties. It began with a group of physicians who were interested in alcoholism and available treatments in the 1950’s. After several permutations, the group of physicians involved named their society as ASAM. They state their mission as increased access to improved quality of addiction treatment, education of the public and healthcare professionals, promotion of research and prevention, and recognition of the specialty by the American Board of Medical Specialties. Membership is open to any physician within all specialties and types of work.
Why is this important to me?
Addiction specialists include psychiatrists certified by the American Board of Psychiatry and Neurology. Psychiatrists may obtain a one year addiction psychiatry residency approved by ACGME. They have demonstrated eligibility and have passed a rigorous certification exam.
However, one may become a “specialist” in addiction medicine that is only certified by their own society, the American Board of Addiction Medicine. An addiction medicine physician should apply medical care with a bio-psycho-social perspective for those patients with substance-related health problems, manifestation of unhealthy substance use, and for affected family members. Although ASAM claims its members are “specifically trained in a wide range of prevention, evaluation and treatment modalities addressing substance use and addiction in ambulatory care settings, acute care and long-term care facilities, psychiatric settings and residential facilities,” in fact there is no substantive training in co-existing psychiatric disorders, and members of ASAM, positioning themselves as experts in this field, often suppress public dissemination of economic evidenced based practice in favor of treatment in residential long-term facilities with a rate of recidivism as high as 70%.
When you visit your general practitioner for advice on treatment of a substance abuse disorder or dependence, chances are good that you will receive a recommendation to attend Alchoholics Anonymous or, depending up your means, to a long-term residential facility.
Has your physician informed you of all alternative treatments when seeking help for a family member with a substance use disorder or if seeking help for yourself?
An essential practice expected of physicians is to obtain informed consent from their patients by telling them of the variety of treatment modalities available for their problem and by informing them of the statistical rate of success or failure. Only in that way can a patient make an autonomous decision, a key patient right. Most physicians are only dimly aware of other effective modalities of treatment, and this is largely because a group of self-designated experts, most with a history of addiction or abuse of alcohol or other substances, have found it profitable to maintain their insistence upon 12 step facilitation as the solution to drug or alcohol problems.
Over 90% of treatment centers in this country are based upon the 12-steps of AA, a group without evidence of success, only anecdotes. The drop out rate is high, and 12 step rehab centers are a revolving door. With this in mind, why would ASAM continue to push this model of treatment? Because of financial incentives that result from the high fees assessed to patients for treatment and, in some cases, drug testing.
What is AA?
It is important to recognize that AA is in theory a decentralized group, but they have successfully financed operations from sale of the “Big Book” and other publications, even suing counselors in other countries for producing copies of the AA literature for free distribution. That is the result of organization.
AA was started in the 1930’s by two alcoholics, one of whom was a stockbroker, Bill W., and Dr. Bob, an alcoholic physician. They mutually supported each other in their efforts to stop their abuse of alcohol, and soon began to help others. Eventually, the movement spread from Ohio to New York and then throughout the country.
It is very important to recognize that despite every proclamation that AA is not a religious organization, it has all of the elements of religion, including rituals, a prophet, a Bible (the Big Book), commandments (the Twelve Steps) and prayer to a Higher Power. Although proponents claim that the higher power can be whatever you want it to be (“One participant said his higher power was his dog,” the factual information is quite different and reveals the roots of this organization in the Oxford Evangelical Group. Participants are called upon to pray Christian prayers and some prayers particular to the group. They must proceed through a confession of all past sins (The Fifth Step). Bill W. tells members, in the Big Book, to obscure the spiritual foundation of the group when offering support.
The courts at the state and federal level in several states have overturned coerced participation in 12 step programs as a violation of the Establishment Clause of the First Amendment.
Is alcoholism a disease or a behavioral issue?
The disease model of alcohol was created by Bill W., a lifelong alcoholic with probable brain damage. He proclaimed without evidence that alcoholism was a lifelong disease without a cure. This model was adopted over time, piece by piece, by the AMA and traditional medicine. In reality, despite evidence of genetic components to alcoholism or substance dependence, those genes, like genetic predisposition for diabetes or cancer, are not expressed unless the environment and individual behavior result in their expression.
Proponents of the disease model claim that there are permanent brain changes in the cortex of alcoholics or drug addicts. If you compare this statement to the reversible brain damage that occurs in a stroke victim, or to the new cortical pathways we create through education and experience, it becomes clear that this statement has no basis in reality.
Diseases are treated in the 21st century on the basis of evidence, yet AA claims its anonymity prevents rigorous study.
12-step long term residential treatment is often suggested for those with the means, although the results are extremely poor, and patients are rarely seen by a physician or psychiatrist, perhaps the first or last week of a treatment that may last 30 to 90 days. They spend their days attending AA meetings, and are “counseled” in group sessions that are regulated by moderators or counselors who often have no more than a high school degree and no certification is required in many states. The chief qualification of those counselors encountered in 12 step residential centers is their history of substance use disorder, in many cases.
Statistics provided by AA
A Triennial Study produced by AA revealed that their success rate was no better than the spontaneous rate of remission (2% annually) among patients with substance use disorders, George Valliant MD, a researcher at Harvard and a board member of AA’s worldwide organization, admitted that not only was there no evidence of success, but the cohort of AA patients had a higher rate of suicide.
What are evidence based modalities of treatment?
With alcoholism or certain drug problems, there are medications that allow the patient to stop illegal drug seeking behavior, while maintaining normal functioning. The American Society of Addiction Medicine has found this a controversial subject, and as a result, many physicians are unaware of the wide variety of medical (pharmacologic) treatments available, thus unable to inform or refer their patients.
There are also a number of psychological therapies that have been shown efficacious in clinical trials, including Motivational Enhancement Therapy and Cognitive Behavioral Therapy. Physicians rarely have the time for extended patient encounters and are not trained in psychological interventions. That doesn’t mean that they don’t exist. Some of the most prominent researchers in addiction treatment in the country are psychologists.
Finally, it must be said that 12-step long term residential treatment is often suggested for those with the means, although the results are extremely poor. Patients are rarely seen by a physician or psychiatrist except perhaps during the first or last week of a treatment that may last 30 to 90 days. They spend their days attending AA meetings, and are “counseled” in group sessions that are regulated by moderators or counselors who often have no more than a high school degree and no certification is required in many states. The chief qualification of those counselors encountered in 12 step residential centers is their history of substance use disorder, in many cases.
What can I do after I have unsuccessfully been treated in a 12 step facility?
If you believe you have not been provided the information to give informed consent for your treatment, or if you have been coerced into attendance at a facility utilizing a twelve step model, as a prisoner or by your employer, you may have rights under the law. In addition to violation of informed consent and forced participation in a religious group, if you have not been successfully treated it may be due to negligence and inattention on the part of the medical director of the facility. You should consult an attorney if you believe you have been a victim of this profitable scheme.
ASAM and the Mental Health Parity bill
This is a problem about which we should all be concerned. The American Society of Addiction Medicine was a large force behind passage of the mental health parity bill several years ago, and now with funding mandates, they have openly described the necessity of 90 days of residential inpatient treatment for successful treatment of substance use disorders. At costs between $10,000 and $60,000 per month, the beneficiaries, owners of these treatment centers, will continue to lobby and to change the standard of care. This diversion of our health care dollar to an unsuccessful treatment when patients can be supported and treated as outpatients by other evidence-based modalities is a problem all Americans should consider critical.