The Anatomy of Addiction (3 page)

Why don't all the rehab clinics switch to a scientific treatment of addiction? After all, being profitable and providing effective treatment are not mutually exclusive.

The answer is the degree of profitability. It would greatly
increase the cost of doing business and diminish profits if rehab clinics adopted a scientific approach to treating addiction. Evidence-based medicine must be administered by trained medical professionals. A 12-step program is largely self-administered, costing facilities virtually nothing in labor or, at most, the expense of a low-level addiction counselor—a job that has no mandated requirements (not even a college degree) in most states.

The other reason the vast majority of rehab clinics don't use evidence-based medicine is because they don't have to. There are no federal laws governing what constitutes an addiction treatment center and most state laws are weak and loosely defined. Truly, in most states, you can open a rehab clinic in your living room, call yourself the chief addiction counselor and openly advertise your business with impunity. And, you can shroud the whole farce in the mantle of respectability by trumpeting that you offer AA's 12-step treatment. (AA will never dispute it.)

Unfortunately, this charade is not limited to backyard operations. Two of the most respected names in addiction treatment—the Betty Ford Center, located in southern California and Hazelden Foundation in Minnesota—merged in 2014 into one business venture. In one of his first interviews on the merger with the
Los Angeles Times
, the new CEO of the combined facilities, Mark Mishek, matter-of-factly dismissed evidence-based medicine for addiction treatment. “Nonprofits that have abstinence-based programs that are focused on the 12 Steps of Alcoholics Anonymous need to stick together. We are under attack from a competitive perspective,” he said.

Hazelden has a special placeholder in the development of the
rehab industry in the United States. In 1949, it was the first center to open using AA's 12 steps as its treatment modality. This in itself was a curious development, because AA founder Bill Wilson purposely created the organization with a bottom-up structure (he called it “benign anarchy”). Individual AA branches were meant to be self-governing. Hazelden turned that notion upside down by establishing a top-down structure and adding discipline to its treatment, in effect, embracing the AA 12 steps without its self-governing philosophy.

Is it any wonder that the public remains confused about addiction when no less than the name of Betty Ford—a former First Lady of the United States who became synonymous with addiction—is evoked to reject modern-day, scientifically proven treatments?

The Problem with AA in the Twenty-First Century

There is no war being fought against AA. Most clinicians, like myself, who deal every day with addicts know that 12-step programs can be a valuable tool in the management of the chronic disease of addiction. Like all chronic diseases, treatment over the long term requires, first, medications and, second, psychological therapy and counseling about lifestyle choices. For some substance abusers, a 12-step program can help them manage their chronic condition.

The problem with AA occurs when it's used instead of or to exclusion of evidence-based medicine. And, while we should point a finger at a rehab industry that preys on some of the most
vulnerable in society, AA itself—or, rather, some of its hardcore members—also must share in the blame.

Self-appointed AA sponsors too often demand that those under their supervision renounce all medications, including those helping them with their addiction and, in many cases, a dual diagnosed mental disorder, notably depression. That's not only galling from the perspective of anyone in the medical profession and particularly the field of addiction medicine, it's also dangerous. I've seen too many patients who have suffered serious health consequences—even suicide—after following the advice of a 12-step sponsor to abandon all their medications. While an AA pamphlet states that “No AA members should play doctors; all medical advice and treatment should come from a qualified physician,” there is absolutely no consequence if an AA sponsor thumbs her nose at the mandate and demands the new member embrace complete abstinence (meaning no drugs, even medications).

As bad as AA is, its cousin Narcotics Anonymous (NA), whose philosophy incorporates Bill Wilson's 12-step method, is worse. It publicly states it is proudly a “program of abstinence and that a member who takes medication like Suboxone violates the organization's philosophy.” In a recent interview with the
Huffington Post
, NA national office's public relations manager Jane Nickels said that if addicts “are taking a drug to treat their addiction, they are not clean in our eyes.”

Plenty of Blame to Spread Around

The medical profession itself is also part of the problem. Doctors who don't fully understand the concept of addiction as a chronic disease (with medications available to treat it) are too quick to send a patient who admits to substance abuse to a 12-step program. The prime directive of a doctor is to do no harm to the patient, and such cavalier treatment of patients with a diagnosed alcohol or drug addiction violates this solemn oath. There are too few doctors who have been trained to diagnose and treat addictions. Only 2.5 percent of primary care doctors are certified to prescribe one of the most effective anti-addiction medications, Suboxone.

Like too many doctors, too many judges willfully embrace their ignorance of addiction medicine and send addicts into the hands of 12-step treatment centers, even when evidence-based treatment centers exist as alternatives. Who's to judge whether talking about your problems with other addicts or being treated by a medical professional is the better course of treatment, right?

Private insurance companies and Medicaid also contribute to the problem. In eleven states, Medicaid programs put limits of one to three years on how long addicts can be prescribed Suboxone, one of the leading medications used in addiction treatment. Imagine if we had similar limitations on inhalers for asthma sufferers and insulin for diabetics. The restriction reflects a fundamental misunderstanding that addiction can somehow be cured. Like every other chronic disease (they would not be “chronic” if
they could be cured), addiction cannot be cured. But it can be treated and managed successfully so that a high quality of life is achieved.

Some managed care organizations mandate authorization of Suboxone every month. Medicaid has tried to deny payment for Suboxone if a patient fails a drug test. Um, the patient is taking Suboxone to wean himself off a narcotic, so of course it will be present in his body. Equally puzzling, Medicaid will also at times deny payment for Suboxone if the drug test is clean. In other words, you can't win.

If not covered by Medicaid, the Affordable Care Act (ACA), or private insurance, addiction medications can be prohibitively expensive, costing thousands of dollars.

The media, which should be the arbiter of truth, also sometimes gets it all wrong. In a 2013 article sensationally headlined, “Addiction Treatment with a Dark Side,” the
New York Times
, no less, asserted that Suboxone was linked to 420 deaths in the United States by the Food and Drug Administration (FDA). The FDA later repudiated the article's false assumption that Suboxone was a cause of the purported overdose deaths and rather was merely detected. The fact of the matter is that, like marijuana, it's almost impossible to overdose on Suboxone.

Finally, blame popular entertainment for creating a narrative spanning decades that the only way to treat substance abuse is through AA. Literally, dozens of films have reinforced this notion, including
Lost Weekend
, circa 1945 with Ray Milland (who won an Oscar for his performance);
Come Back, Little Sheba
(1952, with an Oscar-winning performance by Shirley Booth);
The Days
of Wine and Roses
(1962, another Oscar winner; are we seeing a pattern here?);
Clean and Sober
(1988), starring Michael Keaton;
The Basketball Diaries
(1995), starring Leonardo di Caprio;
Leaving Las Vegas
(1995), starring Nicholas Cage (who won an Oscar for his performance) and Elisabeth Shue;
28 Days
(2000), starring Sandra Bullock;
Half Nelson
(2006), starring Ryan Gosling; and on and on.

Of course, many of the films about addiction were made before the advent of evidence-based medicine beginning in the 1990s. Still, having the climax of a film's plotline revolve around a dramatic scene where the protagonist overcomes his addiction through sheer willpower remains very tempting to Hollywood. Treating addiction as a chronic disease through modern science—like hypertension—isn't half as sexy.

The Story of Russell

I am an addiction medicine specialist, psychiatrist, and assistant clinical professor of psychiatry and the behavioral sciences at the University of Southern California. I treat patients, educate medical students, and conduct research.

I wanted to write this book to deliver a clear message: alcoholism and addiction are preventable, treatable medical conditions. But I was motivated to write by a young man I encountered in the ER.

In addition to diagnosing and treating patients, I also provide hands-on education to medical students and doctors in training at Los Angeles County Psychiatric Emergency Services. One
evening, I met an emotional and physical wreck of a man brought in by the California Highway Patrol. He had flagged them down on the interstate and begged them to rescue him from the voices in his head and from those pursuing him.

They immediately brought him to the emergency room, and I was promptly notified. I gathered my team of doctors and interns, and we went to the ER to ascertain what was going on. I will never forget what I saw and what I heard from the lips of this most distraught and disheveled young man.

Drenched in sweat, he was a walking nightmare. His clothes were dirty, tattered and torn, and his skin had numerous scrapes and scratches. He was highly agitated, and his eyes darted back and forth as if he were expecting someone to break in at any moment.

We calmly assured him that we were there to help him and that we needed to know how he wound up on the freeway. Despite his extreme agitation, or perhaps because of it, he eagerly poured out his story.

He was a thirty-year-old from Sacramento who had come to Los Angeles for alcohol treatment. He'd been drinking a case of beer and 1.5 liters of vodka every day for the past ten years, and he finally turned to his father for help. He was sent to a free, church-sponsored rehab center in Los Angeles where there was no medical staff awaiting his arrival, no medical diagnosis of his condition, and no medical detox service. All that awaited him was a bed and spiritual counseling.

By the second day in rehab, he had the shakes, anxiety, insomnia, and paranoia—all signs of potentially life-threatening
alcohol withdrawal. He asked the resident pastor for help and was given one Tylenol and told to pray.

On the third day, he became further disoriented and even more paranoid. He was hearing voices and having disturbing hallucinations that got worse by the moment. Fearing for his sanity and his life, he made a daring decision. He escaped from the rehab center under the cover of darkness, scaled the chain-link fence and threw himself over the side to the bushes below.

He tore his clothes in the process and sustained numerous scratches and abrasions. Terrified, disoriented, and believing he was being chased by the rehab staff, he struggled through bushes and brambles in almost total darkness before sighting the interstate.

He forced himself over the concrete wall onto the busy freeway, where he dodged traffic until spotted by the highway patrol. He could have been splattered on the interstate or died of seizures in his delirious and psychotic state before being rescued.

We diagnosed his condition as alcohol withdrawal and immediately started him on appropriate medications. His crisis situation was under control within three days, but a CT scan revealed significant brain damage from years of heavy drinking. His brain looked as if it belonged to a demented seventy-year-old.

I arranged a scholarship for him at one of the few medically based treatment centers in the area, and I supervised his medical care personally. He is now independent, working, attending church meetings, and in a happy personal relationship.

Had he not escaped from rehab, he would be dead. He
needed far more than a Tylenol and prayer. I have no problem with prayer. Pray all you want. But I absolutely assure you that whatever benefits prayer may offer are greatly increased when you take the right medicine.

Reality Check: Addiction Treatment Today

This one young man was fortunate that he didn't die from alcohol withdrawal, but others are not so lucky. There are detox places where patients are tied down to a bed and “allowed to detox.” If they survive, they are the lucky ones. If not, that's too bad. One of my patients referred to these places as “Deathbed Detox.” And they're all legal in the United States.

If you are poor, that is what you can expect in the way of detox and rehab in the progressive and enlightened state of California. Even those who can afford high-priced treatment centers often find themselves in facilities that don't bother to diagnose their medical conditions. The center evaluates insurance but not the patient. It's big business with big profits. Success rates are minimal, even for the most expensive facilities.

While there are a few excellent treatment centers that have full-time medical specialists on staff, most drug and alcohol rehabs do not offer comprehensive medical diagnosis or individualized care.

Just Who Is an Addict?

I began writing this book specifically for individuals concerned about their own relationship to drugs and alcohol or that of someone they love. I wanted to dispel myths, counter outright propaganda, and give people hope where they previously had fear and despair. The more I wrote, the more I realized the importance of reaching the largest audience possible. Too many people believe that anyone who drinks often is an alcoholic and anyone who uses a recreational drug is an addict at worse, drug dependent at best. Those who are
not
addicts are told that they are; those who
are
addicts are being treated with two long-standing failed methods: slogans and stigma.