Show Some Humility


Let’s admit—in how we fund substance use treatment—that we don’t know everything about our brains

If we don’t know something, we should say so.  If we don’t, people can get hurt.  The way we fund substance abuse treatment through grants states don’t have to compete for shows why.

In 1992 Senator Ted Kennedy’s bill (Public Law (PL) 102-321) established two such grants: one to combat substance use and another to combat mental illness. But what you had to do to get the money under those two grants was very different.  In order to get funding for addiction, states and counties had to serve certain people in certain ways.  For example, they had to treat pregnant women and women with dependent children.  By contrast, mental health grant funds were pretty accessible.  Those funds have to be used to treat children and adults (so everyone) and rather than focus on process, the mental grant funding focuses on what works.

It should therefore surprise no-one that in 2012, only 10% of New Yorkers who were suffering from substance use addiction and were involved in standard treatment considered themselves in recovery but that 70 percent of people who were treated in the community reported they were in recovery.

Standard treatment is when the patient goes to a provider and receives off-the-shelf care.  The standard options are: medical detox, long-term residential treatment, short-term residential treatment, outpatient and intensive outpatient as well as medication-assisted treatment programs.  Medical detox (a supervised medical detoxification process which allows the drug to leave the body) tends to be widely available.  Long-term residential treatment is where, for six to 12 months, people live in a supervised and highly structured setting and get therapy to help them deal their addiction.  There is usually a long waiting list for these treatment centers. Certain populations (such as women with children) often go to the front of the line.  Short-term residential treatment is typically a three-to-four week program that provides a modified 12-step program as well as some legal, vocational and housing assistance.  These programs also tend to have long waiting lists and prioritize certain people. Women with children first.  Outpatient programs tend to be modeled on (or be) 12-step or Alcoholics Anonymous (AA) programs.  And, finally, there is medication-assisted treatment that helps people overcome their craving for drugs.  Typically, patients walk into a treatment facility and, after waiting in line and receiving approximately five to 10 minutes of “counseling” they get a small dosage and have to go through the process again in a week.

Treatment in the community is very different.  To begin with, the health professional meets people where they are, be that at school, jail, hospital, community-run organization or the river bank.  A lot of that is counseling—either individual or group but it also hooks people up with resources: legal, housing, education, vocational rehabilitation.  In the community, the person’s treatment is centered around that individual and the treatment plan reflects what he/she needs. Treatment is tailored to the person and not the other way round.  Of course people do better in the community.

But not only is individualized care virtually impossible to bill for in substance use, it’s often hard to bill for evidence-based “standard” care if it’s relatively new.  For example, in 2012 researchers found that many of Ohio’s providers were not making buprenorphine accessible even though that is a promising practice.  One of the reasons given was that “county boards and providers expressed a need to preserve existing therapy-based services instead of reallocating funds for buprenorphine use.”  People in Ohio had to make do without buprenorphine (which may have worked for at least some of them) in part because counties could not figure out how to bill the grant for it.  It doesn’t make sense.

It doesn’t make sense that in 2018 we are funding best practices from 1992.  It doesn’t make sense that approximately 80 percent of substance use treatment in America consists of AA meetings.  Nor does it make sense that even though at least 60 percent of the people who seek help for their addiction suffer from mental illness, getting treated from for both is difficult if not impossible.  Many mental health organizations won’t take people who are using drugs and many substance use treatment programs won’t treat people who have a mental health diagnosis.  People bounce from place to place until they (or their family) break through somewhere—hopefully before it’s too late.  Or, as the Surgeon General put it in 2016, evidence-based substance use prevention and treatment strategies were being “underutilized.”

Don’t get me wrong.  I am not trying to diminish the amazing work done every day at the local level.  My hat is off to the folks who go out there and save lives—often in spite of and not because of—the crazy healthcare system we have.  I just think we should make their jobs easier.  And as a first (very small) step we should at least consider making the substance use grant funding work the way mental health grant funding does.  It’s not a silver bullet but it might help.



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