In homes, doctors’ offices, hospitals, schools, prisons, jails and communities across America, misperceptions about addiction are undermining medical care. Although advances in neuroscience, brain imaging and behavioral research clearly show that addiction is a complex brain disease, today the disease of addiction is still often misunderstood as a moral failing, a lack of willpower, a subject of shame and disgust. Addiction affects 16 percent of Americans ages 12 and older--40 million people. That is more than the number of people with heart disease (27 million), diabetes (26 million) or cancer (19 million). Another 32 percent of the population (80 million) uses tobacco, alcohol and other drugs in risky ways that threaten health and safety.
Like other public health and medical problems, we understand the risk factors for addiction. We have effective ways of screening for risky use and intervening. While as of now there is no cure for addiction, there are effective psychosocial and pharmaceutical treatments and methods of managing the disease. But as this landmark report by CASA Columbia shows in sharp detail, this is where the comparison with other health conditions ends. Unlike other diseases, we do little to effectively prevent and reduce risky use and the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.
The medical system, which is dedicated to alleviating suffering and treating disease, largely has been disengaged from these serious health care problems. The consequences of this inattention are profound. America’s failure to prevent risky use and effectively treat addiction results in an enormous array of health and social problems such as accidents, homicides and suicides, child neglect and abuse, family dysfunction and unplanned pregnancies. CASA Columbia estimates that risky substance use and addiction are this nation’s largest preventable and most costly health problems, accounting for one third of hospital inpatient costs, driving crime and lost productivity and resulting in total costs to government alone of at least $468 billion each year.
In many ways, America’s approach to addiction treatment today is similar to the state of medicine in the early 1900s. In 1908, the Council on Medical Education of the American Medical Association turned to the Carnegie Foundation for the Advancement of Teaching to conduct a survey of Medical Education in the U.S. That survey, which became known as the Flexner Report, was led by Abraham Flexner who famously observed of the discrepancy among physicians’ qualifications, “there is probably no other country in the world in which there is so great a distance and so fatal a difference between the best, the average and the worst.” This CASA Columbia report identifies a similar gulf in the knowledge and practice skills of addiction treatment providers today. The education and training of persons providing addiction treatment vary considerably by state. In many cases, entry requirements for the profession are minimal in terms of education and are based on apprenticeship models rather than on science-based instruction.
Flexner noted that the turn of the 19th to 20th century was a time of scientific progress in the understanding of disease and its treatment; however, due to the lack of a standardized and rigorous education for physicians, society reaped “but a small fraction of the advantage which current knowledge has the power to confer.” Similarly, 100 years later, advances in science and medicine have drawn a much clearer picture of addiction--including its causes, correlates and how to treat it--yet we are woefully unprepared to apply this evidence to practice. Our medical professionals are not trained to look for risky use and addiction or to intervene or treat the disease. Without medical attention, the disease progresses, forcing doctors to expend valuable resources treating the more than 70 other conditions requiring medical attention that result from substance use and addiction, while taxpayers shoulder the costs of these health and other social consequences. This neglect by the medical system has led to the creation of a separate and unrelated system of addiction care that struggles to treat the disease without the resources or the knowledge base to keep pace with science and medicine.
Because addiction affects cognition and is associated primarily with the difficult social consequences that result from our failure to prevent and treat it, those who suffer from the disease are poor advocates for their own health. And due in large part to the shame, stigma and discrimination attached to the disease, individuals with addiction and their family members too often are isolated in their struggle to understand the disease and find help. Only recently have we begun to see those affected by the disease working to raise awareness in ways, for example, that families of breast cancer victims have done. But these efforts are small, challenged by public misunderstanding and have failed to raise sufficient funding for needed research.
Even individuals who can transcend the stigma face significant barriers to receiving effective care, and this report paints a dismal picture of a treatment ‘non-system.’ While almost half of Americans say they would go to their health care providers for help, most doctors are uninformed about this disease and rarely are equipped to offer a diagnosis, provide treatment or connect patients with appropriate specialty care. Insurance coverage varies widely. Services rarely are tailored to individual needs and are based primarily on an acute care model rather than recognizing the chronic nature of the disease. There are no national standards of care. Patients face a patchwork of treatment programs with vastly different approaches; many offer unproven therapies and little medical supervision. Some promise “one time” fixes; others offer posh residential treatment at astronomical prices with little evidence justifying the cost. Even for those who do have insurance coverage or can pay out-of-pocket, there are no outcome data reflecting the quality of treatment providers so that patients can make informed decisions.
This report focuses long overdue attention on the disease of addiction. It clarifies the important difference between this disease and risky use of addictive substances; identifies the human and economic costs of our current approach to these health problems; and documents the breadth of available knowledge on how to prevent risky use and treat addiction.
As our nation struggles to reduce skyrocketing health care costs, there are few targets for cost savings that are as straightforward as preventing and treating risky substance use and addiction. This report shows that modest public health interventions and relatively inexpensive addiction therapies, compared with other medical treatments, would reduce this burden significantly.
The report calls for modernizing addiction treatment--to harness the scientific knowledge we have acquired to prevent risky use and treat this disease. This report is a call to action. Like the Flexner Report a century ago, it shines a bright light on the problem and offers a roadmap for action. Addiction Medicine: Closing the Gap between Science and Practice represents more than five years of intensive research, and draws on policy and treatment research conducted by CASA Columbia over two decades and on a wide body of scientific, clinical and policy research conducted by others. This major undertaking was the result of the work of a large team of dedicated individuals and institutions and was conducted with the able advice and counsel of The CASA Columbia National Advisory Commission on Addiction Treatment which I had the privilege to chair. The Commission includes an impressive group of individuals knowledgeable about the many aspects of substance use and addiction in America today. We are grateful for their expert assistance.
The project was made possible by the generous financial support of The Annenberg Foundation; The Diana, Princess of Wales Memorial Fund and The Franklin Mint; The New York Community Trust; and the Adrian and Jessie Archbold Charitable Trust.
Peter D. Hart Research Associates conducted the National Addiction Belief and Attitude Survey for this report; Survey Research Laboratory (SRL) of the University of Illinois at Chicago administered the survey of New York State addiction treatment providers. We are grateful to Karen Carpenter-Palumbo, former director of the New York State Office of Alcoholism and Substance Abuse Services (OASAS) for helping to make the New York State survey possible.
We thank the following organizations which generously helped connect CASA Columbia with treatment providers who participated in a national online survey of members of professional associations involved in addiction care: The American Academy of Addiction Psychiatry (AAAP); the American Association for the Treatment of Opioid Dependence (AATOD); the American Psychological Association (APA); the American Society of Addiction Medicine (ASAM); the Association for the Treatment of Tobacco Use and Dependence (ATTUD); NAADAC, the Association for Addiction Professionals; the National Association of Addiction Treatment Providers (NAATP); the National Association of County Behavioral Health and Developmental Disability Directors (NACBHDD); the National Council for Community Behavioral Healthcare (National Council); the State Associations of Addiction Services (SAAS); and Treatment Communities of America (TCA). Also, we thank the following organizations for connecting us with individuals in long-term recovery for CASA Columbia’s online survey of this population: Hazelden, Freedom Institute, Faces and Voices of Recovery, Betty Ford Center, National Council on Alcoholism and Drug Dependence, Inc. (NCADD), Treatment Communities of America (TCA), Alcoholism and Substance Abuse Providers of New York State, Inc. (ASAP) and an anonymous treatment program alumni group. Finally, we are grateful to the 174 key informants who shared their insight and recommendations.
Susan E. Foster, MSW, CASA Columbia’s Vice President and Director of Policy Research and Analysis, was the principal investigator and staff director for this effort. The senior research manager was Linda Richter, PhD, Associate Director of the Division and CASA Columbia Scholar. The data collection and analysis was conducted by CASA Columbia’s Data Analysis Center (SADACSM), headed by Roger Vaughan, DrPH, CASA Columbia Fellow and Professor of Clinical Biostatistics, Department of Biostatistics, Mailman School of Public Health at Columbia University, and associate editor for statistics and evaluation for the American Journal of Public Health. He was assisted by Elizabeth Peters and Sarah Tsai, MA. Emily Feinstein, JD, senior policy analyst, assisted with the research and writing. Other research staff members who worked on the project are: Nina Lei, Mark Stovell, Akiyo Kodera, Dina Feivelson, PhD, Gina Hijjawi, PhD, Harold Wenglinsky, PhD, Swapna Reddy, JD, Kristen Keneipp, MHS, Nabil Ansari and Sarah Blachman. David Man, PhD, MLS, is CASA Columbia’s librarian; he was assisted by Barbara Kurzweil. Jennie Hauser managed the bibliographic database and Jane Carlson handled administrative details.
While many individuals and institutions contributed to this effort, the findings and opinions expressed herein are the sole responsibility of CASA Columbia.