standards and proven treatment practices.
The credentials of treatment providers vary
dramatically from state to state and from
program to program. Compounding the
problem, quality assurance standards that do
exist focus more on administrative processes
than on measureable patient outcomes. Inadequate Allocation of Financial
Resources: Financial investments in
addressing addiction and risky substance use
are aimed disproportionately at coping with
their costly health and social consequences
rather than at the effective implementation
of available prevention, intervention and
treatment approaches. In 2010, only 1.
percent ($28.0 billion) of total health care
costs went to treating the disease of
addiction.^17 Spending on addiction
treatment disproportionately falls to the
public sector. In contrast to the role of
private insurance in general health care
spending--where it covers 54.4 percent of
costs--private insurers cover only 20.
percent of the costs of addiction treatment,
and the private share has been decreasing.^18
This profound gap between the science of
addiction and current practice related to
prevention and treatment is a result of decades
of marginalizing addiction as a social problem
rather than treating it as a medical condition.
Much of what passes for “treatment” of
addiction bears little resemblance to the
treatment of other health conditions. Much of
what is offered in addiction “rehabilitation”
programs has not been subject to rigorous
scientific study and the existing body of
evidence demonstrating principles of effective
treatment has not been taken to scale or
integrated effectively into many of the treatment
programs operating nationwide. This is
inexcusable given decades of accumulated
scientific evidence attesting to the fact that
addiction is a brain disease with significant
behavioral components for which there are
effective interventions and treatments. It also is
unfair to the thousands of addiction counselors
who struggle, in the face of extreme resource
limitations and no medical training, to provide
help to patients with the disease of addiction and
numerous co-occurring medical conditions.America’s tendency to frame risky use of
addictive substances and addiction as the same
issue and as moral or social problems has
resulted in an unmitigated failure on the part of
policymakers and the health care community to
educate the public about these health problems
in ways that can help prevent them and to offer
effective interventions and treatments that match
those offered for other health conditions; instead
the focus has weighed heavily toward law
enforcement. The end result is that we have
declared war on drugs rather than mounting a
rational approach to prevention, treatment and
finding a cure for the disease of addiction. We
largely have punished rather than treated those
in need of help even though treatment for a
disease and accountability for behavior are not
antithetic concepts.It is long past time for health care practice to
catch up with the science. Failure to do so is a
violation of medical ethics, a cause of untold
human suffering and a profligate misuse of
taxpayer dollars.The CASA Columbia Study.................................................................................................
Substance use can be understood as a continuum
ranging from having never used tobacco, alcohol
or another drug* at one end to having an
unmanaged chronic, relapsing disease† at the
other. (Figure 1.A)* Including any use of illicit drugs or the misuse of
controlled prescription drugs.
† This continuum focuses on substance use; the
category labeled addiction includes those individuals
who meet current clinical criteria for this disease but
does not include all individuals with addiction.