Drug Rehab: Does it Work?
I'm not drinking any more. Of course, I'm not drinking any less.
Last year Congress passed the mental health parity law requiring for the first time that insurers cover mental health, including addiction treatment, at parity with physical illness. The yearly cost to state and federal governments of substance abuse treatment has been more than $15 billion, and to insurers another $5 billion for over 4 million people. Thanks to the new law that cost will rise precipitously.
Rehabilitation programs, both in- and outpatient, run by governmental, county, state and federal, along with private agencies represent a thriving growth industry, particularly in the private sector. Many clinics across the country have long waiting lists, and researchers estimate that up to "20 million Americans" (sic!) could benefit from treatment. I assume many of these patients are suffering from depression with or without drug dependency, but the definition of those who "could benefit" is slippery, if not opaque. Enormous sums of public and private as well as tax-supported government money are lavished on these highly promoted programs, yet few dollars are spent on critically important studies of the comparative effectiveness, if any, of various approaches to addiction, whether conventional AA group therapy, medical/psychiatric, faith-based, or voodoo.
The 12-steps of Alcoholics Anonymous, AA, one of the first and most widely respected and copied peer support therapies, is based on the philosophy that it is the responsibility of recovering groups of people to help others like themselves overcome drug and alcohol dependency. AA and its founders are largely opposed to institutionalized or inpatient treatment of addiction. (No one, however, denies the occasional medical need for short term detoxification of addicts in an institutionalized setting.)
No standards exist for the long term management of various forms of addiction, particularly to drugs and alcohol; each of the thousands of programs has its own philosophy and methods of implementation. Although most treatment programs have borrowed or plagiarized from AA no one knows what is best for the individual patient, how long treatment should last, and virtually no statistically reliable long range data is available on the outcomes of treatment. Even AA, Alcoholics Anonymous, (and NA, Narcotics Anonymous) the most well-known of all substance abuse programs have never published -let alone to my knowledge-collected data on its participants' success rate.
The National Institute on Drug Abuse (NIDA) initiated studies in 1992 with the Drug Abuse Treatment Outcome Studies (DATOS). The baseline data used currently was gathered from only 10,010 adult clients entering 96 drug abuse treatment programs during 1991-1993. Although "treatment progress" data were collected at 3 and 6 months, follow-up data were collected only from a sample of approximately 3,000 clients at 12 months post treatment. 3,000 patients!!! An extended follow-up gathered data on these 3,000 clients over a 5-year follow-up period. The resulting publication gave uninterpretable vague data on outcomes. I wonder how much money the NIH and NIDA spent on these incomplete and unsatisfying studies. Some "cost-benefit analysis" was attempted, however.
The resort-and-spa private clinics in particular almost never allow outside researchers to verify their published success rates-when those rates are indeed collected. According to this source "The majority of treatment programs do not have success rates higher than seen from those who quit without professional help; which translates to a 10%-15% success rate."
An excellent article in The New York Times (Dec. 23, 2008) in an important series on "The Evidence Gap in Medicine," quotes A. Thomas McClellan, CEO of the nonprofit Treatment Research Institute in Philadelphia: "What we have in this country is a washing-machine model of addiction treatment...You go to Shady Acres for 30 days or to some clinic for 60 visits for 60 days...And then you're discharged and everyone's crying and hugging and feeling proud-and you're supposed to be cured." He added, "It doesn't really matter if you're a movie star going to some resort by the sea or a homeless person. The system doesn't work well for what for many people is a chronic, recurring problem."
I am strongly in favor of AA, and any or sensible outpatient treatment program that can supply plenty of convincing anecdotal endorsements. If indeed there are programs that can offer some 2-5 year data on relapse and/or success rate, I would invite them to contact me. So far I have searched for this data in vain.
I am highly skeptical of inpatient or institutionalized rehab usually lasting for one to several weeks; whether private or Government-sponsored. These programs cost hundreds to thousands of dollars a day for little more than a promise and a primrose. Hugs and kisses on graduation hardly seem appropriate for a future filled with relapse and remorse for so many.
Martin F. Sturman, MD, FACP
Copyright 2009, Mathemedics, Inc.
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