Cindy West
The Gadsden Times

Most drug treatment programs aren’t adequate, advocates say

LAST OF A SERIES
Susan Rook believes if she had been released from drug treatment when her insurance ran out, she would have relapsed. The end result, given the extent of her drug abuse, would have been her death, she said.

Rook is a former Cable News Network anchor. She is currently public affairs director for Step One Substance Abuse Services in Winston-Salem, N.C. Rooks spoke at the Addiction Studies Program for Journalists in Canada in June.

Rook was hosting "TalkBack Live!," a show that had been created for her on CNN, when she overdosed in March 1996.

"Inpatient (care) was very important to me for several reasons," Rook said.

"I was very sick, and then once I detoxed I was really ragged physically, emotionally and mentally," she said. "The value was that I was in a safe environment while I was very, very, very vulnerable. That gave me a bit of 'clean time' so that I could even hear the idea of sobriety/recovery and then choose it."

After 28 days of inpatient treatment, CNN gave Rook two months off work, which gave her time for psychiatric therapy, dental work and medical care to help her physically recover from the effects of the abuse.
Some insurance companies will pay for only five days of inpatient treatment for substance abuse, while three months of inpatient care might not be enough, some say.

The cycle of addiction
Steve Moore, a certified social worker and a program coordinator for the UAB Addiction Recovery Program, said people tend to see drug addiction as black or white. "We have a tendency to look at the problem of drug addiction as being on drugs or off drugs," he said. "That makes the substance be the problem and its absence be the solution. That's just not true. If it were, I could cure addiction by locking people up for long enough.

"The person's response to mood alteration itself is the problem. Now that we understand addiction to be a brain disease, much like other diseases, we can start seeing how people relapse," Moore said.

When a person is faithfully taking his high blood pressure medicine but his blood pressure gets high anyway, someone might look at that patient and say that the medicine didn't work right or doctors weren't aggressive enough in treating the problem.

"It's only with addiction that we blame the patient for the relapse," Moore said.

Rochelle D. Schwartz-Bloom has developed a model to show the cycle of addiction. Schwartz-Bloom, who studies how drugs affect the brain, is a professor at Duke University Medical Center's Department of Pharmacology and Cancer Biology in Durham, N.C.
With acute drug use, the initial use of a drug, the user gets feelings of pleasure from the drug, so he learns to use the drug again to get that same feeling. When the user develops tolerance to the drug, he needs more of it to get the same high, which creates chronic drug use.

Once he becomes dependent, he experiences withdrawals if he stops using for a few hours or days.
If the user is able to quit for longer periods of time, such as days or years, he could still experience cravings, but long-term abstinence is necessary for the addict's brain chemistry to attempt to return to its original state and for the addict to make changes in his behavior so he doesn't start using again, Schwartz-Bloom said.
If the addict relapses, he immediately returns to acute drug use, and the cycle begins again.

Once an addict is through the short-term abstinence stage, the acute withdrawal, he may experience other symptoms in addition to cravings, including difficulty thinking clearly, emotional problems and problems with physical coordination. "All this we believe is due to changes in the brain," Moore said.

"Once they get off drugs, they're doing what they're supposed to be doing and they're still not feeling good," Moore said. "The persistent, false belief of addiction is that 'Chemicals make me better.' For addicts, the chemical was the solution, not the problem. Even if it did horrible things to them, it may be their solution."
Moore said the frequency, intensity and duration of treatment all affect a person's changes of fighting his addiction.

"Research shows the longer you keep people in a structured environment, the better they do," Moore said.
Most insurance companies pay for three days of inpatient treatment for detoxification, and then some pay part of the costs of inpatient treatment after that. "It's not the fault of the insurance companies," Moore said.

The law
The insurance section of Alabama state law doesn't require insurance companies to pay for drug abuse treatment. The law requires minimum treatments be available for the mentally ill (Section 27-54-1), but that section of the law specifically excludes those addicted to alcohol and drugs. Another section of the law focuses on treatment for alcoholics (Section 27-20A-1).

"Most times when you have mental health or substance abuse issues, the Code doesn't mandate treatment except in sections 54, 20A and 27-1-18," said Elizabeth Bookwalter, assistant counsel for the Alabama Department of Insurance. Section 27-1-18 deals with mental health issues.

The law doesn't allow families to commit addicts for treatment, either. Just about the only way a person can be coerced into getting treatment is to be arrested.
"If you walk in and see a family member shooting up OxyContin and you bring him to the hospital, you can't have him locked up for psychiatric treatment," Moore said. That situation is different in other states, such as Florida, he said.

The Alabama Code may be searched on the Internet at http://alisdb.legislature.state.al.us/
acas/ACASLogin.asp.

The solution?
Herbert Kleber is one of those who believes longer equals better drug abuse treatment. The first director of Demand Reduction in the Drug Czar's office under former President George Bush, Kleber is a professor of psychiatry at Columbia University and the director of the Division on Substance Abuse for the College of Physicians and Surgeons and the New York State Psychiatric Institute.

Rook received medical and psychiatric care during her recovery. Kleber said the combination is critical to gain any sort of improvement.

"Between one-quarter and one-half of substance abusers also have psychiatric disorders," Kleber said.

"Untreated depression and anxiety disorders are common causes of relapse. Withholding psychiatric treatment from a depressed, substance-abusing patient would be like withholding penicillin from a drug abuser with pneumonia."

"The brain of a drug addict is no longer like the brain of a normal person in the same way that the brain of somebody who is depressed, has an anxiety disorder or maybe even who has epilepsy is not the same as the brain of a normal person," Wake Forest School of Medicine professor David Friedman said. "If you believe it's a brain disorder, then the moral solution (to the problem) - put them in jail - is ridiculous. It makes much more sense to put them in treatment."

Scientists who see addiction as a brain disorder believe addiction should be treated with psychotherapy to change behavior and medicines to alleviate withdrawal symptoms, if available.

Therapy helps hold a person in substance abuse treatment and helps bring about the behavioral changes a person needs to give up drug abuse.

The public generally doesn't consider treatment a priority for addicts, and public officials - those who generally have the power to affect policies - are skeptical about it, Kleber said.

Politicians sometimes see drug treatment for offenders as being easy on criminals. "Treatment is not a liberal or conservative approach, but a cost-effective one," Kleber said. "Numerous local, state and national studies have demonstrated the cost effectiveness of treatment. In general, a dollar invested in treatment saves $4 to $7 elsewhere in the health and criminal justice system."
Addiction not only affects the addict and his employer with poor health and lost time from work, it also affects the children, who can suffer abuse and neglect, and society, which sometimes ends up paying the cost of those problems.

Society also usually has unrealistic expectations about treatment, expecting one treatment for substance abuse to "cure" an addict. Given the chronic, relapsing nature of addiction, sometimes an immediate goal of treatment is to see improvement, or less use of the drug, Kleber said.

No one treatment is universally effective. A variety of treatment approaches are needed because of the differences in the types of people who become addicts and the differences in the types of addiction.

A drug such as alcohol creates a great physical dependence, and a person abstaining from alcohol can have physically dangerous withdrawals. Medicines can help alleviate those withdrawal symptoms, which increases the addict's resistance to relapsing.

There are medicines to help ease addicts off most drugs, such as methadone for heroin, OxyContin and other opiates. There are also medicines to make an alcoholic sick if he drinks while he's taking it. There is no medicine to help fight crystal methamphetamine addiction, Kleber said.

Another treatment option is residential therapeutic communities, where the patient receives therapy while living among other recovering addicts, particularly criminal addicts.

While only 30 percent of those who enter residential therapeutic communities complete the program, studies have shown that 85 percent of those who complete it remain drug-free for at least two years.

Whatever the treatment, it must be tailored to the patient. Careful assessment of the addict's needs is the first, and most important, step in finding a treatment program that works, Kleber said.