NYTimes.com
By BENEDICT CAREY
Published: December 22, 2008
ROSEBURG, Ore. — Their first love might be the rum or vodka or gin and juice that is going around the bonfire. Or maybe the smoke, the potent marijuana that grows in the misted hills here like moss on a wet stone.
But it hardly matters. Here as elsewhere in the country, some users start early, fall fast and in their reckless prime can swallow, snort, inject or smoke anything available, from crystal meth to prescription pills to heroin and ecstasy. And treatment, if they get it at all, can seem like a joke.
“After the first couple of times I went through, they basically told me that there was nothing they could do,” said Angella, a 17-year-old from the central Oregon city of Bend, who by freshman year in high school was drinking hard liquor every day, smoking pot and sampling a variety of harder drugs. “They were like, ‘Uh, I don’t think so.’ ”
She tried residential programs twice, living away from home for three months each time. In those, she learned how dangerous her habit was, how much pain it was causing others in her life. She worked on strengthening her relationship with her grandparents, with whom she lived. For two months or so afterward she stayed clean.
“Then I went right back,” Angella said in an interview. “After a while, you know, you just start missing your friends.”
Every year, state and federal governments spend more than $15 billion, and insurers at least $5 billion more, on substance-abuse treatment services for some four million people. That amount may soon increase sharply: last year, Congress passed the mental health parity law, which for the first time includes addiction treatment under a federal law requiring that insurers cover mental and physical ailments at equal levels.
Many clinics across the county have waiting lists, and researchers estimate that some 20 million Americans who could benefit from treatment do not get it.
Yet very few rehabilitation programs have the evidence to show that they are effective. The resort-and-spa private clinics generally do not allow outside researchers to verify their published success rates. The publicly supported programs spend their scarce resources on patient care, not costly studies.
And the field has no standard guidelines. Each program has its own philosophy; so, for that matter, do individual counselors. No one knows which approach is best for which patient, because these programs rarely if ever track clients closely after they graduate. Even Alcoholics Anonymous, the best known of all the substance-abuse programs, does not publish data on its participants’ success rate.
“What we have in this country is a washing-machine model of addiction treatment,” said A. Thomas McClellan, chief executive of the nonprofit Treatment Research Institute, based in Philadelphia. “You go to Shady Acres for 30 days, or to some clinic for 60 visits or 60 doses, whatever it is. 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.”
In recent years state governments, which cover most of the bill for addiction services, have become increasingly concerned, and some, including Delaware, North Carolina, and Oregon, have sought ways to make the programs more accountable. The experience of Oregon, which has taken the most direct and aggressive action, illustrates both the promise and perils of trying to inject science into addiction treatment.
Evidence-Based Treatments
In 2003 the Oregon Legislature mandated that rehabilitation programs receiving state funds use evidence-based practices — techniques that have proved effective in studies. The law, phased in over several years, was aimed at improving services so that addicts like Angella would not be doomed to a lifetime of rehab, repeating the same kinds of counseling that had failed them in the past — or landing in worse trouble.
“You can get through a lot of programs just by faking it,” said Jennifer Hatton, 25, of Myrtle Creek, Ore., a longtime drinker and drug user who quit two years ago, but only after going to jail and facing the prospect of losing her children. “That’s what did it for me — my kids — and I wish it didn’t have to come to that.”
When practiced faithfully, evidence-based therapies give users their best chance to break a habit. Among the therapies are prescription drugs like naltrexone, for alcohol dependence, and buprenorphine, for addiction to narcotics, which studies find can help people kick their habits.
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