The treatment of substance-related problems depends on the type of substance, the specific problems it is causing, the stage of the illness, your insight and motivation, and whether the environment is more likely to support efforts at change or to provide temptations to stay hooked. Before there is even a chance that treatment can be effective, you must recognize that you have a serious substance problem and be motivated to change your behavior and stop using alcohol or drugs. Often the person with the problem is the last to know and will consider treatment only after others confront the denial in the most unmistakable terms.
Unfortunately, our society is also in denial and is not providing anything approaching adequate resources for the treatment of substance problems. Every year there is a disproportionate expenditure of vast sums of public funding in a futile attempt to seal our borders and “interdict” the smuggling of illegal substances. Similar fortunes are spent on the correctional system in an equally futile attempt to seal away those whose crimes are the direct or indirect result of substance use.
Despite the best efforts to make drugs unavailable, they remain remarkably cheap and easily purchased on many street corners across the entire country. A new smuggler, a new pusher, and a new addict are all ready to spring up whenever their predecessors are incarcerated. Serious efforts to develop adequate treatment resources have been sacrificed in the mindless (and politically motivated) charade of border patrols and explosive prison building. The entry into substance abuse treatment by managed care companies promises to make this bad situation even worse. These companies enhance their short-term profitability by reducing treatment resources for substance-related problems and are strongly motivated on financial grounds to deny care or restrict its access.
What has been almost completely lost in the shuffle is that treatment for substance-related problems is very cost-effective — especially considering the long-term direct and indirect costs both to the individual and to society of not providing treatment. Untreated substance use leads eventually to expensive medical illness, psychiatric illness, lost productivity, family disruption, policing, judicial proceedings, and prisons. Unfortunately, the allocation of treatment resources for addictions is remarkably shortsighted and system-specific. There is constant penny-pinching, pound-foolishness that fails to account for the indirect cost savings that adequate treatment might promote across the medical, psychiatric, and correctional systems.
For example, the criteria for admission for inpatient detoxification have been set so high that most people who want to beat their addiction are not eligible unless they also have a serious medical or psychiatric problem. This extraordinary stringency in inpatient admission criteria has been justified based on the theoretical possibility that outpatient detoxification will be adequate and the fact that many people revert to their substance use anyway shortly after an inpatient detoxification.
Unfortunately, the vast majority of addicts referred for outpatient detoxification never wind up receiving it—either because they don’t show up or because the programs are so overwhelmed that they are put on a long waiting list. Left to their own devices on the street, these people are likely to contribute to crime, AIDS, and the spread of drug addiction. Given the long-term indirect costs of not providing help, inpatient detoxification is a relatively inexpensive and worthwhile treatment, even if only a small fraction of the people who receive it are able to make the substantial next step toward rehabilitation.
This is a situation that cries out for staunch patient, family, clinician, and political advocacy—and has so far received almost no such support and lobbying. There are as yet no “addictions” equivalents to the National Alliance for the Mentally III (which advocates so successfully for Schizophrenia) or the National Depressive and Manic Depressive Association, or the Obsessive Compulsive Foundation, and so forth. AA is a highly successful organization that provides extremely effective treatment, support, and information but it does not define a political role for itself.
This means that there is no counterbalance to the know-nothing good politics (but failed policy) of interdiction, incarceration, and “just say no.” We should not abandon hope, however. Ten years ago, Schizophrenia was the lost stepchild of medicine—now it has achieved parity in medical benefit plans, an enthusiastic advocacy that includes many senior politicians, increased funding for research, and a promise of more powerful treatments. We may be on the verge of similar advances in public support and research contributions to the treatment of Substance Dependence.