Addiction research – Who are we studying?

I teach a class on the psychology of addiction (Psych 477 at California State University in Long Beach) and as I have been preparing the lectures something has become very clear to me – textbooks patently gloss over important details about the addiction research they cite. One of the most obvious gaps I’ve noticed this semester concerns the population of research subjects most addiction research is conducted on. An example will clarify:

A student group in my class had to read a study assessing the residual effects of methamphetamine on mood and sleep. They were amazed that no changes in mood were observed and that participants slept a full 6-8 hours the night after being administered meth! Would you have been surprised with these results given that we all have been told that crystal meth improves mood and causes insomnia?

Would it matter at all if I told you that the participants in the study were current meth abusers who use an average of 4 times every week?

For anyone not aware of the tainted history of health research in the U.S. (I’m including psychological research in this group), go ahead and read about the Tuskegee Syphilis Experiment and Stanford Prison Experiment (video here). There are other examples including Stanley Milgram‘s obedience studies, and more but as exciting as the discussion of these studies is, it’s time to get back to my main point.

It is mostly due to the ethically-questionable, psychologically damaging, research above that research institutions are now required to vet proposed research studies using Institutional Review Boards (IRBs) to assure that human participants in studies are consenting to participate of their own free will, are not coerced, and are not suffering undue damage. This is also true of addiction research. Rarely does the public consider this fact however when they are being reported on research relevant to addiction. I know this because the kids in my class never gave it a second thought.

When reading about addiction research, think about the subjects participating in itNearly all addiction research, especially studies utilizing “hard” drugs like cocaine, meth, opiates, etc., are required to make use of a very limited part of society – drug using individuals with a history of use of the specific drug of interest who are specifically not interested in treatment. Individuals who have never tried the drug or who want to be treated for drug abuse or dependence (addiction) are excluded due to ethical concerns. In most studies, participants can not qualify if they are addicted to drugs other than those being studies (except smoking, for which exceptions are usually made since we’d be able left with no participants otherwise) or have any associated mental health disorders, which are very common among addicted individuals. I would further assert that for at least a substantial portion of these research participants, the term “addicts” may not be appropriate since many addicts would not willingly give up using their favorite substance for a week or two to be replaces with a hospital bed and an experimenter controlled dose of drug or placebo. Taken together, our research subjects are pretty obviously not representative of all drug users, or all addicts, or all anything else. They make up a very specific group – less than perfect, but what we have to work with.

In some studies that attempt to make a direct comparison between controls (or drug naive participants) and drug users, this is likely less of an issue. This can happen when researchers try to examine brain structure differences, or performance on a specific psychological or physical test. In such cases researchers can at least statistically identify contributions of length of use, method of use, and other relevant data on differences between people who use and those that don’t. There are probably still some serious differences between “true” addicts, recreational users, and semi-chronic users that would be important to understand here, but we can’t so we don’t. But when it comes to assessing mood effects, or indeed any of a number of subjective effects of drugs, drug cravings, and withdrawal, this limitation in the population to be studied is something that often needs to be made explicitly clear to most public consumers of research. Since we can’t assess changes in mood, absorption rate, anxiety, or any other such measure (some exceptions for very low doses in very specific circumstances) among people who are new to the drug, we end up assessing them among people with a lot of experience, but not enough of a problem to want addiction treatment. Again, this should be considered a pretty specific type of drug user in my opinion.

There are other types of studies – those conducted with abstinent ex-users or addiction treatment intervention studies utilizing addicts who want, or who reported to, treatment on their own or in response to advertisements. While these studies make use of populations that can be considered at least closer to the individuals they are specifically aimed at – assessing the return of  cognitive function after short or long term abstinence or testing a new intervention on those who want treatment – they still bring on limitations that need to be specifically considered.

An important point – most researchers recognize these issues and make them explicitly part of their research publications, in a specific section called “Limitations” but what seems troubling is that the public doesn’t have any awareness of these issues. So when someone tells you that “they just found out meth doesn’t actually make people lose sleep,” take a second to ask “for who?”

Overcoming mental health problems is more than possible

Addicts and others with mental health issues continuously feel as if they need to hide their problems as well as hide from them. But an ongoing west-coast (U.C.L.A. and U.S.C.) study with a group of mental health patients suggests that hiding may be the wrong approach.

The participants in the study, all successful individuals with ongoing mental health problems who seem to be stable and productive are being examined for the specific factors that make them defy the stigma so closely linked with mental health problems. Doctors, lawyers, and CEOs are all part of the group and have all figured out ways to work with their mental health issues and succeed in life.

Mental Health Problems, Addiction, and Stigma

We’ve written before about the dilemma of mental health disclosure and I’ve talked over and over about the notion that stigma is one of the major obstacles to addiction treatment and recovery. This study’s preliminary results suggest that indeed, taking ownership of one’s problems and figuring out how to best function with the characteristics each of the holds has allowed these individuals to succeed where most psychiatrists and psychologists would have expected them  to fail – in high-pressure, high-stakes, positions of power.

The relevant metaphor I share often, especially to those who attend our A3 Academy sessions is this:

Imagine that two people you know drive two very different cars. One owns a Toyota Prius, one of the most efficient cars on the market with lots of storage and convenience. The other drives a Lamborghini Gallardo, one of the world’s fastest cars with an engine that makes your whole body shake and a body that reminds everyone of speed and sex. If tasked with giving the two a little guidance on taking the drive between Los Angeles and San Fransisco you would probably give the two very different suggestions…

To your Prius owner-friend you would tell that they should feel free to bring a suitcase and that the entire trip will likely require less than a full tank of gas, making the trip very cheap and economical. However, it’s likely going to take him 7 to 8 hours each way so he should leave early to not waste the day on the road. At least he won’t have to stop for gas. But the Lamborghini driver has a very different trip ahead of him, one that likely includes 2-3 stops for gas but, assuming no speed-traps or traffic, he can still probably make it to San Fran in 4 hours flat. He’s also not likely to be able to bring anything along except for an overnight bag and even that is only true if he’s not bringing anyone on the trip with him.

Unless one comes to the table with judgements about fast versus slow, or gas-efficient versus gas-guzzling, driving I think that few would suggest that I am somehow stigmatizing the cars or their owners in this story. Instead, I am offering a pretty objective description of their most likely and appropriate functioning. But when talking about people, feelings and stereotypes often get in the way.

Overcoming Mental Health Problems

This study from UCLA and USC in collaboration with The Veteran’s Administration shows us that in reality it is likely that, even for those with mental health problems, the real key is to figure out what the requirements of the “machine” you’re driving are and then plan your life accordingly. For Ms. Myrick, one of the participants in the study, that meant a high powered detail oriented job rather than a hiding spot on her favorite couch at home. Still, the researchers have identified a set of common characteristics they’ve written about. Many of the study’s participants do the following:

  1. Adhere to a medication regimen
  2. Often check their thoughts and perceptions with those around them
  3. Actively control their environment, sometimes with the help of a therapist.
  4. Some avoid travel, or crowded, noisy places while others prefer not to be alone.
  5. Stay away from illicit drugs and alcohol.

Knowing where you're going and believing you can get there is key when struggling with mental health and addiction issues.Overall, it’s obvious that their mental health diagnoses have made them very aware, and thoughtful, about daily activities that most people disregard. Still, with a specific regimen and some help, they’ve all managed to succeed.That regimen might include medication to control attention problems, delusions, or depression; it seems to certainly include some outside perspective when it comes to big decisions; it may also include some regular exercises (physical and mental) to control anxiety and other related emotional responses.

I believe that identifying your own recipe for success is key to success, that believing in your ability to succeed is necessary, and that plotting the course between here and the future is helpful if you’re trying not to get lost. That’s not stigma, it’s practicality.

Loss, but not absence, of control – How choice and addiction are related

In a recent post the notion that “loss of control” is an addiction myth was raised by our contributing author, Christopher Russell, a thoughtful graduate student studying substance abuse in the U.K. Though I obviously personally believe in control- and choice-relevant neurological mechanisms playing a part in addiction, this conversation is a common one both within and outside of the drug abuse field. Therefore, I welcome the discussion onto our pages. I’d like to start out by reviewing some of the more abstract differences between my view and the one expressed by Christopher and follow those with some evidence to support my view and refute the evidence brought forth by him.

Addiction conceptualization – Philosophical and logical differences and misinterpretations

One of the first issues I take with the argument against control as a major factor in drug addiction is the interpretation of the phrase “loss of control” as meaning absence, rather than a reduction, in control over addiction and addictive behavior. Clearly though, one of the definitions of loss is a “decrease in amount, magnitude, or degree” (from Merriam-Webster.com) and not the destruction of something. Science is an exercise in probabilities so when scientists say “loss”, they mean a decrease and not a complete absence in the same way that findings showing that smoking cigarettes causes cancer do not mean that if an individual smokes cigarettes they will inevitably develop cancerous tumors. Similarly, the word “can’t” colloquially means having a low probability of success and not the complete inability to succeed. Intervention that improve the probability of quitting smoking (like bupropion or quitlines for smoking) success are therefore said to cause improvements in the capacity for quitting.

Next, Christopher wants scientists to identify the source of “will” in the brain but I suggest that “will” itself is simply a term he has given a behavioral outcome – the ability to make a choice that falls in line with expectations. In actuality, “will” is more commonly used as a reference to motivation, which while measurable, isn’t really the aspect of addiction involved in cognitive control. Instead, what we’re talking about is “capacity” to make a choice. The issue is a significant, not semantic one, since the argument most neuroscientists make about drug abuse is that addicts suffer a reduced capacity to make appropriate behavioral choices, especially as they pertain to engaging in the addictive behavior of interest. If someone is attempting to get into a car but repeatedly fails, we say they can’t get in the car (capacity), not that they don’t want to (will). Saying that they simply “don’t” get in the car doesn’t get at either capacity or will but instead is simply descriptive. I don’t believe that science is, or should be, merely descriptive but instead that it allows us to form conclusions based on available information.

That there is a segment of individuals who develop compulsive behavioral patterns tied to alcohol and drug use and who attempt to stop but fail is, to my mind, evidence that those individuals have a difficulty (capacity) in stopping their drug use. Their motivation (will) to quit is an aspect that has been shown to be associated with their probability of success but the two are by no means synonymous. It is important to note, and understand, that the attribution for the performance should not fall squarely on the shoulders of the individuals. We humans are so prone to making that mistake that it has a name, “The fundamental attribution error,” and indeed, individuals who show compulsive, addictive, behavior do so because of neuropharmacological, environmental, and social reasons in addition to the complex interactions between them all. But no one is disputing that and in fact, the article used by Christopher to point out the notion of a “tipping point” in addiction directly points out that fact in the next paragraph (Page 4), which he chose not to reference or acknowledge.

“Of course, addiction is not that simple. Addiction is not just a brain disease. It is a brain disease for which the social contexts in which it has both developed and is expressed are critically important… The implications are obvious. If we understand addiction as a prototypical psychobiological illness, with critical biological, behavioral, and social-context components, our treatment strategies must include biological, behavioral, and social-context elements.” (Lashner, 1997)

Lastly, Christopher’s philosophical musings are interesting, but they seem to stray away from trying to find an explanation for behavior and instead simply deconstruct evidence. In a personal communication I explained that while most addiction researchers understand that addiction, like most other mental health disorders is composed of a continuum of control ranging from absolute control over behavior to no control whatsoever (with most people fitting somewhere in the middle and few if any at the extreme ends), categorization is a necessary evil of clinical treatment. The same is true for every quantitative measure from height (Dwarfism is sometimes defined as adults who are shorter than 4’10”) to weight (BMI greater than 30 kg/m²). I think it’s equally as tough to argue that someone with a BMI of 29.5 is distinctly different from an individual with a BMI of 30 as it is to argue that there is no utility in the classification. Well, the same applies for drug addiction, although some people categorically object to classification and believe it has no utility or justification.

Now for the evidence – “Choice” and “control” are not the same as “will”

Some people quit, even without help – Christopher and a number of the people he cites in support (Peele, Alexander), suggest that because some people do stop using that it can’t be said that there is a problem with any individuals’ capacity to stop. The problem with that argument is that it supposes that everyone is the same, a fact that is simply false. As an example I would like to suggest that we compare cognitive control with physical control and use Huntington’s Disease (HD or Huntington’s Chorea) as an example.

HD patients suffer mental dementia but the physical symptoms of the disease, an inability to control their physical movement resulting in flailing limbs often referred to as the Huntington Dance, are almost always the first noticeable symptoms. Nevertheless, HD sufferers experience a number of debilitating symptoms that originate in brain dysfunction (specifically destruction of striatum neurons, the substantia nigra, and hippocampus) and that alter their ability (capacity) to control their movements and affect their memory and executive function leading to problems in planning and higher order thought processes. So, while it is true that most people can control their arm movements, here is an example of individuals who progressively become worse and worse at doing so due to a neurophramacological disorder. There is currently no cure for HD but some medications that help treat it no doubt restore some of the capacity of these patients to control their movements. If a cure is found it would be difficult to say, as Christopher suggests of addiction, that the cure does not affect the capacity of HD patients to control what they once could not. I chose HD for its physiological set of symptoms but a similar example could easily be constructed for schizophrenia and a number of other mental health disorders (including ADHD and drug addiction). Importantly, cognitive control is a function of brain activity, activity that can become compromised as the set of experiment I will discuss next show.

An experiment conducted at UCLA (1) has shown that cocaine administrations reduced animals’ ability to change their behavior when environmental conditions called for it. Even more meaningful was the finding that once animals are exposed to daily doses of drugs, the way their learning systems function is altered even when the drugs themselves are no longer on board and even when the learning has nothing to do with drugs per se.

In the experiment, conducted by Dr. David Jentsch and colleagues, monkeys were given either a single dose (less than the equivalent of a tenth of a gram for a 150lb human) or repeated doses (1/8 to 1/4 of a gram equivalent once daily for 14 days) of cocaine. The task involved learning an initial association between the location of food in one of three boxes and then learning that the location of the food has changed. We call this task reversal learning since animals have to unlearn an established relationship to learn a new one.

Obviously, the animals want the food, and so the appropriate response once the location is changed is to stop picking the old location and move on to the new one that now holds the coveted food. This sort of thing happens all the time in life and indeed, during addiction it seems that people have trouble adjusting their behavior when taking drugs is no longer rewarding and is, in fact, even troublesome (as in leading to jail, family breakups, etc.).

In the experiment, animals exposed to cocaine had trouble (when compared to control animals that got an injection of saline water) learning to reverse their selection when tested 20 minutes after getting the drug, which is not surprising but still an example of how drug administration can causally affect an individual’s ability to make appropriate choices. As pointed above, the most interesting finding had to do with the animals that got a dose of cocaine every day for 14 days. Even after a full week of being off the drug, these animals showed an interesting effect that persisted for a month – while their ability to learn that initial food-box association, they had significant trouble changing their selection once the conditions changed. Remember, this effect was present with no cocaine in their system and with learning conditions that had nothing whatsoever to do with cocaine.

If that’s not direct evidence that having drugs in your system can alter the way your brain makes choices, I don’t know what is.

Another study conducted by Calu and colleagues with rats found similar (or even more pronounced) reversal learning problems after training the animals to take cocaine for themselves, clarifying that it is the taking of cocaine and not the method that causes the impairments.

Another entire set of studies has shown that stimuli (also known as cues or triggers) that have become associated with drugs can bring back long-forgotten drug-seeking behavior once they are reintroduced. This was shown in that Calu paper I mentioned above and in so many other articles that it would be wasteful to go through all the evidence here. Importantly, this evidence shows that drug associated cues direct behavior towards drug seeking in a way that biases behavior regardless of any underlying will. My own research has shown that animals who respond greatly to drugs (nicotine in our case) likely learn to integrate more of these triggers than animals who show a reduced response, indicating once again that these animals bias  their behavioral selection towards drug-seeking more than usual. While we have more studies to conduct, we believe that genetic differences relevant to dopamine and possibly other neurotransmitters important for learning (like Glutamate) are responsible for this effect.

While we can’t do these kinds of experiments with people (research approval committee’s just won’t let you give drugs to people who haven’t used them before), there is quite a bit of evidence showing an association between trouble in reversal learning and chronic drug use in humans (see citation 3 for example) as well as research showing very different brain activity among addicted individuals to drug-associated versus non-drug cues (like seeing a crack pipe versus a building). All this evidence suggests that drug users are different in the way they learn generally, and more specifically about drugs, than individuals not addicted to drugs. When it comes to genetics, we know quite a bit about the  association between substance abuse and specific genes, especially when it comes to dopamine function. As expected, genetic variation in dopamine receptor subtypes important in learning about rewards (D4 and D2) has been revealed to exist between addicts and non addicts. Without getting into the techniques and analysis methods involved in these genetic studies, their sheer number and the relationship between substance abuse and other impulse disorders points to a direct relationship between drug use disorders (and possibly other addictive disorders) and a reduced capacity to exert behavioral control. Less capacity for control is what researchers have found sets addict apart from non-addicts.

Summary, conclusions, and final thoughts

The toyota Prius is slow but efficientIn closing, there are undoubtedly imperfections about the ways we diagnose addiction (drug addiction and others). It would probably be nice if we could figure out a way to incorporate what we know about the continuous nature of the disorder with the need for clinical delineation of who requires addiction treatment and who doesn’t. Addiction researchers are far from the only ones who wonder about this question though (the same issues are relevant for schizophrenia, depression, and nearly every mental health disorder) and I am certain that better and better solutions will emerge.

However, the discussion of stigma in this context needs to allow us to discuss the reality of addiction without having to resort to blaming and counter-blaming. If I describe the Toyota Prius as being slow but incredibly efficient I am no more stigmatizing than if I describe a Ferrari as being incredibly fact but wasteful in terms of fuel. The same applies, or should apply, to health and mental health diagnoses – Just because an individual is less able to exert cognitive control over impulses should not by definition call into question their standing as a human being. We are complex machines and by improving our understanding of the nuts and bolts that make us function we can only, in my opinion, improve our ability to make the best use of our capabilities while understanding our relative strengths and weaknesses. Any other way of looking at it seems to me to be either wishful (I can do anything if I want it badly enough) or defeatist (I will never be anything because I’m not good at X) and neither seem like good options to me.

Citations:

1) Jentsch, Olausson, De La Garza, and Tylor (2002): Impairments of Reversal Learning and Response Perseveration after Repeated, Intermittent Cocaine Administrations to Monkeys. Neuropsychopharmacology, Volume 26, Issue 2, Pages 183-190

2) Calu et al (2007) Withdrawal from cocaine self-administration produces long-lasting deficits in orbitofrontal-dependent reversal learning in rats. Learning & Memory, 14, 325-328.

3) Some evidence in humans from Trevor Robbins’ group: Reversal deficits in current chronic cocaine users.

Compulsive choices in addiction?

Is addiction an issue of bad choices or is it a case of biological, compulsive, necessity?

If you know anything about me and my views, you know that I think little of anyone who tries to separate these. I see and talk to people all the time who are stuck in compulsive behavioral patterns but with some education and good helping of supportive tools they can begin to change these patterns and return to normal life.

But then there are those who just don’t seem to ever get better.

The frustration and shame that come along with compulsive, addictive, behavior can be greatBe it lack of motivation, readiness, mental health issues, or a simple case of not having found a good enough reason to stop, these addiction clients can be the most frustrating and the most rewarding to work with. Any victory, no matter how small, with a difficult patient can put a big smile on my face. I love nothing more than to have someone tell me that they’re sending me a very “tough” or “resistant” client only to discover that when they’re with me, neither of these traits is really representative of their personality.

Or maybe it’s just a matter of perception, right?

Life is about choices, and compulsive or addictive behavior is certainly included in that equation. But that doesn’t mean that all choices were created equal. Indeed, all the evidence points towards the conclusion that choices are differently easy or difficult depending on a person’s experience, biology, and environment. In so many animal studies (called conditioned place preference experiments) researchers have shown that exposure to an environment in which drugs are given makes an animal much more likely to spend time there. We’re talking about 3 to 4 exposures at most and animals find it hard to leave – imagine what 3 to 4 years of that kind of exposure can. Self-administration studies (the kind where animals press levers and buttons for drugs) have revealed that animals can go through some pretty lengthy, complicated procedures to get their drugs and that their experience makes them continue pressing for a long time after the drugs have been removed from the equation. If a rat can learn to press one button, wait some time before pressing another, and finally poke his nose in a whole to get a hit, you can bet that people can do the same without needing to resort to explanations about unhealthy family environments. Family environments matter, as do friends, neighborhoods, and cultures – along with neuroscience they all create the picture we end up calling addiction.

As far as I’m concerned, there is no doubt that experience with drugs can lead to reduced self-control over activity that has been linked with drugs. Add triggers and cravings to the mix and the question of some compulsivity in addiction seems moot to me. Still, there is no doubt that compulsive or impulsive behavior can be helped when you’re not approaching the client as if they are somehow flawed but that doesn’t mean they weren’t compulsive in the first place.

Trying to make the picture simpler is like trying to draw a Picasso without being able to sketch a simple bowl of fruit – it might fool those who don’t know much but it’s far from true cubism.

Is personal experience necessary for successful addiction treatment?

In the “recovery” community, one often hears about how the best person to reach an addict is another addict in recovery. The question is whether personal experience with, and victory over, addiction is necessary for a counselor or therapist to be successful in providing successful addiction treatment?

I’ll spoil the surprise by telling you that I personally don’t believe such personal experience is necessary, and that is despite my own personal experience with addiction. I also think that spreading the notion that the above is true is counterproductive to addiction treatment as a field and that it creates an atmosphere whereby mental health professional are a little weary of getting involved in treating drug addicts.

Personal experience as a requirement for treatment in general?

Imagine for a second that you had acne and needed to get a treatment for it, would you only seek out dermatologists who have had severe acne as teenagers themselves thinking they will be best able to assist you? What about if you were diagnosed with cancer or diabetes? I’m assuming most of you can see that requiring the ones treating us to have experience with the same issues we’re dealing with is a bit silly, at least in the physical health sense. We need clinicians that know what they’re doing, can diagnose problems quickly and accurately, and who are familiar with appropriate treatment options and keep up with the latest advancements. They don’t need to have personal-experience with the problem.

But what about mental health issues like depression, schizophrenia, or bipolar disorder, would having one of those require a therapist who suffers from the same disorder in order to truly provide tangible results? Should schizophrenics only be treated by schizophrenics? Here again I think that most people can see that experience is not necessary. It might be nice to have a therapist who sympathizes, but really, what we need is knowledge and ability, which often involved empathy, but not necessarily shared experience.

So what makes addiction so different and special?

There’s no doubt that addicts like to think of themselves as special. I would certainly place myself in that group and have personally heard countless addicts who are no longer using exclaim that once addict recover “we are a special and capable bunch.” All of this makes sense in the whole “in-group/out-group” mentality that is so familiar to everyone in psychology as an effect generally observable in the population. But my sense is that when it comes to treatment it can be a dangerous premise.

Think about it – There is no question that addicts are far less common than the general non-addicted population. This means that in essence, believing this dogma – that addicts are best treated by other addicts – leaves the field less open to outside influence that are no doubt able generate great insight into the addiction treatment field. We can feel as special as we want, but I hope that no one believes that addicts somehow have a monopoly on knowledge, expertise, ability, and empathy. We don’t, and thinking we do is at best narcissistic and at worst ignorant and stupid.

I work with dozens of researchers who have no first-hand knowledge of what smoking crack uncontrollably is like (and probably a handful who do) and I can tell you that each of them has had incredible insight into the problems of addiction. I can also tell you that I’ve met many addicts in recovery who think they have found the end-all-be-all answer to our collective problems simply because these things have worked for them. Experience as an addict does not equal insight into addiction treatment. Experience in recovery may give some insight, but thinking that it is necessary and sufficient for providing great treatment is… unwise.

I believe that we need to get better at measuring, identifying, and replicating good addiction treatment, not setting up barriers for clinicians interested in treating addicts based on their own personal experience. My guess is that as we do this we’ll find that some addicts are great at treating addiction and some are horrible and that the same goes for “normies.”

Rehabing Rehab – How we can fix America’s addiction treatment system

When Charlie Sheen finally entered rehab, it wasn’t terribly shocking news. But what most people did find surprising was that instead of checking into a swanky Malibu addiction treatment center as he has done in the past, Sheen opted to receive in-home rehab. Immediately the media began criticizing his choice and questioning his commitment to getting sober.

There are undoubtedly certain challenges related to in-home rehab, but are you really guaranteed better care if you check into a treatment center?

Absolutely not, thanks to the lack of standardization in our current rehab system.

Seeking addiction treatment in The U.S.

Each year, about three million Americans seek help from a seemingly endless list of addiction treatment facilities. But who is ensuring these treatment centers are qualified to effectively treat them?

With a lax application process for state licensure and certification, there is little accountability placed on facilities, or their ownership, to ensure proper treatment is being offered. With more than 12,000 rehab centers in the country, the odds of finding the one that best fits your needs are next to impossible.

When treatment fails, which it often does, it is then assumed to be the addict who failed, when in reality it was often the addict who was failed by a flawed system.

This leads to a vicious cycle of relapse — a story all too familiar to families struggling with addiction, not to mention one we’ve seen repeatedly played out by Hollywood stars.

It is true that some don’t take advantage of their treatment and fail at sobriety on their own, but others simply weren’t given a chance to succeed.

The whole story is made worse by the fact that most rehab clinics market themselves as “all inclusive” — able to treat any type of addiction disorder — which most are certainly not. Addicts and their families are often so desperate to get help that they select a rehab clinic based on cost and availability, without understanding whether or not the care providers are properly certified in the type of addiction that affects them or are qualified to fulfill any additional needs they might have (including mental health needs).

This is especially true of first-timers (over 60 percent of those seeking addiction treatment are doing so for the first time). They don’t know what questions to ask or even what they are looking for out of a treatment center, making it nearly impossible to find the right option for their individual needs.

How to set standards for addiction treatment

We need to try and get some measure of standardization into the addiction treatment system so that we are able to match those looking for treatment with providers that fit their needs. Currently, there is essentially no oversight regarding the services addiction treatment providers report and their actual capabilities for providing those services.

In the place of a centralized federal or state-level vetting system, there are some private groups that provide directories. But it is not easy to tell how well these directories actually vet the treatment centers listed. It is critical for treatment candidates to know exactly what type of credentialed treatment services are provided. This should be provided by the public health departments, but until that happens, it’s basically “every man for himself.” (Here All About Addiction, we recently launched our own “rehab finder,” to provide a vetting system we think can help.)

We believe this is a crucial element for successful treatment; especially when you consider that more than 50 percent of addicts suffer from mental health issues, meaning they need special care by a trained professional. And while some may promise this, there is no verification process to ensure they are able to deliver on their promise.

In fact, a huge survey of the addiction treatment industry found that more than 20 percent of addicts entering treatment were missing crucial mental health services that they needed. (About 50 percent were missing other necessary medical services.)

Rehab is a business — a booming one, at that — and right now it is too easy to sell the idea of recovery. Because there is no model of care to follow, the system is compromised with clinics that don’t know how to do things better, some that limit their treatment due to dogma and other centers that are actually trying to “game” the system.

The bottom line is, without some level of standardization, treatment becomes nothing more than a crapshoot. You are left at the mercy of a broken system and never know what kind of treatment you are going to receive until it is too late.

Right now, you could easily check into rehab facility and find they offer nothing more than an expensive 12-step program. This is unacceptable. We have tools, like cognitive behavioral therapy and motivational enhancement therapy, which we know are effective, we just need to ensure they are part of the treatment model being offered to patients.

Add to that some very effective, if poorly utilized, medications and it’s clear we’re handicapping our patients, pun and all.

However, there is hope, and a better way of doing things, but it will require us to adopt a more progressive model of treatment.

Our society has too readily accepted the supposed “fact” that recidivism rates are high, and will always be high, for addicts. The fact of the matter is that the treatment process itself is deeply flawed and until we fix the model of care for recovering addicts, we will never be able to truthfully tell how many of them can recover. Addiction isn’t a death sentence. It is a treatable disease; we need to acknowledge that the way we are doing things doesn’t work and do something to change it.

After many years of trial and error, researchers and doctors have finally begun to grasp what works and what doesn’t in terms of treating addiction.

It is now our job and our responsibility to start developing a system that gets the proper treatment to the people who need it.

Any doctor will tell you, there are no guarantees with addiction. All we can do is give people the best shot at treatment, and sadly, right now, our system is failing at that.

Who is accountable for the treatment services addicts receive?

It’s not often that I let my opinions out freely rather than letting the data do the talking, but this issue’s been making me mad for a while and now it just has to come out. As part of our work on the A3 rehab-finder we’ve been trying to get some measure of standardization into the system so that when we match those looking for treatment with provides we get a good fit. The problem is that when SAMHSA collects this data there is essentially no oversight whatsoever regarding the services addiction treatment providers report and their actual capabilities for providing those services.

One of the most obvious examples of this has to do with providing services for clients who suffer from both mental health issues and drug and/or alcohol problems. This happens often and SAMHSA has a few specific fields that ask providers if they can handle these more difficult cases. Over 50% of addiction treatment providers claim they can, but since no one ever checks up on them, it’s just their word we’re supposed to count on. Well, as far as at least some of them are concerned, having a psychiatrist come by once a month for a few hours is enough, still other providers offer even less in terms of mental health provisions. Believe it or not, some who claim to offer mental health services do not allow the use of any psychiatric medication… I think that actually qualifies as negligence.

There is some research looking into this sort of stuff, including work from Dartmouth (and Dr. Mark McGovern) using an instrument called the DDCAT (Dual Diagnosis Capacity in Addiction Treatment). Unfortunately, as usual, the findings aren’t making it into the actual field. I think it’s due time that we hold providers accountable and set some sort of standard for each of these services that they claim to provide.

I mean seriously, could you imagine gynecologists being able to provide post-mortem examinations without training? Oh, I guess that’s happening too… Nevermind.