If you recall the Ebola crisis and the impending destruction of the planet that was unavoidable due to said crisis, then you may also recall expert testimony that the real danger was “if the disease mutates”.  In the case of there was a significant concern that Ebola would mutate to airborne transmission.  The world was not ready for the disease to manifest itself in that way.  Essentially there were zero protocols in place to managed an “airborne version” of Ebola.  Disease or viral mutation is not uncommon.  It happens with influenza.  People are concerned it will happen with A.I.D.S.  In those cases, the mutation will happen at a cellular or genetic level.   Is it possible that addiction could mutate?  Obviously, not at a cellular level but could it manifest itself in a fundamentally different way with an entirely new set of concerns.  Furthermore, are we ready to respond to these mutations?  I would say it already has.  Do we have protocols in place to respond to an “airborne version” of addiction?   I think we have serious work to do in this area.

Historical Context:

I am not a recovery historian by any means.  There are many people who have a deeper understanding of the way addiction has been handled by society.   See William White’s epic Slaying the Dragon for example.   That’s not my purpose in this blog post.  However, it is important to have an understanding of how our current drug and alcohol provider system has evolved over time.  Of course, it is impossible to provide this context in a completely objective manner.  My personal experience and interpretation of the “historical context” will come into play.

Addiction has been around from the dawn of time.  “Ancient Greek remedies for alcohol use included placing an eel at the bottom or the unfortunate drinker’s generous goblet of red wine” (Miller, Carroll, 2006).   History has seen problem users “whipped, dunked, shocked, poisoned with potions, chained, dialyzed” (Miller, Carroll, 2006).  In 2016 we have the Philippine dictator, Rodrigo Duerte, openly talking about killing 3 million addicts to clean up that country.

There have been successful and compassionate remedies to addiction over the years.  In addition, it is a fact that many people recovered on their own or with non-traditional help.  I would imagine that millions stopped the destructive use of drugs through supportive relationships.  Many found their way through church or through unofficial mentorships.  I believe traditional psychotherapy was probably helpful in mitigating addiction over the centuries.  These people did not classify themselves as “recovering” they simply went about their lives without the presence of alcohol and drugs.

As many of you know, the early 20^th century saw the advent of Alcoholics Anonymous.  This mutual support program became the first program to gain substantial reputation as a remedy for alcoholism.  There may have been many who recovered prior to AA, however, there was no specific program they could point to and say “this is how I did it”.  Alcoholics Anonymous grew rapidly and now stands at more than 2 million people nationwide.  AA is a phenomenal program.  But remember, AA was developed as a mutual support program.  A non-professional, free, program of one alcoholic helping another alcoholic.  However, the strangest thing happened along the way.  AA became the cornerstone for all addiction treatment programs.  It remains that way today.  90% (probably more) of treatment programs in America rely on the 12-step programs as foundation for their programming.   But more on that later.

As AA took off, and other anonymous programs came on board-most notably Narcotics Anonymous, the addiction treatment industry started to come of age.  Clearly a business model or “treatment model” had to be developed.  If treatment was going to be professionalized and seen as a healthcare procedure it needed a clear approach.  Also, it seems clear that if people are going to “pay for it” there needs to be a professional model that makes sense.  It was completely natural that that the industry would rely on Alcoholics Anonymous as a guiding light during 1950’s.  Alcoholics Anonymous was the pathway that was most well-known at that time.  AA had stepped into the void with a willingness to help alcoholics and an apparent solution.  The 12-step world spoke with authority regarding addiction and the organization was willing to work with emerging treatment centers. The Minnesota Model was born and utilized at Pioneer House in 1948, Hazleden in 1949 and Willmar State Hospital in 1950.  All these facilities were in Minnesota.  The Minnesota Model brought medical professionals and psychological professionals into the process but AA remained the core of the program.  In his manual on the model, titled The Minnesota Model, author Jerry Spicer put it this way on page 3: “Willmar merged AA principles with a multidisciplinary team: psychologists, physicians, and members of the clergy” (Spicer, 1993).  It is important to note that this model has remained the predominant model of addiction treatment to this day.  Variations and additions to the multidisciplinary team have occurred but the model and approach has remained unchanged at a core level.  For the past 66 years.  But more on that later.  For now, it is clear, modern addiction treatment was founded on 12-step principles and AA and NA are cornerstone of the addiction treatment industry.

As these programs grew another phenomenon took root.  These programs were viewed as successful.  One because there was anecdotal evidence.  Stories of success, even if isolated, became evidence of facts.  There was no real quantitative data. The great recovery historian William White puts it this way:

“Modern addiction treatment came of age in the 1960’s and 1970’s as a community-based phenomenon.  Representation of recovered and recovering people and their families was very strong; AA and NA were the driving force behind this era of addiction treatment.  In addition, there was a perception of treatment efficacy (anecdotal in nature; nonetheless a perceived efficacy) (White, 2006).

The issue of efficacy has since been addressed in a more comprehensive manner but we really don’t know if the model works for the people who do access treatment.  There will be more research in this area and perhaps we can a better sense of efficacy.  Regardless of what we find out in the future we know for sure.  The model exploded and is used by 90% of facilities despite the lack of evidence.  Another phenomenon that drove this growth also centered around effectiveness of the approach.  Unintentionally the business fell into a can’t lose model.  Basically, any relapse or problems post treatment were placed at the feet of the patient.  In other words, if a patient relapsed it was because “they didn’t work the program” or “they were not willing”.  As the cliché says “It works if you work it”.  Ostensibly then, “if it doesn’t work it’s because you didn’t work it”.  The idea something needed to change on the service delivery end was never even considered.  It was a wonderful business model.  It was a wonderful way to launch an industry.  Why would the industry change if everything is going well and outcomes are placed on the patient?  All these factors, and more, have contributed our current state of affairs.  Addiction treatment services are homogenous and, at the core, the same as they were in 1950.  For example, 1998 Study of representative sample of 450 private substance abuse treatment centers found that 90% of the facilities based their treatment on the 12-step principles of Alcoholics Anonymous (Roman, Blum, 1998).  This is the case despite the fact that clear recommendations have been made for alternative approaches and the growing presence of motivational interviewing in the substance misuse arena:

“What we hope to do is to actually have a menu of treatments that clinicians could choose from.  If one drug doesn’t work or they can’t tolerate it,” patients would “try another one and so forth, and hopefully they’ll find one that is effective.” 

–Raye Z. Litten, PhD Associate Director Division of Treatment and Recovery Research National Institute on Alcohol Abuse  and Alcoholism (NIAAA)

Unfortunately, this ideal has not been put into practice.  The stone-cold reality is that anything short of 100% acceptance of 12-step recovery is viewed as non-compliance in the majority of treatment programs in America.  All you need to do is talk to any client post treatment and you will hear the same experience repeated over and over.  For some this experience was positive and “it works” because they “worked it”.  For others, not so much.

It is difficult to move away from deeply held traditional views.  The addiction services workforce is an older workforce.  William White says it this way:

“Many addiction treatment organizations present a profile of long-tenured and graying administrators, clinical directors and senior clinicians combined with an exceptionally high (20-40%) annual turnover of younger, front-line direct service personnel. In addressing meetings of directors of state-funded addiction treatment agencies, I have observed more than three-fourths of those present being over age 45”.

This older workforce was “brought up” on very traditional views around addiction and recovery.  They are not likely to change those views unless compelled.  Of course, this doesn’t mean there won’t be outliers who can see the writing on the wall.  But it is clear that, overall, there is little enthusiasm for substantial change.  Couple this with the built-in lack of accountability centered in a philosophy that blames the patient (“IT works if you WORK IT”) and you have a ship that is going to be very hard to turn.  Why in the world would the addiction services industry do anything substantially different?  There is no real motivation to do so.

This leaves us, at it currently stands, with the same basic approach to addiction.  It is essentially the same medicine that was being administered in 1950.  The Minnesota Model carries the day. I am hopeful that things will change and I hear leaders talking more and more about alternative approaches.

Addiction has changed in many ways, however, I want to focus on the very fundamental issue of progression.  In this case, accelerated progression and how it leads to a demographic and a disease state we are not prepared to address.   

The Accelerated Progression:

• The Progression Has Accelerated: Addiction has always been a protracted progressive process with using career lasting on average 20 plus years and multiple attempts at recovery.  It has unfolded over time in an individual’s life.  Where polysubstance use is concerned (and remember this is the norm) it historically progressed along a relatively predictable path.  Concepts and ideas arose within this context that made some sense at the time.  Waiting until a person “hit-bottom” and waiting until a person “wanted it” was problematic but not nearly as dramatic when it involved a 33 year old who had a good deal of life experience and consequences associated with using.  This made the sit back and wait approach acceptable.  Professional services sit back and wait in a manner consistent with the 12-step philosophy of “go out and do some more research”.  This “progression” also made the total abstinence argument an easier sell.  When dealing with an older person who had used, and many times abused, multiple drugs it made sense to many people in need.  This “normal” progression can be illustrated in the following way:

         In this case the individual start with alcohol at 14 and mixes in other things along the           way ultimately finding recovery after an 18 year using career with 5 distinct and                       genuine “attempts” at recovery along the way.  It may look like he just woke up at age           32 and “rehab worked” but that is not at all the case.  Our current approach (wait until         the pain gets great enough, come see us when you want it) was designed for this dude.

        However, we live in a world where prescription opioids have nearly over-taken                         as drug of first use.  Back in the day it was a relatively unusually experience to have               someone offer you a handful of Xanax or other pills at the age of 14.  Of course they               were “around” but they were not mainstream.  Well they are now.  If you don’t think             they are you are engaging in collective community denial.  The progression has                       accelerated.  Using careers that were on average 20 plus years until arrival in recovery           have been paired down to 3 or 4 years.  The progression now looks more like this:

         In this case our client starts at 14 with weed but is immediately introduced to pills as      well.  Alcohol is an after-thought.  By 16 he is using pills regularly.  We know that               the tolerance and escalation of pills use is rapid.  By 18 he is using pills heavy rarely               smoking weed and alcohol is an after-thought.  Heroin enters the picture at 19 for            “economic” reasons and by 20 he is IV heroin user.  At 21 he enters rehab and is told              to stop all substances and is “held accountable” when he expresses desire to stop          heroin but occasionally drink.  This is labeled denial and treatment resistance because  that is how the model is laid out.  The young person will probably be held back in the          program until he realizes that superficial compliance will get him through quicker                 and with more status.  After all “fake it ’til you make it” is a cornerstone of the                       process.  However when “free” there is little likelihood of follow through.                                 Integration with recovery for the younger age group is exceedingly difficult for this                 group.  Consider the following.  According to Substance Abuse Mental Health Services Administration (SAMHSA), National Household Survey on Drug Use and Health:

      Relatively speaking, youth and young adults represent the largest demographic group           in need:

• At any given time 8.2% of the general population (age 12 and older) meets criteria for substance abuse or dependency.
• However, among 18 to 25 year-olds, the percentage meeting criteria for substance abuse or dependency is 17.3%. Over 2x the rate of the general population.

     And relative to other demographic groups youth and young adults are involved in                    treatment at higher rates than the general population.  For example:

• Among 18 to 21 year olds 8.1% of those in need were involved in treatment.
• For example: As compared to:
  • 26 to 29 year olds: 2.9%
  • 30 to 34 year olds: 2.6%

   However, they seem to be vastly under-represented within the recovery community.  For    example:

• According to the Alcoholic Anonymous member survey less than 1% are 21 or younger and the average age of member is 50 years old.
• According to the Narcotics Anonymous member survey less than 1% are 21 or younger and the average age of member is 43.3 years old.

Interesting dynamic: There are vastly more young people in need and they access treatment more often.  However, they are nearly non-existent (statistically) within the recovery community.

Why higher rates of abuse and dependency?: This demographic includes college age students and the obvious implications of that abstinence-hostile environment contributes to this condition.  In addition, the natural risk taking associated with youth mixed with access to new and more dangerous drugs makes this group more vulnerable.

Why higher rates of treatment participation?:  Parents and other authority figures have influence over this demographic.  They can be forced into treatment more readily than older individuals.  In other words they are made to attend treatment.

Why such low rates of engagement in traditional recovery?: Because our traditional programs are tailored made for middle age white men (average age 50, race Caucasian) and our current treatment paradigm promotes superficial compliance and lacks individualized recovery planning.

The current manifestation, and the coming manifestation, of addiction is fundamentally different than 60 years ago.  Essentially, the default setting for our treatment programs is grounded in principles developed to help middle aged alcoholics with little exposure to alcohol (as discussed above in the exploration of the Minnesota Model and AA’s prominence in the treatment industry).  We are now faced with a younger client population and a compressed addiction process.  A 19 year old heroin addict is drastically different than a 43 year old alcoholic.   We may want to explore ways to provide a fundamentally different type of treatment and addiction recovery services.

Working with younger people is fundamentally different than working with adults.  There will be some young people who do engage in recovery.  There is a growing group of young people in recovery, however, all things considered it is remarkably low participation rate given the potential candidates.  Specialized young adult services goes way beyond a segregated “young person’s unit”.   We need a culture change that moves toward specialized engagement, increased family involvement, and even harm reduction potentialities.  We will discuss these in detail at a later date.  For the time being I would encourage you to think over the reality we are currently facing.  I hope we act before the damage gets too intense.