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Research to Practice: How Advancements in Science Are Helping People With Mental and Substance Use Disorders

A. Thomas McLellan

04 How Advancements in Science Are Helping People With Mental and Substance Use Disorders

Ask the Expert:  A. Thomas McLellan, Ph.D. is the CEO and founder of the Treatment Research Institute (TRI), a Philadelphia-based research and development organization dedicated to science-driven transformation of treatment, other practice and policy in substance use and abuse.  He is the former Deputy Director of the White House Office of National Drug Control Policy.  In his more than 35 years of addiction-related research, he has received several awards, including Life Achievement Awards of the American and British Societies of Addiction Medicine (2001 & 2003); the Robert Wood Johnson Foundation Innovator Award (2005); and awards for Distinguished Contribution to Addiction Medicine from the Swedish (2002) and Italian (2002) Medical Associations.


1) Question: Can social model training as well as classes on mental health issues form a good parallel for treatment professionals?

Answer: I like Social Model programs very much and they have demonstrated effectiveness but I have to say that it is a unique model and I doubt that most treatment professionals would be interested in or benefit from participating or training in that model.  In my view (just my opinion), social model programs offer the kinds of services that are best considered “recovery support” rather than primary treatment for “recovery initiation.”  One of the good policy developments in the past few years is the Parity Act which encourages approximately equal access and equal types and amounts of services for mental and substance use problems – as are currently available for general medical conditions.   This is one of those types of services that are unique to substance abuse and have – to my knowledge – no parallel in general medicine.   As such, I do not think they will qualify for most forms of healthcare insurance reimbursement.

2) Question: I am working in drug treatment in Afghanistan, the number of drug users has been increasing with an alarming rate because of easy availability and so many other factors, meanwhile we have low capacity for treatment, we have high relapse rates, and the recovery rate is low here. What is your advice for us in this situation?

Answer: I am assuming you are in a military environment and that these are truly “addicted” patients.  One important issue about true “addiction” is that it is unlikely that once addicted, such a person could ever again use an opioid or possibly any other abusable substance (e.g. alcohol or marijuana) in a controlled way– it is a cardinal feature of addiction.

Under those stipulations there are a number of effective treatments for opioid addiction.  The one that is most often suggested is abstinence-based treatment, usually in a residential setting but continuing into outpatient care.  The goal of this kind of care is for patients to reduce their dependence upon opioids and learn to live a drug-free life.  The good things about this form of care are that when it is effective it produces an ideal therapeutic outcome – a drug-free individual who needs no continuing treatment.  The bad things are that this kind of care is scarce, it takes a long time to get a person functional (at least 3 months), it is expensive, and outcomes are not certain – there is the same rate of 6-month relapse (50%) as you find in other chronic illnesses.

There are three maintenance medications that can be used in outpatient treatment for opioid addiction.  The first two are synthetic opioids or partial opioids (Methadone and Buprenorphine [called Suboxone commercially]).   These medications given on a daily basis for a long period (at least a year and often for 10+ years) under medical supervision, have a demonstrable effect on reducing opioid use and promoting function.   These medications are (when done correctly) safe and effective but they also have an abuse potential themselves and they require close supervision and monitoring that is rarely done in many public clinics.   The military has traditionally refused to support Methadone and Buprenorphine maintenance because each of these is a synthetic opioid and there is the worry that military performance might be affected by an opioid maintenance regimen.

The third medication is an opioid antagonist (Naltrexone or Trexan commercially).  This is a very different type of medication – it can only be given to a person who has completely detoxified from opioids and once it is taken (either orally on a daily basis or by an injection which lasts a month) any subsequent use of any opioid will not be felt by the patient – it will be like taking water.  It does not make the patient sick or high – just like taking water. 
Finally, it is entirely possible to combine several of these treatment methods and medications.  Please also see my answer to Question 11 below for additional information.

3) Question: Since trust is such an essential issue for addicted persons, how has research on therapeutic alliance and the nature of therapist-client trust advanced our understanding of addictions treatment? In other words, what are the active ingredients of therapy with addicted persons and how can research advance our understanding of treatment efficacy?

Answer: The great majority of the research on therapy has been with individual counseling and therapy – NOT group.  Group therapy is very difficult to study and harder to do correctly – I know the economics of group vs. individual but it is a rare group therapy session that is as good as an individual therapy session.  It is also mathematically more difficult to establish trust for all members of a group (especially when the group is changing) than for an individual counselor.    That said, here is a rough summary of research results on INDIVIDUAL therapy or counseling.

1. Not just anyone can be a therapist – personal qualities are very important in establishing the initial engagement and these include active listening skills, general warmth and a good personality – without these it is not possible to train a therapist (if you aren’t tall and can’t jump, no amount of training will make you a basketball player).  

2. It is not just personal qualities – there are clear skills of therapy and the specific skills necessary to do the therapy vary with the type of therapy being applied.   Many studies have shown that therapists who do a “pure” form of almost any recognized therapy have better post-treatment outcomes.   Be wary of therapists who say they are “eclectic” – meaning they do a bit of this and a bit of that.   Therapy is very much like a way of understanding life – it must present a coherent reformulation, one that is consistent and meaningful – harder to do if you mix techniques and strategies from different types.  

3. Final point – it is NOT necessary for an addiction therapist to be in recovery from addiction – over 30 studies have looked at this and none show a significant difference in outcomes.   This does NOT mean that being in recovery is bad or irrelevant – indeed it can be a very nice additional feature – as long as the recovering therapist is also personally engaging, well trained, and well-practiced in a particular form of therapy.

4) Question: As a fairly new director of a treatment center, I’d like to know what tools exist to measure the effectiveness of treatment, so that we can determine if the treatment we are giving is working.

Answer: I am going to give you what may be an unconventional answer.   The gold standard for measuring addiction treatment effectiveness is a 6-month post treatment follow-up where patients are re-interviewed and often with a urine drug screen or breathalyzer to assure honesty.   Note that this evaluation is expected to take place AFTER treatment is completed – much as you might evaluate the function of a previously broken leg after a cast has been removed or the results of a course of an anti-biotic after the prescription has been completed.   Like bone breaks and infections, addiction has been evaluated with the view that some finite amount or type of treatment would eliminate the condition (addiction) and return the patient to normal or better function (total abstinence).   These kinds of evaluations typically reveal relapse rates of 50 % and this has not been considered very effective.

Here’s the newer approach to evaluation.   It now appears based on science and common sense that most serious addictions are really chronic illnesses.  In brief, this is due both to the many findings showing the protracted physiological and emotional effects of addiction last for over a year following abstinence – and to the fact that we simply do not have a “cure” for any addiction.  Like diabetes, hypertension, and tooth decay, we can manage recovery from addiction but not cure it.   So why did I go into this discourse?  Because let’s think about how one might evaluate the effectiveness of treatments for any other chronic illness.   The best way is to repeatedly measure the signs and symptoms of the illness being managed during the course of outpatient or clinic-based care.   Repeated use of blood pressure testing or HgA1c testing while the patient is being managed during treatment will provide very clear indication of whether the treatments delivered are having the desired effects – and will provide good clinical guidance to both the patient and the treatment team about appropriate next steps.

OK – that’s the general approach – but what are the specific measures and is there an “instrument?”   Our organization, TRI has developed a brief 10-minute structured clinical check-up designed to be implemented monthly during the course of standard outpatient substance abuse treatment program- it asks standard questions about “how many days in the past month did you use any kind of drug; did you drink alcohol – and more than 5 drinks (binge); did you work; did you experience family problems; did you experience medical and emotional problems.”   It is very simple but it is designed to be a counseling conversation with standard measures that both the counselor and the patient can see over time.   But if you are a physician in a more general medical setting, this may be too much for you.   At the very least I would ask the patient a couple standard “how many days ….” questions about drug and alcohol use and emotional problems – things you can actually do something about; and I would take a urine drug screen (standard 5 – 7 panel test) and a breathalyzer.   If the patient objects to the drug screen that should raise suspicion.  If there is an objection you can accurately say that if there are problems at work or at home or … the patient may want valid indication that s/he has not been using.   Urine screens are not perfect in this regard – they measure previously ingested substances for 1 – 4 days typically and this is not a big window.   However, at the same time, they are cheap and fast.   A bigger window to measure previously ingested substance use is hair analysis – same fundamental process but you simply trim any kind of hair from the patient (a few strands) and a centimeter in length gives roughly a month-long window to drug ingestion.  Hair testing is about 5 times more expensive than urine testing.

Either form of this kind of testing is exactly equivalent to blood pressure and HgA1c testing; the self-report and urine testing will give you the same kind of functional information to guide your treatment suggestions; and will provide the patient and (if the patient consents) his/her loved ones some objective evidence of status and improvement.  

By the way – if you are prescribing an opioid medication or a sedative or a stimulant for some other condition – there is even more reason to do this kind of concurrent monitoring and outcome evaluation.


5) Question: Do you believe that spiritual growth plays an important part in recovery?

Answer: I do believe spiritual growth is important and it is a key part of 12-step facilitated recovery.  I am not sure that spiritual growth is essential for everyone – simply important.  The main problem is defining what spiritual growth is and how one develops that growth.   I have heard many very credible accounts that prayer, church attendance, yoga, mountain climbing, public service and many more CAN promote spiritual growth – which should be recommended and how should they be promoted?   Also – this is one of those issues that make health insurers crazy.  Even if it is acknowledged that “spiritual growth” is good for treating addiction and probably other illnesses – how is this to be packaged, what “dose” is to be recommended, and should the public pay for it?  Sorry that’s all I can say about this very complex issue.

6) Question: Addiction is a recurring problem, can a person be “in recovery” even though he is totally abstinent?

Answer: Yes – In fact a person who previously met criteria for a serious addiction can ONLY be called “in recovery” if s/he is totally abstinent from all non-prescribed substances of abuse.   Abstinence from non-prescribed substance use is the foundation and core requirement for being considered to be in recovery.

Why do I say abstinent from “all non-prescribed substances of abuse?”  An addicted patient might be prescribed an opiate agonist (methadone or buprenorphine) to help them remain abstinent from non-prescribed heroin and other opiates.   Similarly, an addicted patient who also has depression might be prescribed an anti-depressant or an anxiety medication.   Though these medications can be abused – if a patient is taking them as prescribed and does not use any other substances they are considered to be in “medication-assisted recovery.”

7) Question: How do we actively incorporate prevention into the recovery discussion?  So many prevention interventions are the same as what we do as part of recovery support.  Prevention can include the reduction of risk for family members of persons in recovery. It also includes all those activities we use to prevent relapse.

Answer: That is a very interesting question and I do agree with you about the similarity of the interventions that are used before an addiction illness happens – and to prevent reoccurrence once recovery has been initiated.   Here is the policy answer.   Prevention services ARE now covered as part of healthcare – in fact in the case of Medicare and Medicaid, prevention services are 100% paid by Federal dollars with no State match required.   For private insurance starting in 2014, prevention services will also be paid with no deductible.   In the policy language, “prevention services are those interventions approved by the US Preventive Services Task Force” and at this point only tobacco screening and brief interventions as well as alcohol screening and brief intervention (soon drug screening too) qualify as effective prevention services.    So while prevention has not been considered “part of recovery from addiction,” it is a firmly established part of the “continuum of care for substance use disorders.” 

But part of what I think you are saying is that the kinds of outreach, social, and community services that are so important in keeping kids from initiating drug and alcohol use – should also be used following primary addiction treatment to “prevent” recovering individuals from slipping back into old habits.   I completely agree with that and hopefully (this is my opinion) the increased emphasis on treating “addiction” (I keep using quotes here to distinguish addiction as the most serious of the substance use disorders) as a chronic illness will include training and funding for “continuing care “ services to sustain the benefits.  In this connection, you might look at articles describing standard treatment for addicted physicians and airline pilots.   These groups have high rates of addiction (NOT just substance use disorders – addiction) and they receive 5 years of care, support, and monitoring with consequences – 5 years!   Oh yeah – and their 5-year outcomes are better than 85% positive throughout the entire five year period.   Too much to go into here, but I think it makes your point.

8) Question: Mutual-aid support groups play a vital role in facilitating recovery for many people. Research has shown that finding a good support group fit for the recovering individual is a key factor in successful long term recovery.  What can be done to better promote the use of non-12-step approaches, such as Secular Organization Sobriety, Women for Sobriety, and SMART Recovery, for those individuals that are not a good fit with the 12-step approach?

Answer: I agree with the opening premise of your question – there IS good evidence that these and other support groups promote continued recovery.   This is also true for individual therapy, athletic activity (especially in groups), religious involvement, and generally any activity which promotes healthy, social activities that are inconsistent with drug or alcohol use.

I do not know what it will take to promote such alternatives but I agree that more alternatives are a good thing.   A couple of things in this regard.  First, AA is NOT out there selling itself – they do not promote themselves at all and yet they remain by far the most broadly used recovery resource.  This is likely due to the innately attractive structure of most 12-step oriented meetings and to their affordability ($0) and to their accessibility (everywhere, all the time).    But (there is always a but) – most studies of AA show that this form of care is attractive to and used by 10 – 30% of those who attend a single meeting.   So while AA type meetings are the most widely used in our field (by far), they still only reach 10 - 30% of those needing help.   My suggestion to those who want something different is to do what Bill White did – create it and make it attractive to the group you are striving to engage.  I do know that many psychologists and counselors have made a very handsome paying practice of providing continuing support services to individuals who want to maintain their recovery.  Many of these private services are attractive to recovering people who do not like or are intimidated by groups – they want privacy and individual one-on-one contact.   I know too that at on any day there are over 15,000 individuals “meeting” on internet support sites – some of which are 12-step oriented and some are not.

Well if you have read closely, you will see that I mostly did not answer your question – just restated it with some information I happened to have available and some personal ideas – sorry but that’s the best I’ve got – hope it helps.



9) Question: I have been a huge supporter of medicine-based therapies. I am the mother of an opioid addict. I am always surprised by the response that some people have against the use of them. Are there any good studies you could point me to that show an effective use of them, as it relates to long term outcomes? Were results tied to the patient receiving or not receiving some form of recovery care therapy?

Answer: I am not completely sure what you are asking for – if as I suspect you are advocating for medications for opioid and other addictions then the answer is assuredly yes.  All the medications approved for treatment of cigarette, alcohol, opioid, benzodiazepine (sedative), and cocaine dependence have been approved by the Food and Drug Administration.  All have passed the same level of safety and efficacy testing as all other drugs for all other diseases.  They are safe and effective in long-term studies but there are so many it is difficult to pick any single study or summary.  See also my answer to Question 11 below for additional information.

10) Question: What about the research showing marked improvement in recovery from PTSD with the use of psychedelic drugs (MMDA)? Is this an avenue that sufferers should pursue under professional guidance?

Answer: I am familiar with that research and both for PTSD as well as for some phobias it has been shown that VERY carefully done therapy by VERY experienced therapists under VERY controlled conditions (MDMA with known potency and purity) – can have beneficial effects.   Note too that only 1 – 3 of these sessions are required.   This is still a developing area of clinical research and when it was undergoing study in the late 1960’s (remember Dr. Timothy Leary?) it got way out of control and led to serious harms.   Also – the promising work with MDMA does NOT mean that marijuana, LSD, psilocybin or any other hallucinogenic compound will have the same effects – they are all quite different.

11) Question: The question that I have is related to the treatment of opioid addiction.  Is methadone a good current choice treatment?  What about Suboxone? There seems to be some resistance to utilize Suboxone from treatment providers.  Is there significant cost difference?  Many individuals who have addictions problems seem to prefer the Suboxone, yet it seems much more difficult to access it. For long standing opioid addiction can it be used long term?  Are there other new drugs that assist in the treatment of opioid addiction that we should consider using? What would the pros and cons be for each?

Answer: See answer above in Question 5 as well.   First – true confession – I worked in a methadone maintenance program for 27 years.  So I have what you would either call experience or bias or both.   That said, here are some facts.  

Suboxone and methadone have largely the same types and amounts of clinical impact – both can be and usually are effective.   Suboxone is much safer than methadone – very difficult to overdose on this partial agonist – which in turn allows it to be prescribed by trained (2-day training required) physicians.  Methadone can only be prescribed for addiction in the context of special Methadone maintenance treatment programs.   There is a significant cost difference between these medications – Methadone costs about 50 cents per dose and Buprenorphine (Suboxone) costs about $5 – 7 per dose.  Buprenorphine is often not covered by private insurance but this is changing.

Both the above drugs are synthetic opioid agonists (methadone is a full agonist and buprenorphine is a partial agonist) – this means these medications are designed to mimic SOME of the effects of other opiates.  When an addicted patient takes these medications in oral form – the patient remains physiologically dependent upon opioids.   This is a big deal – many patients and most of society would rather have addicted patients NOT be dependent upon an opiate.   Why are these effective medications then?   First of all – for some patients (and we do not know which yet) getting off opiates is VERY difficult to impossible – every time they try they relapse and with it the associated dangers of infections and overdose.   Under these circumstances either of these two medications is useful.  For these patients, it is FAR better to take an ORAL dose of these medications once every 24 – 30 hours than to shoot heroin every 6 – 8 hours.  Not only does this reduce patient contact with illegal drugs and needle-borne infections – it is a fundamentally different form of opiate dependence.   A slow acting, oral opiate does make a person physiologically dependent on the opiate – but both the onset of the opiate effects (every time the patient takes a dose) and the offset of the opiate effects (24 – 30 hours later) are very gradual – not at all like the extreme highs and lows associated with rapid onset and offset heroin injections.   There is no reason why a properly maintained methadone or buprenorphine patient cannot work or discharge all normal responsibilities – we have had police, stockbrokers, teachers, coaches, and many other people successfully maintained on methadone and buprenorphine.   

Why do these kinds of medications have such a bad name? Two reasons.  First, because these are both MAINTENANCE medications they require long-term clinical management.  It is irresponsible to simply give either of these drugs without monitoring and managing the drug use and other drug-related health and social problems that so typically affect patients.   Many “methadone programs” do not do the appropriate monitoring and do not offer individualized services.   Some of these “programs” are simply very badly managed and become a haven for uncontrolled drug use.  Of course poor management is not confined simply to these programs – you can find badly run McDonalds, junior high schools, and doctors’ offices.   Second, because both these drugs are opioids they can produce a “high” when taken by individuals who are not properly evaluated and prescribed – all to say they have a street value and without close monitoring both these medications (methadone way more than Suboxone) can be diverted improperly.

There are two other drugs that are quite different from the opioid agonists – they are opioid antagonists – naltrexone and nalmafene.   Antagonists – like agonists – attach to the body’s internal opiate receptors but antagonists prevent the receptors from firing off and producing most opiate effects such as euphoria or “high.”   These antagonists simply sit on the receptor and prevent the body from feeling any other opiate.   In the early trials of these medications, patients were given an oral dose of naltrexone and told to inject their own heroin or other opiate – they would be amazed to find they had no effect whatsoever – no high, no sickness, no nothing.   Oral naltrexone is a very cheap (~$1.00 per pill) medication that is very safe and has been FDA-approved for many decades.  It is extremely effective – not only in eliminating opioid use, but it was later found to be effective in reducing (not eliminating) alcohol abuse in many patients.   But both naltrexone and nalmafene must be taken daily or at least three times weekly – or they will not work.   Adherence to naltrexone has been a problem – many addicted patients are tempted to skip doses so they can get high “one more time.”    So, in the past 8 years there has been a new form of injectable naltrexone (trade name Vivitrol) which is really the same naltrexone but encapsulated in the same kind of material that is used in surgical sutures.   Thus, when a patient receives a shot in the buttocks (these hurt for about an hour because the needle is large – so it has to be in the butt), the encapsulated naltrexone is gradually released into the body over about a month.  This means the patient will not be able to feel any heroin or other opiate for about a month.   The injection has to be done by a trained physician and costs about $750 - $900 for the month protection).

12) Question: I am finding my doctors are not working with one another when it comes to medication interactions.  As a result of taking the initiative to learn about my medications, I am discovering most of my mental and physical troubles are pharmaceutical in nature and not the original diagnoses.  How can I make sure my meds are being given for my health and not to the detriment of my diagnoses?

Answer: Wow – big question and I am not the guy to answer it – this has been true for many of the other questions and it hasn’t stopped me, so here goes.    First, in general I agree with you that it is tough to find a physician that is well qualified to give high quality addiction care in concert with general medical care.   It is mostly not their fault as they do not get training or education in substance use disorders including addiction – this is changing but that doesn’t help you now.  I would suggest as a practical matter that you get a listing of physicians in the American Society on Addiction Medicine and see if you can locate one near you.   These guys and gals have the kind of training I think you may need.   Second, I am not sure how you know “…most of my mental and physical troubles are pharmaceutical in nature and not the original diagnoses.”  I am not saying you are wrong – just wondering how you know; how does this manifest itself – are these medication interaction effects you are experiencing?   If this is the case then regardless of who your physician is or how they were trained you need to raise the worry with your prescriber – many so-called medication side effects or drug-drug interactions only get worse over time and need to be corrected promptly.   If your physician doesn’t know how to do this, get another physician.   It could also be (my opinion) that as some of your major problems were medicated, other less obvious problems gained salience and you may actually need additional medications or interventions.   It is NOT possible for me or anyone to know this without a full examination and history and I urge you to be fully open and honest with your physician – if you don’t get satisfaction go to another physician.



13) Question: Can you please indicate the latest findings in best practice research on the delivery of children's health care services, and any SAMSHA projects or grants to support them?

Answer: I am sorry but this is far too big a question to answer in a few sentences.   Here are some important findings though.  

1. Alcohol and drugs affect the developing brain – can this possibly be a surprise to anyone?   But brain imaging and cognitive development studies show that seemingly low levels of alcohol and drug use measurably affect memory, attention, and concentration in kids from 15 – 25. 
2. The brain does not stop developing till about 25 (slightly earlier for girls) – this may be news to people, it had been thought that most development was done by age 18 (this is why the draft was set at 18 and lots of state alcohol laws used to be set at that age).   In fact, the areas of the brain responsible for judgment and inhibitory control (thinking twice) are not fully developed till about age 25.  
3. Most adolescent treatment programs do not use age-appropriate therapies or appropriately trained therapists.  This is not my opinion, it is the result of many state surveys.   Most adolescent therapy available is taken directly from adult 12-step model work.   It is unknown whether or to what extent that approach is effective. 
4. Most medications that are FDA approved for adults are NOT approved for adolescents – this is for safety reasons – just as it is just becoming clear what drugs of abuse can do to a developing brain, so to for medications.  

Sorry this is just scratching the surface but there is way too much to discuss.

14) Question: As you know, people can have a predisposition to alcoholism, and have immediate high tolerance. Have you found evidence that suggests that these same people typically eat a lot of sweets while growing up, which acts as a gateway substance to alcohol?

Answer: There has been a long and storied connection between variations in sugar metabolism and sugar preference – and susceptibility/vulnerability to alcohol dependence.  The first person I know about who studied this is the Canadian physician and scientist Yedy Israel – you might look up his work because it will be more informative than this.   I can say that I have seen no relationship between high sugar content diet and increased tolerance for alcohol.  Further, if you are worried that giving sweets to your child will in some way increase their susceptibility to alcoholism – I think your concerns are better placed on prevention of Type 2 diabetes – no link that I know between pediatric or adolescent diet and later vulnerability to alcoholism. 

15) Question: I agree that advancements in science regarding addiction are generally positive. However, a consequence appears to be that these advances also bring with them a burden on many of the workers and potential workers in the treatment and recovery field. For many workers keeping up with State and Federal requirements, such as licensing and certification demands a financial and time expenditure that is beyond the capacity of too many otherwise well-qualified people. Ultimately, the advances narrow recovery options to very clinically-oriented, highly professionalized program models. Are follow-up studies are being done to examine whether this trend and the increasing staff requirements (often without any advantage to some effective program modes) have helped in either retention or successful program completion rates? Do the new program designs only provide opportunities to a type of addict who does well in that particular type of clinical and professionalized setting?

Answer: I couldn’t possibly disagree more.   I can see that it is something that is bothering you so I want to be helpful in my answers – let’s see.   First, in my lifetime the only treatments for people with “substance use disorders” were specialty treatments (programs) for the seriously addicted – this really narrowed the treatment population and produced few treatment options and generally – stigma to those getting or providing that treatment.    The science and the recent legislation based on that science is opening up treatment options by increasing both the number of people being served (healthcare reform) and broadening and making more fair, the nature and amount of services that are covered for those with less severe substance use disorders (Parity Act).    For the first time, there are options derived from science that will be covered by insurance and should increasingly be available from the very same people and institutions that provide the rest of a person’s healthcare.  These options should reach and be attractive to people in early stages of a developing substance use disorder – well before they lose their health and their dignity.

I call this real progress for both the affected patients and for the rest of healthcare.   Think of it this way – suppose I took your words and applied them to another disease – say hypertension; and suppose your kid has hypertension.   Now with that perspective see if you agree with your own opening words “…for many workers keeping up with State and Federal requirements, such as licensing and certification demands a financial and time expenditure that is beyond the capacity of too many otherwise well-qualified people.”  I am sorry if this sounds rude but these words sound like whining to me – and if I am looking for somebody with the credentials and work ethic to treat my kid, well….    You go on to say “Ultimately, the advances narrow options to very clinically-oriented, highly professionalized program models…”  I am not sure about you, but I WANT my kid to be treated by “highly professionalized” individuals and programs and I WANT those individuals to spend the time required to get “licensing and certification”   I explicitly do not want my kid to be treated by unprofessional or unlicensed individuals.
I am sure you are a caring professional in this field and I sense in you some worry that the more human or personal or spiritual elements of old-fashioned recovery (not making fun here – I respect good old-fashioned recovery) will be lost in science, medicalization and professionalization.   There is no doubt that there are many counselors and AA sponsors and others who have given selflessly and very capably in the substance abuse field – my own family benefitted substantially from those services.  You must also be aware that over 90% of the Americans who are affected with substance use disorders do not want existing treatments – they do not think they work – they do not trust the models or the practitioners.   There is no other industry that would survive if 90% of potential customers did not want the main product.   Again – I want to repeat that most of my family owes its health to the benefits of good old-fashioned substance abuse treatment but that does not change the facts.   We need more options for those who are affected.  

Also I just do not see this issue as either or – it is BOTH high-quality, high-science medicine – exactly what every patient with every other kind of disorder is entitled to – AND ALSO very compassionate and quality counseling and peer recovery services that are very important to recovery.   Hope that helps.

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