Cover Story

For more than five years, David Sheff watched his son Nic battle methamphetamine addiction. By age 25, Nic had been in and out of rehab and tried half a dozen treatment programs. Some helped, temporarily. But always, he had relapsed, ending up back on the streets, terrifying himself and his parents.

By one of the later relapses, Sheff, a journalist, had already begun researching a book about addiction and had interviewed some of the world's leading experts on the biology of addiction and treatment.

"I was frantic," he says. "I called the guy who knows more about meth than anyone in the world, and I asked him ‘Where can I send my son?' And he had no idea. He was stunned. He asked colleagues, other researchers, and they didn't know either."

Sheff did find a treatment program for his son, but not through his scientist contacts — he found it through a friend, another father with an addicted child.

Today, Nic is 30 years old and five years clean, married and the author of two memoirs about his addiction. But the episode, according to Sheff, illustrates the chasm between the science of addiction treatment and the programs that are available to most of the people who need them.

More than 40 million people in the United States — 16 percent of all Americans over age 12 — suffer from nicotine, alcohol or drug addiction. Only about 10 percent of those people receive treatment, according to a recent report by the National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia). And far fewer receive effective, evidence-based treatment, according to the report, entitled "Addiction medicine: Closing the gap between science and practice."

Over the past decades, researchers have developed effective pharmaceutical and behavioral treatments for addiction. Yet in residential and community treatment programs around the country, these evidenced-based treatments are relatively scarce, according to the CASA Columbia report. Instead, programs might involve wilderness camping, abusive tactics labeled "tough love," and, most commonly, Alcoholics Anonymous and Narcotics Anonymous, peer-support models that have helped many addicts but failed many others.

It's a brew of "pseudoscience, tradition and the best guesses of people who are sincere, but that doesn't mean they know how to help," as Sheff puts it.

There are many interrelated reasons for the science-practice gap in drug treatment, including a long history of treating drug addiction as a moral failing rather than a disease; a health insurance industry that rarely covers substance abuse treatment; and a fragmented state-by-state licensing system that doesn't always require addiction counselors to have adequate training.

To solve these problems, addiction experts say, our health system has to move past saying that addiction is a disease, and actually treat it like one, integrating it into the health and mental health care systems.

And psychologists, who have helped to develop many of the evidence-based behavioral treatments, have a role to play in that change.

What works

There are many forms of evidence-based behavioral treatments for substance abuse. Some of the most strongly supported include:

  • Cognitive-behavioral therapy. CBT can help addicted patients overcome substance abuse by teaching them to recognize and avoid destructive thoughts and behaviors. A cognitive-behavioral therapist can, for example, teach a patient to recognize the triggers that cause his or her craving for drugs, alcohol or nicotine, then avoid or manage those triggers.
  • Motivational interviewing. This therapy technique involves structured conversations that help patients increase their motivation to overcome substance abuse by, for example, helping them recognize the difference between how they are living right now and how they wish to live in the future.
  • Contingency management. Using this method, addiction counselors provide tangible incentives to encourage patients to stay off drugs. Those rewards might include offering cash, clinical privileges, work at a steady wage or even restaurant vouchers for each clean drug test. Although these rewards might seem small in comparison with the force of addiction, studies have found that carefully structured contingency management programs can help people stay clean.

These behavioral treatments can sometimes be particularly effective when combined with pharmaceutical treatments that either mimic the effects of the drug in a controlled way (such as methadone and buprenorphine for opiate addiction or nicotine chewing gum for cigarette addiction) or reduce or eliminate the "high" the user gets from the drug (such as naltrexone for opiate or alcohol addiction).

Different methods can also be effective for different populations, and at different times in the treatment process. For example, University of Vermont psychologist Stacy Sigmon, PhD, who studies contingency management, says that the technique can serve as a bridge to help people early on. Drugs provide an immediate reward, whereas the rewards of sobriety — better health, a stable job — can take longer to materialize.

"The idea is that these somewhat contrived voucher rewards could really bridge that incentive delay," she says. "If you can string a few days or weeks [of sobriety] together, it really helps [patients] get clear heads and make changes that move them toward true, lasting sobriety."

Complications

Unfortunately, solving America's drug treatment problem will not be as simple as requiring every licensed treatment program to implement CBT, motivational interviewing or some other evidence-based approach. That's because some studies have found that what works in the lab doesn't always work as well in community settings.

Several examples come from the Clinical Trials Network (CTN), a NIDA-sponsored initiative in which community treatment programs implement and study evidence-based treatment methods, according to John Kelly, PhD, associate director of the Center for Addiction Medicine at Massachusetts General Hospital in Boston. In one CTN study of more than 400 substance users for example, researchers compared using motivational interviewing at a program's first contact with a substance user, with using a standard intake/evaluation session. They found that although the MI method slightly improved retention rates in the programs, it didn't significantly improve patients' outcomes in the end.

Why don't evidence-based treatments always work as well in the community as they do in the lab? There are several reasons.

One is that the mix of patients is more variable in the community. "When you're implementing a treatment that was shown to be effective in a rigorously controlled trial, and then you implement it in a clinical setting, you get a different patient mix, sometimes under different environmental conditions — so you will get variable results," says Kelly.

Another is that the people providing the treatment may be different as well. Licensing regulations for addiction counselors vary tremendously by state. According to the CASA Columbia report, 14 states do not require all addiction counselors to be certified, six states don't have any minimum educational requirement for licensure and 14 require only a high-school diploma or GED. Only one state requires a master's degree.

That means that the people providing front-line addiction treatment often don't have the background and expertise to do so effectively, says Alan Budney, PhD, an addiction researcher at Dartmouth College.

"The typical training ground for substance abuse providers is workshops," he says. "They may learn a little bit about cognitive behavioral therapy or motivational interviewing, and may try to do a little. But those things take a lot of training to do well."

Kelly agrees. "If you go around the country and ask programs what they're doing, they'll say, ‘Yes, we're doing that.' But if you look at what they're actually doing, it doesn't resemble the treatments that are found in the original trials."

Solutions

For Kelly, the solution to this problem is to work from the bottom up rather than the top down. He believes that treatment systems and funding agencies should invest in a network of measurement and reporting. Clinical treatment programs that receive federal funding would be required to report their patients' response to treatment or ‘during-treatment outcomes' in a standard way. Then, researchers could identify underperforming programs, as well as spot clinical innovators and more effective programs and find out what they're doing right.

"This has been done in other fields, like cystic fibrosis for example," he says. "It's ‘measurement-based practice,' rather than ‘evidence-based practice.' But really, it is evidence-based."

Another perspective comes from Sarah Feldstein Ewing, PhD, a clinical psychologist at the University of New Mexico Center for Alcoholism, Substance Abuse, and Addiction. She and Tammy Chung, PhD, a psychologist at the University of Pittsburgh Medical Center, co-edited the June special issue of the journal Psychology of Addictive Behaviors, which focuses on using neuroimaging to examine the brain basis of addiction treatment. The idea, she says, is that if researchers can figure out the neural mechanisms that underlie these therapies, they can learn what makes them work and how to apply them more effectively.

In her research, for example, she's used fMRI to examine the brains of teenagers who have received motivational interviewing treatment for marijuana abuse. She found that getting clients to engage in "change talk" — making statements like, "I need to back off my marijuana use, it's causing problems with my family" — increased activation in brain areas related to introspection and contemplation.

Such research is just taking off, Feldstein Ewing says, but the goal is to eventually gain a better understanding of what makes behavioral addiction treatments work.

"I'm hoping this research will eventually point to the active ingredients in treatment," she says.

Psychology's role

Psychologist researchers like Feldstein Ewing, Sigmon, Kelly, Budney and others are on the front lines of figuring out how to design effective addiction treatment.

But engaging the field more broadly in addiction treatment is crucial to improving outcomes, experts say. Right now, not all psychologists are properly trained to recognize the signs of addiction, and given the size of the addiction problem, they should be, many say.

"I know that when I was getting my degree at NYU, there were no courses, none at all, in addiction," says CASA Columbia's Jon Morgenstern, PhD. "When I was teaching at Rutgers, it was a very small part of the curriculum."

It's a problem that David Sheff ran into personally. At one point early in his son's meth addiction, he took him to a well-respected psychologist. "In restrospect, my son was on meth at the time. We were sitting in a room with this esteemed psychologist, and the guy didn't know. It wasn't his fault, but he hadn't been trained to recognize it."

It's a problem that's rampant in the medical profession, too. In one study, for example, CASA Columbia found that 94 percent of primary-care physicians failed to recognize the signs of risky alcohol use and offer addiction as a possible diagnosis.

All psychologists and physicians, Sheff suggests, should be trained to recognize the signs of addiction and refer patients to appropriate providers.

More psychologists are needed in the drug treatment workforce as well, says Morgenstern. It's not realistic or necessary that all direct treatment providers have PhDs, he says, but "we need more psychologists in key infrastructure positions. Right now there are some psychologists who are the directors of treatment programs, but it's the exception rather than the rule."

More broadly, he says, providing evidence-based treatment means treating addiction as a disease and integrating it into the health-care system, improving the addiction workforce, and treating addiction as a chronic rather than an acute illness with comprehensive long-term care, he says.

"I can tell you that every day I have a family with a young person who has no place to go," he says. "There is such a lack of quality treatment. People suffer and young people are dying every day because we don't have high-quality addiction treatment. We have enough knowledge now that if we put the resources behind it, we could fashion a workforce and a treatment system that would do a much better job."