Is Community-Based Substance Abuse Treatment More Effective Than Individual?

By Jordan Rosenfeld 06/12/16

Current treatment models are based on “therapeutic punishment, which is this idea that even though you have an illness, you are still morally responsible and can be punished for it.”

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Community-Based Addiction Treatment
Less anonymity and more emphasis on creating support networks.

In the United States, almost everyone knows someone with a substance abuse disorder. One in ten people over the age of 12 are classified with substance abuse or dependence, and opioid addiction is now being treated as an epidemic, forcing tighter federal regulations and a national conversation. Still, despite addiction being medically recognized as a chronic brain disease, persistent stigma plays into scattershot treatment that relies heavily upon an individual’s own initiative to get help, unlike other diseases like diabetes or cancer. Since addiction often thrives in isolation, the solution, then, might be to expand “community” models of treatment, integrating multiple resource prongs, from the behavioral to the medical, together, with less anonymity and more emphasis on creating support networks for individuals. 

Peg O’Connor, a professor of philosophy and self-proclaimed recovering alcoholic, teaches a course on philosophy and addiction at Gustavus Adolphus College in Minnesota. She feels that humans’ fundamentally social nature is often overlooked when considering how to treat addiction. “There has been enormous emphasis that it’s individuals who must recover and be willing, but how do we have a deep stake in someone regaining sobriety?” she tells The Fix.

While 12-step groups undoubtedly offer community in which like-minded people can find understanding and support, the issue of anonymity may inadvertently help keep some of the stigma of addiction in place. 

Jennifer Murphy, an associate professor of criminal justice at Penn State Berks, took an in-depth look at how substance use disorders are treated on both the treatment side of addiction and the criminal justice side, while researching her book Illness or Deviance. In both cases, she found what she calls “therapeutic punishment, which is this idea that even though you have an illness, you are still morally responsible and can be punished for it,” she says.

Besides, getting people off of their substances is only one piece of the larger puzzle. Murphy says many people need a lot more than just detoxification, such as “other kinds of skills, and training, and education. That could be integrated into treatment. I think people want just to be able to find a job, and maybe need better skills in being able to do that like searching the Internet, or putting a resume together.”

She feels that there’s a lack of integration of necessary treatment programs and that addiction treatment may work better if integrated into hospitals. “Most drug treatment places are off on their own, and it’s ghettoized as not real medical treatment,” she says. “I think that creates part of the stigma.” It would be better, she feels, “to actually have more doctors involved” and “really take a medical approach to dealing with it.”

New solutions are cropping up for people who don’t want or can't get to in-person 12-step groups. Alongside in-person options, the Eagle Advancement Institute offers online groups, designated as “tele-health”, which are led by a psychologist so they can be billed to insurance companies. After patients have had medical treatment to safely detox them from any substances, they can choose the online option. Director Jim Carpenter tells The Fix, “We found that the [online] participation rate is much greater [than in-person groups]. It’s getting people re-interested in life, re-entrenched and communicating with their peers.” Once they’ve become acclimated to the online group, they are encouraged to attend in-person groups and reach out to other support networks. Carpenter hopes that utilizing technology and the privacy of an individual’s home can help remove feelings of stigma at the individual level, though he would like to see a larger movement to normalize addiction disorders. “If somebody gets cancer because they smoked, they don’t yell at them or refuse medical treatment.” 

Standardizing Addiction Treatment

Though there are plenty of medical detoxification programs in the United States, there is still no unified standard of evidence-based best practices for treating addiction. To remedy this huge gap in care, Cigna, a health insurance company, and the American Society of Addiction Medicine (ASAM) are launching an initiative “with the goal of improving treatment for people suffering from substance use disorders across the United States,” according to a press release. They are collaborating with the Department of Veterans Affairs to “test and validate performance measures using their data,” says Dr. Corey Waller, Chair of ASAM’s Performance Measures Expert Panel and Legislative Advocacy Committee. He states that increasing morbidity rates from substance over-use and abuse has driven this move. “Now that the U.S. has hit crisis level, we’re actually making changes.” 

Waller feels that having a standardized approach to addiction treatment will help reduce the stigma, and thus increase the forms and methods of treatment. He makes the case that type 2 diabetes is no different than addiction, to prove his point. “You have the genetic predisposition and access to high glucose foods. You utilize those high glucose foods, it changes your glucose sensitivity to the point where your insulin no longer does the job and you require outside influence. And we don’t worry one bit about prescribing insulin or getting them a nutritional consult or having behavioral therapeutic interventions so we can change their habits.” He likens our view of addiction now to the way that HIV/AIDS was viewed in the '80s. “The stigma was bad, but we realized eventually that this was a viral infection, that everybody was at risk, developed medical treatments for it.” He feels the only way to evolve our attitudes about addiction is to “get it out of the shadows and treat it.”

To that end, Waller says that the confidentiality clause of AA and the other 12-step groups—while they are helpful and even necessary for the sobriety of those who participate—have posed barriers for gathering relevant medical data that could help create standards. “We can’t measure what’s helpful for people in AA because it’s anonymous by design. But now, with the development of performance measures, we can get enough data to improve the outcome of patients.”

AA and other support groups are often a key component of recovery but they are not medical treatment, which most people will need in the early stages of detoxifying from any substance, to avoid serious health risks. 

Recovery Capital

Substance use disorders also often require and benefit from behavioral therapy as well as medical treatment. O’Connor worries that some of the focus on the “neuroscience of addiction” could lead treatment away from the social benefits of connection and community. “I think there is a comfort in knowing that physiologically something is happening, but we are not just brains in a vat,” she says. “The brain is itself an environment, within an environment of the physical body, within the environment of a natural and social world. For me it’s about making available, taking advantage of whatever kinds of help or support that there may be out there…there isn’t just one path into addiction so there have to be multiple paths out of addiction.”

One such alternate path came out of a study led by Ann Cheney, PhD, an anthropologist and assistant professor at UC Riverside in the Department of Social Medicine and Population Health. She studied how addicts in underserved and minority communities recover without access to rehab centers or medical treatment. Cheney’s study focused on cocaine users in rural Arkansas, comprised primarily of African Americans living at the poverty level, where there were few to no addiction treatment programs. She was surprised to find that the individuals struggling with substance use still managed to maintain recovery without formal treatment “by leveraging resources we refer to as ‘recovery capital’—employment, education, faith community,” Cheney says. “They do this by obtaining support from non-drug using friends and family.” 

Marc Galanter, Deputy Director of the Division of Alcoholism and Drug Abuse at the NYU School of Medicine, also found that his patients’ recovery benefitted from a bulwark of close family and friends who supported the patient in between therapy or treatment. “These people could come in at intervals between when I saw the patient,” Galanter says. “The understanding was that if they had further trouble after they stopped seeing me, we could still summon up the network and help them out.”

“A lot of treatment models are typically individually focused,” Cheney says. “You go in, you’re there for a certain number of days and the focus is on you getting better rather than it being a normalized, in-community, engaged approach to helping the individual recover.”

The move toward standardized treatment in particular could begin to shift the scenario of substance abuse recovery away from lone individuals pulling themselves up by their virtual bootstraps and holding onto an uncertain state of recovery in secret, toward one in which the person’s immediate community—family, friends, doctors, and more—are all integrated into that support. A community-based model of recovery might provide outcomes that offer better quality of life and a greater chance of success in staying sober. 

“What would it be like if we tried to figure out ways to help people flourish, not just [stay sober/not overdose]?” says O’Connor. “That’s a different picture.” 

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