Last weekend I attended the 2nd annual David E. Smith symposium on addiction medicine in San Francisco. It was a treatment star-studded event, featuring doctors mostly, plus a few therapists, addiction treatment advocates of various kinds, all congregating (and I sort of mean congregating) to celebrate Dr. Smith, who founded the Haight Ashbury clinics in the sixties, and to reflect upon trends in the addiction treatment industry, many political in nature, and dominantly extolling the disease concept while ignoring anything to do with harm reduction. From Dr. David Mee-Lee, there was an overview of addiction medicine placement criteria: a system designed to help providers assess afflicted individual’s needs and therefore place would-be patients in appropriate levels of care: residential, intensive outpatient, day treatment, etc. There were overviews of the history of addiction treatment and the various models of care, both medical and not, which featured familiar chestnut complaints: the “discrimination” that addicts experience across the spectrum of services, thus adversely impacting treatment outcomes; the ability or even the desire of individuals to access services. I’d heard much of this rhetoric before, which is not to say that it’s incorrect. Doesn’t society realize that addiction is a disease? Would you turn away or impugn patients who presented with cancer, just because they were manifesting the symptoms of that disease: denial, compulsive behaviors(s). You get the idea.
On day two, much focus was given to a review of programs specifically aimed at physicians and nurses: meaning, programs specifically designed for medical professionals who present with substance use disorders (“abuse”, dependency, and the range of “axis II” disorders are no longer indicated by the latest version of the APA’s diagnostic standards manual). Dr. Gregory Skipper cited his and others’ studies of the last decade (roughly) which indicated through 5-year follow up measures that these programs are quite successful in terms of treatment outcomes and lasting abstinence from substances. The program standards, as well as the profile of patients, are notable: taut definitions of relapse that provide behavioral guidelines and compel abstinence; urinalysis testing to provide accountability; workplace “monitoring” to assure lack of substance use in the workplace (which many doctors/patients found oppressive, if follow up surveys are anything to go by); mandatory attendance at 12-step meetings; physician-specific support groups to discuss things like the evils of medical boards, the terror of losing licenses.
One presenter joked that doctors don’t make good patients in drug rehab. Well, actually they do if these studies are an accurate reflection of what’s happening in these programs. At the symposium, these studies and these physician-specific programs were held up as models for how services might be aimed at the general population. They also serve as a rebuke to skeptics who claim that drug treatment does not work. As I listened to later case presentations, including a fascinating, psychoanalytically-influenced treatment of an adolescent in residential care, I wondered about the application potential of the physician-specific model. Adolescents, for example, have less power in society than adults, much less physicians. Dr. Michael Wachter and a therapist colleague of his spoke of a privileged and “pseudomature” teen whose parents seemed to have abrogated caretaking responsibilities, “empowering” their son with the rights of an adult versus placing age-appropriate limits. Treatment presented a childlike regression, but a reality-check in another sense—a watershed moment that disoriented the parents and teen, but which enabled subsequent growth. The rigor of treatment grounded the family in reality: “This is a 16 year old meth addict,” the therapist kept saying. Still, I asked Wachter if anyone thinks that what works for doctors might work for everyone else: can you imagine installing program elements akin to “workplace” monitoring for teens? What would that look like? Or, can you picture a homogenous interest or vocation-based support group for a population yet to decide upon its future—yet to feel what it has to lose?