For many years, I have treated individuals with substance use disorders. I have found this work to be both gratifying and frustrating. Part of the frustration stems from interactions with governmental agencies and families.
The families are, of course, fearful and frustrated. They are watching their loved ones “die” before their eyes and want someone to fix it. It is difficult to understand that their loved one’s brain has changed, that we do know that this is a chronic relapsing disease, and many individuals die from their illness. We also know that treatments are not equally effective. One size does not fit all in substance use treatment, and developing an effective treatment is a challenge. Some individuals benefit from 12-step programs. Others require medication. Some require inpatient treatment, while others do well in the outpatient setting. Often the treatment plan changes during the course of the individual’s life.
I have had multiple calls and interactions with families, administrators, and governmental agencies over the years. The vast majority have been negative in quality. I listen but can say little. Therefore, in response, I wrote this little blurb entitled, “Please don’t yell at me.”
To the families: Please do not yell at me. Please do not accuse me of not caring if your child lives or dies. I wake up every morning facing a challenge that most refuse to face. I must provide services to individuals who are unlikely to benefit from these services, or even show any gratitude for these services. I do so because I care about your family member.
Even though I know that chances are they will fail in the treatment, I remain hopeful that maybe someone will do well. I am hopeful that someone will take advantage of the treatment and use it in a positive way. When you accuse me of not caring it hurts. I cannot defend myself against your accusations. I also cannot tell you the things that I know. I cannot tell you that your son smuggled drugs onto the unit, or that your daughter is trading sex for methadone.
I cannot tell you that they have told me that they are only here so that they can avoid their court date. I cannot tell you much of anything. I cannot tell you that they refuse treatment nor that they left against medical advice. I must quietly stand there and listen without answering.
To the government officials that tell me I am not doing enough: Put your money where your mouth is. It is easy to point fingers and tell others what they need to do, but has anybody thought that I need the money to provide the service?
There is always a cost to providing quality care. These governmental agencies also prohibit me from calling family or other caretakers without the express consent of the affected individual. While privacy is important, we often need the support of others in order to assist in recovery. This is different from other illnesses, which focus on communication with supporters in the community. It treats the disease of addiction as different from other diseases and allows for individuals to self-destruct while I watch helplessly. I am tired of treatments that are reported to be “evidenced based”, but do not have any evidence of efficacy.
To the taxpayer: We are not spending “a lot of money.” We are barely spending enough for minimal services. We have no problem paying 100s of thousands of dollars to treat end stage disease, but the $500 a day for an inpatient bed is too much. We spend money on dialysis, and do so for many years, while we fail to recognize that addiction is a chronic, relapsing illness for which there is no cure, just control. We will pay for the diabetic to receive medications but not for the addict. By negating the medical validity of the disorder, we create a system of inadequate care. Someone does end up paying for this care. That someone tends to be the taxpayer. It is time to accept that the cost of care is cheaper to society than the cost of the untreated disease.
A rational approach to substance use disorders is required. The firstly, we need to fully embrace the disease model. This will allow us to focus resources based on well-documented research into models of care that are effective. This allows for the creation of effective treatment plans that serve a variety of individuals. Treatment centers should have meaningful statistics concerning outcomes and quality measures. Individuals who enter treatment need to be engaged in individual work, but also family systems work. The disease of addiction is a family illness and it is good practice to ensure that they are involved. Privacy rules should follow federal standards for all other illnesses. Individuals who have a “need to know” about the patient’s problems should be informed. This communication ensures that other providers are part of the chronic plan of treatment.
Finally, we need to see the problem as a chronic one. We may be able to bring about a meaningful and sustained remission but the affected individuals must always be aware of the potential of relapse.
Constantine Ioannou is a psychiatrist.
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