Addiction and Segregation

Tom McLellan (Who I have a lot of respect for.) has a provocative column about the categorical segregation of addiction treatment. He suggests that this plays an important role in the low numbers of people who identify their own substance use problems and seek help for it.

Imagine if we began to treat diabetes in a system such as we have designed for addiction. First, insurance would restrict treatment only to the “truly diabetic,” those who had lost toes or some of their vision. Prevention and early interventions so common in primary care would not be reimbursed and thus rarely practiced in such a system. Hence, most of those entering treatment would be very overweight, have multiple co-occurring physical and psychiatric problems and a guarded prognosis. Even effective treatment has limited effects on very severe cases.

These are typically not the kinds of patients that health care professionals aspire to treat. So very soon it would be considered more convenient for these unattractive, severely affected diabetic patients to have their own special building, perhaps near the edge of the property, down by the boiler plant. These are not the kinds of treatment settings that inspire career goals in young health care professionals. There would be little interest among faculty in teaching courses about this “special condition.” In turn, funding would also be segregated through “carved out” reimbursement plans designed for these “specialty” programs.

An important perceptual phenomenon would also take place concurrent with this segregation process. These very ill patients and the segregated, specialty treatment settings would come to define the illness of diabetes in the eyes of health care establishment and the public at large; and it would not be a favorable image. Individuals who were early in the course of diabetes would find it impossible to imagine that they had anything in common with those in treatment. This would foster denial and treatment refusal until they could literally no longer live without it.

The problem with this is that we do have specialized centers for other illnesses—cancer centers, heart and vascular centers, dialysis centers, geriatric centers, pediatric centers, etc.

Bill White commented on, what he referred to as “service integration mania”:

American history is replete with failed efforts to integrate the care of alcoholics and addicts into other helping systems. These failed experiments are followed by efforts to move such care into a categorically segregated system that, once achieved, is followed with renewed proposals for service integration. After fighting 40 years to be born as an autonomous field of service, addiction treatment is once again in the throes of service-integration mania. This cynical evolution in the organization of addiction treatment services seems to be part of two broader pendulum swings in the broader culture, between specialization and generalization and between centralization and decentralization. Once we have destroyed most of the categorically segregated addiction treatment institutions in America, a grassroots movement will likely arise again to recreate them. When the 21st century once again gives birth to specialized addiction treatment, perhaps this “new” institution will be given a colorful name fitted to its form and function – perhaps something like inebriate asylum.

Clearly, we need to build bridges between medical systems and specialty addiction care. I’m an advocate for linking primary care and addiction treatment. Also, medical settings may be able to respond to low severity drug and alcohol problems. However, I worry about attempts to absorb addiction care into other systems.

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