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To be treated, the disease of addiction must be contained. Traditionally, the way it was contained was by containing the individual who had the illness. Put him within 4 walls, contain him, and you contain the illness. There are a couple of problems with that.

The first is that it only works if the disease is limited to drugs and alcohol. There’s a lot the disease can use, even while in rehab, besides drugs and alcohol. So locking someone up away from drugs and alcohol actually doesn’t completely contain the illness. The second problem is that it’s pretty expensive to keep someone closed up in rehab. Fortunately, the solution to the first problem points the way to solve the second.

People running residential rehabs noticed how the disease could use other things besides drugs and alcohol. The first one they noticed was sex. Since their model of containment was one of separation and physical containment, some solved this problem by limiting admissions to one gender or keeping the genders separate during treatment. That solves one problem, but it’s not the only way the disease can use sex. And even if you could stop the disease from using sex, there’s always food.

So some rehabs reacted to the disease using food and overeating with the same methods of containment. They had set diets, restricted meal times, limited snacks. But here, mostly because of how difficult it is to contain someone’s eating even in rehab, there was a glimmer of a solution. Some rehabs decided to not focus on containing the disease physically but rather knowingly. The illness of addiction lives in the shadows. If it’s in the light, it has a hard time thriving. So knowing what someone is eating and discussing it with them without shaming them works to contain the illness from using that behavior. So if knowing works, why not use it with drugs and alcohol? That’s in large part what makes outpatient treatment successful.

When I first started treating addiction I didn’t think drug testing was so useful, but I’ve come to see that it is a cornerstone of any outpatient treatment. However, given its importance, we still aren’t doing it right.

A friend of mine, Kevin McCauley, once joked about trying to know what was going on with this illness using random urine drug testing. He said, “Can you imagine having a heart attack and them coming to talk to you in the ICU and explaining their random EKG policy?” His point is that the patient is ill every day, the disease needs to be contained every day, we need to know the status of the patient every day.

And here we run into a problem, cost. It costs about $5 a cup to screen a patient for a regular panel of drugs commonly used in outpatient treatment programs and about $5 a test for the equivalent to measure saliva alcohol. However that panel doesn’t include some very important drugs: Soma, the “z drugs,” the synthetic cannabinoids, and others. Also, it can’t tell you that the patient drank the day before but had no alcohol right before the test. These require more advanced testing that has to go to a lab. On top of that, the cups aren’t that reliable and should be confirmed with more specific laboratory testing anyway. That total testing comes out to something more like $250-$300 a panel. This still doesn’t approach the cost of inpatient treatment, but it’s more expensive than we like in outpatient treatment.

What we need is a lab on a bracelet, like they have for alcohol. We need something a patient can wear that monitors their sweat and sends a signal to the treatment center anytime it detects anything that’s useful to the disease. In addition, while we’re at it, we may as well get the bracelet to monitor levels of things like THC and methadone that are falling slowly in treatment so we can be sure the patient hasn’t restarted using them. Maybe Dr Who has something like that; I don’t.

So in the meantime, those of us who treat addiction in an outpatient setting have to do what we can to know what the disease is up to. Drug testing, alcohol testing, asking about sex and food and spending smoking are not ways to “catch” the addict; they are ways to see the disease. We have to make sure we and the patient look at all of these and more without shame and see the illness for what it is. Then and only then can the disease of addiction be contained.

© Howard C Wetsman MD FASAM

I read an article on CNN’s website called “Where Alcoholics Can Drink Themselves to Death” about a “wet house” in Minnesota. Alcoholics are allowed to live there and drink, but their drinking is restricted to certain areas of the house. The people who run the program, like program manager Bill Hockenberger sees the house as a harm reduction model instead of treatment. While the staff would love the residents to get sober, there doesn’t seem to be any active treatment of the illness.

Meanwhile, the public advocacy executive director for Hazelden, William Cope Moyers, was quoted in the article as saying, “We feel that that it’s never too late, and that even if the alcoholic doesn’t want help, doesn’t mean that their drinking should be condoned or in any other way enabled or facilitated…I see the wet house model as a model that enables the addict in the alcoholic to continue those destructive patterns.”

So we’ve got two poles. One group will let them drink as long as they stay off the streets and don’t hurt themselves or others and the traditional treatment provider demands they stop drinking and take the treatment offered. There’s a line in Alcoholics Anonymous that is apropos, “Do you have a sufficient substitute?” Obviously, not for these guys.

They’d all tried traditional treatment and ended up in a wet house. Because the people that run the wet house believe the people who run treatment programs, they think they have nothing to offer except harm reduction. But the wonderful thing about addiction treatment is that addiction is a disease, and treatment works. You just have to give the treatment. The wet house seemed to have doctors and nurses for care of sequelae of alcoholism but no addiction medicine treatment for the underlying illness.

It’s a shame that between a place like Hazelden, which is on record as being generally against agonist substitution treatment, and a wet house there’s no middle ground. Since only a small percentage of people with addiction can just stop and wait to feel better and only a small percentage of people are actually hopeless to the point where no treatment will work, most addicts live in the middle. Those of us who treat addiction should meet them there.

© Howard C Wetsman MD FASAM