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