Addiction Treatment in America: Not Based in Science, Not Truly ‘Medical’

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Addiction is typically characterized as a disease by experts and government officials. Yet, unlike most known diseases, the treatment of addiction is not based on scientific evidence nor is it required to be provided by people with any medical education — let alone by actual physicians — according to a new report.

The 586-page tome, which was published by Columbia’s National Center on Addiction and Substance Abuse (CASA), is based on large surveys of treatment providers, people who suffer from addiction and those in the general public, as well as a review of more than 7,000 publications on addiction.

It finds that most addiction care is administered by “addiction counselors” for whom there are no national standards of practice. It finds also that 14 states don’t require any education or licensing at all for addiction counselors. The risks to those seeking treatment can be dire: California is one of the states that allows uncredentialed providers, for example. In a recent case in that state, a sexual predator was found to be offering “intimacy therapy” to addicted teenage girls; treatment consisted of sex with him. Without oversight, there’s no way to stop people from preying on vulnerable people under the guise of addiction care.

Only six states require addiction counselors to have a minimum of a bachelor’s degree; just one requires a master’s degree, according to the CASA report. The main qualification for treating addiction in this country is having suffered from the disorder oneself — a standard of care that would be considered absurd if any other medical condition were involved.

Moreover, addiction treatment providers are typically not held accountable for their patients’ outcomes: the report found that nearly half of all patients with illegal drug problems are referred to treatment by the criminal justice system and, of course, it is the patients, not the counselors or program directors, who go to prison if they fail.

(MORE: DSM 5 Could Mean 40% of College Students Are Alcoholics)

The new publication is not free of CASA’s tendency toward hyperbole, however. It overstates the breadth of the addiction-treatment problem in the U.S. by arguing that anyone who takes any illegal drug needs help. The report makes the exaggerated claim that 16% of the U.S. population suffers from addiction (this includes cigarette smokers) and that an additional 32% are engaged in “risky” substance use.

The report’s estimates do highlight some inherent problems in the definition of addiction, particularly in the proposed definition slated for the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the standard manual used to diagnose all mental disorders. The new DSM-5 definition, which collapses addiction under one diagnosis, instead of the current two, may well result in widespread overdiagnosis, opponents of the new definition say.

In the current DSM, addiction is described under two diagnoses: the short-term and less severe “substance abuse” (a classic case would be a college binge drinker who outgrows the behavior), and the chronic and more dangerous “substance dependence” (classic case: a full blown alcoholic). DSM-5 would define all alcohol and other drug problems as substance-use disorders, which would be further characterized as “mild” “moderate” or “severe.”

The DSM-5‘s definition of “severe” substance use disorder will replace what was formerly known as addiction or dependence. That means that anyone who uses a drug but will never have a chronic problem would be diagnosed as “mildly” addicted — a condition that most people would see as akin to being “mildly” pregnant.

(MORE: Do Family Dinners Really Reduce Teen Drug Use?)

The CASA report points out that even under the current diagnostic rules, the lack of professional training of most treatment providers means that severity is rarely assessed adequately. Most people are therefore slotted into one-size-fits-all programs, typically based on the 12 steps of Alcoholics Anonymous. Such programs advocate total abstinence, a tack that offers little help to the majority of people whose problems aren’t severe, since they need guidance on moderation.

The dominance of the 12-step approach also leads to a widespread opposition to change based on medical evidence, particularly the use of medications like methadone or buprenorphine to treat opioid addictions — maintenance treatments that data have shown to be most effective. Other medications that are known to treat alcohol and drug addiction, such as naltrexone (reVia, Vivitrol), are also underutilized, while philosophical opposition to the medicalization of care slows uptake.

To fix these problems, CASA recommends a more careful definition of addiction and substance-use problems (note to the center: start with your own), as well as the requirement that all treatment providers be licensed as health-care organizations. CASA calls for national standards for accreditation of such care and for all physicians to receive required education about substance-use disorders in medical school.

The report notes that only 10% of people with substance-use problems seek help for them: given its findings about the shortcomings of the treatment system, that’s hardly surprising.

Maia Szalavitz is a health writer at Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland’s Facebook page and on Twitter at @TIMEHealthland.