Yet Another Way to Misunderstand President Obama’s Record on Addiction Treatment

President Obama has done more to expand the quantity and quality of addiction treatment than any President in at least 40 years, but you wouldn’t know it from much of the coverage his drug policy receives. In the latest critique, Rebecca McCray and Emma Andersson praise the public health rhetoric of White House drug policy director Kerlikowske but are disappointed to find only a small increase in treatment funding in the President’s FY13 federal drug control budget. I applaud McCray and Andersson’s public health advocacy, but they are misunderstanding something quite important about how health care is financed relative to other components of drug policy.

Their analytic error is not as serious as those which have plagued similar criticisms of the President: John McWhorter condemned the lack of treatment funding in the Department of Education, which doesn’t fund healthcare, while Mike Riggs completely missed the significance of (indeed, didn’t even mention) the Affordable Care Act. Nonetheless, McCray and Andersson’s mistake is worth pointing out because it supports an inaccurate and unfair conclusion about the President’s drug treatment policy.

For most categories of spending in the federal drug control budget, government dollars are 100% of total expenditures. Only the federal government has Coast Guard cutters intercepting cocaine-filled powerboats in the Caribbean. Likewise, only the federal government provides the budget of the courts in which drug traffickers are tried and convicted. Therefore, if you want to know how much is being spent on these sorts of drug policies, all you have to do is tally up what the government is spending as does the federal drug control budget.

In contrast, billions of private dollars are spent on addiction treatment each year. Federal policies that increase the amount of those dollars, for example by mandating that insurers cover addiction treatment, don’t show up in the federal drug budget. Indeed, a pro-treatment federal government policy could even reduce treatment expenditures in the federal drug control budget if the policy enabled addicted people to access privately funded care instead of publicly funded care.

For example, one of the reasons those of us who worked on the substance use disorder-related provisions of the Affordable Care Act are pleased with the legislation is that it allows parents to keep children on the family health insurance policy until the age of 26. Because the early 20s are high-risk years for the incidence of addiction, the ACA thus expands drug treatment coverage to a high-need population. How much of the spending on treatment received by young adults because of this new federal policy shows up in the federal drug control budget? None of it, because it’s private money. The President’s policy drives the increase in private sector spending but that’s irrelevant in the calculation of the federal drug control budget, which only reports public expenditures.

As the ACA is phased in, its provisions will drive much more private money into addiction treatment provision. That’s because the legislation requires the privately financed policies offered in the state health exchanges to fully cover addiction treatment at parity with treatment for other conditions.

To quote the mandarin Harold Pollack, whom everyone who writes one of these misleading articles about the President’s drug treatment policy ought to consult before going to press: Wonderfully, the Obama administration has quietly revolutionized financing of addiction services. This change is readily overlooked because it occurs outside the $15.5 billion “National Drug Control Budget”.

Drinkers Decide What Constitutes Unhealthy Drinking

Andrew Sullivan is concerned that the new DSM-V psychiatric classification system will define the 40% of college students who sometimes binge drink as alcoholic. He links to an angry critique by Russell Blackford, who sees the potential over-extension of the alcoholic label as misguided and oppressive.

As I outlined a few days ago, and Dr. Deni Carise elaborates on today at Huffington Post, the alarming 40% figure that keeps being quoted is misleading. If criteria were broadened, the purpose would be specifically to identify problem drinkers who are not what is commonly understood as alcoholic. Continue reading “Drinkers Decide What Constitutes Unhealthy Drinking”

The Rise and Fall of a “Miracle Cure” for Drug Addiction

Dr. Walter Ling, one of the world’s most respected addiction treatment researchers, has completed the first long-term placebo-controlled trial of PROMETA. This alleged miracle cure for methamphetamine addiction proved completely ineffective. I have a short commentary in the journal Addiction (pdf here) describing the rise and fall of this heavily-promoted treatment protocol.

60 Minutes did some investigative reporting on PROMETA a few years back, noting that the treatment protocol was never FDA-approved and that a suspicious number of its advocates were discovered to have a financial stake in the product. The whole story is worth watching as a cautionary tale:

As someone who has worked with addicted patients, I am struck by the moment when journalist Scott Pelley asks the creator of PROMETA (a former junk bond salesman named Terren Peizer) about the need for evidence before an addiction treatment is marketed. Peizer responds as follows:

If you had a son. If you had a son or a daughter, and maybe you do. If he’s strung out on meth. And he’s going to kill himself. Would you, if you had the opportunity. And I said to you, will you treat your son with Prometa?…Would you take that option for your son?”

The answer to this question is yes for many people, but this undermines rather than supports Peizer’s contention that it’s wrong to wait for evidence. Rather, it is *because* people are so desperate for a cure to addiction that we have a responsibility to rigorously research putative cures before they are marketed to the public. Otherwise, vulnerable, frightened people may spend thousands of dollars on ineffective treatments instead of pursuing other options that have a greater chance of restoring them to health.