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Members of the TSF group were encouraged to attend AA meetings, find a sponsor, and work through the first five steps. Patients in the CBT group were taught skills to avoid relapse, including drink-refusal techniques and ways to manage negative moods. MET therapists used motivational psychology to encourage individuals to consider the effect of alcohol on their lives and to develop and execute a plan to stop drinking. Individuals in the TSF and CBT groups met with their therapists once a week for twelve weeks. MET consisted of four sessions over twelve weeks.20
In 1996, the NIAAA announced a surprising result: matching did not work; the patients fared the same in all three groups. But Project MATCH also showed that all three treatments had been effective. One year after the study, half of the subjects reported they were no longer drinking heavily, and the number of days they were drinking each month had declined from twenty-five to six. These results provided important validation of the effectiveness of alcoholism treatment at a moment when it was under heavy attack from Herbert Fingarette and others. They had argued that in its heavy dependence on AA’s twelve steps, the treatment industry was perpetrating a fraud. Project MATCH provided the first scientifically valid evidence of the effectiveness of the Minnesota model. In addition, it was certainly good news that the other approaches were effective since this strengthened the argument that alcoholism was a treatable illness. Even the critics of the Minnesota model could take some satisfaction in the results, since they had argued that other treatments were more cost effective than twenty-eight-day inpatient rehabilitation.
The argument for the effectiveness of treatment was strengthened by the development of a new paradigm for understanding addiction. The advocates of this view acknowledged that alcoholism and drug addiction were not like most diseases, because drinking and drug taking were voluntary in the beginning. Yet there were other diseases that closely resembled addiction, including type 2 diabetes, hypertension, and asthma.
In a 1996 article in the Lancet, Charles P. O’Brien and A. Thomas McLellan observed that these are “conditions that show a similar confluence of genetic, biological, behavioral and environmental factors.” All three were regarded by the medical profession as “chronic” disorders because there was no expectation of a cure. They were also treated successfully as long as patients followed a strict diet and proper exercise regimen. But patients often failed to follow a doctor’s orders and experienced a recurrence of their symptoms. O’Brien and McLellan argued that there were also effective treatments for alcoholism and drug addiction and that their rate of relapse was actually lower than some other chronic diseases. “Is it not time that we judged the ‘worth’ of treatments for chronic addiction with the same standards that we use for treatments of other chronic diseases?” they asked.21
Four years later, McLellan and O’Brien renewed their plea in an article in the Journal of the American Medical Association. Physicians continued to see addiction as a social problem instead of a health issue, they said. Few medical schools required their students to take an adequate course on the subject, and most doctors were not asking about alcohol or drug use during routine exams. A survey of general practitioners and nurses found that a majority were unaware of effective medical treatments for addiction.
McLellan and O’Brien acknowledged that the rate of relapse one year after alcohol or drug treatment was high—between 40 and 60 percent. But they reiterated the fact that the relapse rates for patients with diabetes, hypertension, and asthma were also high, and this did not mean that the treatments were ineffective. In this article, they also went into great detail on some of the proven methods of treating opioid and alcohol addiction. The relapse rate for addictions would decline when alcohol and drug dependence were treated properly. “It is essential that practitioners adapt the care and medical monitoring strategies currently used in the treatment of other chronic illnesses to the treatment of drug dependence,” they concluded.22
There was already an outstanding example of a program that was executing the policies they were describing. In the 1970s, state medical boards began to respond to rising concern over addiction in the medical profession by creating physician health programs (PHP). The PHPs investigated reports of impaired doctors and then gave them a choice—accept treatment or lose your license to practice medicine. Unlike many employee assistance programs, however, the PHPs retained the commitment to rehabilitation that had inspired the sober drunks who started the first industrial alcoholism programs. Physicians who were in recovery played a key role in the program, counseling the newcomers during treatment and then helping them connect with other recovering doctors and twelve-step programs on their release. What made the PHP programs unique, however, was the fact that they played an active role in the lives of their patients for five years and sometimes more. They conducted periodic interviews and random drug tests. When doctors relapsed, they reevaluated them, deciding whether to require more treatment or to recommend disciplinary action. License revocation was relatively rare. While 25 percent suffered a relapse, many of them got sober again. PHPs reported success rates between 70 and 96 percent.
William L. White was enthusiastic about the success of the PHPs. In 2008, he sensed “an historical opportunity.” He joined McLellan in publishing an article that urged “re-engineering addiction treatment into a system of sustained recovery support.” White believed that the philosophy of addiction treatment was returning to its roots. While the members of the American Association for the Cure of Inebriety considered alcoholism a disease, they had also recognized that it was a complex disorder that resembled other chronic illnesses in its most extreme form. But this understanding disappeared with the AACI. “The emphasis on alcoholism as a chronic disease was lost in the larger battle to convey to the American public and policy makers that alcoholism was a disease,” White and McLellan wrote. Although the idea of alcoholism as chronic illness had been reborn, it had yet to change much:
While many in our field have come to consider some (not all) forms of addiction as chronic—this change in thinking has not been followed by changes in treatment strategy, monitoring methods, insurance coverage or outcome expectations.
The purpose of the article was to outline the wide-ranging changes that had to be made.23
White and McLellan began their task by attempting to clear away the wreckage of decades of debate over the nature of alcoholism. They wrote:
Our focus in this article is not on what addiction is—a disease, illness, disorder, habit, problem, etc.—but on the temporal course of addiction and how the span of the disorder from onset through sustained recovery can be most effectively managed at personal and professional level.
The first step was to make clear that not all alcohol or drug (AOD) problems were chronic. “[M]ost do NOT have a prolonged and progressive course,” they wrote. “All persons with AOD problems do NOT need specialized, professional, long-term monitoring and support—many recover on their own, with family or peer support.” But the line between problem drinking and alcoholism was hard to decipher in the early years of a drinking career. White and McLellan called for research to identify early signs of progression.24
They also sought to reassure alcoholics, drug addicts, and their families. “Among those who do need treatment, relapse is NOT inevitable, and all persons suffering from substance dependence do NOT require multiple treatments before they achieve stable, long-lasting recoveries,” they wrote. Even in the most difficult cases, partial recoveries were possible:
Recovery management strategies for persons with the most severe and persistent disorders include multiple goals: reducing the number, intensity, and duration of relapse episodes; strengthening and extending the length of remission periods; reducing the personal and social costs associated with relapse; reducing the propensity for drug substitution and other excessive behaviors during early periods of recovery initiation; and enhancing the quality of personal/family life through both the remission and relapse phases of the disorder.
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nbsp; Abstinence remained the goal of treatment, but under the chronic care model, it was no longer the sole measure of success.25
White and McLellan pointed to a 2006 study that concluded that the recovery rate from alcoholism was almost 50 percent. Only 18 percent of those in recovery were abstinent. The rest were still drinking but had not reported symptoms of abuse or dependence during the previous twelve months. Many had no desire to quit drinking and might have succeeded in their goal of moderating their drinking. But others continued to try to achieve abstinence. The promise of the chronic disease model was that it would develop strategies to identify all these people and help them achieve their goals. “We invite those on the frontlines of addiction treatment to join us in writing this new future for addiction recovery in America,” they wrote.26
As professionals reimagined addiction treatment, an advocacy movement was organizing to press for its realization. The spirit that had animated recovering alcoholics in the 1950s and 1960s to staff hospital wards, open chapters of the National Council on Alcoholism, and lobby for the Hughes bill faded after 1970. One exception was a sober drunk named Paul Molloy who joined with other occupants of a county-run halfway house in Silver Springs, Maryland, in taking over the lease in 1975. Molloy later launched Oxford House, which began renting homes for alcoholics and addicts who were trying to stay sober. But activism was declining. Harold Hughes attempted to reinvigorate it by organizing a Society for Americans in Recovery in 1991, but the organization closed several years later.
It was only in 1996 that veteran activists began to notice new local groups organizing around issues like the need for detox services for indigent patients or a decision to reduce the number of beds in a treatment facility. “We came from the grassroots,” one activist said. In Santa Barbara, California, one group gathered a large number of supporters at a board of supervisors meeting. “They asked all those in recovery to stand, and the whole room stood up. . . . They invited us to the table in a strategic planning process,” an organizer reported.27
The federal government attempted to encourage these new groups. In 1998, the Center for Substance Abuse Treatment, a division of the Substance Abuse and Mental Health Services Administration (SAMHSA), issued grants to nineteen community groups to assist them in organizing people in recovery to advocate for improved addiction treatment. At the same time, the Johnson Institute Foundation, which was formed to promote the early-intervention strategy of Vernon Johnson, was funding regular meetings of leaders in the addiction field.
Recognizing the potential of the community groups, organizers began to outline a plan for a public awareness campaign that would be launched at a summit meeting in St. Paul, Minnesota, in October 2001. The first step was to identify participants who represented every aspect of “the national recovery community.”
Organizers sent a questionnaire to representatives of sixty-six groups actively promoting recovery at the local level and individuals who had recovered from alcohol or drug addiction. Whenever possible, a balance was sought based on geography and cultural diversity. There was also an attempt to ensure that different methods of recovery were represented by including people from secular, twelve-step, and religious groups. A special effort was made to include those who had recovered with the assistance of medicine like methadone.
Six hundred questionnaires were distributed, and two hundred people who responded were chosen to attend, including some family members of alcoholics and addicts and representatives of recovery organizations, many of whom were also in recovery.
The Faces & Voices of Recovery Summit had two major goals. The first was to get people in recovery to identify themselves publicly. The news media were full of stories about addicted people, but almost all were active alcoholics or addicts. The few who were sober or clean were generally early in their recoveries, including celebrities who were still cycling in and out of rehabs. The public needed to see that alcoholics and addicts were living full and satisfying lives; engaged in demanding, important careers; raising children; and contributing to their communities. There were millions of potential role models. But few people were speaking up, in part because there was a widespread belief that it violated AA and NA traditions of anonymity. One of the first speakers confronted this issue directly on the opening night of the St. Paul summit. “By our silence, we let others define who we are,” she said.28
The other objective was to plan an advocacy campaign to seek changes in laws and government policies that would enhance the prospects for recovery. Summit participants were polled to identify the most important issues, and there was strong support for a campaign to end discrimination against people in recovery. At the time of the summit, one of the most pressing issues was the failure of insurance companies to provide adequate coverage for behavioral illnesses, including alcohol and drug addiction.
Legislation had been introduced in Congress and state legislatures to force the companies to provide equal treatment of mental and physical illness. But the insurance companies were lobbying hard against the parity bills. In California, they had succeeded in getting the legislature to drop addiction treatment, although recovery groups there were fighting hard to restore it. Other goals included ending job discrimination against people who had been in treatment and allowing people who had been convicted of drug offenses to gain access to government welfare and education programs that would help them make a new start.
While these were ambitious goals, a national poll conducted by the organizers showed that there was strong support for them among people in recovery. A random survey of drunks and addicts in recovery revealed that 87 percent agreed that it was important for the American people to understand the basic facts of addiction and recovery. More surprisingly, half said they were willing to talk about their experience publicly.
The 2001 summit put the recovery movement on a new footing. Faces & Voices of Recovery, which began as a publicity campaign, was incorporated in 2004, making it the national voice of the recovery community organizations (RCO). The summit also encouraged the creation of new groups, which proliferated rapidly. By 2016, there were one hundred local, regional, and state RCOs
Some of the RCOs operated community centers that helped people in recovery find services and advice. There were twenty-five recovery community centers in New England in 2012, including three centers operated by the Connecticut Community for Addiction Recovery (CCAR). In 2013, the CCAR centers recorded fifty-nine thousand visits and hosted eleven hundred events, including support meetings, GED classes, and computer classes. CCAR also sponsored a hot line that received more than fourteen hundred calls that year from people who were in danger of relapsing.
In addition, the RCOs were seeking to reverse the sharp decline in the number of people in recovery who were working in the addiction field. CCAR trained seventeen hundred “recovery coaches” in 2013 and established a Recovery Technical Assistance Group to help other RCOs establish coaching programs.
The birth of an organized movement of former drunks and addicts played an important role in expanding government support of recovery. When Senator Paul Wellstone addressed the Faces & Voices of Recovery Summit in 2001, he said there was no chance of passing his insurance parity bill if it contained addiction treatment. But, by 2008, people in recovery were making themselves heard. Wellstone had died in an airplane crash, but by the time his bill came up for a final vote in 2008, it included coverage for addiction treatment. When the Mental Health Parity and Addiction Equity Act was sitting in committee in the House of Representatives, recovery groups generated ten thousand calls to Speaker Nancy Pelosi to help move it to the floor, where it passed.
An even more important victory followed two years later with the enactment of the Patient Protection and Affordable Care Act. The centerpiece of President Barack Obama’s legislative agenda, the Affordable Care Act (ACA), expanded health-insurance coverage for millions of Americans. It had great significance for alcoholics and addicts because it defined addiction treatment as an
“essential” health service and required insurance companies to provide it to all their customers. The law prohibited insurance companies from denying coverage to people with preexisting conditions, making it possible for people in recovery to seek further medical help if they relapse. The ACA also encouraged the states to extend Medicaid to make it possible for poor people, who are disproportionately affected by addiction, to receive treatment for the first time.
The Obama administration went even further in its effort to help alcoholics and addicts. Although the Clinton and Bush administrations had launched several helpful programs, the Obama administration was the first to officially embrace recovery as a cornerstone of US drug policy. The first signal of a dramatic change in policy came soon after the new president took office in 2009. The White House Office of National Drug Control Policy (ONDCP) had been established by the Reagan administration to lead the war on drugs. The leader of the ONDCP was known to the nation as the “drug czar” and had usually been a man with military or law enforcement background. After Obama was elected, a new office was added to the ONDCP and charged with encouraging recovery. Leaders of the recovery movement were invited to consult with White House officials, and recovery was announced as one of the four principles of a new national drug control strategy.
The administration also began to add recovery leaders to the ONDCP. McLellan, whose articles comparing addiction to other chronic diseases had been highly influential in the recovery movement, was hired as deputy director in 2012. He was succeeded two years later by Michael Botticelli, who had directed the Massachusetts Bureau of Substance Abuse Services. Botticelli was also an alcoholic who had quit drinking in 1988 following his arrest for drunk driving. In 2015, he succeeded his boss, becoming the new drug czar.