cqr treating addiction · 388 cq researcher me ntal health and substance abuse treat - ment as for...

Treating AddictionIs medication the best way to treat drug abuse?

An estimated 22 million Americans are dependent on

or abusing drugs or alcohol, at huge costs to society.

Deaths from overdoses due to heroin and other

opioids, including the prescription painkillers

OxyContin and Vicodin, are on the rise, with many parts of the

country fighting what U.S. Attorney General Eric Holder has called

a public health crisis. But the way to stem the crisis isn’t clear.

Scientists and clinicians differ over what causes addiction, with

some calling it a genetic disease and others contending that its

roots are psychological or psychosocial. And with differences over

the causes come disagreements over the way to treat addiction.

The controversial medication buprenorphine is being prescribed to

opiate addicts in a bid to reduce the number of deaths. But some

clinicians believe the 12-step program pioneered by Alcoholics

Anonymous, coupled with psychotherapy, still represents the best

chance for recovery.

The number of Americans dependent on or abusingheroin more than doubled from 2002 to 2012, to467,000 people. With deaths from heroin and

prescription painkillers on the rise, Attorney GeneralEric Holder says many communities face a publichealth crisis. Treatment professionals differ over what causes addiction and how best to treat it.

CQ Researcher • May 2, 2014 • www.cqresearcher.comVolume 24, Number 17 • Pages 385-408

RECIPIENT OF SOCIETY OF PROFESSIONAL JOURNALISTS AWARD FOR

EXCELLENCE � AMERICAN BAR ASSOCIATION SILVER GAVEL AWARD

I

N

S

I

D

E

THE ISSUES ....................387

BACKGROUND ................393

CHRONOLOGY ................395

CURRENT SITUATION ........399

AT ISSUE........................401

OUTLOOK ......................403

BIBLIOGRAPHY ................406

THE NEXT STEP ..............407

THISREPORT

Published by CQ Press, an Imprint of SAGE Publications, Inc. www.cqresearcher.com

386 CQ Researcher

THE ISSUES

387 • Is addiction a biologicaldisease?• Are AA’s 12 steps effectivein helping to beat addiction?• Is access to treatmentavailable for all who need it?

BACKGROUND

393 Ancient AddictsThroughout history, peoplehave struggled with addiction.

394 Minnesota ModelRecovery based on 12-stepself-help groups has beenthe standard for decades.

397 Medicating AddictsPrescriptions to help addictsgain popularity, spur debate.

CURRENT SITUATION

399 Parity ActNew laws, regulations coveraddiction treatments.

400 Sentencing ChangesObama administration pushesfor less prison time for drugoffenders.

402 Buprenorphine AccessTo control costs, some statesare restricting access to apopular medical treatment.

OUTLOOK

403 Vaccines, GeneticsScientists continue to searchfor ways to help addicts.

SIDEBARS AND GRAPHICS

388 Americans Favor Treatmentfor AbusersNearly 70 percent tell pollstersthey prefer treatment overprosecution.

389 Death Tolls from OverdosesRisePrescription pain drugs killmore users than heroin orcocaine.

392 Number of AmericansUsing Heroin RisesHeroin use grew by 66 per-cent between 2002 and 2012.

395 ChronologyKey events since 1920.

396 States Struggle withSpread of HeroinHeroin use has spread torural areas.

398 The “Anonymous People”Speak OutIn a new documentary, peo-ple in recovery discuss theiraddiction.

401 At Issue:Should medication be usedto treat addiction?

FOR FURTHER RESEARCH

405 For More InformationOrganizations to contact.

406 BibliographySelected sources used.

407 The Next StepAdditional articles.

407 Citing CQ ResearcherSample bibliography formats.

TREATING ADDICTION

Cover: Getty Images/Universal Images Group

MANAGING EDITOR: Thomas J. [email protected]

ASSISTANT MANAGING EDITORS: Maryann Haggerty, [email protected],

Kathy Koch, [email protected]

SENIOR CONTRIBUTING EDITOR:Thomas J. Colin

[email protected]

CONTRIBUTING WRITERS: Brian Beary, Marcia Clemmitt, Sarah Glazer, Kenneth Jost,

Reed Karaim, Peter Katel, Robert Kiener, Barbara Mantel, Tom Price, Jennifer Weeks

SENIOR PROJECT EDITOR: Olu B. Davis

EDITORIAL ASSISTANT: Ethan McLeod

FACT CHECKERS: Eva P. Dasher, Michelle Harris, Nancie Majkowski

INTERN: Kaya Yurieff

An Imprint of SAGE Publications, Inc.

VICE PRESIDENT AND EDITORIAL DIRECTOR,HIGHER EDUCATION GROUP:

Michele Sordi

EXECUTIVE DIRECTOR, ONLINE LIBRARY AND REFERENCE PUBLISHING:

Todd Baldwin

Copyright © 2014 CQ Press, an Imprint of SAGE Pub-

lications, Inc. SAGE reserves all copyright and other

rights herein, unless pre vi ous ly spec i fied in writing.

No part of this publication may be reproduced

electronically or otherwise, without prior written

permission. Un au tho rized re pro duc tion or trans mis -

sion of SAGE copy right ed material is a violation of

federal law car ry ing civil fines of up to $100,000.

CQ Press is a registered trademark of Congressional

Quarterly Inc.

CQ Researcher (ISSN 1056-2036) is printed on acid-

free paper. Pub lished weekly, except: (March wk. 4)

(May wk. 4) (July wk. 1) (Aug. wks. 3, 4) (Nov. wk.

4) and (Dec. wks. 3, 4). Published by SAGE Publica-

tions, Inc., 2455 Teller Rd., Thousand Oaks, CA 91320.

Annual full-service subscriptions start at $1,054. For

pricing, call 1-800-818-7243. To purchase a CQ Re-

searcher report in print or electronic format (PDF),

visit www.cqpress.com or call 866-427-7737. Single

reports start at $15. Bulk purchase discounts and

electronic-rights licensing are also available. Periodicals

postage paid at Thousand Oaks, California, and at

additional mailing offices. POST MAS TER: Send ad dress

chang es to CQ Re search er, 2300 N St., N.W., Suite 800,

Wash ing ton, DC 20037.

May 2, 2014Volume 24, Number 17

May 2, 2014 387www.cqresearcher.com

Treating Addiction

THE ISSUEST he sad news about

Philip Seymour Hoff-man broke on a sunny

Sunday in February. The Oscar-winning actor, 46, had beenfound dead from a drug over-dose in a New York City apart-ment, a needle still hangingfrom his arm. 1 More than 50packets of heroin were scat-tered through the apartment.

As fans and neighborsbegan the ritual of leavingbouquets and notes in frontof the building, Americanswere once again gripped bya very public, and shocking,celebrity drug death.

The death of Hoffman, whohad gone into rehab in May2013 after remaining sober formore than two decades, high-lighted once again how littleis known about addiction,even though it is omnipresent.It weighs down U.S. societywith an estimated $400 billion-plus in annual lost workerproductivity, court costs, hos-pitalizations and outlays for pris-ons, not to mention the wreck-age of tens of millions ofAmerican families. 2

The U.S. government says an esti-mated 22.2 million Americans 12 or olderwere dependent on or abusing alcoholor drugs in 2012, including marijuana,cocaine, heroin, hallucinogens, inhalantsand prescription painkillers. 3

Nonetheless, scientists and doctorsare still debating what kind of diseaseaddiction is: genetic, biological, psy-chological or psychosocial. They alsodisagree over which treatments work.The 12-step program of AlcoholicsAnonymous (AA), coupled with coun-seling and psychotherapy, has beenthe standard of care. But now, some

scientists and therapists say those 12steps are ineffective in helping manyaddicts and alcoholics into recovery.And a growing number of physiciansare using medications to combat addic-tion to heroin and opioid* painkillers.(See “At Issue,” p. 401.)

Of the 22 million Americans whoare dependent on or abusing substances,about 18 million abuse alcohol, ac-

cording to the federal govern-ment’s most recent National Sur-vey on Drug Use and Health. 4

According to the federal Cen-ters for Disease Control andPrevention (CDC), about 88,000deaths each year are “attribut-able to excessive alcohol use,”far more than the deaths fromillicit drugs and painkillers. 5

More than 4 million Amer-icans met the clinical standardfor dependence on or abuseof marijuana, according to gov-ernment statistics for 2012, fol-lowed by 2 million hooked onprescription pain pills, suchas Vicodin and OxyContin.Cocaine and heroin followed.There is overlap; almost 3 mil-lion people were classified asdependent on or abusing bothalcohol and illicit drugs.

From 2002 to 2012, thenumber of Americans depen-dent on or abusing heroinmore than doubled, to 467,000,according to the government’sstatistics. 6 Heroin delivers arush of euphoria, according tothe National Institute on DrugAbuse. 7 But heroin and pre-scription opiates depressbreathing, which can be fatal.

More than 3,000 Americansdied from heroin overdose in

2010, up 45 percent from 1999, ac-cording to the government. 8 Over-doses from prescription painkillers andmethadone, a heroin substitute, quadru-pled from 1999 to 2010, killing morethan 16,000 people in 2010 alone. 9

In March, Attorney General Eric Hold-er declared the rise in overdoses fromheroin and prescription painkillers “an ur-gent public health crisis.” 10 The governorof Massachusetts echoed his warning. 11

The Mental Health Parity and Ad-diction Equity Act, known as the Par-ity Act, requires most health plans toprovide the same level of benefits for

BY JANE FRIEDMAN

Get

ty Im

ages

/Variety

/Joh

nath

an L

eibs

on

The shocking death of acclaimed actor Philip SeymourHoffman from a drug overdose on Feb. 2 underscores theimpact that drug abuse has on the nation. In addition tothe wreckage of millions of individual lives and families,drug and alcohol addiction costs the nation an estimated$400 billion-plus annually in lost worker productivity,hospitalizations, court costs and prison operations.

* Opioids are narcotic pain medications madefrom opium poppies or synthetically created fromchemicals. The terms opioid and opiate are usedinterchangeably.

388 CQ Researcher

mental health and substance abuse treat-ment as for other illnesses. However,the health insurance industry, addiction-care activists and government regulatorshave not agreed on what specificallyshould be covered.

What Americans increasingly doknow, though, is how addiction af-fects people’s lives, because more peo-ple are talking about it, including thosefrom affluent families.

Author David Sheff, in his 2008memoir Beautiful Boy, described hisson’s descent into addiction beginningas a teenager. 12 Once, after disap-pearing for four days, Nic called hisdad, who fetched him in an alleywaynot far from their California home. “Hegoes limp in my arms,” Sheff wrote.“He spends the next three days shiv-ering as if feverish, curled up in bed,whimpering and crying.” Nic was ad-dicted to crystal meth, a form of thestimulant methamphetamine.

Ben Cimons, a 23-year-old from sub-urban Bethesda, Md., wrote in TheWashington Post about his near-deathfrom a heroin overdose. 13 “I snuckout of the house after my mom wasasleep, met my friend, and we droveto Southeast Washington looking forheroin. We both shot up in the car. Iremember starting to drive, but then— as I later learned — I passed out andslumped onto the horn, blocking trafficon Pennsylvania Avenue. I had stopped

breathing and my lips were turning pur-ple. My friend, already on probation,made the 911 call — then fled.”

Cimons wrote that he’s working torepair his relationship with his motherand that he is living in North Carolina,far from where he became addicted.

According to government statistics,drug use is highest among people ages18 to 25. Marijuana use by teenagersis on the rise, with 6.5 percent of 12th-graders using marijuana every day, com-pared with 5 percent in the mid-2000s,says the National Institute on DrugAbuse. 14 The increase is partially fueledby the perception that “weed” is notan addictive drug. However, of thosewho use it, 10 percent will becomeaddicted, says A. Thomas McLellan, headof the nonprofit Treatment Research In-stitute in Philadelphia.

Currently, 62 percent of Americanteens in drug treatment are dependenton marijuana. 15

The spike in heroin overdoses isoverturning stereotypes. Heroin addictsused to be seen mainly as inner-citypredators or homeless people livingunder bridges in big cities. Now, though,use of heroin, an opiate, is spreadingto suburban and rural areas and manyof its victims are young.

“Opiate addiction is the great leveler.It doesn’t discriminate anymore,” saysGeorge Kolodner, a psychiatrist whoseKolmac Clinic provides outpatient ad-

diction treatment in the Washington,D.C., area.

Many addicts go untreated. AlthoughHollywood figures such as LindsayLohan and Robert Downey Jr. may beable to disappear into expensive resi-dential rehabilitation facilities costingupwards of $50,000 a month, that levelof treatment is beyond the reach ofmost addicts. Nationally, only 2.5 mil-lion alcoholics and drug addicts re-ceived treatment in 2012, or one outof 10. 16 Most who don’t get treatmentdeny they have a problem, says West-ley Clark, director of the Center forSubstance Abuse Treatment at the gov-ernment’s Substance Abuse and Men-tal Health Services Administration(SAMHSA). But some say they can’tafford it.

Although the Obama administrationsays it is focused on expanding treat-ment, Washington’s reaction to the in-crease in heroin and prescription painkilleroverdoses has been muted, some say.

Kevin Sabet, a former senior advis-er in the Obama administration’s WhiteHouse Office of National Drug ControlPolicy, says the administration sees ad-diction as a lose-lose issue. “They don’twant to make their constituency thinkthey’re soft on drugs. And they don’twant the liberals to feel they’re tootough on drugs. This has been a WhiteHouse agnostic to the drug problem.”

Holder’s Justice Department hasmoved to reduce federal prison sen-tences for some drug offenders, andto offer clemency to others. 17 (See“Current Situation,” p. 400.) The ad-ministration also has promoted the ex-panded use of naloxone, a prescrip-tion drug that reverses heroin and otheropioid overdoses, often called by itsbrand name, Narcan. In early April,the Food and Drug Administration(FDA) approved a new form of nalox-one that will be available by pre-scription to friends and families of hero-in and opiate addicts so they canadminister it in the event of an over-dose. 18 It will be injectable, the way

TREATING ADDICTION

Source: “America’s New Drug Policy Landscape,” Pew Research Center, April 2, 2014, http://tinyurl.com/mvylx98

Most Americans Favor Treatment for Abusers

Nearly 70 percent of Americans surveyed said federal drug policy should focus on providing treatment to drug users, versus one-quarter who want more focus on prosecution.

Percentage Favoring Treatment or Prosecutions in Drug Policy

Don’t know

SR

Prosecuting drug users

Providing treatment


medication for allergic reactions is de-livered via an EpiPen.

But advocates for treatment, such asCarol McDaid, a Washington lobbyistwho urged Congress to pass the men-tal health and parity bill, say the ad-ministration should make naloxoneavailable over the counter so thatfewer overdoses end in death. For now,naloxone is mostly available to firstresponders and law enforcement.

Scientists and treatment profession-als continue to disagree over whichtreatments work best, such as regimensthat use medication versus those thatdon’t. McLellan, of the Treatment Re-search Institute, who lost his son to adrug overdose and is a leading researcheron programs for prevention and treat-ment of addiction, calls the fights be-tween advocates of medication-assistedtreatment and 12 steps “silly.”

He says doctors should tailor treat-ment to the individual.

The Parity Act and the AffordableCare Act, which requires more Amer-icans to have health insurance, couldbe the arbiters on the standard treat-ment. Former Rep. Patrick Kennedy,D-R.I., a recovering painkiller addict, iscalling on the treatment community tounite around the standard of care thatit wants insurance to cover.

“The insurance industry will defineit for us if we don’t do it,” says Kennedy,who was key in guiding the Parity Actthrough Congress in 2008.

As expanded insurance coverage forAmericans with substance abuse dis-orders goes into effect, here are ques-tions scientists and treatment special-ists are debating:

Is addiction a biological disease?Stuart Gitlow, president of the Amer-

ican Society of Addiction Medicine(ASAM), likes to talk about addictionso lay people will understand it. “Thedisease is a genetically transmitted ill-ness that works by making a personuncomfortable in their own skin,” heexplains. “Hundreds of times it’s been

proven that it’s genetics. That’s notdebated anymore, just like the Earthisn’t flat.”

In 2011, ASAM issued a new defi-nition of addiction, which may be lessunderstandable for lay readers thanGitlow’s, but does not touch on whetheraddiction is genetic: “Addiction is aprimary chronic disease of brain re-ward, motivation, memory and relat-ed circuitry. Dysfunction in these cir-cuits leads to characteristic biological,psychological, social and spiritual man-ifestations. This is reflected in an in-dividual pathologically pursuing re-ward and/or relief by substance useand other behaviors.”

While scientists studying addictiontend to subscribe to this definition, theydiffer about the specifics. And a mi-nority of physicians and therapistsdon’t believe addiction is biological atall, saying instead that it is psychologicalor psychosocial.

Fifty-eight years after the AmericanMedical Association first defined alco-holism as a disease, the debate aboutthe nature of addiction still kicks upa storm, probably because rates of re-covery are generally agreed to be low.

“The American Society of AddictionMedicine is now in two very vocalcamps,” says Dr. Ronald Smith, a psy-chiatrist in Washington who has longspecialized in treating addicts. “One campsays this is a biological disease and thetreatment is biological. The other groupbelieves it’s a psychosocial disease andbelieves in Alcoholics Anonymous, usingpeople to support recovery.”

Those who back the biologicalmodel cite advances in science andbrain imaging. Leading the pack is NoraVolkow, a neuroscientist who is direc-tor of the National Institute on DrugAbuse (NIDA), part of the National In-stitutes of Health (NIH). She has beenexamining brain scans of human drugusers and rats and has shown that asdrug use increases, so do changes inthe receptors of the brain involved withfeelings of reward and happiness.

Addiction is genetic, biological andpsychosocial, she says, “Fifty percentof the vulnerability to addiction is ge-netic.” By genetic, she means inherit-ed. “Exposure to drugs strengthens theareas of the brain sensitive to sub-stances and can lead to addiction. Theenvironment is the other 50 percent.”

Prescription Overdose Deaths Rose the Most

Deaths from overdoses of prescription medications rose five times more than deaths from heroin between 2006 and 2010.* Deaths from cocaine overdoses fell by 44 percent.

* Most recent data available.

Source: “5 Things to Know about Opioid Overdoses,” Office of National Drug Policy Control, http://tinyurl.com/kj5jqhz; data retrieved from Centers for Disease Control, http://wonder.cdc.gov/

Overdose Deaths Involving Prescription Opioids, Cocaine and Heroin (1999-2010)

0

5,000

10,000

15,000

20,000

Cocaine and Heroin (1999-2010)

201020092008200720062005200420032002200120001999

Rx OpioidsCocaineHeroin

(No. of deaths)

390 CQ Researcher

She concedes that because she hasstudied brain images of addicts butnot images taken of those same peo-ple before they began using drugs, agenetic cause is not obvious from thatwork. Instead, she says, there are con-trolled studies on identical twins thatcompare them to nonidentical twins.“And there’s a much greater concor-dance between the identical twins re-garding addiction. So you can assumethat it has genetic components.”

Mark S. Gold, chair of the psychi-atry department at the University ofFlorida College of Medicine, has donegroundbreaking research on the caus-es of addiction. “There is universal

agreement that genes can be changedby exposure to drugs,” he says.

“A person [whose] mom smokedwhen she was pregnant has geneticreceptors that were changed becauseof the exposure,” making that personmore likely to become addicted tonicotine, Gold says.

But some physicians and psychol-ogists reject biology as the source.Lance Dodes, a psychoanalyst and for-mer head of substance abuse treat-ment at Harvard’s McLean Hospital inBoston, has been making waves witha new book, The Sober Truth. 19 Heargues that addiction is a psychologi-cal compulsion, plain and simple.

“Addictive acts are always precipi-tated by a feeling of helplessness,” hesays. “When people feel helpless, theyhave to do something about it. Ifyou’re stuck in a cave, you won’t staycalm. There’s an intense drive to re-verse helplessness. That’s the drive be-hind addictive behavior. It’s compul-sive behavior, and that’s why it canshift from one drug to another.”

Similarly, Smith, the Washington psy-chiatrist, boils it down to this: “Life ispainful. So we have work, diversionslike wrestling, football, TV and intox-icating substances.”

He says the destruction of traditionalculture isn’t helping. “We take more an-tidepressants than everywhere else. Wemedicate the hell out of ourselves.There’s not much that glues the familyand there’s a breakdown in worship.”

The plethora of explanations reflectsthe lack of solid proof about the causeof addiction.

McLellan, at the Treatment ResearchInstitute, says that addiction is similarto diabetes. “It’s an acquired illness.You eat your way into diabetes, andyou’re in denial.”

The same with addiction, he says.“You drink your way into it. Nobodyin science knows when that switchgets flipped. You don’t make a choiceto be an addict.”

Are AA’s 12 steps effective inhelping to beat addiction?

Every day across the world, alco-holics and other addicts gather for 12-step meetings. Many start with a mo-ment of silence. The 12 steps of AAare then read, starting with “we ad-mitted we were powerless over alco-hol and that our lives had become un-manageable.”

Members take turns identifying them-selves by first name only. They sharetheir struggles in reaching sobriety. Be-fore disbanding, they hold hands in acircle and recite the Serenity Prayer. 20

Alcoholics Anonymous was createdin 1935 by Bob Smith, a physician,

TREATING ADDICTION

Kara Schachinger, 22, from Oakton, Va., died of a heroin overdose in 2012. Twoother people who bought heroin from her supplier also died. The dealer who sold

it to them was sentenced in April to 30 years in prison. Heroin is one of thehardest drugs to conquer. Withdrawal causes muscle and bone pain,

insomnia, diarrhea, vomiting and cold flashes. After withdrawal, people who relapse can die from an overdose.

Get

ty Im

ages

/The

Washing

ton Post/

Eva

Rus

so


and Bill Wilson, a stock broker. Bothalcoholics, they encouraged other al-coholics to band together to help oneanother stop drinking through spiritualsupport.

AA has helped uncounted numbersof addicts and alcoholics reach sobriety,meaning they neither take drugs nordrink.

Those who have reached sobrietythrough the 12 steps, like Tara, ayoung professional in Washington, D.C.,swear by it. She’s 13 years sober andsays, “My dad is 74, and he’s beensober for more than two years. I neverthought he’d be able to walk me downthe aisle. But now he will.”

For decades, 12-step programs havebeen at the core of most rehab facili-ties, which offer them along with coun-seling. In addition to teaching aboutthe 12 steps, many facilities requirepatients to attend 12-step meetings. 21

But in recent years, the program hascome under criticism as ineffective intreating a chronic, relapsing disease.

Bankole A. Johnson, head of psy-chiatry at the University of Maryland’sSchool of Medicine, fired an earlysalvo in the recent debate. In a 2010article, he wrote, “There is little com-pelling evidence that the AA methodworks, inside or outside a rehab fa-cility.” 22 He said AA can be harmfulbecause it blames addicts and alco-holics if they fail to remain sober.Johnson advocates medicine to com-bat addiction and is researching med-ications already on the market but notapproved for addiction that he sayshave reduced cravings for alcohol andcocaine in clinical studies he led.

“If you have a serious disease, youget medical help,” he says. “For ex-ample with cancer, support groupswill help. But I would still want treat-ment for my cancer.”

One of the most recent critiquescomes from psychoanalyst Dodes, whosenew book attacks the 12 steps. 23

“The statistics for AA are among theworst,” he says, adding that only 5 to

10 percent of those who achieve so-briety are AA members. He cites theCochrane Library, an international col-lection of databases that contains in-dependent evidence and studies re-lated to health care decision-making.It examined clinical trials spanning 40years and found “no experimental stud-ies unequivocally demonstrated the ef-fectiveness of AA or Twelve Step Fa-cilitation approaches for reducingalcohol dependence or problems.” 24

Dodes says studies finding AA and12-step programs effective, such asone by Lee Ann Kaskutas, a seniorscientist at the University of CaliforniaBerkeley’s School of Public Health,were flawed because they based theirconclusions on addicts and alcoholicswho remained in the program. 25 “Thepeople who dropped out were un-doubtedly those who didn’t do well.”Kaskutas’s study, which is a survey ofother research, points out that reviewsof experimental studies, including theCochrane Library work, have foundvarying results; it argues that on anumber of criteria, “the evidence forAA effectiveness is strong.” 26

Dodes favors psychotherapy so ad-dicts will discover the underlying sourceof their problems and recommendsthey be allowed to remain in therapyeven if they continue to use drugs andalcohol.

Robert DuPont, a psychiatrist andformer head of the National Instituteon Drug Abuse (NIDA), the federaldrug abuse research institute, oppos-es that approach. First, he says, ad-diction is a primary disease, not asymptom of something else. Plus, “pa-tients don’t typically tell their thera-pists that they’re using, and the ther-apist doesn’t ask questions. Thepatient is using the therapist as a coverfor continuing the addiction.”

Adding to the challenges facing the12-step approach is the growth of“medication-assisted treatment.” AAand its spin-offs insist that total ab-stinence from alcohol and drugs de-

fines recovery, and that includes drugsmeant to wean addicts, such asbuprenorphine. Sold under trade namesincluding Suboxone, buprenorphine isa “partial opioid agonist,” says McLellanof the Treatment Research Institute,that is unlike methadone, meaning itdoesn’t fully stimulate the body’s opioidreceptors.

Buprenorphine reduces cravings andcan prevent deadly relapses. It is usedto treat those addicted to prescriptionpainkillers and heroin. 27 “And it’s al-most impossible to overdose on. It’san advance,” McLellan says.

Hazelden in Center City, Minn., amongthe most respected residential rehab fa-cilities, has long opposed medicationand championed 12-step recovery. Re-cently, however, it announced it wouldalso use medication-assisted treatment,saying such treatments had beenproved effective. 28

As at Hazelden, many scientists saymedication coupled with counselingand 12-step meetings, rather than ei-ther approach alone, offers the bestchance for heroin and opiate addictsto recover their lives.

But DuPont says some advocates ofmedication-assisted treatment “aredeeply involved in harm reduction.” Inother words, they’re not aiming for ab-stinence, and that goes against the phi-losophy of AA and related programs.

Some Narcotics Anonymous groupshave refused to allow heroin and opi-ate addicts who are taking buprenor-phine to speak at meetings becauseit violates the groups’ tradition of ab-stinence.

Neither side is absolutely right,DuPont says. “Medication-free peopleare going to have to accept that a lotof people are being helped by med-ication,” he says. But, at the same time,he believes, “you have to be workingtowards recovery,” and the standardfor recovery should remain abstinencefrom all drugs.

“The recovery standard” espoused byAA is right, he says.

392 CQ Researcher

Is access to treatment availablefor all who need it?

Anthony and his cousin both areaddicts. Anthony, 21, lives in a smallOhio town. He didn’t go to collegeand he began stealing his mom’s pre-scription painkillers some years back.His grandmother, who has a high schooleducation, tried to get him into treat-ment, but she was afraid of the costand didn’t know how to researchavailable programs. She dragged An-thony to an AA meeting, but that wasas far as they got. Since then, Antho-ny, who asked that his full name notbe used, has not been able to hold ajob and is still using.

His cousin grew up in a middle-classsuburb outside Washington, D.C. Heflunked out of college, mostly due todrinking and drugs. But his mother gothim into a residential treatment pro-gram, dipping into her savings. But itwas worth it. He’s been sober for morethan a year and is working the 12 steps.Following the 12-step tradition, the cousinasked to remain anonymous.

On the surface, it’s a tale of un-equal access to treatment.

According to the federal govern-ment, only about a tenth of peoplewho needed treatment in 2012 receivedit. 29 That would seem to indicate alack of access.

However, Clark at the Center for

Substance Abuse Treatment says thattreatment programs are available — butmany addicts don’t use them. “Ninety-five percent of people who need treat-ment don’t think they do. They say‘there’s nothing wrong with me.’ ” Only1.7 percent of those who needed treat-ment in 2012 felt they needed it andmade an effort to get it. Of those, al-most 40 percent had no health cover-age and could not afford to pay for treat-ment. 30 In the end, says Clark, 2.5 millionreceived treatment.

Denial is characteristic of addiction.“It takes people six to eight years be-fore they realize they have a prob-lem,” says Clark. “The standard is, youdrink a six pack of beer every nightand go to work the next day. That’sokay until you crash your car and beatup your wife.” That sort of crisis iswhen many seek treatment, he says.

Treatment is generally available, evenif it varies by type and cost, says Clark.The most expensive residential treat-ment runs about $70,000 a month, Clarksays. The average cost is $30,000 for amonth. For treatment of a single drugepisode, the low range, he says, is $2,000.Eighty percent of treatment facilitiesoffer outpatient programs in which pa-tients spend several hours a week orsome hours every day at a facility butdon’t live there. It’s much less costlythan residential treatment.

Under the Affordable Care Act,most health plans must offer coverage— both residential and outpatient —for substance abuse treatment. Clarksays residential treatment centers cur-rently have about an 89 percent oc-cupancy rate. But with only half oftreatment facilities accepting Medicaid,or health insurance for the poor, thereare waiting lists in some places. “Peo-ple say, ‘Guess what? I’ll go back tousing’ ” if a spot isn’t open immedi-ately, Clark says.

Marvin Seppala, chief medical offi-cer at Hazelden, says the quality ofcare in the public system, where mostpeople are treated, leaves much to bedesired. He says addiction counselors“are poorly paid, often don’t have grad-uate degrees, and there’s high turnover.You don’t get counselors who can getthe job done.”

But the Kolmac Clinic’s Kolodner saysinequality of access is mostly linked togeography. In some rural areas, treat-ment is many miles away. 31 Kolodneralso says the number of doctors whoare federally approved to prescribebuprenorphine for opiate dependencevaries by state and city.

There are other subpopulations —such as prisoners and soldiers return-ing from battle — who are known tobe seriously underserved by treatmentprograms. But, says Gold, the Univer-sity of Florida researcher, some kindof care is accessible for all.

At the high end, Gold and DuPontstudied 904 physicians receiving treat-ment that included several months ofintensive care, then outpatient treat-ment, 12-step meetings and five yearsof monitoring and drug testing. Afterfive years, 78 percent of the physi-cians were abstinent. 32

That kind of care is rare, but Goldpoints out that treatment is availablein many different ways, includingthrough Medicaid and drug courts forthose who face criminal penalties. Drugcourts focus on sending arrested drugoffenders to rehab instead of jail.

TREATING ADDICTION

Source: “Research Report Series: Heroin,” National Institute on Drug Abuse, February 2014, p. 2, http://tinyurl.com/kjypozn

Number of Heroin Users Rose 66 Percent

Heroin use among Americans grew from 404,000 persons in 2002 to 669,000 in 2012.

Past Year Heroin Use Among Persons Age 12 or Older, 2002-2012

(in thousands)

300

400

500

600

700

800

20122011201020092008200720062005200420032002 Get

ty Im

ages

/Mar

io T

ama


“Are we doing people a favor bytelling them that they can’t afford thesame treatment that a doctor gets?”Gold asks rhetorically, making the pointthat some care is better than none.

Clark, at the Center for SubstanceAbuse Treatment, is worried about theimpact of the Affordable Care Act, withmillions of Americans newly insured.“If twice the number of people turnup on your doorstop, there’s not enoughpeople with the skill sets to treatthem,” he says.

The Treatment Research Institute’sMcLellan believes greater demand willfuel an expansion of services. “Whatwe need the public to do is step upand say, ‘I want this for my kid.’ Thatwill be the start of market forces. In ayear or so, you’re going to see a wholedifferent approach to addiction treat-ment. The public has rights.”

BACKGROUNDAncient Addicts

“A ddiction goes as far back inrecorded history as you can go

— to the Egyptians, Romans and Greeks,”says William L. White, author of an au-thoritative history of addiction and ad-diction treatment, Slaying the Dragon. 33

“The literature shows there were spe-cialized roles for people helping thosewho were suffering from excessive alco-hol use.” In fact, the word addiction isderived from the Latin addictus, a Romanterm for a person who is enslaved. 34

In his 340-page account, White quick-ly moves forward to the 18th century,when Americans wavered between see-ing alcoholism as a moral failing andas a disease, an ambivalence that con-tinues today.

Drinking became a concern evenbefore the republic was established,White wrote. Benjamin Rush, a signer

of the Declaration of Independenceand a physician, was concerned aboutdrunkenness among soldiers in the Con-tinental Army. He also recommendedthat farmers stop providing daily ra-tions of liquor to their laborers. 35

A temperance movement emergedin the early 1800s and, in the middleof that century, so-called asylums spe-cializing in the medical treatment of“inebriety,” spread around the coun-try, as did quack remedies for bothalcoholism and opium use. 36 Even-tually, asylums disappeared, and in the20th century alcoholics were confinedin psychiatric hospitals.

As support grew for the view thatalcoholism was a disease, treatmentsarose including diet and exercise; watercures such as baths, steam and va-porizers; and even lobotomies. Therewas also a search for a vaccine againstalcoholism that used antibodies in hors-es’ blood. It didn’t work. 37

In 1920, with the 18th Amendmentto the Constitution, the United Statesestablished Prohibition, which barred

the production, sale and importing ofalcoholic beverages. Prohibition fosteredcorruption, and criminal gangs becamerich from bootlegging. In 1933, the 21stAmendment repealed Prohibition. 38

Two years later, two alcoholics —physician Smith and stockbroker Wil-son — had a chance encounter in Akron,Ohio, and ended up talking for hoursabout their struggles. Some monthslater, they founded Alcoholics Anony-mous, a spiritual movement that wouldradically change the approach to treat-ing alcoholism and drug addiction. 39

As they reached out to other alco-holics, Bill W., as he came to be known,set about writing The Big Book, the AAtext published in 1939 that describesthe steps to recover from alcoholismand documents stories of recovery. In2012, the Library of Congress said thebook, which has sold some 30 millioncopies, was among the 88 books thathave shaped America. 40

By the early 1950s, AA membershiphad grown to more than 90,000. 41 AAis a mutual aid society with no eco-

Police dump liquor after a raid on an illegal liquor operation in Cambridge, Mass.,during the Prohibition era. Congress banned the sale, production andpossession of alcohol in 1920 but repealed the unpopular law in 1933.

Get

ty Im

ages

/The

Boston Globe

/Hug

h E

. O'D

onne

ll

394 CQ Researcher

TREATING ADDICTION

nomic or social barriers to participa-tion, where membership is free andmeetings are available just about any-where, any day. Soon there were spin-offs, notably Narcotics Anonymous, es-tablished in 1953, to help drug addicts.

Minnesota Model

A ccording to historian White, AAand medical advances led to the

growing acceptance of alcoholism as adisease. In 1949, Hazelden, one of theearliest private treatment centers orga-nized around the 12 steps, opened inMinnesota.

“It was started by a handful of busi-nessmen and began on a potatofarm,” says Christine Anderson, spokes-woman for the Hazelden Betty FordFoundation, which runs Hazelden,still located on that “farm.” Betty Ford,who died in 2011, was the formerfirst lady whose public admission ofher drug and alcohol addiction raisedthe profile of the issue. The BettyFord Center in Rancho Mirage, Calif.,is another respected residential treat-ment program.

At first, Hazelden was a guest housefor alcoholic men, but it developedinto the prevailing method of treat-ing addiction, which came to be calledthe Minnesota Model. 42 It incorpo-rated lectures about AA’s 12 steps intoits treatment program and encour-aged family involvement as well asparticipation in AA during and aftertreatment, according to a historicalstudy. 43 Today, it handles 2,200 pa-tients a year, says Seppala, Hazelden’schief medical officer.

The Minnesota Model spread acrossthe country, carried by people whohad been treated at Hazelden or whohad treated patients there. They wereconverts, committed to the cause.

Although the American Medical As-sociation recognized alcoholism as anillness in 1956, government policies onalcoholism and drug addiction have

flip-flopped over the last 58 years, frus-trating scientists and clinicians on thefront lines.

In the early 1960s, addictions weredivided along class lines, with heroinafflicting mainly inner-city populations.Young people from more affluent back-grounds revolted against the “Estab-lishment” and the Vietnam War. Drugs— especially marijuana and LSD —became symbols of youthful rebellion,social upheaval and political dissent.

After taking office in 1969, Repub-lican President Richard M. Nixon shift-ed federal drug policy from empha-sizing law enforcement to reducingdemand. In 1971, he declared a “waron drugs,” focusing on prevention, treat-ment and rehabilitation of drugabusers and research into addiction.NIDA, the national drug abuse re-search center, was set up in 1973 tostudy the effects of drugs on the humanbody and to develop new approach-es to treatment and prevention. Fed-eral spending on drug programs ex-panded from $3 billion in the 1970-75period to $5.2 billion in 1976-81. 44

The military also had a major rolein focusing on treatment over en-forcement. “As many as a third of thepeople in uniform were using drugsin the 1970s, and it absolutely wreckedour professional competence,” saidGen. Barry R. McCaffrey, a former di-rector of the Office of National DrugControl Policy. “We worked our wayout of it, and we did so not by ar-resting people, but by running oneof the largest drug-treatment programsthe world had ever seen. It took usa decade.” 45

The 1970s also saw the beginningof major government programs part-nering with the states. Governmentmoney flowed through NIDA and theNational Institute on Alcohol Abuseand Alcoholism to the states, whereregional training centers were set upand “Washington did major training ofphysicians and addiction counselors,”says White.

Crack Cocaine

H owever, the administration ofRepublican President Ronald Rea-

gan, inaugurated in 1981, initiated aperiod of stepped-up law enforce-ment with less emphasis on treatment.Cocaine became the big drug on thescene, fueled by Colombian drug car-tels and massive smuggling. Crack co-caine, a cheap, highly addictive smok-able form, took over inner cities,sending the murder rate skyrocketingas drive-by shootings became a reg-ular occurrence in some big urbanareas. The crack epidemic triggered“an explosive growth of the penal sys-tem and the incarceration of blackmales,” says White. “We went fromsystems of care to systems of crimi-nal justice.”

Both state and federal legislators re-acted to the crack epidemic by adopt-ing stiff, mandatory-sentencing rules,and many low-level, nonviolent drugoffenders were locked up for long pe-riods, triggering a rapidly rising prisonpopulation and a prison-building boomacross the country. 46

Disparate sentences for crack, usedmainly by blacks in inner cities, andpowdered cocaine, used largely bywhites, led to controversy (see p. 400).

First lady Nancy Reagan punctuat-ed the administration’s emphasis onpersonal responsibility with her famousslogan, “Just Say No.”

As the prisons filled up and the ju-dicial system became overloaded withdrug cases, some jurisdictions beganexperimenting with alternatives to lock-ing up drug addicts and throwing awaythe key. In 1989, Miami, a hotbed ofcocaine use, began experimenting withdiverting low-level, nonviolent drug of-fenders to so-called drug courts.

To avoid jail time, defendants whoappear in drug court must agree to out-patient treatment, usually for two years,regular meetings with judges and urine

Continued on p. 396


Chronology1900s-1930sDrinking is seen alternately asa moral failing and a disease.Sanatoriums and inebrietyasylums give way to psychi-atric hospitals for alcoholicsand morphine addicts.

1920The United States adopts Prohibition,banning the sale and production ofalcoholic beverages.

1933Prohibition is repealed.

1935Bill Wilson and Bob Smith launch Al-coholics Anonymous in Akron, Ohio.

1939The book Alcoholics Anonymous,known as The Big Book, is published.

•

1940s-1960sProgress is made in treatmentsfor addiction, but drug use es-calates.

1949Hazelden, a guest house for alco-holics, is founded in Minnesota.

1953Narcotics Anonymous is launched.

1956The American Medical Associationrecognizes alcoholism as an illness.

Mid-1960sHeroin use is rampant in innercities and prisons. Methadone, asynthetic opiate, is approved fortreating heroin addiction.

Late 1960sDrugs, especially marijuana and

LSD, become popular among youngwhite Americans.

•

1970s-1980s“War on Drugs” launched; co-caine use skyrockets.

1970Congress passes the Comprehen-sive Drug Abuse Prevention andControl Act.

1971President Richard M. Nixon launchesthe “war on drugs,” says drug abuseis “public enemy No. 1.”

1978Former First Lady Betty Ford an-nounces she’s addicted to alcoholand prescription drugs and willseek treatment.

1984First Lady Nancy Reagan’s “Just SayNo” campaign becomes centerpieceof President Ronald Reagan’s anti-drug campaign.

1985Crack cocaine use races throughurban areas, adding to pressure to im-pose stiff jail sentences for drug users.

1986The Anti-Drug Abuse Act createsmandatory minimum penalties forfederal drug trafficking offenses.Penalties for possession of crackcocaine outweigh penalties for thepowder form by 100 to one, fuelinghuge racial disparities in prisons.

•

1990s-PresentUse of crystal methamphetamine,prescription drugs and heroin

escalates; health insurance forsubstance abuse is mandated.

1990sMethamphetamine and crystal meth(speed) pervade America, withcooks producing it in hidden labs.

Mid-1990sPresident Bill Clinton signs billsbarring addicts with felony convic-tions from welfare, food stamps,public housing and Social SecurityDisability benefits.

1995The Food and Drug Administration(FDA) approves OxyContin, anopioid for pain reduction, for usein the United States.

2003Buprenorphine is marketed as abetter alternative to methadone forhelping heroin and prescriptiondrug addicts.

2008Congress passes the Mental HealthParity and Addiction Equity Act,requiring health plans that coversubstance abuse disorders to doso in a way that is comparable tocoverage of medical illnesses.

2010Drug deaths climb to more than38,000, mainly from prescriptiondrug overdoses. Congress passesthe Affordable Care Act, requiringmost health plans to cover treat-ment for substance abuse.

2013With prescription painkillers morestrictly regulated, addicts turn toheroin, fueling an epidemic.

2014The Obama administration calls forreducing minimum sentences fornonviolent drug offenders.

396 CQ Researcher

tests. If they are abstinent, they stay outof jail. According to studies cited by theNational Association of Drug Court Pro-fessionals, 75 percent of drug court grad-uates remain arrest-free at least two yearsafter leaving such programs. 47 Today,there are nearly 3,000 drug courts na-tionwide, and the Department ofHealth and Human Services provides$40 million a year to help fund them. 48

During the late 1980s and early ’90s,Republican President George H. W. Bushcontinued the crackdown on abusers.In a nationwide address, he launched anational strategy, with increased spend-

ing for treatment but also tougher sen-tences, beefed up law enforcement andthe construction of new prison space for24,000 inmates. He said the states mustpass their own laws with “stiffer bail,probation, parole and sentencing.” 49

Successive presidents have targetedthe eradication of the drug supply, fo-cusing on spraying coca fields in Colom-bia and Peru or hacking down opiumpoppies in Afghanistan. But as onedrug of choice faded away, anotherappeared. The 1990s saw the in-creased use of methamphetamine, es-pecially in the form of crystal meth,a powerful central nervous system stim-

ulant that sparks an intense high thatcan last for several hours. The ingre-dients — a variety of easily purchasedchemicals in addition to ephedrineand pseudoephedrine found in coldremedies — were so flammable thathome laboratories sometimes explod-ed. Thousands of young addicts endedup in emergency rooms with delu-sions, hallucinations, severe depression,exhaustion and suicidal thoughts, aswell as heart attacks and strokes.

According to one study, “Metham-phetamine use among short-stay hospi-tal patients more than tripled” between1991 and 1994, as did methampheta-

TREATING ADDICTION

A nita Gadhia-Smith knows about heroin. By age 11, shewas drinking her parents’ liquor. When she got to col-lege, she began using heroin, shooting up intravenously.

“You get addicted to a state where you’re not suffering,”she says. “It’s complete bliss,” a contrast with what she recallsas her “horrific” childhood.

But heroin can be deadly. As an addict progresses in hero-in use, the body requires more. Withdrawal is painful and cancome within hours of the previous dose. And use of the drug,long perceived as a scourge confined to the most desperate ofaddicts, has spread to the middle class in recent years.

“My life got darker,” says Gadhia-Smith, now a psychologistin the Washington area. “I was up using at night and sleepingall day. You spend a lot of time being sick. And you spend alot of time procuring the drugs so you don’t get sick. I wassinking, not functioning.”

After she was caught driving under the influence for a sec-ond time and was facing jail, she says, “That broke my denial.”She attended support meetings and got sober. She now mostlytreats addicts.

Heroin is one of the hardest drugs to conquer. Withdrawalinvolves muscle and bone pain, insomnia, diarrhea, vomitingand cold flashes. 1 After an addict has been sober for a while,the body loses its tolerance for the drug. If the addict relapses— and heroin addicts have among the highest rates of relapse— they can die from an overdose. 2

In recent years, given heroin’s addictive grip on users, Mexi-can drug cartels knew they could make a financial killing sellingthe drug, according to The Washington Post. 3 As the wholesaleprice of marijuana fell, partly because of decriminalization in partsof the United States, Mexican drug farmers began tearing up theirmarijuana fields and planting opium poppies instead.

Meanwhile, the United States was cracking down on the il-licit trade in prescription painkillers after lethal overdoses morethan quadrupled from 1999 to 2010. As the pills became difficultto find, addicts around the country turned to heroin. 4

And the price was right for both dealers and addicts.“In New York, a bag of heroin is $6,” says Vermont Health Com-

missioner Harry Chen. “Dealers resell them for $30 in Vermont.”In the past two years, Vermont and the surrounding New

England states have experienced a heroin epidemic, accordingto health officials. Chen says deaths from heroin in Vermonthave doubled. Like other Northeastern states, the Green MountainState was ill-prepared.

“One of the challenges of rural states,” Chen says, “is thatwe don’t expect drug addiction to be here.”

In an unprecedented move, Democratic Vermont Gov. PeterShumlin devoted his Jan. 8 State of the State address to whathe called Vermont’s “full blown heroin crisis” and proposedmeasures to expand treatment. 5

But Vermont’s geography is working against its ability todeal with the crisis. Many people seeking treatment are poorand live in rural areas. “Some people have to go 30 miles to getto their doctor,” Chen says.

So the state is creating hubs to stabilize patients, some withmethadone, a replacement opiate prescribed for some addicts.Opiate addicts will then connect with the spokes, where theywill find a nurse practitioner and a therapist and also get ac-cess to buprenorphine, which eases cravings and helps addictsmove toward recovery. The medication is sold under namesincluding Suboxone.

Vermont, 17 other states and the District of Columbia alsohave expanded legal access to naloxone, also known by its tradename Narcan, a substance that, when administered quickly to

States Struggle as Heroin Spreads“We don’t expect drug addiction to be here.”

Continued from p. 394


mine-related deaths reported by medicalexaminers. 50

By the time the government restrict-ed access to Sudafed and the other coldremedies that were being used to pro-duce meth, new drugs were emerging.

The stigma of drug addiction wors-ened, especially under Democratic Pres-ident Bill Clinton in the 1990s. “We lostaddiction being a qualifying event forSocial Security disability,” the govern-ment payments that go to people whoare unable to work, says McDaid, thelobbyist for better treatment and rightsfor people with substance abuse prob-lems. In addition, “Student federal loan

applications asked if you ever havebeen convicted for a drug offense,” Mc-Daid continues, and that could affecteligibility. Some states drug-tested wel-fare or food stamp applicants who hada previous drug conviction.

By the mid-1990s, OxyContin, a newprescription painkiller, had been approvedby the FDA, joining Vicodin, anotherprescription pain pill. These medicationsare opioids — partly derived fromopium — and people with chronic painwere becoming addicted, as were peo-ple who took the drugs to get high. 51

The government eventually crackeddown on prescription drug addiction

by reclassifying the main ingredient inVicodin as a restricted, Schedule II sub-stance because, like OxyContin, it has ahigh potential for abuse. 52 In addition,drug makers reformulated OxyContin tomake it more difficult to abuse.

Addicts soon turned to heroin,which had become cheap and easierto acquire. 53 (See sidebar, p. 396.)

Medicating Addicts

I n 2003, buprenorphine, an opiatereplacement that eliminates cravings

and helps to prevent relapse, was re-

overdosing opiate addicts, reverses the overdose and has savedthousands of lives. 6

But some states, such as Maine, say naloxone only en-courages heroin addicts to keep using because they come tobelieve they won’t die from the drug.

Hazelden, the respected residential program in Center City,Minn., last year announced it will use buprenorphine, a partialopioid itself, to treat people addicted to heroin and prescriptionpainkillers, saying the treatment has been proven “effective andsafe.” 7 The treatment center for decades had been committedexclusively to counseling and treatment organized around the 12-step program originated by Alcoholics Anonymous.

Dr. George Kolodner, who runs several intensive outpatientcenters in the Washington, D.C., area, says doctors who refuseto use buprenorphine for their opiate addicts do so “at the perilof their patients.”

But buprenorphine is being diverted and showing up on thestreet, according to The New York Times. Buprenorphine has be-come “a treatment with considerable successes and also failures,as well as a street and prison drug bedeviling local authorities,”the newspaper reported, adding that the drug was a “primarysuspect in 420 deaths reported to the Food and Drug Adminis-tration” since reaching the market in 2003. 8 Buprenorphine pro-vides an initial rush that subsides and then makes addicts feelnormal, without cravings for heroin and painkillers. But somepeople are buying it to get high. And that has resulted in deathsbecause, as an opiate, it can trigger respiratory depression. Thereare also indications that some addicts who are prescribed buprenor-phine are using it to ease withdrawal while they seek more hero-in, or are continuing to use other drugs that could be deadly.

Many treatment specialists, however, say the downside tobuprenorphine is minimal compared with the large number of

lives it has saved and the thousands of addicts who have beenable to rejoin society because of it.

— Jane Friedman

1 “What are the long-term effects of heroin use?” National Institute on DrugAbuse, undated, http://tinyurl.com/knym8vp.2 Marty Ferrero, “Men, Addiction and Relapse,” Caron, July 22, 2013, Caronchitchat.org.3 Nick Miroff, “Tracing the U.S. Heroin Surge Back South of the Border asMexican Cannabis Output Falls,” The Washington Post, April 6, 2014,http://tinyurl.com/n7tocx3.4 “Heroin Use Among People 12 And Over,” 2012 National Survey on Drug UseAnd Health, September 2013, http://tinyurl.com/mt3lzyq..5 Katherine Q. Seelye, “In Annual Speech, Vermont Governor Shifts Focus toDrug Abuse,” The New York Times, Jan. 8, 2014, http://tinyurl.com/m2jcvuo.6 “Legal Interventions to Reduce Overdose Mortality: Naloxone Access AndOverdose Good Samaritan Laws,” The Network for Public Health Law, March15, 2014, http://tinyurl.com/l3mrtgc.7 Marvin D. Seppala, “Hazelden Responds to America’s Opioid Epidemic,”The Partnership at Drugfree.org, Feb. 8, 2013, http://tinyurl.com/alycnj5.8 Deborah Sontag, “Addiction Treatment With a Dark Side,” The New YorkTimes, Nov. 17, 2013, p. A1, http://tinyurl.com/k747uck.

The opioid buprenorphine is widely prescribed to addictsas a substitute for heroin and painkillers. It does not cureaddiction but prevents cravings and is hard to overdose on.Nearly a million addicts were prescribed “bupe” in 2012.

Get

ty Im

ages

/Joe

Rae

dle

398 CQ Researcher

leased; it became the first blockbustermedication for addiction. The British com-pany Reckitt Benckiser develped it in ajoint venture with the U.S. government,which financed the clinical trials.

Addicts take Buprenorphine, soldunder the trade name Suboxone, byputting a medication-infused strip underthe tongue. The government requiresdoctors to get permission from theDrug Enforcement Administration (DEA),along with eight hours of training, toprescribe buprenorphine. Numerousreports have found that the medicationnevertheless is being diverted and soldon the street. 54

Most private residential treatment cen-ters initially declined to prescribe it totheir opiate patients, except for detox-ification. But in 2012, Hazelden decid-ed it could no longer refuse the med-ication to heroin and prescription drug

addicts in its care. Reports had startedtrickling in that about 10 opiate addictsit had treated with its traditional mix ofpsychotherapy and 12 steps had diedfrom overdoses after leaving theHazelden campus.

“It was devastating to everyone in-volved — families, staff members andcounselors who were very involved withthese people. It was a recognition thatwe needed to do more,” says Seppala,Hazelden’s chief medical officer.

Hazelden developed a special pro-gram for opiate abusers, separatingthem from other patients regularly fortheir own group therapy and pre-scribing buprenorphine for those whoagreed. In 2013, about 100 opiate ad-dicts entered the special program andnone has died. Of those who didn’tenter the program, six died last year.Thirty of those in the special program

agreed to take buprenorphine.“Our goal is to get them off buprenor-

phine when they get into good re-covery,” says Seppala, because Hazeldenstill embraces 12-step recovery, whichmeans abstinence. “Maybe in six months,a year. We suspect some will be on ittheir whole lives.”

If addicts have been abusing drugsfor years, the standard 28-day residen-tial treatment is not enough to rewiretheir brains, experts say. That doesn’tmean that patients need to live at aresidential treatment center for years.Instead, says Gold, the University ofFlorida researcher, it means that sev-eral months in treatment is optimum,followed by five years of regular urinetesting, peer group meetings and theaddict’s understanding that his or herjob could be in jeopardy if there’s arelapse.

TREATING ADDICTION

G reg Williams is a documentary film maker from a small,affluent community in Connecticut. He’s been in re-covery from addiction for 12 years. And he wants you

to know about it.His film “The Anonymous People” is making the rounds of

small movie theaters and art houses around the country.“My name is Greg Williams’” it begins. “I’m 29 years old and

I live in a small house in Connecticut. Here are my two bestfriends in the world: my wife Michelle and our dog Jersey. . . .Oh, there’s one other thing I should tell you. I’m a drug addict.I can’t have a drink or use any drug without wanting more.

“I’m not supposed to tell you about my addiction,” he con-tinues. “I’m not supposed to want to tell you.

“My friends and I are people with addiction who don’t usealcohol and drugs anymore. We prefer to describe ourselveslike this: I’m Greg Williams and I’m a person in long-term re-covery.”

And that’s the point. Most addicts and alcoholics in recov-ery used to believe they had to remain anonymous, especial-ly if they had worked a 12-step program such as AlcoholicsAnonymous. They got used to describing themselves as ad-dicts, not as persons in recovery.

But now, a small group of addicts in recovery is trying tochange the way alcoholics and addicts see themselves and areseen. They believe those in recovery have only to gain by com-

ing out of the shadows. They’re lobbying for better prevention,treatment and support systems for those in recovery.

Williams’ film, which he completed in 2013, is part of thatmovement.

“Addiction is the leading epidemic in our country, especiallyfor people under 30, and we don’t talk about it,” he says. “Thefilm is trying to get people talking openly about addiction andrecovery so people will be interested in solutions.”

And talk they do, throughout the film. Emmy Award-win-ning actress Kristen Johnston, who played Sally Solomon in theTV series “3rd Rock from the Sun,” speaks about her addictionto prescription painkillers and how she made TV host DavidLetterman uncomfortable when she discussed it on his show.

Former Rep. Patrick Kennedy, D-R.I., jokes in the film thathe was never able to be anonymous. In 2006, after crashinghis car into a concrete barrier on Capitol Hill, he admitted hewas addicted to prescription painkillers and entered rehab.

Williams’ story is powerful and, sadly, typical. He startedusing alcohol when he was 12, stealing it from his parents’liquor cabinet. When he was 15, he moved on to prescriptionpainkillers. He liked the way they made him feel.

“One night, I wrapped my car around a tree,” he explains.“I was so high on drugs, I didn’t feel anything, and I walkedinto town.”

His parents found him and got him into treatment.

The “Anonymous People” Speak Out“I felt their story needed to be told.”


CURRENTSITUATIONParity Act Rules

T he recent rise in heroin deaths, in-cluding actor Hoffman’s highly pub-

licized overdose, appears to have cre-ated new momentum for substance abusetreatment, coinciding with the roll-outof the Parity and Affordable Care acts.Some say the increasing numbers ofpeople seeking treatment for addictioncould overwhelm the current system.

“The Affordable Care Act is goingto flush in addicts, and the systemwon’t be ready for them,” says Kolod-ner of the Kolmac Clinic.

Nevertheless, lobbyist McDaid, whohelped get Congress to pass the Par-ity Act, is optimistic. At the end ofApril, a forum on addiction treatment,heroin and the criminal justice systemwas held on Capitol Hill, signaling thepossibility of new legislation, McDaidsays. “There’s a feeling in the air,” shesays, “that it’s finally our time.”

As the rollout of the two laws pro-gresses, advocates for more and better-defined benefits for substance abusetreatment are pushing for their visionof the best standard of care.

The federal government issued itsfinal rule in November on how theParity Act will work to ensure cover-age for mental illness and substanceabuse treatment that is comparable tocoverage for medical illnesses.

The two laws act together. The Par-ity Act applied to employer-backed in-

surance plans that were already cover-ing mental illness and substance abuse.It did not apply to plans purchased byindividuals. But the Affordable Care Actmade such coverage mandatory in mostinsurance policies.

The final Parity rule prohibits insur-ers from setting higher copays and de-ductibles or stricter limits on treatmentthan they do for medical and surgicaltreatment. For instance, if employersand insurers don’t set limits on the num-ber of doctor visits and hospital daysfor medical illness, they can’t do it formental illness or substance abuse. Theyalso cannot put geographical limits onwhere one gets treatment if they don’tdo so for other illnesses. 55

The Parity rule issued in Novemberdoesn’t apply to Medicaid, which provideshealth care for the poor. The final rulefor Medicaid is expected later this year.

“I just wanted to get my family off my back,” he says. Buttreatment changed his mind, and he wanted to get better. Ayear later, he went to college, earning a master’s degree thatcombined filmmaking with the study of addiction and becameinvolved in the “youth recovery world.”

And that led him to drug historian William L. White and lobby-ist Carol McDaid, two people in long-term recovery who wereleading a movement to get the 23 million Americans in recoveryto raise their voices for better policies. In 2001, they formed Facesand Voices of Recovery. McDaid was key in lobbying for the Men-tal Health Parity and Addiction Equity Act, a 2008 law that guar-antees equitable insurance coverage for substance abuse treatment.

“I felt their story needed to be told,” says Williams. “I under-stood they were on the front end of what will become massivesocial, cultural and political change in the coming years, whenpeople and their families most closely connected to this issuebegin to end their silence and no longer accept the status quo.”

To do it, he raised money on the crowd-funding websiteKickstarter and depleted his savings.

The movie advocates for community centers that providelife coaching and moral support for recovering addicts; it takesviewers to a recovery high school in Boston. It interviews pris-oners who want access to drug treatment. And it profiles well-known addicts in recovery, including a former Miss America,who have chosen to “come out.”

Beyond those who appear in the movie, celebrities in-creasingly are talking about their recovery, including former“Friends” star Matthew Perry and Disney’s “High School Musi-cal” star Zac Efron.

Says McDaid, “I think it’s a personal decision for celebritiesto speak openly about their recovery. But I think it’s fair tosay we have played a role in making it easier to do that.”

— Jane Friedman

Documentary filmmaker Greg Williams interviews Emmy-winning actress Kristen Johnston about her addiction to

prescription painkillers. She is now in recovery.

4th

Dim

ensi

on P

rodu

ctio

ns, L

LC

400 CQ Researcher

TREATING ADDICTION

Advocates for those suffering fromsubstance abuse say the standard of careneeds clarity. How will insurers definemedical necessity? What treatments willbe covered and for how long?

Kennedy, the former congressmanwho cosponsored the Parity bill, sayshe’s mobilizing treatment professionalsand scientists for a Mental Health Lead-ership Alliance that will define what is

necessary in substance abuse treatment.“We need early screening and a check-up from the neck up once a year,” hesays, referring to a substance abuse ses-sion with a primary care provider everyyear, among other things.

Susan Pisano, a spokeswoman forAmerica’s Health Insurance Plans, ahealth insurance trade association inWashington, says, “The full scope oftreatments for substance abuse arecovered. Care plans will be tailored tothe individual patient.” Typically, shesays, “There would be a combinationof treatment settings and treatments.”

Sentencing Changes

B ipartisan bills to reduce mandatoryminimum sentences for drug of-

fenders in federal prisons are making theirway through the House and Senate.

The legislation, if passed, would alsomake retroactive recently revised sen-tences for crack cocaine offenses, which

critics had called racially unfair. The sen-tences were longer by 100 to one forcrack cocaine — used mostly by mi-norities — compared with the powderform preferred by whites. The changecould result in up to 12,000 federal pris-oners having their sentences reduced. 56

It would also give federal judges moreleeway in sentencing, says Jesselyn Mc-Curdy, senior legislative counsel at theAmerican Civil Liberties Union (ACLU).

The Obama administration has beentrying for years to reduce the country’sprison population and reserve the harsh-est penalties for the most serious of-

fenses. Some 2.2 million Americans arein either federal prison, state prisons orlocal jails. 57 Of the 216,000 people infederal prison, almost half were drugoffenders, according to the Justice De-partment. 58

The administration also wants todeal with racial inequities among pris-oners: African-Americans, who makeup 13 percent of the U.S. population,represent 37 percent of the federalprison population, largely because ofthe sentencing disparities for crack andpowder cocaine. 59

Speaking in March, Attorney Gener-al Holder said, “Certain types of casesresult in too many Americans going toprison for far too long, and at times forno truly good public safety reason.” 60

The U.S. Sentencing Commission,which establishes some sentencing poli-cies and practices for the federal courts,voted in April to lower federal sentencingguidelines for all drug offenses, includ-ing dealing, for prisoners convicted offederal crimes that don’t carry minimumsentences mandated by Congress. Thecommission said about 70 percent offederal drug trafficking defendants wouldqualify for the change, with their sen-tences decreased by an average of 11months. The commission estimates that,as a result, the federal prison popula-tion will drop by 6,550 inmates overfive years. 61 But the commission doesnot have authority to change mandato-ry minimum sentences set by law. OnlyCongress and the states can do that.

In fact, most drug offenders are notin federal prison. Of the 1.36 millionAmericans serving time in state pris-ons, about 240,000 are there for drugoffenses, more than twice as many asin the federal system. 62

At least 30 states — run by bothRepublicans and Democrats — haverolled back mandatory sentences insome form since 2000, usually by re-laxing sentences for low-level drug of-fenders. 63 Often the motivation hasbeen to ease the states’ financial bur-

Continued on p. 402

Former Rep. Patrick Kennedy, D-R.I., a recovering painkiller addict, played a key role in guiding the Parity Act to passage in 2008. Kennedy is mobilizingtreatment professionals and scientists into an alliance that will help determine

what is necessary for substance abuse treatment and what should be covered by health insurers. “We need early screening and

a checkup from the neck up once a year,” he says.

Get

ty Im

ages

/Chi

p S

omod

evill

a

no


At Issue:Should medication be used to treat addiction?yes

yesGEORGE KOLODNER, M.D.MEDICAL DIRECTOR OF KOLMAC CLINIC INMARYLAND AND WASHINGTON, D.C.

WRITTEN FOR CQ RESEARCHER, MAY 2014

m y decision to use medications beyond withdrawalmanagement to treat patients who suffer fromsubstance-use disorders is based on two sources.

First, the research literature consistently documents thatmedication improves treatment outcomes, reducing relapsesand deaths as well as increasing overall recovery.

Second, many patients I have treated over the past 40 yearscredit medications with having increased their ability to resist re-turning to addictive substances. They also report a dramatic re-duction in cravings, which — even more than withdrawal symp-toms — can lead to relapses. I repeatedly hear reports thatbuprenorphine makes my opioid-addicted patients feel “normal”rather than high. I find that it enables them to do the difficultpsychological work involved in recovery in a way that I rarelyencountered before the advent of that medication in 2003.

Antabuse, another drug, enables my alcoholic patients tomanage business situations and enjoy social occasions thatwould otherwise be high risk due to the presence of alcohol.

Medication is particularly important for people who chooseto begin treatment in an outpatient setting. That is becausethey are exposed daily to reminders about the substances aswell as to the actual substances at a time when they are justbeginning to learn how to live without them. Medication canalso be useful during continued treatment after discharge frominpatient care.

Addictions are best understood as chronic illnesses, similarto hypertension and diabetes, for which there is no cure. If,however, the illnesses are well managed — medications beinga part of this management — acute crises can be minimized.

It is important not to overvalue medication. The availablemedications play a supplementary role to nonpharmaceuticalapproaches and can be compared to the use of anesthesia.Surgery has been done without it, but most people would notmake that choice. On the other hand, to have the anesthesiawithout the surgery would be pointless. To be effective, med-ications must be used properly, including:

• In active collaboration with the patient, carefully supervised.• Following accepted dosage guidelines, individualized.• Prescribed in a way that minimizes diversion.• Continued for as long as useful to the recovery process,

with discontinuation being carefully monitored.Patients should not be required to take medications against

their will, but to not offer patients the choice is becoming aquestionable medical decision.no

RONALD E. SMITH, M.D., PH.DPSYCHIATRIST/PSYCHOANALYST IN PRIVATEPRACTICE IN VIRGINIA AND WASHINGTON,D.C.

WRITTEN FOR CQ RESEARCHER, MAY 2014

t he current zeitgeist in addiction treatment involves twodifferent perspectives on the origins and definition of ad-diction and treatment.

The “medication first” group, usually physicians — who,incidentally, make their living by prescribing medication —views addiction as primarily a brain molecular problem. These“neuropsychopharmacologists” prescribe “medications” to alterbrain chemistry so addicts won’t use “illegal drugs” to altertheir own brain chemistry.

The “meetings first” group sees addiction as a craving, a sus-tained drive to fill a void, whether it’s psychological, physical orspiritual. Treatment involves love, service and a capacity forconcern for others. This group would first acknowledge that lifeis painful, indeed miserable, at times, and this misery may beused as energy to make us grow, reach out to others and servethem. This is the basis of the self-help movement AlcoholicsAnonymous. Suffering is relieved primarily by love and service.

The medication-first group has great support from Big Phar-ma, the American Medical Association and the American Psy-chiatric Association. The economic forces driving the medica-tion of the culture are formidable. The promise of faster reliefof psychic pain by medication avoids the suffering involved inself-help meetings, 12-step work and caring for others. Instead,front and center is the therapist-patient responsibility to findthe right medication to treat brain chemistry imbalance.

The meetings-first group supports Sigmund Freud’s observa-tion that work, love and responsibility are three of life’s mostimportant areas. Those in the meetings-first group also areconcerned about overmedication and the danger of a “numbingof America.” Their emphasis on the responsibility to createmeaning in one’s life, serve others and make restitution is notpopular in a zeitgeist where addiction is a molecular problem.

Meetings and medications both have roles. In a culture ofmaterialism enamored with technology, though, where mostpeople spend their waking hours relating to photons on acomputer screen, medications will probably prevail.

However, should the recovering addict trade “alive, responsibleand uncomfortable” for medications that make him “numb andhappy?” Each addict ultimately must answer this question for him-self. Prayerfully, we can hope the economic forces of Big Pharmaand organized medicine will not overwhelm the soft voices ofthe 2 million men and women in recovery in Alcoholics Anony-mous, Rational Recovery and other effective self-help movementsthat get very little press because they are, after all, free.

402 CQ Researcher

den of building and maintaining largeprisons, and in some cases due to courtorders to halt prison overcrowding.

Even though many states are re-vising their mandatory sentencing laws,the ACLU’s McCurdy says, “It’s hugelyimportant for the attorney general ofthe United States to be looking at whowe are putting in federal prison. Itsends a signal.”

But the signal may not reach Con-gress. McCurdy says, “Like most things inD.C., the question is whether it will hap-pen on the [Republican-controlled] Houseside.” A Senate committee has approveda sentencing bill, but it has not yet comeup for a vote in the full Senate. 64

As with some other issues, the Obamaadministration is working around Con-gress. In 2011, Holder asked U.S. attor-neys not to charge low-level drug of-fenders with crimes that carry mandatoryprison sentences. 65 In December, Pres-ident Obama commuted the sentencesof eight people with crack cocaine con-victions who had already served longsentences. 66 And in January, the Jus-

tice Department announced it was ask-ing defense attorneys to help the gov-ernment locate prisoners who want toapply for clemency. 67 Now, the JusticeDepartment is expanding that effort,saying it will canvass the federal prisonpopulation, seeking nonviolent felonswho were convicted under tougher sen-tencing laws of the past and who willqualify for clemency. 68

But some proponents of sentenc-

ing reform oppose reducing manda-tory minimum sentences for drug deal-ers. “We shouldn’t allow people to selldrugs to my kids,” says Kennedy. “Iwant them locked up.”

McCurdy says under the proposedfederal legislation, minimum sentenceswouldn’t go away, but the length oftime served would be halved for mostdrug crimes.

Buprenorphine Access

B uprenorphine, the opiate most fre-quently prescribed for people ad-

dicted to heroin and prescription

painkillers, is being restricted by manystates intent on cutting costs, evenwhile it is keeping many addicts alive.

According to a new study, only 28states cover all three of the medica-tions that the FDA has approved foropioid addiction treatment: methadone,buprenorphine and naltrexone. 69

The study also found that most stateMedicaid agencies, even those that coverall three medications, are placing re-strictions on access. For example, as ofMay 2013, 11 states had implementedlifetime limits on prescriptions forbuprenorphine for treatment of opioiddependence. 70

With the United States facing a surgein heroin and prescription drug over-doses, depriving opiate addicts of thesemedications could worsen the death toll.According to the Centers for Disease Con-trol and Prevention (CDC), prescriptiondrug overdoses killed more than 16,000people in 2010. 71 In the same year, hero-in overdoses rose to more than 3,000. 72

“Now that we finally have medica-tions that are shown to be effective andcost-effective, it is shameful to throw uproadblocks to their use,” said Mady Chalk,director of the Center for Policy Re-search and Analysis at the TreatmentResearch Institute in Philadelphia. 73

Buprenorphine, like methadone, is asubstitute for heroin and opioid painkillers.“Bupe” is easier to take because it doesnot require going to a clinic. A doctorapproved by the Drug Enforcement Ad-ministration (DEA) can prescribe it. Itdoes not cure addiction, but it preventscravings and is hard to overdose on. Pa-tients report an initial rush that quicklywears off and then they just feel normal.Many physicians trained in addiction med-icine say the ideal treatment for heroinaddicts is a combination of buprenor-phine, psychotherapy and 12-step groupsor other support systems.

Some 940,000 addicts were pre-scribed buprenorphine in 2012, ac-cording to the government’s SubstanceAbuse and Mental Health Services Ad-ministration (SAMHSA).

TREATING ADDICTION

Continued from p. 400

Neuroscientist Nora Volkow, director of the National Institute on Drug Abuse,says that addiction is caused by a combination of genetic, biological and

psychosocial factors. “Fifty percent of the vulnerability to drugs is genetic,” or inherited, she says.

Get

ty Im

ages

/Blo

ombe

rg/J

oshu

a R

ober

ts


Vermont and Maine, two states hithard by heroin and prescription drugoverdoses, are among the states re-ducing access to buprenorphine.

Maine has imposed a two-year capon prescriptions of either buprenorphineor methadone for opiate addicts receiv-ing benefits through MaineCare, the state’sMedicaid program. In his State of theState address earlier this year, Maine’sRepublican governor, Paul LePage, pro-posed hiring four new drug prosecutors,four new judges for drug courts and 13new employees in the Maine Drug En-forcement Agency. 74

Although Vermont aims to step uptreatment for addicts, it intends to cutback on buprenorphine by loweringthe number of patients an individualdoctor can treat with the medicine,says Chen, the state’s health commis-sioner. The federal limit is 100.

Medicaid patients are among thepoorest in the country and, in Ver-mont, most addicts in treatment arereceiving Medicaid, says Chen.

Gitlow, head of the American Soci-ety of Addiction Medicine, says it’s allabout money. “Until 10 years ago, opi-oid dependence was cheap for the states.”He says methadone, which was the onlyopiate substitute, was inexpensive.

When buprenorphine came along in2003, he says, “a doctor could prescribeit in his office. But it was expensive. Thestates felt they had to do something todeal with” the rising costs.

OUTLOOKVaccines, Genetics

I n five to 10 years, addiction treat-ment will be very different, some

scientists hope.At the National Institute on Drug

Abuse, researchers are working to de-velop vaccines against nicotine and co-

caine. These are not traditional vaccinesin that they would not prevent addic-tion. When injected, they would gen-erate antibodies that prevent thosedrugs from reaching the brain. So far,the vaccines are in clinical trial but, saysNIDA director Volkow, they have notproduced a strong enough reaction inthe patients to get FDA approval.

The vaccines would not stop addictsfrom snorting cocaine, for example, butscientists say if the injections stoppedthe drug from reaching the brain andaddicts couldn’t get high, eventually theywould tire of using the drug.

There are no vaccines under devel-opment that would prevent addiction,says Volkow. “I don’t know when we willhave a vaccination against addictions,” shesays, “and I don’t think in five to 10 yearswe will have cures for addiction.”

Gitlow of the American Society ofAddiction Medicine says the way outof addiction is through genetic engi-neering. “The goal in my mind is to fixthe genetic abnormality. I don’t knowif that would fix the problem of peo-ple relating to other individuals. But thecure is biological, genetic,” he says.

But vaccines and genetic engineer-ing aren’t an option yet. White, thehistorian of addiction in America, sayshe hopes the standard treatment foraddiction will include prevention, earlyscreening and long-term after-care thathelps defeat recurrences, as with cur-rent treatments for diseases such asdiabetes and heart ailments. Today,about half of addiction patients relapseshortly after a 28-day stay in residen-tial treatment. Long-term care couldmake a difference, White says.

White is leading a project in Penn-sylvania and Michigan to train primary-care physicians to do frequent “recoverycheckups” on patients who have beendischarged from treatment. “After fiveyears, the risk of falling out of recoveryis 15 percent,” he says, versus a muchhigher risk if support ends earlier.

White also has been training primary-care physicians to identify patients who

are at risk for addiction or are alreadyabusing drugs.

“We’ve been training physicians inscreening, brief interventions and refer-ral to treatment. If we’re successful, thatwill be in place in five to 10 years.”

For opiate addicts trying to stayaway from heroin and prescriptionpainkillers, there likely will be im-proved versions of buprenorphine inthe coming years. Although the FDAhas not approved a buprenorphine im-plant that would release the medicineunder the skin for six months, it re-cently approved a new buprenophinepill produced by the company Orexo.Orexo says its buprenorphine, Zubsolv,is an improvement over Suboxone be-cause a lower dose achieves the sameeffect and it has a menthol flavor thatpatients in a clinical trial liked.

Kolodner of the Kolmac Clinic pre-dicts that in five to 10 years, the Amer-ican Psychiatric Association will classifymore behaviors as addictions. In addi-tion to dependence on alcohol, opioids,sedatives, marijuana, cocaine, ampheta-mines and nicotine, gambling was re-cently added to the official diagnosticmanual as an addiction. Bulimia andother eating disorders, shopping, hoard-ing and sex addiction could be next, hesays. Some treatment centers are alreadytreating people with eating disorders.

Seppala says intensive outpatient treat-ment will become the accepted stan-dard of care. Hazelden, which is knownfor its residential program in Minneso-ta, has already opened several intensiveoutpatient centers across the United States.

“Often, insurance will not pay forresidential, but it will pay for inten-sive outpatient treatment,” he says.

The population of people needingtreatment is expected to surge by 2020as America’s baby boom generation ages,according to government researchers.Americans born between 1946 and 1970used alcohol and drugs more than oldergenerations, the researchers point out.They wrote, “The number of adults age50 and older who will need treatment

404 CQ Researcher

TREATING ADDICTION

for a substance abuse problem will growto 4.4 million in 2020, compared to 1.7million in 2000 and 2001.” 75

Notes

1 Michael Schwirtz, “Hoffman Killed by ToxicMix of Drugs, Official Concludes,” The NewYork Times, Feb. 28, 2014, http://tinyurl.com/lq7fc89.2 “The Economic Impact of Illicit Drug Useon American Society,” U.S. Department of Jus-tice National Drug Intelligence Center, April2011, http://tinyurl.com/krqylkf; “CDC reportsexcessive alcohol consumption cost the U.S.$224 billion in 2006,” Centers for Disease Con-trol, Oct. 17, 2011, http://tinyurl.com/3ggh9qo.3 “Results from the 2012 National Survey onDrug Use and Health: Summary of Findings,”U.S. Department of Health and Human Services,September 2013, http://tinyurl.com/m947kbp.4 Ibid.5 “Fact Sheets: Alcohol Use and Health,” Cen-ters for Disease Control and Prevention,March 14, 2014.6 “Results from 2012 national survey,” op. cit.7 “DrugFacts: Heroin,” National Institute on DrugAbuse, April 2013, http://tinyurl.com/mr4btw7.8 “Five Things to Know About Opioid Over-doses,” Office of National Drug Control Policy,Feb. 11, 2014, http://tinyurl.com/kj5jqhz.9 “Opioids drive continued increase in drugoverdose deaths,” CDC Newsroom, Centers forDisease Control and Prevention, Feb. 2, 2013,www.cdc.gov/media/releases/2013/p0220_drug_overdose_deaths.html.10 “Attorney General Holder, Calling Rise inHeroin Overdoses Public Health Crisis, VowsMix of Enforcement, Treatment,” Departmentof Justice Public Affairs, March 10, 2014, http://tinyurl.com/mp92x7r.

11 Brian MacQuarrie and Martin Finucane, “Withheroin overdoses on the rise, Gov. Deval Patrickdeclares public health emergency in Mass.,” TheBoston Globe, March 27, 2014, http://tinyurl.com/mqb6v6s.12 David Sheff, Beautiful Boy (2008).13 Ben Cimons, “A suburban heroin addict de-scribes his brush with death,” The WashingtonPost, Feb. 10, 2014, http://tinyurl.com/nygjlxs.14 “Drug Facts: High School and Youth Trends,”National Institute on Drug Abuse, January2014, http://tinyurl.com/7oass4y.15 Office of National Drug Control Policy,www.nsjrs.gov/ondcppubs/publications/pdf/marijuana_myths_facts.pdf.16 “Results from the 2012 National Survey onDrug Use and Health: Summary of Findings,”op. cit.17 Sari Horwitz, “Justice Department preparesfor clemency requests from thousands of in-mates,” The Washington Post, April 21, 2014,http://tinyurl.com/k2jrvbk.18 Brady Dennis, “FDA Approves Device toCombat Opioid Drug Overdose,” The Washing-ton Post, April 3, 2014, http://tinyurl.com/kwvq9jp.19 Lance Dodes and Zachary Dodes, The SoberTruth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry (2014).20 “The Twelve Steps of Alcoholics Anony-mous,” Alcoholics Anonymous World ServicesInc., undated, http://tinyurl.com/c4dkzk; “Originof the Serenity Prayer: A Historical Paper,” July30, 2009, http://tinyurl.com/kcgnov4. A commonversion of the Serenity prayer is, “God grant methe serenity to accept the things I cannot change,the courage to change the things I can, and thewisdom to know the difference.”21 David Sheff, Clean (2013), p. 207.22 Bankole A. Johnson, “We’re addicted torehab. It doesn’t even work,” The WashingtonPost, Aug. 8, 2010, http://tinyurl.com/2fccj4a.23 Dodes and Dodes, op. cit.24 Marica Ferri, Laura Amato and Marina Davoli,“Alcoholics Anonymous and other 12 step Pro-

grammes for Alcohol Dependence,” CochraneDatabase of Systematic Reviews, 2006, 3, http://tinyurl.com/nyf9d9s.25 Lee Ann Kaskutas, “Alcoholics AnonymousEffectiveness: Faith Meets Science,” Journal ofAddictive Diseases, 2009, 28: 145-157.26 Ibid.27 Marvin Seppala, “Hazelden Pioneers Treat-ment for the Opiod Epidemic,” The HazeldenFoundation, November 2012, http://tinyurl.com/ku49n2a.28 Ibid.29 “Results from the 2012 National Survey onDrug Use and Health: Summary of Findings,”Department of Health and Human Services,op. cit.30 Ibid.31 Linnae Hutchison and Craig Blakely, “Sub-stance Abuse — Trends In Rural Areas,” TexasA&M Health Science Center, 1999, http://tinyurl.com/l3uhyfb.32 Robert L. DuPont, et al., “Setting the Stan-dard For Recovery: Physicians’ Health Pro-grams,” Journal of Substance Abuse Treatment,March 2009, Vol. 36, Issue 2, pp. 159-171,http://tinyurl.com/k9frfok.33 William L. White, Slaying the Dragon: TheHistory of Addiction Treatment and Recoveryin America (1998).34 Oxford English Dictionary, http://tinyurl.com/asrvx.35 White, op. cit., p. 2.36 Ibid., pp. 64-71.37 Ibid., p. 93.38 National Archives, “Constitution of the Unit-ed States,” http://tinyurl.com/5ahhq6.39 Alcoholics Anonymous, “Origins,” http://tinyurl.com/l2rva43.40 Library of Congress, “Books That ShapedAmerica,” 2012, http://tinyurl.com/mx4vr2c.41 White, op. cit., p. 135.42 “The Minnesota Model,” Hazelden, undat-ed, http://tinyurl.com/lpg2sfn.43 Daniel J.. Anderson, John P. McGovern andRobert L. DuPont, “The Origins of the Min-nesota Model of Addiction Treatment, a FirstPerson Account,” Journal of Addictive Diseases,1999, Vol. 18, Issue 1, pp. 107-114, http://tinyurl.com/l4wf8pp.44 For background, see Mary H. Cooper, “Drug-Policy Debate,” CQ Researcher, July 28, 2000,pp. 593-624.45 Ibid.46 For background, see the following CQ Re-searchers: Margaret Edwards, “MandatorySentencing,” May 26, 1995, pp. 465-488; PatrickMarshall, “Three-Strikes Laws,” May 10, 2002,

About the AuthorJane Friedman is a writer/reporter based in Chevy Chase,Md. She was a foreign correspondent for 16 years with post-ings in Paris for Newsweek and in Jerusalem and Cairo forCNN. Her work has also appeared in The New York Times,The Washington Post and The Christian Science Monitor.She graduated from the University of Pennsylvania with a degreein political science. She is at work on a memoir tentativelytitled The Diamond Dealer’s Daughter.


pp. 417-432; and David Masci, Prison-BuildingBoom,” Sept. 17, 1999, pp. 801-824.47 “The Verdict Is In: Drug Courts Work,” fromthe National Association of Drug Court Profes-sionals, www.nadcp.org/learn/drug-courts-work-0.48 “The National Drug Control Budget, FY2014 Funding Highlights,” Executive Office ofThe President of the United States, www.whitehouse.gov/sites/default/files/ondcp/about-content/fy_2014_drug_control_budget_highlights.pdf.49 George H. W. Bush, “Presidential Address onNational Drug Policy,” Sept. 5, 1989, http://tinyurl.com/mp7lrm6.50 Laurie Wermuth, “Methamphetamine use:hazards and social influences,” Journal of DrugEducation, 2000, Vol. 30, Issue 4, pp. 423-433,http://tinyurl.com/lsll6xy.51 For background, see Peter Katel, “RegulatingPharmaceuticals,” CQ Researcher, Oct. 11, 2013,pp. 861-884.52 “Rescheduling of Hydrocodone CombinationProducts from Schedule III to Schedule II,” Of-fice of Diversion Control, Department of Justice,Drug Enforcement Administration, www.DEAdiversion.usdoj.gov/fed_regs/rules/2014/fr0227.htm.53 Jim Dryden, “OxyContin Formula ChangeHas Many Abusers Switching to Heroin,” Wash-ington University in St. Louis, July 11, 2012,http://tinyurl.com/oflt3sa.54 Deborah Sontag, “Addiction Treatment Witha Dark Side,” The New York Times, Nov. 17, 2013,http://tinyurl.com/k747uck.55 The Mental Health Parity and AddictionEquity Act, http://tinyurl.com/lk3pmw9.56 Matt Apuzzo, “Justice Dept. Starts Quest ForInmates to Be Freed,” The New York Times,Jan. 30, 2014, http://tinyurl.com/nbgc3cv. Forbackground, see also, Sarah Glazer, “Sen-tencing Reform,” CQ Researcher, Jan. 10, 2014,pp. 25-48.57 The Sentencing Project, “Incarceration,”http://tinyurl.com/lwdornm.58 Julia Edwards, “U.S. to expand clemencycriteria for drug offenders,” Reuters, April 21,2014, http://tinyurl.com/lojg2zu.59 Matt Apuzzo, “Holder Endorses Proposalto Reduce Drug Sentences in Latest Sign ofShift,” The New York Times, March 13, 2014, http://tinyurl.com/n5fqc29.60 “Attorney General Holder Urges Changesin Federal Sentencing Guidelines to ReserveHarshest Penalties for Most Serious Drug Traf-fickers,” Testimony to Sentencing Commission,Department of Justice Office of Public Affairs,March 13, 2014, http://tinyurl.com/kfhpx87.61 Ibid.

62 “America’s Prison Population: Who, What,Where and Why,” The Economist, March 13, 2014,http://tinyurl.com/lznd3nn. Peter Wagner andLeah Sakala, “Mass Incarceration: The WholePie: A Prison Policy Initiative Briefing,” PrisonPolicy Initiative, March 12, 2014, www.prisonpolicy.org/reports/pie.html.63 Glazer, op. cit.64 “Bill Summary and Status, 113th Congress(2013-2014) S.1410,” Library of Congress, updat-ed March 11, 2014, http://tinyurl.com/md9mklnc.65 “Attorney General Holder Urges Changesin Federal Sentencing Guidelines to ReserveHarshest Penalties for Most Serious Drug Traf-fickers,” op. cit.66 Charlie Savage, “Obama Commutes Sentencesfor 8 in Crack Cocaine Cases,” The New YorkTimes, Dec. 19, 2013, http://tinyurl.com/jvpkqp2.67 “Justice Dept. Starts Quest for Inmates tobe Freed,” op. cit.68 Matt Apuzzo, “Justice Dept. Expands Eli-gibility for Clemency,” The New York Times,April 23, 2014, http://tinyurl.com/kd2gk8j.69 Michael Ollove, “Painkiller Addicts Hit

Medicaid Limits,” Pew/Stateline, July 6, 2013,http://tinyurl.com/k48p5jv.70 Suzanne Gelber Rinaldo, PhD; David W.Rinaldo, PhD, “Availability Without Accessibility?State Medicaid Coverage and AuthorizationRequirements for Opioid Dependence Med-ications,” The Avisa Group, 2013. Preparedfor the American Society of Addiction Med-icine, http://tinyurl.com/khep2cm.71 Centers for Disease Control and Prevention,“Opioids drive continued increase in drug over-dose deaths,” Feb. 20, 2013, http://tinyurl.com/bzw6f36.72 “5 Things to Know about Opioid Overdoses,”Office of National Drug Control Policy, Feb. 11,2014, http://tinyurl.com/kj5jqhz.73 Ollove, op. cit.74 Eric Russell, “Drug treatment funding inMaine is falling but demand is greater thanever,” Portland Press Herald, Feb. 23, 2014,http://tinyurl.com/k4vasar.75 “More Americans Will Need Substance AbuseTreatment by 2020,” Substance Abuse and Men-tal Health Services Administration,” 2003,http://tinyurl.com/m5j9ksr.

FOR MORE INFORMATIONAlcoholics Anonymous, P.O. Box 459, Grand Central Station, New York, NY 10163;212-870-3400; www.aa.org. Website offers detailed information about the 12-step pro-gram, where to get AA literature and how to find a meeting.

Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333;800-232-4636; www.cdc.gov. Government research center that provides informationabout alcohol and drug addiction, including prevention, treatment and recent data.

Henry J. Kaiser Family Foundation, 2400 Sand Hill Rd., Menlo Park, CA 94025;650-854-9400; www.kff.org. Focuses on health care issues facing Americans, in-cluding drug addiction and health coverage.

National Center on Addiction and Substance Abuse at Columbia University,CASAColumbia, 633 Third Ave., 19th Floor, New York, NY 10017-6706; 212-841-5200; www.casacolumbia.org. Has done groundbreaking studies on addiction andtreatment for addiction.

National Institute on Alcohol Abuse and Alcoholism, 9000 Rockville Pike, Bethes-da, MD 20892; 888-696-4222; www.niaaa.nih.gov. The government’s primary agency re-sponsible for biomedical and health-related alcoholism research; website contains infor-mation on alcohol abuse, alcoholism and the latest news about the disease.

National Institute on Drug Abuse, 6001 Executive Blvd., Rockville, MD 20852;301-443-1124; www.drugabuse.gov. The government’s primary agency responsiblefor biomedical and health-related opioid abuse research; website contains informa-tion on research regarding drug abuse, available treatments and statistics onwhich groups use which illicit drugs.

The Partnership at Drugfree.org, 352 Park Ave. South, 9th Floor, New York,NY 10010; 212-922-1560; www.drugfree.org. Nonprofit group that provides infor-mation for parents about how to help prevent children from turning to drugs andhow to find treatment; has a hotline for immediate advice.

FOR MORE INFORMATION

406 CQ Researcher

Selected Sources

BibliographyBooks

Lawford, Christopher Kennedy, Recover to Live, BenBellaBooks, 2013.A recovered addict and member of the extended Kennedy

clan provides an encyclopedic look at addictions — includ-ing addictions to alcohol, drugs and pornography — and thelatest treatments.

Sheff, David, Beautiful Boy: A Father’s Journey ThroughHis Son’s Addiction, Houghton Mifflin Co., 2008.The author, a journalist, describes his son’s addiction to

methamphetamine.

Sheff, David, Clean: Overcoming Addiction and EndingAmerica’s Greatest Tragedy, Houghton Mifflin Harcourt,2013.Sheff, author of the memoir Beautiful Boy, examines different

treatments for overcoming addiction.

White, William, Slaying the Dragon: The History of Addic-tion Treatment and Recovery in America, Chestnut HealthSystems, 1998.White, a long-time researcher on addiction, has written what’s

considered a must-read on the history of addiction.

Articles

Ollove, Michael, “Painkiller Addicts Hit Medicaid Limits,”Pew/Stateline, July 6, 2013, http://tinyurl.com/lyyhubh.To save money, many states have restricted buprenorphine

prescriptions to addicts receiving Medicaid, including imposingpreauthorization requirements and lifetime caps.

Seelye, Katharine Q., “Heroin in New England, MoreAbundant and Deadly,”The New York Times, July 18, 2013,http://tinyurl.com/jvgu754.Young heroin addicts in Maine talk about their addictions.

Sontag, Deborah, “Addiction Treatment With a Dark Side,”The New York Times, Nov. 17, 2013, http://tinyurl.com/k747uck.Buprenorphine has both up and down sides.

Sontag, Deborah, “At Clinics, Tumultuous Lives and Tur-bulent Care,” The New York Times, Nov. 18, 2013, http://tinyurl.com/katqp5h.Two physicians dispensing buprenorphine to opiate patients

have different approaches.

Zuger, Abigail, “A General in the Drug War,” The NewYork Times, June 13, 2011, http://tinyurl.com/knz5c7d.Neuroscientist Nora Volkow, director of the National Institute on

Drug Abuse, has spent her career studying addiction.

Studies and Reports

“The Mental Health Parity and Addiction Equity Act,”Centers for Medicare and Medicaid Services, undated,http://tinyurl.com/lk3pmw9.The U.S. Department of Health and Human Services ex-

plains the provisions of the Mental Health Parity law.

“Prescription Drug Overdoses at Epidemic Levels,” Centersfor Disease Control and Prevention, Nov. 1, 2011, http://tinyurl.com/3pnfh93.Addiction to prescription painkillers has become the main

cause of drug overdoses in recent years.

“Principles of Drug Addiction Treatment: A Research-Based Guide (Third Ed.),”National Institute on Drug Abuse,2012, http://tinyurl.com/7v5t7jg, www.drugabuse.gov/publications/principles-drug-addiction-treatment.The nation’s top drug addiction research arm lays out a

list of principles for drug addiction treatment.

Collins, Gregory B., and Jason M. Jerry, “Medication-as-sisted treatment of opiate dependence is gaining favor,”Cleveland Clinic Journal of Medicine, June 2013, http://tinyurl.com/ltfpk2z.Physicians at a prestigious clinic’s Alcohol and Drug Re-

covery Center provide a short history of medication-assistedtreatment for opiate addiction.

Csete, Joanne, Richard Parker and Nancy Worthington,“Rethinking the War on Drugs: The Impact of US DrugControl Policy on Global Public Health,” Columbia Uni-versity Mailman School of Public Health, March 2010,http://tinyurl.com/k3lwh4y.Public health researchers describe long-running U.S. policies

to deal with the supply of drugs rather than the demand, andsuggest ways the country could shift its drug policy focus.

Marlowe, Douglas B., “Research Update on Adult DrugCourts,” National Association of Drug Court Professionals,December 2010, http://tinyurl.com/m937hdr.The chief of science, law and policy for an association of

drug courts professionals examines the courts’ success ratein curbing drug use and crime.

Rinaldo, Suzanne Gelber, and David W. Rinaldo, “Avail-ability Without Accessibility? State Medicaid Coverageand Authorization Requirements for Opioid DependenceMedications,”The Avisa Group, 2013, www.asam.org/docs/advocacy/Implications-for-Opioid-Addiction-Treatment.In a report prepared for the American Society of Addiction

Medicine, researchers who have advised the federal government,states and counties on substance abuse initiatives studied ad-diction to opiate painkillers across the 50 states.


Buprenorphine

Elbow, Steven, “Suboxone might be the most effective wayto beat heroin addiction. So why is it so hard to get?”The Capital Times (Madison, Wisc.), April 9, 2014, http://tinyurl.com/msmnmqj.The drug Suboxone, a combination of buprenorphine and

naloxone, is said to be extremely effective in helping ad-dicts kick their opiate habits, but it is difficult to obtain be-cause of high costs, long waiting lists and the lack of doc-tors certified to prescribe it.

Lowry, Fran, “Take-Home Induction of BuprenorphineFeasible, Safe,”Medscape Medical News, April 16, 2014,http://tinyurl.com/mj4pq2w.Research study gave patients a one-week prescription of

buprenorphine, written instructions and telephone support andfound that unobserved induction — that is, a patient’s initialuse of the prescribed medication at home rather than in a doc-tor’s office — had very few adverse effects. That could helpclose the gap in treatment caused by the time-consumingprocess of administering initial doses of the drug in person.

Defining Addiction

“Addiction Now Defined As Brain Disorder, Not Be-havior Problem,” LiveScience, Aug. 15, 2011, http://tinyurl.com/3ryjy5l.The American Society of Addiction Medicine updates its de-

finition of addiction as a chronic brain disorder and not justa behavior problem involving alcohol, drugs, gambling or sex.

Kerr, David H., “Addiction Recovery Requires a PersonalCommitment first, Treatment second,” NJ.com, April 15,2014, http://tinyurl.com/loemoru.A recovery group leader says addiction is not a medical illness,

but a choice made by the person to begin using drugs.

Heroin

DiSalvo, David, “Why Is Heroin Abuse Rising While OtherDrug Abuse Is Falling?” Forbes, Jan. 14, 2014, http://tinyurl.com/muazokg.A reporter concludes heroin abuse is likely rising because

prescription drugs have become more expensive and harderto get, while heroin is cheaper and more available.

Elinson, Zusha, and Arian Campo-Flores, “Heroin Makesa Comeback,”The Wall Street Journal, Aug. 8, 2013, http://tinyurl.com/qfwkezv.Heroin use in the United States is becoming widespread,

with the number of people who say they have used hero-in in the past year increasing by 53.5 percent between 2002and 2011.

Miroff, Nick, “Tracing the U.S. heroin surge back southof the border as Mexican cannabis output falls,” TheWashington Post, April 6, 2014, http://tinyurl.com/p9jup5b.Mexican marijuana growers have converted their fields to

poppies to meet the growing U.S. demand for heroin.

Welsh-Huggins, Andrew, “Ohio sees record high heroinoverdose deaths,” The Associated Press, April 18, 2014,http://tinyurl.com/kb5cmaz.Heroin-related overdoses in Ohio increased from 426 deaths

to 680 from 2011 to 2012, a 37 percent increase, accordingto the state’s Department of Health.

Recovery Programs

DuPont, Robert, “Alcoholics Anonymous, the 12-StepFellowship: A Modern Miracle (Op-Ed),” LiveScience,March 28, 2014, http://tinyurl.com/ke8f5co.A psychiatrist says Alcoholics Anonymous offers a well-estab-

lished, sophisticated and effective path to recovery.

Flanagin, Jake, “The Surprising Failures of 12 Steps,”The Atlantic, March 25, 2014, http://tinyurl.com/mjb6vtc.A reporter analyzes why society considers Alcoholics

Anonymous a successful recovery program, despite researchshowing its limited success.

Heilig, Markus, “The right medicine for alcoholics,” TheWashington Post, Aug. 30, 2012, http://tinyurl.com/kqt5u2o.A physician scientist at the National Institutes of Health ar-

gues that medications like Naltrexone are more effective attreating alcoholism than 12-step programs such as AlcoholicsAnonymous.

The Next Step:Additional Articles from Current Periodicals

CITING CQ RESEARCHER

Sample formats for citing these reports in a bibliography

include the ones listed below. Preferred styles and formats

vary, so please check with your instructor or professor.

MLA STYLEJost, Kenneth. “Remembering 9/11.” CQ Researcher 2 Sept.

2011: 701-732.

APA STYLE

Jost, K. (2011, September 2). Remembering 9/11. CQ Re-

searcher, 9, 701-732.

CHICAGO STYLE

Jost, Kenneth. “Remembering 9/11.” CQ Researcher, Sep-

tember 2, 2011, 701-732.

ACCESSCQ Researcher is available in print and online. For access, visit yourlibrary or www.cqresearcher.com.

STAY CURRENTFor notice of upcoming CQ Researcher reports or to learn more aboutCQ Researcher products, subscribe to the free email newsletters, CQ Re-searcher Alert! and CQ Researcher News: http://cqpress.com/newsletters.

PURCHASETo purchase a CQ Researcher report in print or electronic format(PDF), visit www.cqpress.com or call 866-427-7737. Single reports startat $15. Bulk purchase discounts and electronic-rights licensing arealso available.

SUBSCRIBEAnnual full-service CQ Researcher subscriptions—including 44 reportsa year, monthly index updates, and a bound volume—start at $1,054.Add $25 for domestic postage.

CQ Researcher Online offers a backfile from 1991 and a number oftools to simplify research. For pricing information, call 800-818-7243 or805-499-9774 or email [email protected].

Upcoming Reports

In-depth Reports on Issues in the News

?Are you writing a paper?

Need backup for a debate?

Want to become an expert on an issue?

For 90 years, students have turned to CQ Researcher for in-depth reporting on issues inthe news. Reports on a full range of political and social issues are now available. Followingis a selection of recent reports:

School Discipline, 5/9/14 U.S. Global Engagement, 5/16/14 Online Journalism, 5/30/14

Civil LibertiesAbortion Debates, 3/14Voting Controversies, 2/14Whistleblowers, 1/14Religious Repression, 11/13Solitary Confinement, 9/12

Crime/LawRacial Profiling, 11/13Domestic Violence, 11/13Border Security, 9/13Gun Control, 3/13Improving Cybersecurity, 2/13

EducationHome Schooling, 3/14Homeless Students, 4/13Plagiarism and Cheating, 1/13

Environment/SocietyFuture of TV, 4/14Media Violence, 2/14National Parks, 1/14Big Data and Privacy, 10/13Future of the Arctic, 9/13Women and Work, 7/13Climate Change, 6/13

Health/SafetySynthetic Biology, 4/14Chemical & Biological Weapons, 12/13Lyme Disease, 11/13Domestic Drones, 10/13

Politics/EconomyWealth and Inequality, 4/14China Today, 4/14Youth Unemployment, 3/14Polarization in America, 2/14Resurgent Russia, 2/14Minimum Wage, 1/14

cqr treating addiction · 388 cq researcher me ntal health and substance abuse treat - ment as for...

Documents