Are We Just Floating Down the River?

I was just listening to an interview with an economist who was talking about the phenomenon of innovation coming in spurts. He said it's not just recently but has a lot of historical precedent. Recently we've had the computer/internet revolution, but before that we had a spurt that included electricity, cars and radio. Before that it was steam engines and railroad. I got his point, but I didn't understand why it was that way. Why couldn't progress be, well, progressive? Why did it happen in spurts? He had an explanation. He said that people don't like to innovate. His point was that we see spurts of innovation come out of bad times of inflation or deflation, but rarely while things are going along swimmingly. His exact words were, "Innovation is hard. When things are going well, people would rather just float along on down the river." As soon as he said it all the airplanes and cell phones left my head, and the first thing I thought about was addiction treatment.

It suddenly made sense to me. I've been trying to innovate in addiction treatment for over a decade. We've tried to innovate with cheaper forms of treatment like medically intensive IOP as a true alternative to inpatient care, but the insurance companies seem to feel more comfortable with cheap IOP and even more expensive inpatient. We've tried to innovate with genetic testing, but as soon as we asked patients to pay for it the $200 was too much, even for those who had spent $20K on 3 past rehabs, the last two of which could have been avoided. We've tried to innovate by creating a cognitive scoring system to see where people are in treatment and know exactly what they need next, but there doesn't seem to be much interest in anything other than the standard curriculum of treatment. We've tried to innovate by using computerized neurocognitive testing to help guide treatment but neither patient nor insurance company wants to pay for it even though it's got a great record. We've tried to innovate every way we could because we thought there should be a better way, and I couldn't understand why no one was interested. Now I do.

Times are good. If you open an addiction treatment center and do the same thing everyone else does, you get paid. If you need treatment and you go to the same kind of place everyone else does, you get the outcomes we all expect. If your child needs treatment you can send him to the "best treatment center" and everyone around you will feel sympathy and think you're a good parent. But, for me at least, there's something missing. And it explains why I feel the need to innovate. Current addiction treatment isn't coherent, and it doesn't produce good outcomes for the whole disease.

I probably should say what I mean by that, before all my colleagues start throwing darts. For decades we've been treating "substance abuse," and we've been treating it in a substance specific way. Alcoholics go to AA, narcotic addicts go to NA, etc. Even in more modern times, as medication has entered the picture we are still stuck in substance specific paradigms. Naltrexone is for opioids or alcohol, buprenorphine is for opioids, "there's no medication for cocaine dependence," etc. And gambling, sex, overeating, etc aren't even in the same section of the book, so we need to go to specific treatment for dual diagnosis substance dependence and eating disorders or a special treatment center that has a sexual addiction track. We've had this specific view of addiction for over a hundred years, and we've had solutions based on this basic assumption for that long and the problem is getting worse. And we're doing the same thing over and over. There ought to be a word to describe behavior like that.

That economist I was listening to was talking about how people never see a bubble until it has already popped. He was saying we never see the problem with doing the same thing everyone else is doing, even though there are people who will tell us that such things aren't going to turn out well. He made the point that at the pinnacle of the market average people are running in while sophisticated professionals are running out; the vast majority of people never see the drop coming, though the people working there every day do and are happy to sell to them. He likened it to a car that has driven off the cliff. The outcome is not in question, but for a brief period everyone feels like they're flying.

I wonder if we've reached such a point with addiction treatment and when we'll notice.