Tag Archives: Sober home

Why Isn’t Housing Deemed “Medically Necessary” in SUD Treatment?

I shock friends and colleagues from time to time by telling them that, “Did you hear…. from now on, insurance is no longer going to cover the cost of a hospital stay associated with any medical procedure, and that the costs of room and board while in post-surgical recovery all must come out of pocket.”

The look of incredulity and anger on their faces is priceless.

I entertain the discussion for a while and let it play out, enjoying listening to all of the justifications why that is abhorrent public policy (and equally bad health care).

Only afterwards, I take the time to tell them that, while I was joking, that it really isn’t a joke when it comes to mental health, behavioral health, and addiction treatment; that after detoxification (and for the lucky few, inpatient residential treatment), that the vast majority of people entering the drug and alcohol treatment space will be forcibly placed by their insurance carriers into an outpatient program but will not cover the necessary costs of a properly trained and supervised recovery residence.

At this point in my experience in this space, I am no longer surprised when they start to try to make a distinction.

However, in a news report that was admittedly surprising to me, HHS Secretary Alex Azar said in prepared remarks (as reported by ModernHealthcare.com) that Medicaid may soon allow hospitals and health systems to directly pay for housing, healthy food or other solutions for the “whole person.”

What?!?!

“What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford, nutritious food,” Azar said in a speech supported by the Hatch Foundation for Civility and Solutions and Intermountain Healthcare.

Azar said the Center for Medicare and Medicaid Innovation is looking “to move beyond existing efforts to partner with social services groups and try to manage social determinants of health as they see appropriate…. If that sounds like an exciting idea … I want you to stay tuned to what CMMI is up to.”

“We believe we could spend less money on healthcare—and, most important, help Americans live healthier lives—if we did a better job of aligning federal health investments with our investments in non-healthcare needs,” he said.  According to ModernHealthcare.com, Azar didn’t elaborate on when the model would be launched, but the program could help Medicaid enrollees who need housing.

Granted, the discussion related mostly to seniors, medically-necessary improvements to homes, and home health care visits:

“These interventions can keep seniors out of the hospital, which we are increasingly realizing is not just a cost saver but actually an important way to protect their health, too,” Azar said. “If seniors do end up going to the hospital, making sure they can get out as soon as possible with the appropriate rehab services is crucial to good outcomes and low cost as well. If a senior can be accommodated at home rather than an inpatient rehab facility or a [skilled nursing facility], they should be.”

Azar was focusing on the agency’s approach to social determinants a day after it was announced that CMS would begin allowing states to cover a broader range of mental health services under Medicaid.

Specifically, CMS would consider Medicaid demonstration waivers (referred to as a §1115 waiver) covering short-term stays for acute care provided in psychiatric hospitals or residential treatment centers in return for states expanding access to community-based mental health services (these proposals would waive the so-called institutions for mental diseases (IMD) exclusion, a section of the Medicaid law (within the Social Security Act) that prohibits the use of federal Medicaid funding for most inpatient psychiatric services).

“It is the responsibility of state and federal governments together, alongside communities and families, to right this wrong,” Azar said. “More treatment options are needed, and that includes more inpatient and residential options that can help stabilize Americans with serious mental illness.”

However, Azar is speaking to psychiatric illness, not Substance Use Disorders, which appear to remain the “ugly stepchild” of health care, generally.

Back in 2014, the State of Illinois asked the Centers for Medicare and Medicaid Services (CMS) for permission to spend $60 million in Medicaid funding to help vulnerable enrollees find and maintain stable housing, joining New York and counties in Minnesota and California in efforts to try to add housing to the list of healthcare services offered to chronically ill Medicaid patients.

Under the waiver, Illinois wanted to offer managed-care plans incentive payments for enrollees specifically with mental illness or substance abuse disorders to successfully find temporary or permanent stable housing.

New York unsuccessfully sought $75 million from the CMS to develop housing capacity for high-cost Medicaid enrollees. The state ended up removing the request from its pending Medicaid waiver. But New York continues to seek $75 million to help chronically homeless, mentally ill or otherwise vulnerable adults live independently. Assistance—including counseling, employment aid, legal and budget help and case management—would be directed at those with high Medicaid costs.

At the present time, CMS determined that waivers cannot be used to pay outright for housing. Instead, these state programs can pay for assistance in finding housing, providing home modifications, and educating beneficiaries about tenant rights.

However, CMS has paid rent for Medicaid beneficiaries in the past through grant programs. The “Money Follows the Person” (MFP) demonstration project that was launched in 2008 transitioned Medicaid enrollees from an institutional setting back into the community. 43 states including California, Texas, New Jersey, Ohio, New York, Georgia and the District of Columbia participated in the grant program. Florida opted out.

By the end of 2016, there were 9,995 participants. In 2008, 289 people participated in the demonstration, according to federal data.

Though that grant program expired on September 30, 2016, the authorizing legislation required that the Secretary of HHS provide for a national evaluation of the MFP demonstration and submit a final report to the president and Congress that presents the findings and conclusions of this evaluation.  That report can be found here.

The report concluded:

MFP also provides strong evidence of success at improving the quality of life of participants. After transitioning to the community, participants experience increases across all seven quality-of-life domains measured, and the improvements are largely sustained two years post-transition. The changes in the quality of life that occur when participants move to the community are remarkable and important indicators that this demonstration has had positive impacts on participants’ lives. Estimating the value of the quality-of-life improvements reported by MFP participants would be extremely difficult, and any dollar value placed on these improvements would not adequately reflect what it means for people with significant disabilities when they can live in and contribute to their local communities.

This reads like it was taken verbatim from The American Journal of Community Psychology’s 2013 study on “The Role of Recovery Residences in Promoting Long-Term Addiction Recovery Outcomes.”

However, it was not, and the need for more-than-adequate sober living accommodations for people in recovery from addiction should be at the top of the list when it comes to health care public policy.

As I said before, we would never make a heart surgery patient go find a hotel to recover in and we would never let insurance carriers refuse to pay for such accommodations.

Let’s hope that HHS Secretary Azar is picking up the mantle from his predecessor and continuing to move addiction treatment health care into the full medical health care continuum, rather than to accept society’s generalized and simplistic view that addicts choose to be addicts, and we should not spend valuable resources on saving their lives.

“We can support both inpatient and outpatient investments at the same time,” Azar said. “Both tools are necessary and both are too hard to access today.”

Confusion Over Sober Home Certification Spurs Misinformation Campaign in Florida

Prior to 2016, there was no law in Florida governing the relationship between sober homes and treatment programs.  Certification of recovery residences was voluntary, under the premise (and misunderstanding of legislative staffers in the State’s capitol in Tallahassee) that sober living and treatment programs were entirely separate creatures.

In other states, that may be the case and sober living has historically enjoyed an autonomy (such as the reputable Oxford House International charter model) which led to multitudes of success stories of people finding their own path to recovery and sustained sobriety.

But as Florida cemented itself as a “treatment destination”, the concept of the “sober home “ or “recovery residences” began to turn from an altruistic endeavor to a concern over where and how to house patients while they were in treatment.

By coming to Florida for treatment, patients clearly need a place to stay when not in clinical session. Under the “Florida Model” of outpatient services favored by insurance carriers and as adopted by Florida law under the “Partial Hospitalization” (PHP) level of care, housing is to be provided by the treatment provider.

For many years, the PHP model worked quite well and it simply made sense that a patient needed to be provided a place to sleep that was safe, secure, and drug/alcohol free. “Recovery support services” within the home were never required.

These homes, referred to as the “Community Housing” component of a “Day or Night Treatment with Community Housing” license, may or may not provide any form of peer-supported living. It is at the discretion of the provider.

And that is where the problem comes in, as far as the Fair Housing Act is concerned. Such a home is, by all definitions, a “house,” but is it a “boarding house?” A “dormitory?” A “hotel for addicts” while in treatment?

The Fair Housing Act (FHA) only protects “dwellings.”  It also protects the right of all persons to “choose their own ‘home’.”

The FHA does supersede local zoning codes that wrongfully differentiate between homes for people related by blood or marriage and homes where people live “as the functional equivalent of a biological family” that has a known therapeutic benefit.  The FHA and ADA, however, does not allow a Recovery “Bed & Breakfast” to exist wherever it wants to.

For the past 40+ years in Florida, there have been and continue to be numerous “stand alone” sober living environments (many in Delray Beach, for instance) that have faithfully served as the lifeline between newfound sobriety and living a life in recovery, surrounded by a “recovery community”.  The NY Times even lauded Delray Beach for being “an oasis of sobriety” for long-term sober living and support, calling Delray Beach a Recovery Capitol [“Delray Beach, a funky outpost of sobriety between Fort Lauderdale and West Palm Beach, is the epicenter of the country’s largest and most vibrant recovery community, with scores of halfway houses, more than 5,000 people at 12-step meetings each week, recovery radio shows, a recovery motorcycle club and a coffeehouse that boasts its own therapy group.”].

Those were “recovery residences” to be rightfully protected by the FHA.

But as the Pill Mill Epidemic became replaced with the Opioid Epidemic across the country, people quickly flocked to Google and other informational websites to try to find out what “sobriety” was and where to find it.

Newly-christened addiction treatment entrepreneurs, due in large part to the Great Recession of 2008, began snapping up residential real estate across Southeast Florida in order to provide these supposed “sober living homes” to meet the growing demand.

Then, with the passage of the Patient Protection and Affordable Care Act of 2010, the requirement that insurance carriers pay health care benefits to include addiction treatment fueled the growth of the industry. However, the barrier to entry was (and remains) rather low, and the housing component remains a necessary part in order to have somewhere to “keep” patients while not providing them with clinical services.

Thus, the “Sober Home” problem began as boarding houses for people brand-new to recovery replaced reputable sober living.

In addition, some newer providers of PHP level of services decided to market their housing as the selling point for coming to South Florida; clinical services were secondary, if mentioned at all. To that point, the only requirement to enjoying such a [free] life of leisure was attendance at the housing provider’s off-site clinical treatment location.

This new reality caused local elected officials to plea to the federal government to revisit the Fair Housing Act and the Americans with Disabilities Act, stating that those laws never intended for residential neighborhoods to become de facto hospital districts for persons just released from post-relapse Detoxification services and newly placed into PHP programs. At a minimum, they argued, there should be some modicum of standard for such housing no different than Assisted Living or any other form of supervised group living arrangement.  Stated otherwise, the FHA and ADA do not trump those regulations; why does sober living associated with a treatment program get a free pass?

To begin to bring some level of objectivity to the field, the Florida Association of Recovery Residences (FARR), a sister-organization to the National Alliance of Recovery Residences (NARR), began to seek voluntary certification of sober living residences so that the established homes could differentiate themselves from the new upstarts.

And by 2015, the Florida Legislature elected to formalize that process by directing DCF to identify an entity to credential Recovery Residences.  While voluntary in nature, all licensed treatment providers could not make any refer to a sober living residence if that home was not certified.

Being the only game in town, FARR applied to be the credentialing agency and was thereafter delegated the authority to serve in that administrative capacity.

However, the problem of unregulated sober homes only continued to flourish, as the clear nexus between the locations of overdose deaths and unregulated “sober homes” became abundantly clear.

More had to be done, and faster.

By 2016, the Florida Legislature asked the Palm Beach County State Attorney’s Office to begin conducting a fact-finding mission to determine, fairly and objectively, what was actually “happening on the ground.”

The results were mind-blowing.

After a Grand Jury investigation and report from the separate Sober Homes Task Force Proviso Committee found rampant fraud and abuses of patients by the treatment, housing and marketing industries, further laws were recommended and ultimately adopted.

These new laws, adopted in 2017, sought amongst other protections to clarify unequivocally that treatment centers and sober living residences were regulated by different entities, and that any referral to any sober living residence by a treatment center, whether owned by the treatment center or not, was now to be regulated.

As of July 1, 2018, all sober living residences to which treatment centers were to make a referral of any type had to be certified.

In order to address the long-standing relationship between treatment providers and housing components under the PHP level of care, the Florida Legislature gave all providers until July 1, 2018 (a full year) to become certified.

The reason for the year-long delay was for purposes of fundamental fairness – treatment providers needed to both have their sober living residences certified by FARR as well as secure the services of a Certified Recovery Residence Administrator (CRRA) through approval  by the Florida Certification Board.

Even then, the statute provides that DCF may only begin fining violations as of June 2019.

Still, notwithstanding the well-publicized passage of this law in early 2017 and its signature by Governor Rick Scott by May of that year, many providers continued to claim confusion, based upon misinformation circulated by “consultants” or typical “word of mouth” rumors which are all-too-rampant in the addiction treatment space.

Still, many providers DID follow the law and sought FARR certification long before the deadline of July 1st.

One such provider was Amethyst Recovery Center in St. Lucie County, Florida.

However, Amethyst was ultimately denied FARR certification for its recovery residences, clearly compromising its ability to continue its PHP program.

In response, attorneys for Amethyst filed what is referred to as a “Petition for Declaratory Statement” with DCF, seeking clarification as to whether the housing component of a PHP program must be FARR certified.

Most recently, DCF issued a clearly worded notice on May 29, 2018 to all providers, reaffirming the plain language of the statute that any referral to made to any non-FARR certified recovery residence after July 1, 2018 would be a violation of state statute.

While the outcome of Amethyst’s Petition is now in the hands of DCF, and maybe ultimately the courts, the law has not been suspended, particularly at the local level, where various cities now require FARR certification as a condition of obtaining local zoning approval.

So why are we even commenting on this issue if it is so apparently undecided?

Candidly, we take great offense at the apparent opportunism that some are exhibiting, claiming the “confusion” is due to “random, misleading emails from organizations within the drug and alcohol treatment industry” as to whether PHP housing must be FARR certified, which confusion has been “fueled by the new questionable laws that were passed.”

Such statements are not only wrong, they are irresponsible.

It doesn’t take a lawyer to know that the Florida Legislature said what it meant, and meant what it said. Either one is living under a rock, or is in denial about the state of affairs of sober living in Florida and the country as a whole.

But putting all of that aside, what everyone is missing is the most obvious – certification is an additional burden placed upon treatment providers that compromises their ability as to where they can house their patients, for which insurance refuses to pay.

Since that housing is not reimbursed by insurance, any additional regulatory burden comes out of the treatment center’s bottom line.

But the other side of the argument is even more pressing – the FHA and, by compliment, the ADA, guarantees “fair” housing choices for those who desire to live in a  sober living environment.

PHP patients, by the very nature of PHP housing as well as Res. 5 housing, inherently do NOT choose their own housing. No differently than a hospital patient does not pick and choose which bed to be placed in after surgery.

Moreover, the FHA and ADA only protect “dwellings” which term has a specific federal definition under those laws.

A treatment provider has no inherent federal protections to select a single-family home in a residential neighborhood as a place to house their patients while the residents are in a Partial Hospitalization level of care.

Under long-standing and prevailing law developed under the Fair Housing Act, treatment providers do not enjoy superior rights to zoning laws to house their patients wherever they choose, any more than Hospitals or Institutions do.

However, a “Recovery Residence” does enjoy higher protections, because it can be objectively determined that peer-supported community based living is taking place both inside and outside of the home.

While I understand and an sympathetic to what Amethyst and similar providers are concerned with, their challenge of the law may be causing them to walk right into a trap.

Here is the issue, boiled down to a plain reading of the statutes and rules:

397.311(26)(a)3, Fla. Stat. – “Day or night treatment with community housing” means a program intended for individuals who can benefit from living independentlyin peer community housingwhile participating in treatment services for a minimum of 5 hours a day for a minimum of 25 hours per week.

397.311(37), Fla. Stat. – “Recovery residence” means a residential dwelling unit, or other form of group housing, that is offered or advertised through any means, including oral, written, electronic, or printed means, by any person or entity as a residence that provides apeer-supported, alcohol free, and drug-free living environment.

Rule 65D-30.0081(1) – “Day or night treatment with community housing is appropriate for clients who do not require structured, 24 hours-a-day, 7 days-a-week residential treatment. This component allows clients to live in a supportive, community housing location while participating in treatment.”

Without FARR certification, what objective criteria are we going to use to demonstrate that a treatment center is providing peer community housing, rather than simply providing a “boarding house” to patients while in treatment?

A decision by DCF that PHP or Res. 5 housing need not be FARR certified would give local governments the ammunition they need (and have been desperately waiting for) to say that those “medical boarding houses” can no longer exist in single-family residences or even multi-family zoning districts, but rather may only be in zoning districts for transient housing for medical patients.

A Recovery Residence can be a person’s “home” even if residency is temporary such as at a PHP level of care, but only if the home can meet specific standards proving that unrelated cohabitation is necessary for therapeutic reasons, and which proof can be objectively qualified and quantified.  The US Department of Justice and the Department of Housing and Urban Development agree on this point.

Perhaps most realistic, I do not know of a civil rights attorney in the nation who is going to go into battle over whether PHP housing has the right to exist in any residential neighborhood if there is no ability to demonstrate through evidence that the cohabitation is necessary for therapeutic reasons. Certification of FARR Level 3 and 4 housing creates a rebuttable presumption that the resident medically benefits from such sober living. Simply housing patients in a home while because they need a place to stay while in clinical treatment does not meet that standard.

Perhaps it should. But under the law, it does not.

There is a saying that “bad facts make bad law.” Providers who object to housing oversight and meeting minimum housing standards are further entrenching policymakers that the industry itself is not mature enough to be trusted and that it places profit above patient protection.

On the other hand, those familiar with the Parity Act need to find a way to take a stand that sober living is the “yin” to clinical treatment’s “yang” and the refusal to pay for credible recovery residential services is no different than paying for medical treatment but not the necessary post-surgical residential rehabilitation care.

Either way, within the treatment and housing space, it always seems that the realities of the demands of free market enterprise to conflicts with healthcare policy on an all-too-frequent basis.  Perhaps recently announced collaboration between SAMHSA and NARR will drive the federal government to bring some sanity to an otherwise insane industry without making access to care inaccessible. But in the meantime, the law is what the law says, not what we want it to be.

GAO Releases Report on Oversight of Recovery Residences

On March 22, 2018, April 17, 2018 (yesterday), the U.S. GAO (Government Accountability Office, an independent, nonpartisan agency that works for Congress, often called the “congressional watchdog,” that investigates how the federal government spends taxpayer dollars) issued Report GAO 18-315, “Substance Use Disorder: Information on Recovery Housing Prevalence, Selected States’ Oversight, and Funding.” The report was released to the public yesterday, April 17, 2018. The full report can be accessed here.

According to the press release, the GAO looked at federal health care funding for recovery homes, as well as the actions of five states—Florida, Massachusetts, Ohio, Texas, and Utah—to investigate and oversee these homes in their states.

What GAO Found

Nationwide prevalence of recovery housing—peer-run or peer-managed drug- and alcohol-free supportive housing for individuals in recovery from substance use disorder (SUD)—is unknown, as complete data are not available. National organizations collect data on the prevalence and characteristics of recovery housing but only for a subset of recovery homes. For example, the National Alliance for Recovery Residences, a national nonprofit and recovery community organization that promotes quality standards for recovery housing, collects data only on recovery homes that seek certification by one of its 15 state affiliates that actively certify homes. The number of homes that are not certified by this organization is unknown.

Four of the five states that GAO reviewed—Florida, Massachusetts, Ohio, and Utah—have conducted, or are in the process of conducting, investigations of recovery housing activities in their states, and three of these four states have taken formal steps to enhance oversight. The fifth state, Texas, had not conducted any such investigations at the time of GAO’s review. Fraudulent activities identified by state investigators included schemes in which recovery housing operators recruited individuals with SUD to specific recovery homes and treatment providers, who then billed patients’ insurance for extensive and unnecessary drug testing for the purposes of profit. For example, officials from the Florida state attorney’s office told GAO that SUD treatment providers were paying $300 to $500 or more per week to recovery housing operators for every patient they referred for treatment and were billing patients’ insurance for hundreds of thousands of dollars in unnecessary drug testing over the course of several months. Some of these investigations have resulted in arrests and other actions, such as changes to insurance payment policies. Florida, Massachusetts, and Utah established state certification or licensure programs for recovery housing in 2014 and 2015 to formally increase oversight. The other two states in GAO’s review—Ohio and Texas—had not passed such legislation but were providing training and technical assistance to recovery housing managers.

The Substance Abuse and Mental Health Services Administration (SAMHSA), within the Department of Health and Human Services (HHS), administers two federal health care grants for SUD prevention and treatment that states may use to establish recovery homes and for related activities.

First, under its Substance Abuse Prevention and Treatment block grant, SAMHSA makes at least $100,000 available annually to each state to provide loans to organizations seeking to establish recovery homes.

Second, states have discretion to use SAMHSA funding available under a 2-year grant for 2017 and 2018 primarily for opioid use disorder treatment services, to establish recovery homes or for recovery housing-related activities. Of the five states GAO reviewed, only two, Texas and Ohio, have used any of their SAMHSA grant funds for these purposes. Four of the five states—Florida, Massachusetts, Ohio, and Texas—have also used state general revenue funds to establish additional recovery homes.

HHS had no comments on this report.

Why GAO Did This Study

Substance abuse and illicit drug use, including the use of heroin and the misuse of or dependence on alcohol and prescription opioids, is a growing problem in the United States. Individuals with SUD may face challenges in remaining drug- and alcohol-free. Recovery housing can offer safe, supportive, drug- and alcohol-free housing to help these individuals maintain their sobriety and can be an important resource for individuals recovering from SUD. However, the media has reported allegations about potentially fraudulent practices on the part of some recovery homes in some states.

GAO was asked to examine recovery housing in the United States. This report examines (1) what is known about the prevalence and characteristics of recovery housing across the United States; (2) investigations and actions selected states have undertaken to oversee such housing; and (3) SAMHSA funding for recovery housing, and how states have used this or any available state funding. GAO reviewed national and state data, federal funding guidance, and interviewed officials from SAMHSA, national associations, and five states—Florida, Massachusetts, Ohio, Texas, and Utah—selected based on rates of opioid overdose deaths, dependence on or abuse of alcohol and other drugs, and other criteria. State information is intended to be illustrative and is not generalizable to all states.

What Does It Mean When We Call Addiction a Brain Disorder?

When the 2016 Florida Legislature allocated funds for the formation of the Palm Beach County Sober Homes Task Force, my first instinct was that the State of Florida was looking at the conundrum we here in South Florida were facing through the wrong shade of glasses. To target “sober homes” was simply feeding into the local movement to eradicate addicts in recovery from living amongst society, a long-standing issue which required the U.S. Department of Justice to intervene nationally under the Fair Housing Act and the Americans with Disabilities Act.

The “problem” that we were all experiencing was not “sober homes” [a term, by the way, which has taken on a pejorative meaning, and therefore now rightfully distinguished as either a “Recovery Residence” or a “flop house”], but rather the economy created within the health care sector for delivery of clinical services; the “churn and burn” of patients’ insurance benefits. Law enforcement and government regulators were unable at the time to grasp the vast underground network that was truly the foundational underpinning of everything that was going wrong. Flop houses were merely the effect; the cause was the demand from “health care entrepreneurs” for bodies to put through the machine to bill insurance and make money and the failure of the entire system to sufficiently develop a standard for treatment and post-treatment recovery that health insurance would be required to pay for as being “medically necessary.” This disconnect was further exacerbated by old school, traditional ways of recovery, such as AA and sober living providers, for whom “treatment” was not available decades ago, and who today understandably question the “medicalization” of addiction treatment and care.

As one of the original appointees to the Task Force, it was a pleasant surprise to find that the Palm Beach State Attorney’s Office inherently understood this as well. Their focus was on the entire health care industry serving those afflicted with Substance Use Disorder, and would NOT allow itself to be used as a puppet to develop more sophisticated exclusionary zoning tactics that for far too long had been used to ostracize addicts from cities and make access to care difficult at best. The empaneling of the Palm Beach Grand Jury to study the entire industry simply underscored and emphasized Dave Aronberg’s commitment to fact-finding.

The “Proviso Committee” of the Task Force were made of up health care practitioners, government officials, and industry representatives, who themselves, as a committee, would examine the modern paradigm of addiction care and associated recovery organizations to make recommendations to the Florida Legislature on how to effectively address where the wheels came off the wagon in Palm Beach County and to prevent similar issues developing statewide. Mr. Aronberg noted early on both that “we can’t arrest our way out of this problem” and that addiction treatment and recovery communities have been a long-standing, respectable, and honorable part of the fabric of Palm Beach County.Early on, the Task Force came to recognize the disparate opinions within the field itself. While some felt strongly the focus should be on recovery support services, others leaned towards a medical model of care (to include MAT). Advocates on both sides seemed (and appear to continue to be) at odds over what is the “right” way to address the current opioid epidemic, and well as how to define “best practices” for our future. Even those on the medical/clinic side seemed to debate whether addiction was rightfully classified as a “disease” or a “brain illness.”

As our science has evolved (rather quickly, it seems of late), Dr. Nora Volkow, the director of the National Institute on Drug Abuse (NIDA), which is part of the National Institutes of Health (NIH), attempted to address the medical side of addiction care and the role that recovery support services has, in her article published in Scientific American entitled “What Does It Mean When We Call Addiction a Brain Disorder?” In the article, she writes:

Yet the medical model of addiction as a brain disorder or disease has its vocal critics. Some claim that viewing addiction this way minimizes its important social and environmental causes, as though saying addiction is a disorder of brain circuits means that social stresses like loneliness, poverty, violence, and other psychological and environmental factors do not play an important role. In fact, the dominant theoretical framework in addiction science today is the biopsychosocial framework, which recognizes the complex interactions between biology, behavior, and environment.

Critics of the brain disorder model also sometimes argue that it places too much emphasis on reward and self-control circuits in the brain, overlooking the crucial role played by learning. They suggest that addiction is not fundamentally different from other experiences that redirect our basic motivational systems and consequently “change the brain.”

Some critics also point out, correctly, that a significant percentage of people who do develop addictions eventually recover without medical treatment. It may take years or decades, may arise from simply “aging out” of a disorder that began during youth, or may result from any number of life changes that help a person replace drug use with other priorities. We still do not understand all the factors that make some people better able to recover than others or the neurobiological mechanisms that support recovery—these are important areas for research.

But when people recover from addiction on their own, it is often because effective treatment has not been readily available or affordable, or the individual has not sought it out; and far too many people do not recover without help, or never get the chance to recover. More than 174 people die every day from drug overdoses. To say that because some people recover from addiction unaided we should not think of it as a disease or disorder would be medically irresponsible. Wider access to medical treatment—especially medications for opioid use disorders—as well as encouraging people with substance use disorders to seek treatment are absolutely essential to prevent these still-escalating numbers of deaths, not to mention reduce the larger devastation of lives, careers, and families caused by addiction.

My takeaway from this is article is that my layperson opinion remains unchanged – medical treatment and recovery support services are the “yin” and “yang” of the same medallion. They cannot be separated but rather should be integrated into a continuous model towards sustainable recovery. Each path is different, as each person’s genetics as well as upbringing and life-experiences are unique. We are each a small universe onto ourselves. Therefore, it is my opinion that the billions of dollars being thrown into the “medical” side of the equation but failing entirely to fund the “recovery” side is to simply a band-aid. While I recognize and appreciate American hesitancy to adopt a welfare state for anyone, including the disabled, we must therefore double our efforts to fund and explore brain science so that effective modalities can be implemented which provide people seeking recovery with an accelerated jump start. Medication-Assisted Treatment is but one of those more recent efforts. But we can do more, and as a nation, should spend more, doing so.