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Dear Gov. Newsom: If addiction is a brain disease, where are all the doctors?

April 30, 2023

Fourth in a regular series. See Dear Gov. Newsom: People are dying in the Rehab Riviera. Do something, Dear Gov. Newsom: Their daughter’s been swallowed by California’s rehab monster and How did Frankie Taylor overdose in a state-licensed addiction treatment center?

Dear Gov. Newsom: Today we’ll take a break from harrowing tales of tragedy and death in California’s (poorly regulated, private-pay, 12-step based, insurance-money fueled) addiction treatment system to visit with Dr. Walter Ling, a neuropsychiatrist who’s worked in addiction medicine for nearly as long as you’ve been alive.

Please listen to what he has to say. For thousands of people, it’s a matter of life and death.

Ling has the remarkable gift of clarity, frequently quotes his mother’s wisdom, has an infectious optimism — and will be the first to tell you that his formidable foray into addiction treatment was entirely by accident. The plan was simply to finish neurology and psychiatry training at Washington University in St. Louis and return to the Chulalongkorn University Medical School — he was born in China and grew up in Thailand — but then he met May, a local teacher volunteering at a children’s hospital. Wedding bells rang. May felt that pull west, dearly wishing to raise their kids in California, so he took a job at the Sepulveda VA Hospital in Los Angeles in 1971.

We’ll jump ahead a bit to tell you that Ling has had a hand in studying every major medication for opiate addiction in the United States, is founding director of UCLA’s Integrated Substance Abuse Programs and a keen chronicler of how addiction treatment cleaved from mainstream medicine and was schluffed off to its current, expressly non-medical, silo.

Over there, it’s oft overseen by “recovering” addicts who may or may not be recovered. “Medication-assisted treatment” is still widely shunned. And detoxification — the initial weaning off substances — is tragically mistaken for treatment itself.

“The most common outcome of detoxification,” Ling has written, “is relapse.”

Here are a few of his Mama Ling-esque pearls of wisdom you should memorize:

• Detoxification may be good for a lot of things, but staying off drugs is not one of them.

• The difference between getting off drugs and staying off drugs is the difference between a wedding and a happy marriage. The wedding is a big deal, but it has nothing to do with a happy marriage. Right now, our entire treatment system is targeted to the wedding.

• You can’t get a life if you can’t stay off drugs. And you can’t stay off drugs for long if you can’t get a life. Taking medication is the best guarantee that you don’t die from an overdose and actually stay off drugs.

• The term “medication-assisted treatment” itself is puzzling. What is the medication assisting? It is the treatment.

• If addiction is a brain disease, where are all the doctors?

Gold standard

Shortly after the young Ling family arrived in California, the good doctor was helping out on the general psychiatric ward at the Veteran’s Administration hospital. Nixon was president. Veterans were returning home from Vietnam with troubling heroin addictions. Something had to be done.

Sepulveda had one of the VA’s first methadone programs, and Ling was asked to fill in for a few of weeks when the chief of psychiatry and research was out of town.

The rest, as they say, is history.

Ling worked with these rattled and traumatized young people to find out how best to help them. He helped run myriad scientific studies of medications designed to address addiction, publishing hundreds of papers that have been cited thousands of times.

All three medications approved to treat opioid addiction had to endure Ling’s watchful gaze: methadone, naltrexone, and buprenorphine. These drugs can bind to the brain’s opioid receptors, foil opioid highs, manage cravings, head off overdoses and, generally, pave the way for that happy marriage.

Buprenorphine, in particular, is far more convenient, and thus effective, at keeping people off drugs for the long haul than its medical cousins. And most any medication is more effective than the ubiquitous 12-step approach alone. That, Gov. Newsom, is why medication is an integral part of California’s push for better treatment in its public addiction treatment programs.

But not so much in the private sphere of California’s addiction treatment system.

“Look around the treatment industry and ask whether things have really changed,” Ling writes. “We have studied addiction as a science for more than 40 years, but we treat our patients the way we did 40 years ago.”

In 2023 — after decades of research showing that medication is the gold standard for getting a life — much of California’s treatment system continues to shun it.

• Just 22% of California’s outpatient facilities — where most treatment happens — offered methadone, buprenorphine or naltrexone treatment, according to federal data.

• Only 59% of programs transitioning people back to their regular lives offered overdose education and Naloxone, a drug that can reverse opioid overdose and practically bring people back from the dead.

• Overall, a tremendous chunk of treatment facilities in California — 41% — didn’t provide any “pharmacotherapy services” for their patients at all, despite skyrocketing overdose and death rates.

A buprenorphine implant. Photo courtesy of Jerrey Roberts, DAILY HAMPSHIRE GAZETTE

“We know that medication plays a critical role in keeping addicts off drugs but we insist on assigning medication a secondary role,” Ling writes. “We call addiction pharmacotherapy ‘medication-assisted treatment’ even though there is nothing that the medications are supposed to assist that works. …

“Even when we reluctantly tolerate the use of medications, we want patients to get off them as soon as possible. Nationwide, detoxification is still the most common, most profitable and least effective treatment offered; it has an over 90% relapse rate. We expect detoxifications to return patients to their old non-addict self, ignoring the fact that once addicted, they can’t turn back the clock of their body and brain to before addiction. We act as though we believe contraceptives don’t just keep you from getting pregnant but make you a virgin again.”

Historically, addiction has been viewed as a criminal offense and a moral failing. Medical intervention took a big back seat to behavioral approaches.

“Counseling by counselors who themselves had a history of addiction was based on the premise that counselors’ shared life experiences could uniquely help patients enter into recovery,” Ling writes. “This hypothesis was never tested or proven true, despite becoming a routine component of treatment. Instead of serving to extend patient care, counseling grew into a parallel service often in conflict with the physician’s treatment goals.”

Alcoholics Anonymous uses sobriety coins to represent how long members have remained sober. (FILE PHOTO BY, BRUCE CHAMBERS, ORANGE COUNTY REGISTER/SCNG)

We require doctors who prescribe medications to connect patients to counselling, but we don’t require abstinence-based treatment facilities to connect patients to medical treatment.

We don’t want to go against the abstinence treatment industry, and we let the regulatory agencies become symbiotic with the system they regulate.

And that, Gov. Newsom, is the crux of it.

“We don’t need more treatment that is not treatment,” Ling has told us. “If we want to find sensible solutions, we should stop doing things that don’t work.”

California has the resources and compassion to make such changes, Ling believes. We’re slated to get more than $2 billion in opioid settlement money for fighting addiction. And you, governor, are trying to reform our system and readying an initiative for the 2024 ballot “to build state-of-the-art mental health treatment campuses to house Californians with mental illness and substance use disorders.”

Please. Build a system that treats addiction, first, as a medical issue. Of course, doctors are not all angels — we’ve chronicled the surgeon accused of building a luxurious life on the backs of often-desperate drug users, and the doctors getting kickbacks for ordering gazillions of unnecessary drug urine tests — but I’d rather put my life, and my kid’s life, in the hands of someone with eight years of schooling and three to seven years of residency, instead of the guy who dropped out of high school but has cycled through seven behavioral treatment programs, relapsed as many times, and has been triumphantly sober for five months.

“Yes, we can do better,” Ling writes. “We need to support the use of prescribed medications like buprenorphine and provide the resources to help patients live a life without drugs. We know what we must do, and we have the tools to do it. It’s been said that we Americans love reality shows because if we put things on TV, we don’t have to face them in real life. But if we want to succeed in fighting opioid addiction and reduce overdose deaths, we must have the courage to look in the mirror, resist our biases, acknowledge where we fall short, and find the gumption to make real changes to finally end this crisis.”

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How did Frankie Taylor overdose in a state-licensed addiction treatment center?

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Orange County Register

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Dear Gov. Newsom: If addiction is a brain disease, where are all the doctors?

Gold standard

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