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Editor's note: the medicalization of therapeutic communities in the era of health care reform.

There is a growing awareness by public policy analysts that the current policy of criminalizing addiction has filled our prisons and jails to overcapacity with many individuals who have primary substance abuse and mental health problems. This awareness has emphasized enlightened alternatives to incarceration coupled with crisis intervention, training, community care and jail diversion, which cut recidivism while saving financially strapped communities millions of dollars. At least half a million Americans in prison wouldn't be there today if they had instead been ordered to treatment for their substance abuse and mental health problems (Knopf 2011).

Paralleling this trend toward diversion to treatment has been the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, coupled with the rise of addiction medicine emphasizing the need to recognize addiction as a chronic disease requiring long term treatment (Smith 2012; Roy & Miller 2010).

These trends have produced new models of medicalization that challenge traditional thinking in the addiction treatment field. As therapeutic communities (TCs) across the United States are vital residential treatment programs, particularly for criminalized patients, the medicalization of TCs under health care reform will be particularly important. There will be "many models of medicalization" based on the diverse needs of various communities.

The Haight Ashbury Free Clinics and Walden House, two iconic 1960s nonprofit health care agencies, joined forces in July 2011 to provide primary medical care and addiction treatment services to the most vulnerable members of society. The combined organizations, led by Dr. Vitka Eisen, CEO of the new Haight Ashbury Free Clinics-Walden House (a dba of Haight Ashbury Free Clinics Inc.), emphasized "This merger will give our clients a seamless integration of care, allowing them multiple entry points to access primary and mental health care. We now have the expanded capacity to provide comprehensive medical, substance abuse and mental health care to the community we serve" (HAFC-WH 2011). The merger brings together two organizations with very different backgrounds (Smith 2012).

The Haight Ashbury Free Medical Clinic was founded in June of 1967 during the Summer of Love with the founding philosophy that "Health Care is a Right, Not a Privilege." The Clinic has served the uninsured, the homeless and the socioeconomically disenfranchised, including those with HIV/AIDS, a vast majority of whom have incomes well below the federal poverty line. In 2010, the primary care clinic provided primary medical care to approximately 8,000 individuals.

The Haight Ashbury Free Clinics began as a medical practice designed to deliver health services to the flower children, who believed in "better living through chemistry" and flocked to the Haight Ashbury during the Summer of Love (Smith & Luce 1971). The Clinics' Detoxification, Rehabilitation and Aftercare program addressed the needs of those whose lives didn't get better through the chemicals they were ingesting. Methadone maintenance was available in California beginning in 1968, but medication-assisted detoxification on an outpatient basis in a primary care medical setting was a violation of the law, leading to the arrests of some targeted physicians. The development of the phenobarbital detoxification technique by Smith and Wesson (Smith & Wesson 1971; Gay et al. 1971) served as the basis of the Clinics' outpatient detox program (Wesson 2011), a pioneer in the modern field of addiction medicine. Women's health, medical/crisis care at rock concerts, jail psychiatric services and other programs followed.

Walden House also started in the Haight Ashbury at the beginning of the nationwide drug epidemic to help homeless adolescents and young adults with substance abuse problems. Since 1969, it has been nationally known in recovery services, and last year provided services to over 9000 clients with mental health and substance abuse problems in its various residential and outpatient centers throughout California.

Walden House sprang from a very different culture than the medically-oriented Haight Ashbury Free Clinics, basing its residential therapeutic community on Synanon, a behavioral change model using confrontational group process and work therapy. The early Walden House model was a rigorous program that responded harshly to infractions to create a sense of unity, community and structure. As the organization has grown and evolved, it now promotes a culture of education, community, mutual support and respect, hope, health, and changed lives. With the acknowledgement of the needs of dual diagnosis patients (who exhibit comorbid addiction and psychiatric disorders requiring medication), Walden House has integrated more fully with the medical system. Walden has accepted patients on methadone maintenance for the past 20 years (Bonetta 2010; Sorensen 2009).

Walden House has been in the forefront of developing prison treatment programs and interacting with the criminal justice system. Research on therapeutic communities has found Walden's treatment to be successful up to 18 years after release from prison, reducing new arrests and the health consequences of addictive disease, including HIV risk (Martin et al. 2011).

A major motivation for Walden House to merge with the Haight Ashbury Free Clinics, which at the time was struggling financially, was to develop the capability to provide integrated health care services in the era of health care reform and parity. The spectrum of services at the new HAFC-WH ranges from Rock Medicine, staffed by 1,000 medical volunteers at over 750 concerts a year with a majority of cases consisting of adverse alcohol and drug reactions, to primary medical care for chronic conditions such as hypertension and diabetes, and to six-month therapeutic communities where the primary referral source is the drug court. This integrated care system has a strong primary medical component at different sites and therefore provides multiple entry points for care for the uninsured substance abuser, while introducing large numbers of young health care professionals to addiction medicine and the free clinic philosophy.

One of the major challenges facing HAFCI-WH is the integration of new pharmacotherapy models designed by addiction medicine science into the traditional psychosocial treatment environment of TCs. For example, some addiction treatment policies and protocols stigmatize pharmacotherapies such as methadone or buprenorphine. These therapies are considered inappropriate more because they clash with a drug-free ideology than due to any specific clinical treatment results. Not all patients need pharmacotherapies, but if they do, this therapy must be viewed similarly to prescribing insulin for diabetics or antidepressants for cases of depression.

The integration of pharmacotherapy and talk therapy has great potential to improve the outcome of addiction treatment. Counselors and therapists need to view the primary care medical clinic as an opportunity for collaborative interaction by offering patients who are receiving medication for management of an addiction access to individual and group therapy which are the mainstream of psychosocial treatment in TCs.

A major factor in the decision to medicalize Walden House, a well-established therapeutic community, by merging with the Haight Ashbury Free Clinics, was the public policy initiative of health care reform under President Obama. To implement this strategy, Dr. Eisen, CEO of HAFCI-WH, and Jean Merwin, Vice President of Health Care Services, have introduced certain medical standards into a traditional free clinic culture for the Haight Ashbury Free Clinics to qualify as a Federally Qualified Health Center (FQHC), which is recognized under health care reform guidelines.

HAFCI-WH has multiple programs throughout California, but it must keep a primary care site in the Haight Ashbury in order to maintain its FQHC status (Eisen 2012). Dr. Eisen's vision is that the HAFC-WH complex will serve as a medical home for uninsured psychiatric and substance abuse patients, many of whom have been rejected by the traditional health care system.

Federally Qualified Health Centers (FQHC), under the Patient Protection and Affordable Care Act (PPACA) of 2010, have been envisioned as demonstration projects for new ways of delivering care and training the health care team. An evolving model of health care, the Patient-Centered Medical Home (PCMH) emphasizes prevention and health maintenance to meet the comprehensive needs of a particular target population. The HAFC-WH system combines an FQHC with a TC to serve as a medical home for the criminalized, marginalized, substance abusing and mentally ill not served by the traditional health system.

Typically, nearly 100% of alcoholics and addicts at some time interact with the medical system for a variety of medical conditions, with only a small percentage referred to specialty addiction treatment services. Health care reform, however, will bring an increasing number of patients into contact with a spectrum of addiction treatment services.

This shift in public policy requires the integration of two previously separate cultures. The opportunity and the challenge for addiction counselors, who have not been accustomed to working side-by-side with physicians, physician assistants, nurse practitioners and other medical clinic personnel, will be to work comfortably in medical settings that may be unfamiliar to them.

With 40 million uninsured patients gaining healthcare coverage under PPACA, and with that coverage gaining access to addiction services, the existing system will not be able to handle these patients without new models of collaboration (see Roy & Miller In press).

Integration of the medical model, which is the redefined basis for the field of addiction medicine, and the traditional therapeutic community, which focuses on psychosocial treatment to modify behavior, will be informed by ASAM's (2011) recently released broader definition of addiction, based on advances in brain science.

Is addiction a brain disease, a behavioral disorder or a combination of both, as current neurobiological brain research and clinical expertise indicate? Conceptually, pharmacotherapy works on the primitive midbrain, which is the neurobiological site of dependence, withdrawal and craving, whereas talk therapy and behavioral modification therapy primarily impact the higher thought centers in the prefrontal cortex (Amen & Smith 2010). Medicalization of addiction treatment under health care reform and parity will need to move toward integrated models of pharmacotherapy and psychosocial recovery based on advancements in brain science and treatment outcomes. In the long run, medicalization will provide for prevention, early intervention and better treatment for all forms of addiction, which in all of its medical, psychological and behavioral manifestations represents our number one public health problem.

DOI: 10.1080/02791072.2012.684608


Amen, D.G. & Smith, D.E. 2010. Unchain Your Brain. Newport Beach: Mindworks Press.

American Society of Addiction Medicine (ASAM). 2011. Public Policy Statement--Definition of Addiction. Available at: http://www. public-policy-statements/2011/12/15/the-definition-of-addiction

Bonetta, L. 2010. Study supports methadone maintenance in therapeutic communities. NIDA Notes 23 (3): 8-10.

Eisen, V. 2012. Personal communication.

Gay, G.R.; Smith, D.E.; Wesson, D.R. & Sheppard, C.W. 1971. A new method of outpatient treatment of barbiturate withdrawal. Journal of Psychedelic Drugs 3 (2): 81-88.

Haight Ashbury Free Clinics-Walden House. 2011. Press Release, 7/1/2011.

Knopf, A. 2011. Up to one in four incarcerations should be prevented: Local collaborations working to keep NVOs with behavioral health problems out of jail. Behavioral Healthcare 31 (8): 11-13.

Martin, S.S.; O'Connell, D.J.; Paternoster, R. & Bachman, R.D. 2011. The long and winding road to desistance from crime for drug-involved offenders: The long-term influence of TC treatment on re-arrest. Journal of Drug Issues 41 (2): 179-96.

Roy, A.K. & Miller, M. In press. The medicalization of addiction treatment professionals. Journal of Psychoactive Drugs.

Roy, K. & Miller, M. 2010. Parity and the medicalization of addiction treatment. Journal of Psychoactive Drugs 42 (2): 115-20.

Smith, D.E. 2012. A view to the future: Combining the Haight-Ashbury Free Clinics and Walden House. San Francisco Medicine 85 (2): 23-24.

Smith, D.E. & Luce, J. 1971. Love Needs Care: San Francisco's Haight-Ashbury Free Medical Clinic and Its Pioneer Role in Treating Drug-Abuse Problems. Boston: Little Brown.

Smith, D.E. & Wesson, D.R. 1971. A phenobarbital technique for withdrawal of barbiturate abuse. Archives of General Psychiatry 24 (1): 56-60.

Sorensen, J.L.; Andrews, S.; Delucchi, K.L.; Greenberg, B.; Guydish, J.; Masson, C.L. & Shopshire, M. 2009. Methadone patients in the therapeutic community: A test of equivalency. Drug and Alcohol Dependence 200 (1-2): 100-06.

Wesson, D.R. 2011. Psychedelic drugs, hippie counterculture, speed and phenobarbital treatment of sedative-hypnotic dependence: A journey to the Haight Ashbury in the Sixties. Journal of Psychoactive Drugs 43 (2): 153-64.

David E. Smith, M.D., FASAM, FAACT (a)

(a) Principal, David E. Smith, M.D. & Associates, San Francisco; Chair, Addiction Medicine, Newport Academy, Orange CA; Medical Director, Center Point, San Rafael, CA; Member, Advisory Board, Dominion Diagnostics, North Kingstown, RI.

Please address correspondence to David E. Smith, M.D. & Associates, 856 Stanyan Street, San Francisco, CA 94117; phone: 415933-8759; fax 415-933-8674; email:
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Author:Smith, David E.
Publication:Journal of Psychoactive Drugs
Geographic Code:1USA
Date:Jun 1, 2012
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