TOC Doctor aims to bring the benefits of Theory of Constraints to enable rapid improvement in medicine and wellness. Please join me for the journey. 

The Addiction Treatment Company We All Need

Why we need it

Today the American addiction treatment industry is a large heterogeneous set of overlapping and competing treatment centers. There are outpatient centers and inpatient centers. There are those who use medication and those who don’t. There are those that see themselves as treating an illness and those who believe they are focused on reteaching people how to live without a particular habit. This heterogeneity is not necessarily a bad thing.

Current science does not give us a single best treatment for addiction and probably never will. What treatment that works well for you, may not be the best for your neighbor. The great variety of treatment programs allows those with addiction to find the best fit for their own recovery. This is good.

What is not good is that there is no commonly used way to find the right fit in advance. We hear of many people who only come to recovery from addiction after 5, 10, or even 15 treatment episodes. There’s a lot of time and money wasted trying one or another method at random.

In addition, our treatment industry today is focused on addictions, with an “s.” The idea of addiction in America today is plural. You can be addicted to alcohol, go to treatment, stop drinking and then get “another addiction” when you start smoking or overeating. A lot of time and money is wasted by treating “an addiction” in the person rather than doing a complete treatment of the person with addiction.

Our current system doesn’t treat addiction, a primary, chronic brain illness. It only treats “addictions,” behaviors defined around a certain drug or reward. The result is a large number of treatment failures. This ensures that we do not get more people into recovery every year than we have new cases of addiction. That results in the problem growing over time.

We need a system that clears more cases of addiction into full voluntary recovery every year than we get new cases so that the total load on society is lessened over time. The resulting savings can be used for increasing the scale of that treatment and funding good prevention so that the benefits are increased every year until addiction is no longer a problem in American life. If only, right? Well, I know we can get there.

You might fairly ask, “What’s stopping us then?” The answer, mostly, is us. The way we think and talk about addiction is what is keeping us from taking the steps we need to end addiction as a problem in less than a few decades.

We’ve already solved a bunch of drug problems in our history. We solved the first two opioid overdose epidemics in the 1880’s and 1970s. We solved the alcohol problem with prohibition back in the 20’s. We solved the cannabis problem by scheduling the whole plant in the 30s. We solved the amphetamine epidemic in the 60s by increasing the scheduling of those drugs. We took care of the sedative problem in the 70s. With all our successes behind us, one would think we’re pretty damn good at ending drug problems. That thinking is our biggest problem.

We didn’t have a series of drug problems; that’s just how we wanted to see it. What we had and have is an endemic problem with a primary, chronic, largely genetic, brain illness called addiction. Like the proverbial blind men looking at an elephant, we’ve taken small views of the problem and tried to manage them in isolation from the core problem. No wonder we haven’t made any real progress. Treat an elephant like a piece of rope and see how well you do.

Because we don’t see the core common cause of the problem, we look for smaller, easier to find causes. This has led us to believe that drugs are the cause of addiction rather than drug use being the effect. Our focus on drugs has been less than effective to say the least. It is no wonder our treatment industry seems aimed at the wrong places.

People do what they are incentivized to do. Upton Sinclair said, “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” Currently our insurance payment system, supported by the academic research system, which is supported in turn by government, is completely focused on treatment for an individual drug-based behavior. Why should we expect an addiction treatment company to get it right when they are paid to get it wrong?

But the lack of effectiveness has not been lost on those in the addiction treatment industry. They are not heartless people looking for a quick buck. They want to do good work. They’ve seen the failures and tried to find solutions. But in the absence of the recognition of the common core cause, those solutions have not been to good effect.

The industry has seen that many people stop one drug only to pick up another. Ideas about “addiction switching” and “interactive addictions” have entered the lexicon. This has created a more sophisticated way of talking about the problem, but it hasn’t led to more people entering sustained voluntary recovery across the population. It has been an excuse, not a solution.

The industry has seen that people still have symptoms after stopping drug use and this has also led to a more sophisticated view than we had before. We now understand “dual diagnosis” and “co-occurring disorders.” There are specialized treatment centers and tracks within others for those so diagnosed. While this has been an advance in thinking, it also hasn’t led to large numbers of people with addiction entering sustained voluntary recovery across the population.

We are left with many different programs that see addiction in many different ways. We have a number of different hammers looking for special kinds of nails. What we need is an addiction treatment company that sees itself, not as a hammer, but as a tool box and is able to respond to each individual even if he’s not a nail.

The Goal

The goal of any organization, public or private, dealing with addiction in America today should be to end addiction as a problem in American life. That is not to say we can cure addiction; we cannot today cure it or rid ourselves of it. But addiction isn’t the big problem. Our response to it is. If we had a system that could rapidly identify those with the illness at the beginning and those at risk, we could intervene much earlier at far less cost. If we did not build barriers to treatment and recovery, we could get far more people into care. If we had better systems of care that worked faster, cheaper, and more efficiently, we could get more of those with addiction into full voluntary recovery. Any organization that Americans can trust with handling resources to solve the problem should have the goal of ending the problem. But currently few do.

I took a small poll of friends and colleagues in the addiction treatment space. I asked them to name the corporate goal of any addiction organization (it didn’t have to be theirs). I got several answers.

“To be the best addiction treatment company in the field” was a common answer. But it was rarely stated so succinctly. It was usually something like, “to provide the most patient-oriented, evidence-based treatment available.” Others sought to be the best at diagnosis, “to have the most in-depth assessment of each patient in order to provide the most excellent care available.” Others sought to carve out a niche, “to be the most sought-after source of treatment for addicted individuals with co-occurring disorders of trauma.” Most of the companies I asked used a lot of big words, but it all came down to, “be seen as the best in the industry.”

Another common answer was something you’d expect from any private company that had to return money to shareholders, “To make more money.” This was often phrased in a less focused way such as adding, “in a profitable way” to the anchoring goal such as those noted above. Many in the industry feel guilty about making money doing the work and so phrase it such as, “to make a profit so as to continue our mission.”

But regardless of the answer I got, none of the companies thought they were part of ending addiction. In fact, they need it around. If it’s not there, you can’t treat it. And who cares who’s the best if the problem isn’t a problem any more. Almost all addiction treatment organizations today, whether they realize it consciously or not, are assuming that addiction is here to stay, and that they should build their business plan on that status quo.

But before you think that I’m advocating corporate suicide, ask yourself what any company would be able to do that could create a treatment so fast, effective and inexpensive as to run some 30 million Americans through it to recovery from addiction. Such a company would know how to deal with any chronic illness. Such a company would know how to present solutions to people for any problem in such a way as to facilitate the person’s doing what is in their own best interest in the long term. Such a company would have such intellectual property as to be able to pivot to any available market when addiction was no longer a problem. We all need such a company.

The Derived Strategy

Let’s assume that company exists or soon will. Given the goal of ending addiction as a problem, we can logically derive certain priorities that any such company would have. From there we can derive systems to execute to the goal. It would look very different from existing addiction treatment companies.

The first priority would be safety. If the treatment system isn’t safe, no one would come. People with addiction have a physical brain illness and aren’t always able to ensure their own safety. While we might find fault with the execution on this priority, I doubt we’ll find many in the current industry who would not endorse this as a first principle.

Where we’d start to differentiate from the current field is in the second priority, courtesy. If people aren’t treated courteously, they won’t stay in treatment. We know that when a primate, such as a human, is made to feel subservient or isolated, they lose midbrain dopamine receptor density and dopamine tone. They feel bad and will seek relief. The motor centers of the brain are not far away from these midbrain structures. If we do not treat people with addiction with courtesy, they will not stay.

Now we are getting to the third priority of excellent care. When I took my poll of colleagues, they almost all started with excellent care as a goal, but here it’s only the third priority. There are two big jobs we have before we even get to excellence of care, but the care is where almost everyone focuses. This is focusing on a local optimum. It’s easier to measure excellence of care than safety or courtesy. We didn’t go to school to learn safety or courtesy, but to learn how to treat patients. Let those others be the administrator’s job, right? No, that’s not right.

And finally, we get to the money. Any treatment system doing its part to end addiction as a problem in American life is going to need to expand. Such a company, that logically derives how to create its systems so that it is safe for and inviting to patients and has such excellent care as to provide good satisfaction for payors, will rapidly attract so much business that it will need to expand rapidly. I can envision a nationwide network of outpatient centers treating addiction to full voluntary recovery. No one can get big enough to make an impact on ending addiction without making money to pay for expansion.

So how is anyone going to do all that? Well there’s a system for doing just that, but it’s not taught to people learning addiction treatment. Those of you who follow my writings know that I’m a practitioner of Theory of Constraints (TOC). You know that I believe that TOC can solve any problem, rapidly and at small cost. I’ll add here that TOC is what we used to derive the systems at the treatment company I owned before selling it to another company. And TOC is what I’ll use this year to start developing another.

There is a particular Thinking Process in TOC called the Future Reality Tree. It’s a powerful, but tedious, method of building from a goal by the logic of necessary conditions, all that any organization needs to achieve its goal. You can probably now see why I focused so much here on the goal of current addiction treatment companies. Without the goal of ending addiction as a problem in American life, you won’t build the same FRT even if you use TOC.

The Systems

So, what would such a company look like? Well, the first thing we’d notice is that everyone is clinical. Not only those trained to treat patients, but even the janitor has a clinical job. Understanding the neurobiology of addiction and the goal of ending it as a problem, everyone in the company knows that they are coming to work to save lives. The guy emptying the trash knows that overflowing cans give patients the impression that no one cares. The IT guy knows that lowering a doctor’s dopamine tone with an annoying log in procedure affects patient care. The HR department knows that they aren’t there to follow rules for the rule’s sake but to promote the dopamine tone of the staff so that the patients can get the best care. In the company that can treat addiction so well and so quickly, everyone is clinical. There are no non-clinical interruptions of care.

As you probably noticed above, in such a company everyone is aligned with the goal. The marketing department knows that their job isn’t to make the phone ring but is to get more people into full voluntary recovery. The quality department knows that their job isn’t to improve any one system but to get more people into full voluntary recovery. The doctors know that their job isn’t the finest execution of pharmacotherapy but to get more people into full voluntary recovery.

In such a company there’s no one striving for local opitma. Everyone’s job and goals are aligned with the goal of the company. No one is wasting time trying to improve their department at the expense of someone else’s. No one is focused on doing a good job that has nothing to do with getting more people into full voluntary recovery.

And it’s clear that everyone knows the quality priorities. No one puts excellent record keeping ahead of safety. No one is typing in the medical record rather than greeting a patient. No one is needing to be told what to do when priorities conflict either.

One of the things I see when I look at our industry is a huge amount of waste in the mid-level management. We have people whose only job is to tell others what to do, when, if we had the right goal and good leadership, they would know what to do without being told. This wastes resources of the company that could be used to further treatment and execute to the goal faster and less expensively for all concerned. And it all stems from leadership.

The leader of such a company has to be a special person. They have to be aligned with the goal and have to facilitate everyone else’s alignment with the goal. They have great power and need to use that power to protect those in the system from working against each other.


The CEO of such a company would need to be aligned with the goal of ending addiction as a problem in American life. Such a goal is hard to find in an executive who makes their living in the addiction treatment industry. So much of our industry is focused on keeping addiction alive to provide job security, it’s hard to imagine finding such a person. But such a person would need to see that if they succeeded, they will not have worked themselves out of a job so much as built a company that can do almost anything and proven their worth as a great leader. So, in hopes of finding such a person, I thought I’d describe a bit what they are like.

Such a CEO would be focused on systems. They would not get distracted by the day to day small problems. They’d be focused on the core causes. When someone brought them a problem leaf, they wouldn’t trim it. They would trace it back to the tree trunk and fix that. The CEO of such a company would understand that they had to create systems, not individual fixes.

Those that build systems understand that personnel who fail rarely fail because they want to or because they can’t succeed. Personnel who fail usually fail because the system was designed to make it hard to succeed. Every system creates the results it was designed to create. Such a CEO as this company needs would see every failure as an opportunity to find the problem with the system they built.

The CEO who focuses on systems understands that they are responsible for the people working in the company. They understand that they are not only responsible for the health of the company, but that the company depends on the health of the employees. Making more money and satisfying the market both depend on the workforce being satisfied and fulfilled. Our industry suffers from a lot of turn over now, not because people don’t make enough money, but because once they do, satisfaction depends more on feeling fulfilled than in getting a raise.

The biggest dissatisfiers in our industry today are little things that the company does to itself. In my most recent position, the company had an app so that employees could put in their expenses. The app was so hard to use, and so insulting in the language it has to talk to users, that it clearly lowers dopamine tone in employees. The good CEO would see that such an app directly affects patient care and would change the system.

This brings me to my final criteria. The effective CEO of a company that could make the rest of the industry irrelevant would take responsibility for everything. They would understand that they designed the system, they chose the managers, they run the company. They would accept responsibility for every aspect of the system, and they would act as if they owned every decision. When problems arose, they would not say, “It’s that person’s fault.” They would examine the system for the core problem and follow a course that brought buy in from all parties to eliminate the problem.

Well, I’ve just described superman, haven’t I? You’re probably wondering where we’re going to find this person. Well, so am I, because that’s why I’m writing this.

I wrote in an earlier piece about my goals for this year. One of the key players in the development of a company that will make all others irrelevant is to find the right CEO. So, I wrote this as a want ad. If you want the job, drop me a line. And if you want any other job in such a company, do the same. We’re just getting started.

Using TOC in Clinical Practice

Using TOC in Clinical Practice

Schmutz on my Glasses

Schmutz on my Glasses