Tuesday, September 25, 2012

How to Save $30,000 and Get Better Results

I have had numerous patients who have been pressured by their families to "go away" to some residential treatment program, usually it seems in another state (than Minnesota). Florida, Arizona and California seem to have a concentration of these, especially "Executive Programs" with gourmet food, precious handling, "equine therapy," "golf therapy," yoga, life coaching, and of course first class accommodations. They run from $20,000 to $70,000 for a month. These are people who have severe, recurrent addictions, usually to alcohol but some are addicted to opioids like heroin. Almost all have been through some sort of rehab multiple times before. Many but not all have money. Often enough, it's a family member who is coughing up the big bucks.

What do they get? One patient relapsed on the plane on the way home. Not a single one had any lasting benefit. Almost all relapsed within weeks, often days after returning home. In other circumstances, patients and families, and in Minnesota, state government, will pay for lengthy stays, 90, 120, 180 days in some "recovery environment." Again, it's plenty costly. But do they get any benefit? The vast majority do not.

It's an uphill battle to try to convince family members that sending their loved one away for some period of time to some "special place" is very unlikely to change their long-term outcomes. People just do not want to believe it. And admittedly, it's a hard pill to swallow. After all, the chemical dependency treatment industry has done a commendable job of spreading the idea that anyone can recover "if they really want to." And of convincing people that they have some unique answer to an ancient problem that defies easy resolution. The really difficult fact is this: all of our treatments (yes, that includes 12 Step treatment programs and AA) have modest effects at best. (The exception to this generalization is for opioid maintenance therapy with Suboxone or methadone for addiction to opioids such as Oxycontin or heroin. Opioid maintenance therapy is extremely effective and more cost-effective than almost any medical intervention other than vaccination.) Too many people do not respond to any available treatment. And they die of their illness. They die of a hereditary, brain-based behavioral disorder that makes them vulnerable to compulsive use of alcohol, opioids, cocaine, meth or cigarettes. It's not that they aren't motivated to change. I have to say, this is one of the cruelest things that rehabs do: people are told they could stop the process if they wanted to. But guess what? Some people can't. No matter how hard they try to "work the program." No matter what they do. Even if they go 90x90, or attend 1000 12-step meetings a year. They are mystified. "Why do I keep doing this? I'm not stupid! I know what will happen, but I do it anyway." This is the mystery of addiction.

In other chronic severe diseases, health care providers constantly experience failure of available treatments, and are able to accept it. People die of heart disease, cancer, diabetes, stroke, multiple sclerosis, dementia. But in the rehab industry, staff members are protected from experiencing treatment failure. First, treatment is time limited. So, instead of having to live with patients who come back with recurrent illness when the treatment doesn't work, staff members don't have to live with (and struggle to help) people who don't respond to treatment. Second, the entire industry (and unfortunately, too many 12-step program members) believe without doubt that "treatment doesn't fail patients, patients fail treatment." Try telling that to someone with metastatic cancer, end-stage liver failure, Parkinson's disease or chronic obstructive liver disease. But because we continue to stigmatize people with addiction, we get by with it, we are told to reject them, to use "tough love," to let them "bottom out." In my experience, in too many people "bottom" is 6 feet under ground. We condemn family members who don't abandon their loved ones as "enablers." What could be more cruel than this?

As a healer, one of the hardest things I do is to stay engaged with someone who dies of addiction. To not reject them. To not condemn them. To understand they are in the grips of something neither they nor I nor anyone else can control or stop, short of imprisoning them (and even then, prisons and mental hospitals are usually full of drugs.) To accept the limitations of our available treatments. To be compassionate even as death approaches. In the last year alone, in my part-time clinical practice, I have lost 6 patients to addiction.

It's not actually different than dying of diabetic renal failure, or of multiple sclerosis, or cancer. We can accept those illnesses as "not the person's fault." But when it's a brain-based disease, we cannot fathom that a brain can become dysregulated to the degree that someone loses control of their behavior to such an extent that they die from it. It's too frightening. We can't stand the thought that we aren't in full control of our lives. That we can't control our own behavior completely.

And yet, we all know better. We all have areas of problem, non-optimal behavior. We smoke. We drink too much. We don't exercise enough. We can't get our behavior right with our spouse or partner or children. We lose it. We shop too much. We can't handle money. We eat too much. We don't take good care of ourselves when we have a chronic illness. We lose our tempers. We work too hard, or not hard enough. We ignore important things. We procrastinate.

Yet we cling to the illusion of control. Of self-determination. We control our fates. Why can't "they"?

Just to be clear, I am not advocating that people with brain-based behavioral disorders not be held responsible for their behavior. For example, I am not advocating that people who commit crimes while intoxicated should be found innocent because of their addiction. As we move further into understanding the brain mechanisms underlying destructive and/or illegal behavior, this question looms large. But I have concluded that even though brain dysregulation might underlie much of this type of behavior, society only works if we hold people responsible for their behavior in spite of that fact. Individual responsibility for behavior is a social and political necessity that cannot be sorted out by science. In this blog, I am addressing how to provide health care for people with addiction and nothing else.

It's terrifying to think of having a behavior so out of control that it kills us. Anorexia nervosa. Depression. Bipolar disorder. Schizophrenia. Addictions. Antisocial and borderline personality disorders. All have substantial mortality rates. People with serious mental illness die 25 years early on average! Is it because people don't care if they die? I know that's not true, I've worked with too many of them. No, it's because the brain is a flesh-and-blood organ that can get sick, dysregulated, in specific ways that the individual cannot have insight into and cannot control. And it kills them. We have to come to grips with this grim reality if we have any hope of overcoming these dread diseases.

One thing I do know is this: some short-term high-end expensive rehab program is not going to change anything. The best hope is long-term care management with an experienced and qualified clinician or team of clinicians. That's what we do for diabetes, heart disease, cancer, stroke, arthritis. That's the best we can do for people with severe addictions. And it is a heck of a lot cheaper besides. Give me $30,000; I'll see you daily for a year! Geez, with 8 patients, I could make $240,000 a year!

I can obtain better results at a fraction of the price than any high-end time-limited treatment program. I guarantee it! And yet, I have to accept that despite all of my best efforts, and theirs, and their families', some of my patients will not respond. And some will die as a result. And they deserve our compassion, not condemnation.

What do you think? Please spread this around, comment on it, argue, agree or do something else. These are incredibly important questions.


Friday, September 7, 2012

Families' Health Costs Reduced After Addiction Treatment

This is a the second blog about healthcare costs and substance use disorders (SUD). The first one (6 Sept 2012) dealt with healthcare costs among patients who presented for treatment for SUD. This one is from the same great health services research group founded and anchored by Connie Weisner at UCSF, and addresses a novel topic: the healthcare costs of family members of patients with SUD, and the effect of SUD outcomes (abstinence vs. non-abstinence) in the index patient on family members’ healthcare costs (Weisner, Parthasarathy et al. 2010).
In this study, a group of patients who presented for treatment for SUD (and who were thus likely to have chronic or recurrent, and more severe, SUD, compared to people not presenting for treatment) were followed for 5 years. One year following treatment entry, they were asked questions pertaining to their current (past 30 day) use of a wide variety of intoxicants. Those who had used none in the previous 30 days were considered abstinent for study purposes, while those who had used anything were considered non-abstinent. (Note that in other studies as well as this one, 30-day abstinence at the 12 month time point is strongly related to longest continuous period of abstinence over the entire five years.) Also over this 5 year period, healthcare costs of family members were also tracked, and family members whose index patient were abstinent at 1 year were compared to those who were not. Just to avoid confusion, I’ll state that differently: healthcare costs for families over a 5 year period were compared between those whose family member was either abstinent or not for the past 30 days 1 year after treatment entry.
The results were both surprising and encouraging. First, the authors point out that in the first year following treatment entry, healthcare costs for family members may well go up, as they attend to medical, SUD and psychiatric problems they neglected due to the crisis associated with escalating use and problems in the SUD patients. Thus, it is important to long past the one-year point. Thus, a major strength of the study is that they studied costs over five years. Another strength is that they compared both groups to matched controls without SUD.
And sure enough, in the first two years, healthcare costs were higher among both groups of family members of SUD patients compared to non-SUD control families but were not different between abstinent and non-abstinent groups. However, beginning in the third year the abstinent began to diverge from the non-abstinent families. By year 5, the abstinent family members’ costs were not different from the non-SUD controls, while the non-abstinent family members’ were significantly higher. Average cost for abstinent family members at year five was $3 per member per month, while average cost for non-abstinent family members was $36 per member per month, a 12-fold difference!
In summary, 30-day abstinence one year after treatment for SUD strongly predicted the costs for their family members over the ensuing four years. Healthcare costs of family members of SUD patients abstinent at one year began to go down three years following treatment and by year five, did not differ from control families without SUD. However, costs for family members of SUD patients not abstinent at one year were 12 times higher than for either abstinent SUD families or for control families! Thus, SUD outcomes are strongly related not only to healthcare costs of the SUD patients themselves but to their families as well!
A lot of money could be saved (not to mention the misery that could be avoided) by improving rates of abstinence following SUD treatment. Other studies, by this and other groups, have found that providing ongoing continuing care over long periods is associated with improved rates of abstinence and reduced healthcare costs among SUD patients (see previous blog.)
To me, these findings have two implications:
1)    Current, evidence-based treatment needs to be more widely available to people and, to encourage them to come, they need to include a lot more consumer choice about path to recovery, as well as form and place of treatment, and
2)    We need more research on how to improve rates of abstinence, which are far too low to be acceptable. This will require more money. The only way to get more money for addiction research is advocacy by the people affected: people with SUD, recovering from SUD, and their friends and families. We need to advocate not just for more treatment, but for more money for research. More on this later.

Thursday, September 6, 2012

Continuing Care Produces Reduces Costs for Substance Use Patients

Persuasive Research for a Chronic Care Model for Some People with SUD
There are two fascinating research reports that recently came out of the group anchored and founded by Connie Weisner, a very productive and insightful scientist conducting health services research at Kaiser-Permanente in San Francisco. In addition to being a first-class scientist, Dr. Weisner is a genuinely good person and a great mentor who has built an extremely productive group. Jennifer Mertens is one of her protégés who has emerged as a first-class scientist in her own right.
The first of these two articles examined the healthcare costs of a group of people who presented for substance use disorder (SUD) treatment at a Kaiser facility. First-authored by Sujaya Parthasarathy, another up-and-coming health services researcher, this study followed SUD patients and compared their health care costs over the ensuing 9 years, compared to a matched group of non-SUD patients (Parthasarathy, Chi et al. 2012). The aim of the study was to examine the association between elements of continuing care over that period and health care costs. Continuing care was defined as ideally having three components: an annual primary care visit plus the availability and use of either SUD or psychiatric services as needed. They hypothesized that people with more components of continuing care would have lower healthcare costs. They had previously shown that having more elements of continuing care was associated with greater rates of abstinence.
What did they find? Having all three elements of continuing care available and used was associated with lower health care costs over a 9 year period, compared with those receiving fewer components. The SUD patients who did not receive continuing care had inpatients costs of $66 per member per month (that’s a lot), while those receiving continuing care did not differ from non-SUD controls.
This study is observational. That is, it followed people over time and then examined correlations, or associations among different variables. There is a principle in research, which is, “Correlation does not imply causation.” That is, one cannot determine what causes what, merely that two variables, such as receiving continuing care and abstinence, tend to occur together more than would be expected by chance. So, it cannot be concluded, for example, that providing continuing care caused improved outcomes and reduced healthcare costs. Or whether patients who were already doing well (for whatever reason) caused more continuing care by making better use of appropriate healthcare services.
Nevertheless, I believe that, combined with other studies, there is a powerful argument to be made that SUD services should include all three components when appropriate: primary care, SUD treatment services and mental health treatment, and that these services should be available on a continuing basis for as long as needed. This is, after all, how we treat virtually every other disease, from asthma to depression to arthritis. It also makes sense to make every effort to make them available in as seamless and integrated a fashion as possible.