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.



  1. I generally agree with what you are saying. I think the no fault aspect of the illness is very difficult for many to grasp - most importantly the policy makers and health plan administrators. I think it is captured very well in the latest ASAM definition. I think that Sellman’s Top Ten list and the responses to it are also instructive especially item 7 “Come back when you are motivated” is no longer an acceptable therapeutic response’ is part of your message.

    From a systems standpoint, the lack of a full array of services to treat addiction is striking. Over the course of my career I have seen detox services essentially moved to mental health units and then to the street. I wrote a post about this several weeks ago that was read by current detox staff who agreed with it. It is hard to believe that in many if not most cases people with addictions are sent home from the ED, sent home with a handful of benzodiazepines, or sent to a facility with no medical coverage for a complex detox process. I think the test of any health care system is whether a primary care doc can ask themselves if they have a safe detox procedure for any of their regular patients who are addicted to opioids and benzodiazepines and needs surgery.

    Medical systems in general have a very poor attitude toward people with addictions. I think that these healthcare systems and their personnel are much more likely to take a moralistic attitude toward addicts and not treat them well. I have seen that theme repeated across multiple care settings. Many rationed care settings disproportionately reduce resources necessary to treat addiction. I think it is safe to say that most cardiology patients with suspicious chest pain get a $10,000 evaluation and reassurance or appropriate treatment. Most patients with addictions do not even get a $300 evaluation. They may actually see a physician who provides them with medications that fuel their addiction. Institutionalized stigma plays a big role in that. There are no billboards in the Twin Cities advertising state-of-the-art addiction treatment. There are many advertisements for heart centers.

    I am less pessimistic about the effects of 12-step recovery and time in a residential setting whether it is a high end recovery facility or a state hospital. I think if you are in a setting where there is no active treatment or sober environment you are probably wasting your time. I have seen people who were declared hopeless recover with time away from alcohol and drugs on the order of months. Vaillant’s study of severe alcoholism is a great example of the different paths to recovery and there are many. His subsequent analysis of how AA might work suggests that affiliation rather than blaming may be the most curative element. AA is difficult to study but I think that the message is positive and embodied in #3 of the Twelve Traditions. Up to that point the founders were looking at the issue of exclusion but decided against it because alcoholism was a life threatening disease.

  2. Superb piece, as usual. With 12-step based treatment programs as with AA itself, it is likely that most persons who do not respond drop out of view. Likewise, just enough people with chronic, severe, treatment-resistant addiction achieve sobriety and stay around to reinforce the belief that anyone can make the 12-steps work, and it's the lack of willingness, absence of surrender, etc., that accounts for failure.

    Treatment can be essential in helping a person achieve sobriety; however, what occurs after treatment determines the durability. I'm not aware of research on this, but from what I've seen, people who return to their environment after treatment are more likely to relapse than those who transition to a sober supportive living arrangement away from their old environment. Recovering alcoholics and addicts are vulnerable to relapse from cravings triggered by contact with people, places and things associated with substance use, and from diminished capacity in coping with stress. These can be reduced by avoiding the environment inhabited before treatment.

  3. I found this to be a thoughtful and engaging piece. Thank you. I'm amazed by society's treatment of psychiatric disease and addiction as if the brain were not a part of the body. I fall into this trap often and I'm in recovery. Frankly, while 12-step programs can be a real life-saver, I think that they are also a significant cause for society viewing addiction as if it were not an actual disease.

    I think that society and the medical profession can fall into the trap of seeing addiction as somehow different than other "biological" diseases because the cure, or the treatment to be more accurate, is so vastly different than the standard pharmaceutical or surgical approach. 12-step programs claim that there is no cure for addiction but one can arrest the disease through a spiritual experience and trust in one's higher power, and this seems to many to mean that the cure is spiritual (which, may be quite true). Since no other disease is treated as a spiritual malady, addiction somehow seems less biological and carries with it a level of culpability or even choice so people treat it differently than other diseases. Obviously, this causes much harm. However, the questions you've brought up about whether society should hold addicts responsible for behaviors caused because of their addiction (your example of the alcoholic who drove drunk is but one of many examples) are incredibly important and I'd like to see you write more on this issue. However, I can see how it may take the conversation off-track, too.

    Thank you so much for your website. Thank you for your posts at TheFix.com, and thank you for your work. I look forward to reading more.

    God bless.

  4. Brilliant. I ran an inpatient facility for a while, and we had good results, but I believe that was because we had extensive personal follow-up and contact with the patients on a regular basis for a year after treatment. Now, as I head up an out-patient facility in a sub-economic area where there are very few sponsored beds to in-patient, we reserve those beds for those who seem to not be able to make progress with out-patient. We refer to more medically orientated facilities to address dual-disorders, stabalise medications etc and immediately on discharge they enter out-patient and/or individual counselling/therapy, which continues as long as long as is needed.

    I feel that this is the one plus for AA/NA, it provides a daily point of contact - and this daily point of contact seems to help, no matter what the intervention! We are about to open a social room so that patients can come in daily just to relax and chat, and I believe that this may help improve outcomes. Only time will tell.

    As you say, OST is indeed effective. I just wish we could afford it beyond the detox phase. In the few cases where the patient can afford it, we have excellent results - it kind of replaces the short-term CBT designed to elicit initial behaviour modification - but we still find that many benefit from longer term therapies dealing with past traumas, family of origin issues etc.

    The one thing I am a bit conflicted about is that this message, although true, can seem extremely disempowering for some individuals. It is so difficult to gain a good balance between understanding taking responsibility for treatment engagement yet not responsibility for the condition. I have a problem when "treatment" begins with "only 1 out of 50 will make it!" (the brochures didn't say that I bet). I have found better outcomes when people have hope in recovery (or should that be remission?)and when they understand that although they may be predisposed to addictive disorders, by engaging in treatment and various therapies they can build capacity and resilience. (maybe this has something to do with ego depletion?)

    The recent study by Connolly, Bell, Foxe, and Garavan:"Dissociated Grey Matter Changes with Prolonged Addiction and Extended Abstinence in Cocaine Users" interests me. What is amazing, is that in certain areas, after 35 weeks of abstinence, the gray matter density of a recovering addict exceeds that of a drug naive subject. Not only this, but there is asymmetry between the losses and gains, pre and post use. This would imply that recovery does not simply reverse the affects of drug use but involves distinct neurological processes. Hence my use of the terms "resiliance and capacity building".

    Wow, this thing we call addiction is complex and multi-faceted. There are no easy answers, and if someone says they have easy answers, they are probably more about marketing than treatment!


Comments are welcome.