More Hard Facts About Addiction Treatment

“Yes, we take your insurance.”

Recent reportage, such as Anne Fletcher’s book, Inside Rehab, has documented the mediocre application of vague and questionable procedures in many of the nation’s addiction rehab centers. You would not think the addiction treatment industry had much polish left to lose, but now comes a devastating analysis of a treatment industry at “an ethics crossroads,” according to Alison Knopf’s 3-part series in Addiction Professional. Knopf deconstructs the problems inherent in America’s uniquely problematic for-profit treatment industry, and documents a variety of abuses. We are not talking about Medicaid, Medicare, or Block Grants here. Private sector dollars, Knopf reaffirms, do not “guarantee that the treatment is evidence-based, worth the money, and likely to produce a good outcome.” Even Hazelden, it turns out, is prepared to offer you “equine therapy,” otherwise known as horseback riding.

Knopf, who is editor of Alcoholism and Drug Abuse Weekly, was specifically looking at private programs, paid for by insurance companies or by patients themselves. Who is in charge of enforcing specific standards of business practice when it comes to private drug and alcohol rehabs? Does the federal government have some manner of regulatory control? According to a physician with the Substance Abuse and Mental Health Services Administration (SAMHSA), the feds rely on the states to do the regulating. And according to state officials, the states look to the federal agencies for regulatory guidance.

All too often, the states routinely license but do not effectively monitor treatment facilities, or give useful consumer advice. Florida state officials do not even know, with any certainty, exactly how many treatment centers are in operation statewide. And even if state monitoring programs were effective and aggressively applied, “just because something is legal doesn’t mean it’s ethical,” said the SAMHSA official.

“We see this as a pivotal time for the treatment field as we have come to know it,” said Gary Enos, editor of Addiction Professional, in an email exchange with Addiction Inbox. Enos said that “the Affordable Care Act (ACA) will move addiction treatment more into the mainstream of healthcare, and this will mean that treatment centers' referral and insurance practices will come under more scrutiny than ever before.”

 Among the questionable practices documented by Knopf:

—Paying bounties and giving gifts to interventionists in return for client referrals.

Under Medicare, paying interventionists for referrals is banned. “In the private sector,” says a California treatment official, “it’s not illegal. But it is unethical.” According to treatment lobbyist Carol McDaid, “kickbacks happen all the time. Treatment centers that are doing this will do so at their own peril in the future,” she told Knopf.

—Giving assurances that treatment will be covered by insurance even though only a portion of the cost is likely to be covered.

Under the Affordable Care Act (ACA), says the SAMHSA official, “We are trying to position people to know more about their benefit package. And the industry has to be more straightforward about what the package will cover.” John Schwarzlose, CEO of the Betty Ford Center, told Knopf that “it’s very hard for ethical treatment providers to compete against insurance bait-and-switch,” when patients are told their insurance is good—but aren’t told that the coverage ends after 7 days, or that the daily maximum payout doesn’t meet the daily facility charges.

—Billing patients directly for proprietary nutrient supplements, brain scans, and other unproven treatment modalities.

“Equine therapy, Jacuzzi therapy, those are nice things, and maybe they help with the process of engagement,” said one therapist. “But people need to recognize that these ancillaries aren’t the essence of getting sober.”

—Engaging in dubious Internet marketing schemes.

You see them on the Internet: dozens and dozens of addiction and rehab referral sites. They list private services in various states, and look, on the surface, like legitimate information resources for people in need. As the owner of a blog about drugs and addiction, I hear from them constantly, asking me for links. “Family members and patients frequently have no way of knowing that a treatment program was really a call center they got to by Googling ‘rehab,’ writes Knopf, “and that the call center gets paid for referring patients to the actual treatment center. They don’t know that a program that promises to ‘work with’ health insurance knows full well the insurance will cover only a few days at the facility, and the rest will have to be paid out of pocket.” She points to a 2011 Wired magazine article, which said the Internet marketing cost of key words like “rehab” and “recovery” can be stratospheric. But “by spending that money—not necessarily providing good service—treatment provides can come out on top on searches. It’s the new marketing to the desperate.”

The group with the most to lose from revelations of this nature is the National Association of Addiction Treatment Providers (NAATP), the association representing both private and non-profit rehab programs. The Betty Ford Center has discontinued its membership in NAATP, a move that reflects the turmoil of the industry today. “It’s crazy that we have treatment centers inviting interventionists and other referents on a cruise, and then giving everyone an iPad,” Schwarzlose said.

As one man who lost his son to an overdose said: “I don’t get it. There’s the American Cancer Society, but I look for drugs and alcohol and I can’t find anything. There’s no National Association for Addictive Disease. How can this be?”

The investigative series will be featured in Addiction Professional’s March/April print issue. Enos believes that “influential treatment leaders are more interested than ever to see this debate aired more publically,” and says that the online publication of Knopf’s articles for the magazine has sparked “a great deal of discussion in treatment centers and on social media, including comments about other questionable practices that harm the field’s reputation.”

Craving Relief

Why is it so hard for addicts to say “enough?”

One of the useful things that may yet come out of the much-derided DSM-5 manual of mental disorders is the addition of craving as a criterion for addiction. “Cravings,” writes Dr. Omar Manejwala, a psychiatrist and the former medical director of Hazelden, “are at the heart of all addictive and compulsive behaviors.” Unlike the previous two volumes in this monthful of addiction books, Manejwala’s book, Craving: Why We Can’t Seem To Get Enough,  focuses on a specific aspect common to all addiction syndromes, and looks at what people might do to lessen its grip.

Why do cravings matter? Because they are the engine of addiction, and can lead people to “throw away all the things that really matter to them in exchange for a short-term fix that is often over before it even starts.” When Dr. Manejwala asked a group of patients to explain what they were thinking when they relapsed, their answer was often the same: “I was so STUPID.” But the author had tested these people. “I knew their IQs.” And the best explanation these intelligent addicts could offer “was the one explanation that could not possibly be true.”

In my book, The Chemical Carousel, I quoted former National Institute on Alcohol Abuse and Alcoholism (NIAAA) director T.K. Li on the subject of craving: “We already have a perfect drug to make alcohol aversive—and that’s Antabuse. But people don’t take it. Why don’t they take it? Because they still crave. And so they stop taking it. You have to attack the other side, and hit the craving.” However, if you ask addicts about craving when they are high, or have ready access, they will often downplay its importance. It is drug access unexpectedly denied that sets up some of the fiercest cravings of all. Conversely, many addicts find that they crave less in a situation where they cannot possibly score drugs or alcohol—at a health retreat, or on vacation at a remote locale.

Why are cravings so hard to explain? One reason is that “people use the word to mean so many different things.” You don’t crave everything you want, as Manejwala points out. Cravings are not the same as wants, desires, urges, passions, or interests. They are “stickier.” The brain science behind craving starts with the downregulation of dopamine and other neurotransmitters. As the brain is artificially flooded with neurotransmitters triggered by drug use, the brain goes into conservation mode and cuts back on, say, the number of dopamine receptors in a given part of the brain. In the absence of the drug, the brain is suddenly “lopsided,” and time has to pass while neural plasticity copes with the new (old) state of affairs. In the interim, the unbalanced state of affairs is a prime ingredient in the experience of craving.

Cravings are “disturbingly intense” (Manejwala) and “incomprehensibly demoralizing” (AA). Alcohol researcher George Koob called craving a state of “spiraling distress.” Cravings are not necessarily about reward, but about anticipating relief. “The overwhelming biological process in addictive craving is really a complex set of desperate, survival-based drives to feel ‘normal,’” says Manejwala.

The late Alan Marlatt, a psychologist who studied cravings for years, proposed that apparently irrelevant decisions could trigger or prevent relapse, almost without the addict knowing it. Turning left at an intersection, toward the supermarket, or turning right, toward the liquor store, can feel arbitrary and dissociated from desire. We also know that environmental cues can trigger craving, such as the site of a crack house where an addict used to do his business. Manejwala points to research showing that “some relapses related to cues and context are mediated by a small subgroup of neurons in the medial prefrontal cortex,” and suggests that it may be possible in the future to target this area with drug therapy.

Manejwala is unabashedly pro-12 Step, and favors traditional group work as the standard therapy. For example, he points to a Cochrane analysis of 50 trials showing that group participation roughly doubles a smoker’s chance of quitting. One of the reasons AA works for some people is that AA attendance reduces “pro-drinking social ties.” Simply put, if you are sitting with your AA pals in a meeting, you’re not out with your drinking buddies at the tavern. The author admits, however that alternatives such as SMART recovery work for some people, and that “sadly, much energy has been wasted as members of these various organizations bicker with each other about which works best, and this leaves the newcomer perplexed…. Over 20 million American are in recovery from addiction to alcohol and drugs. I can tell you this much: they didn’t all do it the same way.”

And along the way, you can be sure that all of them became familiar with cravings. Manejwala offers several strategies for managing cravings, and I paraphrase a few of them here:

—Join something. Participate. Get out of your own head and become actively involved in some group, any group, doing something you are interested in.

—Hang around people who are good at recovery. Long-timers, with a solid base of sobriety. You will not only learn HOW to do it, but that it CAN be done.

—Write stuff down. This makes you pay attention to what you’re doing. Keep a cigarette log. Count calories. Know what you’re spending per month on alcohol. Educate yourself about your addiction.

—Tell someone. Tell somebody you trust, because if there is anything harder than dealing with cravings from drinking, smoking, or drugging, it’s doing it in secret.

—Be teachable. Watch out for confirmation bias. “When you think you have the answers, it’s hard to hear alternatives.”

—Empathy matters. The author notes that the Big Book insists that by gaining sobriety, “you will learn the full meaning of ‘Love thy neighbor as thyself.’” Altruism may have evolutionary, physiological, and psychological implications we haven’t worked out yet.

Broken Treatment: How the Addiction Industry is Failing its Clients

It’s not medical. It's not psychiatric. What is it?

1. Most clinicians who treat addicted patients are counselors, not physicians; thus they cannot prescribe medication and they generally don’t “believe” in the use of medication for addictive disorders.

2. Most patients have medical insurance that excludes or severely limits treatment of addictive disorders, so payment for service is not good. This situation may change in the near future with the advent of healthcare reform in the United States.

So writes Dr. Charles O’Brien of the University of Pennyslvania Perelman School of Medicine, in a recent article for The Dana Foundation’s website.  In his article—“If Addictions Can Be Treated, Why Aren’t They?”—Dr. O’Brien asks a basic question: “Why are most patients not even given a trial of medication in most respected treatment programs?”

Even though pharmaceutical companies have throttled back on their interest in anti-craving drugs in recent years, there are, in fact, a few medications recognized by the FDA, primarily for use in the treatment of alcoholism. But they are not much in favor, and O’Brien believes he knows why:

The answer seems to be that there is a bias among treatment professionals, perhaps passed down from past generations when addictions were not understood to be a disease. Medically trained personnel are minimally involved in the addiction treatment system and most medical schools teach very little about addiction so most physicians are unaware of effective medications or how to use them.

What is on offer at most addiction treatment facilities is not actual rehabilitation, but rather short-term detoxification. And what we’ve learned from neuroscience is that taking away the drug is only stage one. The addiction remains, the reward and memory systems still operating erratically. We understand some of this circuitry better than at any time in history, but the concrete effects of these insights at the level of the community treatment clinic have been small to nonexistent. Money, of course, is part of it, since addiction has only recently, and sporadically, gotten the attention of funding agencies in the public health community. 

Health journalist Maia Szalavitz, writing at Time Healthland concurs: “Unlike most known diseases, the treatment of addiction is not based on scientific evidence nor is it required to be provided by people with any medical education—let alone actual physicians—according to a new report.” The report in question, from Columbia University’s National Center on Addiction and Substance Abuse (CASA), notes that most people are shoehorned into a standardized approach built around the 12 Step model of Alcoholics Anonymous. “The dominance of the 12-step approach,” writes Szalavitz, “also leads to a widespread opposition to change based on medical evidence, particularly the use of medications like methadone or buprenorphine to treat opioid addictions—maintenance treatments that data have show to be most effective.”

  Szalavitz also believes she knows why, and her thinking is similar to O’Brien’s. “Other medications that are known to treat alcohol and drug addiction, such as naltrexone, are also underutilized,” she writes, “while philosophical opposition to the medicalization of care slows uptake.”

There is a straightforward reason for considering the use of medication in the treatment of addiction: strong suggestions of recognizable genetic differences between those who respond to a given medication, and those who don’t. As O’Brien explains, a prospective study now in progress will be looking to see if alcoholics with a specific opioid receptor variant show a better outcome on naltrexone than those with the standard gene for that opioid receptor. And if they do, the FDA may allow a labeling change “stating that alcoholics with this genotype can be expected to have a superior response to naltrexone.”

But that won’t be happening tomorrow. In the meantime, we are stuck with the addiction treatment industry as it is. “The [CASA] report notes that only 10% of people with substance-use problems seek help for them,” Szalavitz concludes. “Given its findings about the shortcomings of the treatment system, that’s hardly surprising.”

Photo Credit: Creative Commons

Falling Down and Getting Up: Nic Sheff’s New Addiction Book

 

Sheff jumps back on the carousel, lives to tell about it.

What would it be like to have written a drug memoir and an autobiography before you turned 30? Would it seem like the end or the beginning? Are there any worlds left to conquer?

The last decade has brought us fleshed-out young examples by Augusten Burroughs, age 37 (Dry); Joshua Lyons, 35 (Pill Head); and Benoit Denizet-Lewis, 33 (America Anonymous). This more or less fits the pattern established by the doyenne of the genre, Elizabeth Wurtzel, who, at age 35, wrote the addiction memoir More, Now, Again. And now along comes Nic Sheff to put them all to shame, making geezers out of every one of them.  Sheff wrote Tweak at 24, telling the world about addiction and how he’d conquered it. Well, as it turns out, not really. But for twenty-somethings, a week is like a year, so two years later, in actual time, comes We All Fall Down, in which we learn—if we didn’t learn it the first time—that the author is still learning about addiction, doesn’t have it figured, and isn’t really qualified to give out lessons to anybody just yet. Or perhaps I should wait for We All Stood Up Again two years from now before drawing any conclusions.

I know I am being a bit unfair to this well-intentioned young author. I blame it on the flood of weighty pronouncements found in the addiction memoirs that have flooded the market lately. God bless ‘em all, but Amazon, by listing Sheff’s book as “Young Adult,” probably gets it about right. You can’t go into these projects expecting great literature. Sheff’s text, perhaps in a deliberate appeal to younger readers, is peppered with whatevers, and clauses that begin with “like.” His favorite adjective, without question, is “super.” Too many one-sentence paragraphs give the book an irritatingly staccato effect at times.

But let’s get beyond that. There are good things here, and Sheff is certainly qualified to tell an addiction story: “We stayed locked in our apartment. I went into convulsions shooting cocaine. My arm swelled up with an abscess the size of a baseball. My body stopped producing stool, so I had to reach up inside with a gloved hand and….” And so forth.

There is a standard tension in addiction memoirs by young writers. The dictates of group therapy and 12-step treatment programs clash mightily with their innately sensitive bullshit detectors. It is hard—understandably—to buy into some of the more narrow-minded and coercive treatment programs they’ve been tossed into along the way. I was chilled to hear Sheff quoting substance abuse counselors threatening to commit him to lockdown psych wards, or blackmailing him into signing contracts about who he could or could not be friends with in the compound. For a free-spirited, open-minded young artist, the distinction between rehab and a Chinese re-education camp is pretty much lost entirely when personal freedoms are arbitrarily limited by lightly qualified drug counselors. One of the more compelling themes of the book is that rehab, as practiced in many treatment centers across the country, is something of a cuckoo’s nest joke.  It is a mutual con, where everybody fools everybody in order to turn a profit, on the one hand, and discharge legal or parental obligations, on the other. “Infallible institutions,” as Sheff derides them, “that know, absolutely, the difference between right and wrong.”

So Sheff plays along, he shucks, he jives, he lies, and it’s hard not to sympathize with him as he summarizes one counselor’s admonitions: “We don’t allow any non-twelve-step-related reading material, and you won’t be able to play that guitar you brought with you—so we’ll go ahead and keep that locked in the office.” Much like prisoners who leave prison chomping at the bit to commit new and more lucrative crimes, these kids are coming out of misguided drug rehab centers with nothing but an urgent desire to wipe away the bad memories of mandatory treatment by getting wasted as soon as possible.

And yet, and yet… “Once I had some knowledge about alcoholism and addiction, it was impossible to go back to using all carefree and fun,” Sheff writes. “The meetings and the things people told me had pierced the armor of my fantasy world. Somewhere inside I knew the truth.”

Maybe there won’t be a need for a third memoir. The book has a provisionally happy ending. Sheff found the right doctor, got on the right medications after a diagnosis of Bipolar Disorder (comorbidity, the elephant in the rehab room), and, when last seen, is clean and optimistic.

Sheff does have an appealing, Holden Caulfield-type persona, and this Catcher in the Rye mentality perhaps excuses the litany of things in this world that are phony, fucked up, and lame to this endlessly hip kid. All carpets are faded, all motel rooms are dingy. Even his airline boarding pass is “stupid.” But the style sometimes works for him: “Thinking, man, even that cat’s got enough sense not to jump on a hot grill twice, no matter how good whatever’s left cooking on there might look to her.” Or the time when he realizes that, like any old alkie, it was time to “start switching up liquor stores. That goddamn woman makes me feel as guilty as hell. And, I mean, who is she to judge? Christ.” And he’s got some nice truisms to deliver: “The most fucked-up detoxes I’ve ever seen are the people coming off alcohol. It’s worse than heroin, worse than benzos, worse than anything. Alcohol can pickle your brain—leaving you helpless, like a child—infantilized—shitting in your pants—ranting madness—disoriented—angry—terrified… You don’t go out like Nic Cage in Leaving Las Vegas, with a gorgeous woman riding you till your heart stops.”

Photo Credit: http://www.goodreads.com/

Treating Addictions [Guest Post]

The ABCs of rehab.

[Journalists like me tend to get immersed in the scientific and medical aspects of addiction. Not a bad thing, to be sure—but sometimes a simpler rendition puts a finer point on the matter. Today’s guest post was contributed by Susan White, who writes on the topic of Becoming a Radiologist.  She welcomes your comments at her email id: susan.white33@gmail.com.]

It’s very easy to find fault and assign blame when you’ve never been in the other person’s shoes; how often have we found ourselves judging people for their bad habits? Why can’t he stop that obnoxious habit? Oh, she’s not strong at all, she cannot stop drinking! I would never sink to the drug-induced state he is in, not even if the worst things were to happen to me – it’s easy to say all these things because we don’t know what an addiction feels like and how hard it is for people to quit. They’re just like you and me; they don’t like the way they are, but their substance abuse controls their bodies, minds and everything they do or say.

To understand an addiction, you need to understand that the body goes through changes, both physiological and psychological. If the addiction is to alcohol, drugs or any other chemical substance, the high euphoric feeling is what makes you go back again and again. But as time goes by, the high decreases and you begin to take in more of the abusive substance in your quest for that initial euphoria. It’s a vicious cycle that feeds itself, and if you stop, you feel withdrawal symptoms because your body is so used to its daily or even hourly fix.

It takes a supreme effort to admit that you have a problem and seek help. Rehab centers work because they make the addict quit cold turkey; they are cloistered and controlled environments where addicts have no access to the abusive substance. The sudden withdrawal causes abnormal reactions in your body, and you’re treated with medicines that help soothe your frayed nerves. When the initial craving subsides, you’re put in therapy and other forms of rehabilitation. Your diet is regulated, and your body slowly starts to recover and rejuvenate. 

The hardest part of rehab however comes when you step out of the cocoon of the de-addiction center and enter the real world. You have to face the demon that had its tentacles around you and fight it down, and for some people, this is where they suffer a relapse. Once they are surrounded by temptation, they succumb and are soon back to their decadent and sorry state. Others however, are made of sterner stuff. They know that they cannot afford to lose control again and they are disciplined enough to say no when they come face to face with temptation.

Addiction, be it to a substance, person or thing, is not something to be taken lightly. Unless admitted to and treated at the earliest, it could end up having serious physical and mental consequences. 

Graphics Credit: http://www.nida.nih.gov/