Monday, May 28, 2018

Thank You, John Oliver! (Ripoff Rehabs)



Around my house, John Oliver’s weekly HBO show, Last Week Tonight, is a must-see.  He has found his own way to combine comedy with incisive and often illuminating exposés on a range of subjects important to all of us.  On his May 20 show (https://www.youtube.com/watch?v=hWQiXv0sn9Y), he focused on the too-prevalent abuse of vulnerable individuals, families, and health insurance premium payers by a large number of facilities calling themselves rehabs (and also sober residential programs) which offer either minimal help or actually promote harm. 

In the late 1980s, with the advent of managed care, health insurance, which had previously covered inpatient rehab treatment for virtually anyone with a drug or alcohol problem, dramatically cut back on coverage.  By 1990, most Massachusetts-based plans covered only detox (usually less than a week, the process of physically withdrawing someone safely from an additive substance), and even that only if the person showed signs or history of withdrawal symptoms.  With some exceptions, “rehab” (usually a month-long program that followed detox with a heavy schedule of educational and therapy groups as well as peer support meetings and medical oversight) was available only to those with money.  (At present, a month-long self-pay stay at a nice rehab can easily cost over $60,000.)  Instead, most plans covered (and still cover) a few weeks of intensive outpatient treatment followed by regular outpatient treatment (the latter usually meaning one weekly session).  Fortunately for everyone, self-help groups are much more available and supportive, at no cost.

With the advent of the frightening opioid crisis (itself largely an outgrowth of medical overprescribing encouraged by pharmaceutical companies) and the astounding number of deaths, some health insurance plans have begun covering rehab stays again. With that we have seen a new surge of crooks.  The Boston Globe recently ran a series on how some Massachusetts-based individuals have recruited addicts to fly to Florida, which seems to be the current ground zero for ersatz treatment, where rehabs and residential programs make big profits on frequent urine tests and foster recurrent relapses, creating more business for themselves.  (Relapse is a common feature of addiction in any case, but ostensibly most treatment facilities seek to prevent it.)

John Oliver notes that the term “rehab” itself is not controlled.  (The same is true for “therapist” or “psychotherapist” – you can bill yourself as a therapist or a rehab tomorrow if you’d like to.)  Further, he notes that many of these places are not offering so-called evidence-based treatments.  I’m afraid I have to add that even those that say they are doing evidence-based treatments may not be doing them in the way they were done in the original studies.  In addition, there are ways of getting treatments certified as evidence-based that really are not relevant to real-life needs of real individuals.  And other treatments that no one has had certified as evidence-based may actually be quite useful.  I’m a fan of science, but just cautioning that “evidence-based” is no guarantee of quality.
To my mind, in evaluating a rehab, you’d want to answer questions like these:

·         Upon visiting the facility, does there seem to be a lot of treatment going on?

·         Does the treatment seem to be professional and relevant to the disorders of addiction/alcoholism?  (For example, the program known as “Narconon” actually provides indoctrination in the teachings of the Church of Scientology.)

·         Who are the staff, what are their credentials/training, and what is their history of providing care over time?

·         What kinds of feedback about the program has been forthcoming from former patients in the program being considered?

·         To what extent does the advertising emphasize slickness and luxury?  (These features draw customers but are often not indicative of therapeutic mission.)

·         How long has this facility been in business and to what extent has it earned respect over time (especially if not recently acquired by another corporation)?

·         When they say they take insurance, what does that mean?  Only for certain services or the first few days?  What will the patient’s actual cost be?

When I meet with people, often family members of individuals who are actively mis-using alcohol or drugs, I don’t pretend to know about all the facilities in the country (especially since new ones keep popping up), but I share what I do know of those facilities that have been around for a while, especially those for which I have heard “reviews” from prior patients.  I also attempt to help them sort out whether the inpatient level of care is actually necessary and likely to have a positive impact to justify its cost.  Less expensive levels of care (including a combination of outpatient and residential, which is not the same thing as inpatient or rehab) are sometimes a better match.  I am friendly with representatives of various systems of care who do a lot of networking with professionals in my field, but I myself have no financial relationship with any facility, so the input I provide to those who consult me is the simply my best effort and the same I would give to a member of my own family.  You should be able to find unbiased addiction-savvy professionals in your neck of the woods, too, clinicians who have spent years not in the research lab or the business world, but on the front line with suffering individuals and families.

Monday, March 12, 2018

Don't Forget the Alcohol


All of us in the U.S. have become all too aware of the devastating impact of opioid addiction and overdose in our population.  A problem that was once found more around the margins of our society, thus more easily ignored, now affects all kinds of people in all kinds of American environments, and as a result we are more willing to devote attention and resources to our fellow human beings whose brains have been hijacked.  In many cases, the original pushers and dealers have been physicians and pharmaceutical companies who chose to minimize or ignore the risks of addiction.  Don’t get me started on the string of prescribers, in medical and dental practices and emergency rooms who found it laughable years ago when I raised this concern with them.
Yes, the scourge of opioids is frightening, and there is no cure-all for it.  But, with all our attention on that, it’s easy to forget that alcohol is still our biggest drug problem and killer.  The most recent government statistics indicate that, while drug overdoses are killing close to 64,000 Americans a year [CDC], tripling between 1999 an d 2016, 88,000 of us per year die of alcohol-related causes [NIAAA]. Another 10,000 deaths result from drunk driving.  Perhaps unquantifiable are the consequences of foolish, impulsive decisions made by people under the influence of alcohol, which anesthetizes the part of the brain largely responsible for judgment, reasoning, and inhibition.

Alcohol, of course, is not only legal, but a well-embedded part of social life.  Commercials encourage us to use beer, wine, and liquor, and when talk show guests mention getting drunk audiences applaud enthusiastically.  There are even some indications that moderate drinking (currently defined as 7 drinks/week for women or 14 for men) may have some beneficial health effects – less publicized are indications that drinking has negative cognitive effects – with a couple of drinks a day maybe you’ll gain months but lose IQ points (sorry – gross oversimplification). 

The good news about alcohol, as I’ve found among those I’ve been privileged to see in my practice, is that in many cases the challenge of overcoming the grip of addiction is somewhat more surmountable for those with alcohol use disorder than for many opioid addicts.  It’s not easy, by any means, and often not free of relapse, but there is a range of helpful treatment approaches, supports, and resources, and the company of millions of Americans whose lives are no longer ruled by their drinking.  We are also finding more effective responses to opioid addictions, but don’t kid yourself – alcohol is still our most pervasive drug problem.

Wednesday, July 26, 2017

Your Therapist: It May Be More Who S/he is than What Kind of Treatment S/he Provides


There is now plenty of evidence that, on the whole, therapy/counseling is helpful to people with a range of problems, such as depression, anxiety, and addictive behaviors.  (The evidence was not always clear; way back when I was in grad school, there was a bunch of research questioning the value of talk therapy – but it turned out that lumping all therapists and patients together kind of averaged good and bad results.)  


Most of the research on the effectiveness of psychotherapy tends to focus on comparing this treatment with that treatment, or with no treatment.  Thus, you have a myriad of schools of therapy with their own particular techniques, each making a case that their approach is the most helpful one.  (They can’t all be right, of course, and findings that are not replicated across researchers and settings are of questionable value.) 


My own doctoral dissertation study compared a cognitive-behavioral alcoholism treatment with a “traditional” treatment.  I was not at all surprised to find, when I followed 50 people for a year after treatment, that there was no meaningful difference in their outcomes.  One recurrent finding is that the type of treatment makes less difference than many of the characteristics of the individual, such as whether s/he is employed (i.e., has structure), married (i.e., not alone), and hangs out with heavy drinkers. 



But probably the most important factor about therapy (though it is the subject of many fewer studies) is not the treatment model but rather the specific therapist and the therapeutic relationship.  A former classmate of mine, now a celebrated psychology professor, reminded me about this at a recent reunion – it’s not a new discovery, but resurfaces in different forms every several years.  The importance of the provider’s personality and the treatment relationship, in fact, also applies to strictly medical providers  – there is an increasing body of literature on how doctors’ and nurses’ attitudes and interpersonal behavior affect patients’ confidence and outcomes.


Generally, people beginning therapy, which sometimes means sharing some private information for the first time, need to feel that they are heard and understood, and to develop a sense of trusting the therapist.  Decades ago, the then-prominent Rogerian school of therapy emphasized that, crucially, a helpful therapist  shows a combination of empathy, genuineness, and warmth (or unconditional positive regard).  These conclusions have held up over time.  It appears that patient characteristics matter as well – those who make harsher judgments of themselves may also find it harder to trust or respond positively to a therapist.

It’s still worth learning about the treatment orientation, and particularly the experience, of your new therapist.  But if, after a few sessions, you don’t feel understood or trusting, it may be worth trying another therapist.  (If it happens repeatedly with one therapist after another, however, that’s can be a signal to examine what barriers you may be bringing into the sessions.)

Monday, January 30, 2017

The Role of "Self-Help" Meetings in Alcoholism/Addiction Recovery


Many, many outcome studies (including my own, decades ago) have shown a significant correlation between attendance at “self-help” groups and better alcohol outcomes (and, by extension, addictions to other substances, but this post focuses on alcoholism, which is currently being subsumed under the label of "alcohol use disorder" by those in charge of naming diagnoses). 

These groups would be more accurately labeled “mutual” or “peer support” groups – they are distinct from professionally run therapy groups and derive their impact from the power of community among people who are “in the same boat.”  And yes, correlational findings don’t prove causation, but I like to make an analogy to cardiac, orthopedic, or obesity patients advised to exercise – it seems obvious that those who join a gym and keep going are more likely to achieve sustained fitness. 

Note, too, that the fact that attending self-help groups improves your odds of improvement does not mean that no one is ever successful without such groups.  And some people probably also sustain fitness just by having a treadmill in the house. 

12-Step Groups.  Among self-help groups, of course, the most available and utilized program, by far, is Alcoholics Anonymous, the original 12-step program that, in the 1930s, grew out of the Oxford Group (what was then a recently formed American Christian organization).  AA emphasizes the importance of a “higher power,” which may be defined as a Judeo-Christian God but also in a variety of nonreligious ways.  The 12 Steps comprise a program of personal growth through processes including honest self-examination, acceptance that there are things beyond one’s control, and helping oneself by helping others.  But these steps are phrased as “what we did,” rather than “what you must do,” and there are no rigid rules or requirements other than a goal of abstinence from alcohol.  The myriad of healing factors in AA (many of them shared with other self-help groups) are too numerous to summarize here.

CBT-Based Groups.  In Massachusetts, where I practice, the main self-help alternative to AA for those who wish to stop drinking (or drugging) is called SMART Recovery (SMART stands for Self-Management and Recovery Training).  Like AA, meetings are free and the goal is abstinence, though people who are still drinking are not turned away (nor are they in AA).  SMART’s leaders have some training in running groups, and the program collaborates with affiliated volunteer treatment professionals and bases its techniques on the same kinds of strategies employed by practitioners of cognitive behavioral therapy (CBT).  Unlike AA, SMART has no steps or references to a higher power or spirituality.  There is also much less emphasis, in comparison to AA, on connecting with and relying on others in making one’s way on the path to recovery.  SMART grew out of Rational Recovery, a program that now eschews grew meetings in favor of website and publication dissemination of its methods; its primary method focuses on identifying and resisting the “addictive voice.”  Although AA certainly uses a number of techniques that could be considered types of CBT, it can be considered to place more emphasis on “heart,” “spirit,” and human connection, while the CBT-based programs emphasize techniques for changing one’s thinking.  As you may know, there are many, many more AA meetings available, no matter where you are, than any other kind of meetings addressing alcohol or drug problems. 

Secular-Emphasis Programs.  A nonprofit agency called S.O.S. (Secular Organizations for Sobriety) presents itself largely as a non-religious version of AA.  It was the brainchild of a man who had been raised in a oppressive Baptist family, and who could not find comfort in a religiously-toned program.  In addition, there is a sort of confederation of AA groups specifically geared for atheists and agnostics, known as WAAFT (We Agnostics, Atheists and Freethinkers in Alcoholics Anonymous).  Neither of these programs lists any meetings here in Massachusetts, but S.O.S. offers online meetings. 

Women for Sobriety.  This program has been around since 1976, also nonprofit.  Open only to women, it puts forth 13 affirmations that tend to place a greater emphasis, in comparison to AA, on loving relationships and self-esteem, but like AA promotes the idea of personal growth.  I know of no current WFS meetings in Massachusetts, and the WFS website does not seem to provide a meeting list (though it does offer and sell literature).   
 
Moderation Management.  MM is a program that, in a group format, allows people concerned about their drinking to monitor their attempts to drink in a non-problem way.  It seeks to prevent drinking from progressing to the point of alcoholism (which would imply that control of consumption is not consistently possible).  Many people who attend MM later conclude that the goal of moderation is not realistic for them and move onto an abstinence based program.  There appear to be no active MM meetings in Massachusetts. 

Professionally Led Therapy Groups.  Therapy groups, unlike self-help groups, involve a fee, to cover for the therapist’s time and overhead.  Health insurance may cover group therapy, but because the reimbursement rates tend to be very low, many group therapists only accept self-pay.  Groups can be led in many different kinds of formats, but in general there a less fixed format and more opportunity for so-called “crosstalk,” since a trained professional is in a better position to keep all such interactions constructive.  For reasons I cannot really explain, there are many fewer professionally run sobriety or early-recovery therapy groups (of the weekly, outpatient kind) than there were years ago.  Of course, time-limited inpatient and intensive outpatient or partial hospital programs are composed largely of therapist-led groups. 

“It Doesn’t Work.”  I’ve heard this phrase in relation to multiple kinds of self-help groups as well as other treatments.  To be sure, there will be aspects of any self-help group that will feel useless to a given individual at a given point in time.  But this phrase would usually be better phrased as “I didn’t find a way to make good use of it.”  Recovery isn’t something that happens to you; it’s not like getting a shot of penicillin.  It’s a process that requires sustained commitment, attention, and legwork.  You wouldn’t say (or perhaps you would), “exercise didn’t work for me.”  You might prefer biking to running, or you might feel more comfortable at Planet Fitness than at Gold’s Gym, but getting healthier depends primarily on daily continuity of effort. 

Sunday, June 12, 2016

Eyes Open in Pain Control and Avoiding Relapse

 I commend to you the first-person account of journalist/science writer Seth Mnookin in the June 9 edition of the Boston Globe, in which he recounts his experience of coming very close to opioid relapse in the course of his recent emergency treatment for kidney stones and the accompanying excruciating pain.

Mr. Mnookin handled the situation as recovering people are advised to do – he told his care providers repeatedly of his addiction (which had been in remission for over 15 years) to opioids, and arranged for his wife to hold and dole out his pills.  He was receiving treatment from Mass General, a renowned and Harvard-affiliated hospital among whose services are an addiction clinic (at which I was on staff way back around 1980) and Addiction Consult Teams to attend to patients across treatment units.  Yet, as his pain persisted because of complications/infection following surgery, he was given prescriptions for more and more painkillers, and was feeling worse and worse – eventually, he realized that much of his discomfort was caused by opioid withdrawal symptoms – his physical addiction had returned after all those years, despite the fact that he had only followed doctor’s orders (including those from a surgeon who had not noticed the addiction alert posted prominently on his medical chart).  At that point, he declined a further prescription that was offered.

For many years, surgeons and other physicians railed against the addiction worrywarts such as myself who expressed alarm at how readily addictive painkillers have been prescribed.  Supported by cherry-picked research information provided largely by pharmaceutical companies, they were damned if they were going to allow their patients to endure pain unnecessarily.  Painkillers have been offered to me personally at most ER visits, usually for very annoying but far from intolerable pain, and many
times by dentists after root canals and such (don’t get me started on how many hours I’ve logged in the dentist’s chair).  Over 30 years ago, after I wrenched my back and could barely stand up, I was introduced to Percodan (the predecessor to Percocet), probably in too high a dosage, and loved it so much, felt so happy with life, that I knew (because I was already doing addiction related work) that I’d better avoid it from then on, and that if I were to become addicted to something, opioids would be my drug of choice.  Even without a history of previous substance abuse (my interest in the field, dating back to college, was originally motivated by growing up in an alcoholic household), I was at risk.    Many times over the years, I have asked doctors and dentists why they showed so little caution in prescribing these medications.  Until the middle and upper class opioid epidemic of the last few years, and the publicity about all the overdoses, my comments generally elicited a kind of dismissive laugh. 


Of course, opioid medication is a godsend when necessary – some patients would probably not survive without it – but prescribers and patients alike need to reckon continuously with the relative risks and dangers of overwhelming pain on the one hand, and serious addiction on the other.  Quite often, a combination of non-addictive medications such as acetaminophen and ibuprofen can do a surprisingly good job of making pain manageable.  When it is insufficient, use of opioid painkillers should be kept to workable minimum, with eyes open to the emergence of withdrawal symptoms and/or craving even in individuals who have been in recovery for years.  

Treatment and abstinence can arrest addiction, but once the brain has been changed by repeated, addictive substance use, it is as if addictive brain circuits are dormant, but not erased – they can be reawakened.  I should also mention that there is a certain transferability to this awakening – for example, countless times I have heard from alcoholic individuals that using prescribed painkillers was followed within days or weeks by a relapse to alcohol, their substance of choice.  Be careful out there.

Saturday, February 6, 2016

Is Rehab Back, for the Non-Wealthy?


Prior to the large scale entry of managed care into health care coverage (yes, I’ve been around long enough to remember), mental health/substance abuse professionals regularly referred actively alcoholic/addicted individuals to rehab.  In fact, the term “treatment” used to imply rehab, meaning typically a month-long program, often in a very nice setting.  In those days, insurance covered rehab routinely.   
Suddenly, with the advent of mental health managed care (which happened to come in most aggressively to Massachusetts, a high-utilization state), suddenly (a) most patient could not be approved for any kind of inpatient treatment and (b) inpatient care for those with addictions was usually limited to detoxification (less than a week, and only applicable to those subject to withdrawal symptoms).  As a result, the two most highly regarded rehabs at the time in New England (Spofford Hall in New Hampshire and Edgehill Newport in Rhode Island) both folded.  Those facilities that survived received much reduced daily insurance payments, and were not able to maintain the same quality of care and were not sustained in the same physical/aesthetic condition. 

I became accustomed, for over 2 decades, to telling families that their alcoholic/addicted members could only go to rehab if they had significant funds (and of course with no guarantee of success, since alcoholism/addiction is a condition prone to relapse).  Instead, they could get detox, if physically indicated, at times followed by 2 or 3 weeks at an outpatient day program.  (A couple of such programs provide basic lodging at a nominal fee and can be called “residential”, but do not offer the kind of 24-hour care available at a rehab – because insurance is paying mainly or solely for the day program at a fraction of the cost of inpatient treatment.) 

Although I have missed the days when people without a lot of money could be advised to “go to rehab,” I do understand the reasons why these changes came along.  Health care as a whole has become insanely expensive (largely because of technology in physical health treatment), and behavioral health treatment was the easiest to cut because it is so much less tangible than, for example, treatment for pneumonia.  In addition, at least half of those who were routinely referred to rehab had a good chance of doing well with a less expensive level of care.  (Not to mention self-help groups, a key resource that’s free!).  But in some cases, especially where less intensive interventions have resulted in frequent and repeated relapses, it became painfully obvious that the rich got better treatment.  Rehab costs range from something like $20,000 to over $60,000 for a month.   

But there seems to be some good news on the rehab front.  I have received no announcements from health insurance companies about any changes in coverage, but over the past year patients have begun to report to me that they managed to get covered for a month in rehab (typically in Florida), suggesting that their Massachusetts based managed care companies had developed contracts (meaning hefty discounts) with certain facilities.  Even more recently, a marketing representative from a new detox/rehab in Massachusetts itself told me that they have been able to serve patients covered by PPO or POS plans.  (In these plans, the patient usually has a deductible, after which insurance pays something like 80% -- but that’s much more than zero.)   

Why is this happening?  I can only guess.  Certainly, there has been increasing publicity about the impact of addictions, and it has become one of our governor’s prime issues as increasing numbers of individual die of overdoses.  (Suddenly managed care companies that used to allow me about 8 authorized outpatient visits at a time are authorizing many more, if the diagnosis is alcohol/drug related.)    So, to those of you whom I myself may have discouraged with regard to how much treatment you could get: don’t give up.  Call your health insurance provider and, if rehab is needed, try to get them to cover it.  And please email me to let me know how it goes, and if they covered a facility that was truly helpful.  The individuals and families I see need to know.

Sunday, November 23, 2014

Alcoholism vs Heavy Drinking: Who's On First?

Individuals and families come to me all the time seeking guidance and answers about their loved ones (or themselves) who have drinking problems.  There is no problem finding treatment providers who have the answers – except that there are many different, sometimes conflicting answers to be found.  Some are based on personal experience.  Others are based on studies – but studies vary a great deal in what they find (and in what they emphasize and how they are designed).

Then there is our own national ambivalence about drinking.  A major film fan, I decided to catch a glimpse of the Hollywood Film Awards recently televised for the first time on CBS.  On hand for commentary were two of the 3 newscasters from CBS This Morning, the only major morning news program that actually emphasizes news.  Yet on this occasion they not only seemed to be auditioning for Entertainment Tonight (does that still exist?) but to join in the frequently mentioned advice to the audience to be sure to drink a lot.  Drinking is apparently the major appeal of these awards, as exemplified by Johnny Depp, who was either very drunk or convincingly acting  very drunk, for our viewing pleasure.  One week later, the same CBS This Morning crew interviewed Dr. Holly Phillips as she noted that heavy drinking, while not equivalent to alcoholism, is dangerous to multiple organ systems in the human body.  No wonder so many people are confused.  I’m confused, and I’ve been working in alcoholism treatment for decades.

On top of that, there’s a new diagnostic manual in town, the DSM 5.  (The criteria used I the CDC study came from the DSM IV, as it was known – Roman numerals are so last year.)  In the DSM 5, the whole distinction between Alcohol Abuse and Alcohol Dependence has been replaced by one diagnosis, “Alcohol Use Disorder,” which can vary in severity.  Well, we’ll see where that goes, but it kind of undercuts the thrust of this study.

The fact is that there seem to be many genes and biological traits that contribute (along with many psychological, life history, and environmental factors) to a person’s problems with alcohol consumption, so that in a sense no two cases are identical.  (Yet one has only to attend a self-help group meeting to realize how much people who self-diagnose as alcoholic do have in common.) 

Perhaps the most crucial feature of those who have been designated alcoholic or alcohol dependent is known as “loss of control.”  The term does not refer to uncontrolled drunken behavior, but rather to the ability to regulate consumption, which most of us do in a relatively automatic way.  Those deemed alcoholic are often unable to do so – once they get 2 or 3 drinks in their systems, they are “off and rolling;” there seems to be no internal feedback loop to shut off alcohol consumption after a certain blood alcohol level is reached.  Although remaining very self-aware may enable a person to override loss of control (that is, to regulate cognitively rather than systemically), it’s not easy and that approach tends to fail over time.  For that reason, many individuals with loss of control over drinking ultimately choose abstinence as the only stable, reliable goal.  Heavy drinkers without signs of loss of control may have a better chance of learning new, less problematic patterns of drinking.

One thing the CDC study seems to be pointing out is that there are many, many people who don’t have loss of control (other other criteria such as tolerance or a pattern of proximate negative consequences of drinking) but drink a lot, enough to be considered “binge drinking” (now defined as more than 4 drinks per occasion for men or more than 3 for women) – and that heavy drinkers, even if not alcoholic, are just as susceptible to the many medical problems associated with too much exposure to alcohol.  These conditions include: 
  •  Liver disease (you knew about that one)
  • Lowered resistance to infection
  • Heart disease and stroke
  • Osteoporosis
  • Breast cancer (a more modest connection)
  • Brain damage (including to the white matter -- new study from Harvard Med School)
For the individual who comes to the office of an addiction professional, the question often boils down to:  I’ve run into trouble with my drinking, but I like to drink; what are my options, what should I do, and how?  This study suggests that it’s not only alcoholics who need to ask themselves those questions.  Answering them often involves another kind of research – the kind you do on yourself, perhaps with a therapist as your co-investigator.