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 (, 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.