Addiction Management Blog

Posts Tagged ‘cost of treatment’

The College on Problems of Drug Dependence 2013 – my update

Sunday, June 23rd, 2013

For the past half-dozen years, I have been attending The College on Problems of Drug Dependence, better known as CPDD. The conference has been in existence since 1929 and this year is celebrating 75 years! It is the longest running conference on drug addiction problems in the US and is attended by the brightest minds in the field from all over the world (it even has its own blog). This year it was held in San Diego and included poster sessions, oral presentations, and plenty of networking. Usually I go it alone, but this year decided to drag my family along to make up for the year I brought them to the same conference in Reno where, ironically, gambling, drinking and smoking permeated the hotel and conference (yuck!).

There was a lot of great stuff this year as usual, so I thought I would highlight just a few things that really caught my attention.

  • traumafiveAdverse childhood experiences predict later substance abuse and addiction. We have known for a long time that 80-90 percent of those who go down the path of addiction start their journey early in life – during teenage-age years – most often as an adaptive response to coping with one or more adverse childhood experiences. I have written about the ACE study on this site, but what is new are studies that continue to evolve these findings in more detail, and help us really understand just how complex, pervasive, and critical it is to evaluate and treat underlying traumas in those who struggle with addiction. Current stats on abuse and neglect are frightening, and sadly addiction is not the only outcome of these cases. The British Journal of Psychiatry recently published a paper linking childhood adversity to all classes of mental health disorders. At the conference Cathy Spatz Widom presented some of her work that has involved following 1,575 kids from childhood through adulthood. This amazing study included 908 substantiated cases of childhood abuse and neglect processed by the courts from 1967 through 1971, and then matched this group with a control group of 667 children with no official record of abuse/neglect. The results from interviews over multiple decades provides strong evidence that early life experiences make a difference in the trajectories of our lives. Bottom line for those who struggle with addiction: intervention must involve addressing unresolved issues from the past that perpetuate addictive behavior.
  • Legalization of marijuana. I have not written about this topic on this site before, largely because I continue to struggle with exactly how I feel about it. While it is now legal in two states (Colorado and Washington) many other states are moving to legalize recreational use as well. On many fronts I agree that legalization makes sense, as the drug war has been a miserable failure. At the same time, Nora Volkow, the Director of NIDA, in cannabisher keynote address pointed out that marijuana use among teens is at an all-time high, while research findings are absolutely clear about the dangers of THC in young developing brains. This year the public policy forum was dedicated to this topic, and two great speakers from the RAND Drug Policy Research Center – Beau Kilmer and Rosalie Pacula – provided a lot of food for thought. Beau reviewed his seven P’s and Rosalie addressed the four primary public health goals: 1) prevent youth access, 2) prevent drugged driving, 3) regulate product content and form (potency), and 4) minimize concurrent use with alcohol. The “how” of accomplishing these goals is beyond this post, but if you dig into the RAND site you will find a recent publication that provides all the details.
  • Abuse of prescription drugs. If the 80′s were about cocaine, the 90′s about meth, we are now deeply entrenched in a time where “the” object of addiction are prescription drugs. In the past decade there has been a five-fold increase in treatment admissions for abuse of opioids, and overdose deaths related to pills have tripled in the past two decades. In some states more people die of pill overdoses than motor vehicle accidents. It is a problem that has gained national attention by many government agencies (and non-government groups), and was a hot topic this year at CPDD. Much of the focus was on abuse-deterrent formulations, which studies have shown have reduced abuse and diversion. This is a good thing, but at the same time such formulations are not necessarily reducing the number of people who struggle with abuse/addiction – they are just pushing them in another direction to other more easily abusable products or illicit drugs (what we call the “balloon effect”). The key point goes back to my first bullet point. We need to invest far more resources into prevention and early intervention since this is really the origin of the problem for most who struggle.
  • psilocybinPsilocybin and quantum change. Of all the cool things I learned this year, the one that surprised me the most was a workshop focused on the treatment benefits of psilocybin, a hallucinogenic compound from mushrooms that operates mostly on 5-HT-2a/c serotonin receptors. The session, led by Roland Griffiths and Herb Kleber, reviewed studies where psilocybin produced some remarkable mystical experiences for participants that rated among the most important events in their life! Here is a video clip describing one of the studies. The hope for those who struggle with addiction is that psilocybin may be an accelerated way to induce spiritual experiences that result in profound and lasting behavioral changes. The compound, when used appropriately in controlled conditions, appears to be non-physically toxic and virtually non-addictive. While the early findings are intriguing, I am not so sure we will see it on the list of evidence-based practices any time soon.

If you want to read more about the conference, check out the CPDD Blog.

Lastly, I know many of you won’t believe this, but CPDD has workshops that go from 8pm until 10pm at night, even Sunday – on Father’s Day! My wife never believed me until she saw it for herself. This is a dedicated group of people! So, after one of these very long evenings, I ventured out into the evening and did a little picture taking. Here are two of my favorites:

SD-5sd-1-2

 

Hitting Rock Bottom: New docu-drama about addiction needs your help!

Monday, June 3rd, 2013

I don’t think I have ever done this before on a post, but here goes. I need your help.

Not long ago I was contacted by some folks who have been working hard on a show called Hitting Rock Bottom. It tells the real stories of people who have struggled with addiction, hit rock bottom, and found a way out. Unlike reality television that often turns tragic stories about addiction into entertainment, this show has a far more noble and broader reaching aim. The creater and Director, Corey Snyder, who has been in recovery for the past five years and also happens to be a very talented film maker, wants to instill hope (and action) in those who still struggle. He portrays challenges with addiction through docu-drama storytelling that utilizes actors to dramatize real stories. He and his team have already completed the first four episodes of season one which you can watch right now for free on the Hitting Rock Bottom homepage. Each episode is a few minutes, so watching them all will not take you that long.

HRBThe first season tells the story of Daryl Brown, a very likable young man who sets out in life with no idea of what is ahead for him. The show is more than engaging, and realistically captures the underlying risk factors that contribute to going down a path of addiction. It is real, scary, and unfortunately a story that plays out far too often.

Fortunately, the story of Daryl has a positive ending, but that is where I need your help!

The show is need of funding to finish filming the first season and complete the story of how Daryl overcomes addiction. It’s the best part of the story and has the potential to motivate many struggling souls to seek help. To complete the season, the crew are presently running a fund-raising campaign on Indiegogo. The goal is $57,500 which will cover all costs to finalize filming the remaining episodes. Even with these funds, many involved in this project are giving their time and energy to see this project to its successful completion. By contributing whatever you can, be assured that your donation will go towards a project that has the potential to transform how we understand, treat, and address addiction in this country. Also, there are only 13 days left in the campaign, so please contribute now. And be sure to check out some of the cool perks at various donation levels.

Thank you.

Addiction & Homelessness, Part II

Monday, April 29th, 2013

books-stackIt was early summer and I was deep into my counseling internship at the behavioral health clinic. I was lucky enough to have a giant corner office with many windows overlooking downtown Portland – room enough to conduct both my individual sessions and run groups. It was so big that I decided to bring in two of my own bookcases to fill out the space. Lucky for me, a relative who happened to be a retired psychologist, had a ton of books to donate to my cause. I figured my clients would walk into the room and see all those counseling-related books and be less concerned that I was an intern. I just hoped they didn’t ask me whether I had read them all because then I would have to fess up.

I chose a late night to get the books into my office. The clinic had a hand-truck to make life easier, but it was still a lot of boxes to move. As I was unloading books from my car, a young man in his early thirties came strolling up and casually asked me for $25. While I have been asked for money many times, never has someone on the street asked me for $25! I was taken aback, but even more, just really curious. I told him I would consider his request if he explained to me exactly why he needed the money. Without knowing at all what I did for a living, he said, “I have been in drug treatment for the past month…a couple of days ago, was kicked out and have nowhere to go… I’m homeless and need the money to buy a bus ticket to San Francisco where my parents live.”

Made sense to me. “Why did you get kicked out of drug treatment?” I asked.

The question made him squirm. He looked down at the pavement and said nothing. I could sense he felt shame. Then in a soft voice he said flatly, “I was caught on my bed with another man.”

I replied non-judgmentally that it seemed like a dumb reason to get kicked out of treatment, and that I would help him. I gave him my business card from the clinic and said to come see me the next morning when I could access funds to help him. Because he had nowhere to sleep I pointed him in the direction of a nearby shelter. The next morning when I stumbled tiredly into the clinic, he was sitting in the lobby waiting for me. It was a busy day. I had two evaluations back-to-back and the first client was also in the waiting room. I had him come back to my office where we chatted briefly about the money. I said I would make some calls, fill out some paperwork, and we could reconvene in my office around 11am to finalize things. He thanked me for my efforts and said he would be back then.

But he never returned.

preventing-heroin-overdose

Around 3pm that afternoon I got a call from the county coroner. He had a body and the only item found on it was my business card. The man had overdosed just blocks from my office. My heart sank and my mind raced. What had gone wrong? How could this have happened? What had I missed?

I will never fully know the answers to these questions, but I suspect that he overestimated the amount of drug his body could handle after being clean for a number of weeks while in treatment. I don’t think he was suicidal, but perhaps I missed something. To this day I regret not taking more time to assess his risks for relapse and overdose, but I didn’t know then what I know now.

For me, homelessness will always have a face.

 

Addiction treatment system 14 years later….still in need of an overhaul

Monday, July 9th, 2012

This past week The National Center on Addiction and Substance Abuse at Columbia University released a scathing report of our addiction treatment system: Addiction Medicine: Closing the Gap between Science and Practice. While the report says nothing new, it does a nice job of summarizing the fact that we have made little progress since the Institute of Medicine released Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment on January 1, 1998. Here we are, 14 years later, and well, where are we now?

The new report points out these grim statistics:

  • 15.9% (40.3 million) of US age 12 and older struggle with addiction to alcohol and drugs (the number is higher if we factor in behavioral addictions such as gambling, sex, food, and online activities)
  • 31.7% (80.4 million) of US age 12 and older, while not addicted to anything, engages in risky use of substances that threaten health and safety (again, this number is higher if behavioral addictions are included)
  • 89.1% of those who meet criteria for addiction involving alcohol and drugs (not including nicotine) receive no treatment
  • Of those who do get treatment, about 50% come from criminal justice (only 5.7% are referred from primary care medicine)
  • Over 50% of those who go to treatment drop out
  • Addiction and risky substance use costs our society an estimated 468 billion each year

Not good! I will admit I was a bit depressed reading through the report, but not surprised. Addiction is a problem still very much misunderstood. Take for example this huge 573 page report, that constrains the definition of addiction to substances. How can we possibly make progress evolving our treatment system if we continue to narrowly define addiction. It is not just to substances that people become enslaved, but to food, gambling, sex, and many online behaviors. We now have neuroimaging studies providing empirical support that the brain is an equal opportunity organ that does not care what stimulates it, so long as dopamine provides a nice reward that keeps us coming back for more. In a great book on overeating, cleverly titled, The End of Overeating, by David Kessler (which I plan to blog about soon), he makes the point that animals will work almost as hard for food as they will for cocaine. So, back to my point. How can we make progress in this field when we continue to slice up the addiction problem, and fail to understand that it is not about the objects per se, but the relationships that a person has with these objects – all of these objects?

Accurately defining the problem would be a start, because we could then start building systems of care that leverage interventions for a wide range of chronic conditions, including addiction. But even agreement on a broad definition will likely not be enough. We need big system changes to make big progress. The CASA report provides a list of recommendations for improvement, including:

  • Increasing screening and referral in primary care medicine
  • Improve training on addiction in medical schools
  • Establish national accreditation standards for all addiction treatment facilities and programs
  • Educate non-health professionals about addiction, screening, and referral (dentists, teachers, legal staff, welfare, etc.)
  • Require adherence to use of evidence-based treatments
  • Expand addiction treatment workforce
  • Implement more national public health campaigns

It is a list, but hardly a gutsy one or even close to what needs to be done if we are to make big progress. What would my list look like? Here are my top four suggestions:

  • National Institute on Addiction (NIA): While integrating NIDA and NIAAA into one organization next year is progress, I would like to see an institute called the National Institute on Addiction that puts the emphasis on understanding the relationships people have with all objects of addiction, not just alcohol and drugs. While I know these agencies have invested resources in gambling and food, the money is scant compared to what is spent on substances. One of the primary goals of this organization would be to get all stakeholders (researchers, treatment providers, public) on the same page about how we should define addiction.
  • Leverage the Internet: Over 80 percent of the US population has access to high-speed internet, which means that we have the potential to reach the 90 percent who don’t get care. I am not saying this is easy, but there is a saying in marketing that you go where the customers are – and they are online.
  • Stop criminalizing addiction and treat those who do end up behind bars: The vast majority of folks behind bars suffer from addiction and most don’t get treatment. This needs to change. Because most will get out, why not use their time while in prison to treat their addiction, educate them, and provide them something to live for when they get out? I know, this costs too much money. See my last point.
  • Invest in families/prevention: Addiction is primarily a problem born out of adolescence. Most who develop addictions begin their journey before the age of 15. We need to devote significant resources to helping families flourish. We need programs that help people developmentally obtain the capacities they need for optimal mental health, for intimacy, parenting, and getting along with each other.

What would be on your list?

Addiction is about three relationships

Friday, June 29th, 2012

There has been a push to understand and define addiction in our society as a brain disease, primarily because of the strong evidence from neuroimaging studies that have identified clear changes in the brain for those who struggle with addiction. At the same time, others have provided evidence that addiction is an adaptive response to underlying, unresolved, adverse childhood experiences (i.e., the ACE Study). We know the truth is that both are right. Roughly 80 percent of those who go down the path of addiction begin  prior to the age of 15. So early life experiences are critical to understanding this problem. Although the ACE study provides significant insight into the roots of addiction, we must also factor in to the equation a wide range of risk and protective factors, as well as genetic vulnerability. While I support incorporating all of these perspectives into our understanding of addiction, I believe how we understand this challenging problem should link directly with how we treat it. For me, this has led to a reconceptualization of how I understand and define this problem, one that I want to share with you.

Addiction is about three relationships with Self, Others, and the All. Let me explain.

The relationship with Self is best characterized by shame. Early adverse childhood experiences (and other risk factors) set-up a belief system that something is wrong with Self, and addictive behavior over time becomes a powerful way to manage the trance of feeling unworthy. To add fuel to the fire, when attempts to stop addictive behavior fail (due to changes in the brain), shame and feelings of unworthiness deepen even more, creating a destructive cycle that results in great pain for the Self and those around the person struggling. The relationship with Others is best characterized by isolation. I have written about this particular relationship in past posts. Isolation occurs because the developmental capacities necessary to initiate, form, and maintain healthy relationships with others become constricted over time, due to spending considerable time with objects of addiction (e.g., alcohol, drugs, porn, food) instead of people. In essence, adults who struggle with addiction are childlike in their ability to be in relationship with others. This makes it hard to hold jobs, parent kids, remain in committed, intimate relationships, and build community. It also helps explain why about 80 percent of those behind bars struggle with addiction, as well as many who return home from war and feel isolated and disconnected from those who have not had similar war experiences. The third relationship is that with the All (e.g., God, Atman, the One, Yahweh, Brahman, Allah), or what 12-step programs call higher power. It is a relationship I have devoted little time to on this blog, but one that I intend to give far more attention to in the future. It is best characterized by Truth and Love. The truth comes from experiencing all that addiction is – both its pleasures and pains. It is no coincidence that at the moment of orgasm, the instant the body feels the sensations from a drug, or the second one realizes they have had a Big Win on the craps table, the words “Oh God” come forth. Going deep into addiction is a search for the All, for truth, and ultimately for love.

These three relationships require attention and healing if we are to be successful at helping those who struggle with addiction. Our interventions should target all three relationships, which I should add, are hardly independent, but linked together in a seamless system. Work on one relationship impacts the others. There are two broad paths or categories of interventions: 1) the path of action, and 2) the path of non-action or contemplation. The first path is what we are accustomed to associating with typical interventions and treatments. The path of action happens in our waking states, when we “do” things. I believe there are five broad actions that are important on this path: motivate, evaluate, manage, resolve and create.  The path of non-action or contemplation is equally important, and involves using meditation practices to detach from objects of addiction and embrace our spiritual nature. If you consider meditation an action, then I guess you could make an argument that perhaps there is only one path. But doing contemplative work in essence is about “just being” which takes us back to a path of non-action. If it sounds a bit confusing, it is to me too. And to round out this discussion, both paths meet in consciousness. More about this to come.

As a parting thought on this topic, engaging all three relationships allows us to incorporate all we know about addiction. We can incorporate insights from neuroscience, medications, and healthy living into our treatments and interventions. And, we can evaluate outcomes more holistically when we consider how our interventions impact and change the three relationships.

All you need is love, love, love is all you need.

Tuesday, August 30th, 2011

At a training not long ago on CRAFT, the presenter, Dr. Robert Meyers, told a story that I want to pass on to you. But first, if you have never heard of CRAFT, it stands for Community Reinforcement and Family Training which is an evidence-based approach that family members (or friends) can use to facilitate getting an unmotivated loved one struggling with addiction into treatment. I am most fond of this approach because, unlike traditional interventions that rely upon coercing a person into treatment through harsh group feedback, CRAFT relies upon using basic behavioral strategies to rearrange the world of the addict so he or she internally reaches the decision that treatment is necessary. We have known for a long time that external motivation gets the job done; interventions do often lead to treatment. But unfortunately, once there, the person we so badly care about does not engage in treatment, does not really want to be there, and often drops out. We are back to square one and saying that treatment does not work. It is a vicious cycle.

In these situations, treatment fails because of a lack of internal motivation. Those who need to change their behavior have to want to change their behavior, which is why CRAFT is so powerful. It works to increase internal motivation for change by eliminating the positive reinforcement for acting out in an addiction, and enhancing positive reinforcement for non-acting out behaviors. If you don’t understand basic behavioral approaches to change using reinforcement, then it is time for Dr. Meyers’ story.

A woman who had been admitted to a psychiatric ward was driving the staff crazy. From the time she woke up until the time she went to bed in the evening she would scream her head off. The staff tried everything they could think of to get her to stop screaming, but nothing worked. She had to be placed in a room alone, away from the other residents, and restrained at times. Although medications could have been used to sedate her (and probably were at times), they were not the answer. After many frustrating weeks of listening to her loud cries, a doctor was brought in to see if he could help. His name was Nathan Azrin.

Nate walked down the hall to the woman’s room as staff likely snickered about how he possibly could make a difference given all that had been tried. When he arrived, the woman was sitting on the edge of the bed rocking back and forth screaming like she did throughout the day. He stood at the doorway for quite some time. He may have thought about why she was screaming, but also knew that whatever the driving reason, she could not speak and exploring the why would likely be a long journey. Instead, being a behavioral psychologist, he considered her behavior and what he wanted her to do instead of screaming. Well, this was easy, he wanted her to stop screaming. Then, he considered the times when she was doing what he wanted her to do: eating, sleeping, and breathing. During these activities she did not scream. As he stood in the doorway, he began to focus more on the immediate moment to moment rhythm of her screaming and breathing. Then he got an idea…

Right at the moment when she stopped screaming to take a breath, he walked over to her and gently stroked her hair. After she inhaled and began screaming again, he slowly moved back to the door and waited until she had to take another breath. He then repeated the movements with every breath: move close to her, look her in the eyes, gently stroke her hair, and then move away as she screamed. Nate knew, that at our core, we all have one unifying need: love. And he believed that by reinforcing the moments when she was not screaming, even though they were just seconds, with loving touch, that just maybe…maybe, he could alter her behavior. While staff had isolated her, restrained her, and stayed clear of her, he moved closer to her. And his approach worked. By that evening, he was sitting next to her on the bed, gently stroking her hair, and the screaming had stopped. He told the staff that when she woke up the next morning and started to scream, someone was to sit next to her and gently comfort her. In fact, anytime she began to scream, the antidote was the same.

I love this story because so often when we are challenged in life we tend to overlook the obvious. We seek out expensive treatments, elaborate self-help strategies, or engage in complex change regiments only to become frustrated when change eludes us. Dr. Azrin is among the most cited psychologists of all time, and although he may go down in history for his popular read, Toilet Training in Less Than a Day, for me, he will go down as an individual who taught me about love.

Investing in Addiction Treatment: Is it Worth the Cost?

Saturday, June 11th, 2011

I recently talked with a Huffington Post reporter about the Real Tab for Rehab: Inside the Addiction Treatment Biz. In our discussion, I pointed out that to a large extent we still have an addiction treatment system that provides short-term (acute) treatment for a long-term (chronic) problem (this key point did not make the article). In addition, the current system treats less than 10 percent of those who could benefit from some kind of intervention at a cost that will likely reach $34 billion by 2014, more than double the spending from 2005. In my opinion, a lot of money is being spent on helping a minority of those who struggle with addiction, and sadly being spent on expensive residential treatment stays that research indicates is not more effective than less expensive outpatient care. Bottom line, the billions being spent could be invested in those who struggle far more wisely.

Not too many years ago I was attending an addiction conference where a number of  treatment centers were advertising their services. I struck up a conversation with one of the marketing reps of a well-known residential program. She explained to me that because of the escalating cost of treatment, her team had developed a program that was only ten days in length, thus reducing the total treatment cost to about 15K while maintaining the effectiveness of a longer residential stay. As I always do in these situations, I asked her about proof that the program worked. She had a well-rehearsed answer, but like most treatment programs, no reliable and valid measures had been employed to measure outcomes. Even if some had been used, we know that 10 days hardly scratches the surface of what needs to happen to help someone with addiction.

Am I opposed to residential programs? Not at all. At times I believe these programs are life-savers and provide a strong foundation upon which to build a solid outpatient management plan. Many employ very skilled, compassionate, and hard-working counselors that know how to help patients stuck in addiction. Some charge reasonable rates for their services and avoid the “spa-like” add-ons that contribute nothing to long-term outcomes. What I am opposed to is marketing that feeds on the vulnerabilities of the populations that seek out their help. Many parents will go to the ends of the earth to help their addicted child and not think twice about mortgaging their home and draining their savings if someone tells them their program will save their kid. Even for those with money, the idea that one can “buy good outcomes” if just the right program is utilized is simply not true.

What can you do? You can spend your time understanding the nature of addiction, what science has to say about treatment interventions, and then spend your money wisely on what will result in the best possible long-term outcomes. What are some of the best financial investments in treatment? This slide from a recent presentation provides you a quick reference point for understanding how a number of treatment interventions rank in terms of scientific evidence. Notice that brief interventions, addiction medications (Campral, Revia), the Community Reinforcement Approach (CRA) and motivational enhancement interventions all rank very high in terms of evidence. Also notice what ranks far down the list: residential treatment, Alcoholics Anonymous (AA) and 12-step facilitation therapies, and general counseling. Note that it is not that these things cannot be useful in overcoming addiction, they can be very helpful. But when you compare their effectiveness through the lens of science to other options, and take into consideration the cost of each, it is clear we could be spending the billions of treatment dollars far more wisely.

The goal is to maximize the best possible intervention outcomes over many years (and for some a lifetime), not a few weeks or months. To do this, we need to employ the best interventions at the lowest cost. Combining free community resources, outpatient therapists, medications, self-help groups, and motivational incentives will give you the biggest bang for your buck.