Treatment-Resources: February 2013

Wednesday, February 27, 2013

Treatment for addicts is starting to change

Experts are pushing for a truly medical approach to treating addiction as a disease rather than relying solely on longtime unproven therapies like 12-step programs.

February 27, 2013|By Shari Roan, Los Angeles Times

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Long-acting drugs have emerged that will reduce cravings in people with… (Darren McCollester / Getty…)

A call for change is afoot in the difficult and often heartbreaking world of addiction treatment.

For decades, 12-step programs and a medication-free approach have dominated the recovery industry. But now doctors and scientists and the leader of the National Institute on Drug Abuse are pushing for broad recognition of addiction as a disease and more medical approaches to therapy.

In the last couple of years, a top addiction society officially declared addiction a "brain disorder." A specialty substance-abuse training program for doctors has been ushered into medical schools. The federal government has announced the creation of new resources to help guide patients, families and doctors toward science-based addiction treatment, and more drugs to treat addiction are entering the pipeline.

In June, Gil Kerlikowske, director of the Office of National Drug Control Policy and President Obama's top advisor on drug policy, declared in a speech at the Betty Ford Center in Rancho Mirage that addiction "is not a moral failing on the part of the individual. It's a chronic disease of the brain that can be treated."

About 21 million Americans have a substance-abuse disorder for which they need specialty treatment, according to 2010 statistics from the government-funded National Survey on Drug Use and Health. Deaths from drug overdoses now exceed traffic fatalities.

Nine out of 10 people addicted to drugs other than nicotine receive no treatment, and most of those who do get it are put through unproven programs run by people without medical training, according to a 500-plus-page report released by Columbia University in June. Solid data on effectiveness of the most popular recovery approach — 12-step programs — are lacking, the report said.

Much of the reason for the disconnect is rooted in the recovery movement's history: Addicts, shunned by the medical establishment, received their help from those outside of it, a trend that continues to this day.

"Drug abuse treatment developed outside mainstream medicine," said Dr. Walter Ling, a leading addiction specialist at UCLA. "We're still suffering from that."

And yet decades of basic laboratory science has revealed that addiction is a bone fide medical problem involving profound brain alterations. Alcohol, opiates, cocaine and other substances increase levels of the chemical dopamine in the reward pathway of the brain. With repeated use, baseline dopamine levels wane to compensate and a drug becomes less pleasurable, requiring ever-larger doses.

Even when people are weaned from a drug, their brains don't return to normal. So they remain vulnerable to its draw, suffering mood swings and profound urges to use again.

Such discoveries are filling science journals at a prodigious rate, adding weight to the position taken by National Institute on Drug Abuse chief Dr. Nora Volkow — that addiction is a chronic disorder that will require multiple rounds of therapy to reduce the risk of relapse and to lengthen drug-free intervals.

Several drugs to treat addictions have been approved in recent years, adding to the modest collection already in limited use, such as methadone for heroin addiction, Antabuse for alcoholism and a handful of others.

To Volkow's mind, the new medications are important for two reasons. First, recovery from addiction is hard and patients need every tool that medicine can offer them. But there is another potential benefit: The growing availability of medical treatments will encourage doctors to treat their patients' drug problems, just as they would a patient's out-of-control blood sugar or high cholesterol.

"You are killing two birds with one stone — giving tools to improve outcomes for the patient and giving tools to the physician, increasing the likelihood they will incorporate substance abuse disorders into their practice," she said.

One of the most important new developments has been the emergence of long-acting drugs to reduce cravings that persist even in people who are highly committed to abstinence. Freeing addicts from summoning the willpower to take their medications each day — as well as the temptation to sell them on the street — eases their burden in the challenging first months of recovery, Ling said.

The medication naltrexone, a pill to treat alcohol dependence, was reformulated into a monthly injection called Vivitrol in 2006 and was approved for opioid addiction in 2010. In studies, 36% of the opioid-addicted patients on Vivitrol were able to stay in a treatment program for the full six months, compared with 23% of the patients receiving a placebo injection. That is a significant improvement for addiction, experts said.

Tuesday, February 19, 2013

Insurance companies frustrate N.J. families seeking addiction treatment

By Dan Goldberg/The Star-Ledger
on February 17, 2013 at 12:10 AM, updated February 17, 2013 at 5:25 PM

Ed Murray/The Star-LedgerKim Kaupp and his wife Jennifer Kaupp hold a picture of their son Jack Kaupp in his bedroom at their home in Mendham on Thursday, February 14, 2013. In 2012 they found him dead in a hotel with a needle sticking in his arm.Ed Murray/The Star-LedgerMedical insurance treatment difficult for addicts to acquire gallery (9 photos)

Denise Mariano and her son Michael had been at Princeton House since 9:30 in the morning. It was now after 5 p.m. and the doctors at the in-patient rehabilitation facility were still fighting with Mariano’s insurance company. Michael was going through withdrawal. Denise was desperate.
The doctors, according to his mother, told Michael he’d have better luck with the insurance company if he had a dual diagnosis: a drug addict who was also mentally unstable.
Would he, they asked, be willing to say he was going to harm his mother or himself. If Michael was mentally unstable, they could admit him, Denise said. And his insurance would cover that.
Michael refused. The 18-year old from Roxbury was a drug addict using as many as 40 bags of heroin a day, but not a sociopath. And even though the doctors wanted to help it wasn’t up to them — not really.
It was the insurance company that had the final say.
Denise ended up paying thousands of dollars out of pocket to get her son a room for a few nights in 2011 before her insurance agreed to cover outpatient therapy.

“It was just a disaster,” Denise said. “I’m lucky my son is alive.”
Princeton House would not comment on this specific case. Its policy prohibits doctors from asking patients to make false statements, but health care experts say scenes like this have become far too common as heroin use booms among New Jersey youth.
Many are middle-class, suburban families — too wealthy to qualify for state or federal subsidies and too poor to pay out of pocket if an insurance claim is denied.
Dozens of interviews with parents, addicts, doctors, social workers, psychologists and policy makers reveal many patients are ready to commit insurance fraud to be admitted to in-patient rehabilitation programs.
It is better, some doctors and nurses tell patients, to drop private insurance because Medicaid or state grants can be more generous. It is often beneficial, others say, to lie about how much heroin is used because the more used, the harder it is for an insurance company to deny coverage.
“This is scary as hell if you have an adolescent or an 18 to 22-year old,” said Frank Greenagel, a clinical social worker at Rutgers who specializes in addiction and recovery treatment. “Imagine you have finally gotten your kid to agree to go to inpatient therapy and after all the crap you’ve been through, you’re denied treatment.”
Insurance companies say they have good reasons for their practices.
A clinician might want to err on the side of more treatment, regardless of what it costs. The insurance company can’t pay for everything without the whole system collapsing.
Even critics acknowledge that insurance companies have to make a business decision.
“What they are doing is making a cost benefit analysis,” said Stuart Gitlow, president of the American Society of Addiction Medicine. “My assumption is they are making a business decision.”
Insurance companies have to take a broader view to protect their policy holders from paying outrageous premiums, said Derek DeLia, associate professor at Rutgers Center for State Health Policy.

Frank Cecala/The Star-Ledger

“Each insurer does it a little differently but they have to make some rules about what they consider proven, effective, or treatable with a lower cost alternative,” DeLia said. “Some are better than others but the process can be very frustrating for doctors and patients.”
And for advocates who decry what they see as insurance companies shortchanging the most vulnerable without ever having seen or spoken to the patient.
“They are practicing medicine without a license,” said Louis Baxter, director of the American Board of Addiction Medicine, an independent board that certifies addiction medicine physicians.
About 30 percent of the 33,000 heroin addicts who checked themselves into a New Jersey rehab facility are under 26 years old. These are middle-class kids, many of whom attended college. They don’t peddle wares on street corners or shoot up in alleys. They hide heroin in their parents’ suburban homes and use Facebook to connect to dealers.
“These are hard working families, upstanding citizens dealing with nightmare of addition, and their kids are dying,” Greenagel said.
BROKEN SYSTEM
Alice Silverman of Maple Shade is a licensed insurance agent, but in 2006, when she tried to help her 19-year old son Danny, she was met with one frustration after another.
“The hell I went through getting him treatment was ridiculous,” she said.
Silverman had taken her son to Kennedy Memorial Hospital in Cherry Hill, which had a detox center. Her son, she said, told the staff that he was using two or three bags of heroin a day.
A nurse pulled Alice aside. That wasn’t going to be enough to get him a bed, she whispered, according to Alice. He needed to say he was doing eight or nine bags a day, or that he was suicidal.
Kennedy Hospital has since closed its detox center and could not comment on Silverman, but Alice says she remembers that conversation.
Two or three bags weren’t enough for a bed, but it only took one bag end her son’s life.
“The system is broken,” Greenagel said. “People in the public have every right to be outraged.
Insurance companies do not discuss specific patients but did provide general statements on how they cover those who need rehabilitation.
UnitedHealth, for example, “determines coverage based on evidence-based guidelines,” according to Mary McElrath-Jones, a spokeswoman. That includes the Substance Abuse and Mental Health Services Administration, American Child Academy of Child and Adolescent Psychiatry and the American Society of Addiction Medicine.
Horizon Blue Cross “follows evidence-based clinical protocols for substance abuse treatment prescribed by the American Society of Addiction Medicine,” according to Thomas Vincz, a spokesman for that company.
There are conflicts because what the guidelines mean is often up for debate.
“Certain aspects of the criteria require subjective interpretation,” wrote Paul Earley, a physician who sits on ASAM’s board. “In this regard, the assessment and treatment of substance-related disorders is no different from biomedical or psychiatric conditions in which diagnosis or assessment and treatment is a mix of objectively measured criteria and experientially based professional judgments.”
But, often, an insurance company’s “professional judgement” will lead them to a different conclusion.
The ASAM criteria say, “for both clinical and financial reasons, the preferred level of care is the least intensive level that meets treatment objectives, while providing safety and security for the patient.” That gives insurance companies good ground to stand on when objecting to a clinician’s recommendation.

AFFECTS EVERYONE
The Star-Ledger recently reported the number of New Jerseyans between the ages of 18 and 25 admitted to addiction treatment centers for heroin rose by more than 12 percent between 2010 and 2011, the last year for which data is available.
“State numbers don’t even capture how bad the problem is,” Greenagel said, because so many addicts try out of state treatment facilities, or are too poor to ever bother seeking treatment.
Most insurance companies will pay to detox a patient, but the ongoing care, the kind that can take months or years, is often seen as a luxury, not a medical necessity, Baxter said.
And, in his view, that is plain wrong.
“We have evidence it is a chronic disease just like diabetes,” he said. “When someone has diabetes, we don’t say, ‘See you later. Have a sugar free life.’ The care is ongoing.”
Struggles for appropriate care do not only affect addicts. When private insurance companies don’t pay, it is often taxpayers who pick up the tab - either through emergency room visits, or the criminal justice system.
Studies from UCLA, the National Institute on Drug Abuse and others show for every $1 spent on treatment, $7 is saved from the criminal justice and health care system.
“Even if you feel these are people who are morally bankrupt or brought this on themselves,” Greenagel said, “if we don’t pay for it now, we pay for it later.”
There are no numbers or studies that show insurance companies limiting coverage to deserving customers. No chart or graph tells this story. It is told through stories of addicts falling through the ever widening cracks of a crumbling system.
Kyle Buchta was told in 2009 he needed detox and 30 days of in-patient rehabilitation, according to his mother Sheila. His insurance denied the in-patient treatment and wanted out-patient treatment tried first, she said.
Back in his Little Egg Harbor home, Buchta, then 19, continued using heroin. He was in and out of out-patient programs, some court ordered, some paid for out of pocket. He held and lost jobs. The cycle continued until his death by overdose last July.
“The progression can happen so rapidly,” Sheila said.
“Absolutely no one would help.”Baxter co-wrote a paper last year with Alan Stevens, a behavioral health specialist, analyzing addiction treatment, and found stories like Buchta’s are far from unique.
“Continued misguided denial of access to the appropriate levels of care ... is not cost effective or clinically prudent,” the doctors argued.
Kathleen Foster said she regularly meets with addicts, or parents of addicts, whose private insurance won’t foot the bill for what a doctor has recommended.

“That decision is not always made here,” said Foster, who founded Parent-To-Parent, a group in Trenton that helps families find appropriate detox and rehab centers after her son Christian died in 1998 from a heroin overdose,
“There might be a few people out in California making the decision,” she said. “They don’t know your struggles, they don’t know your loved ones, they don’t have a clue.”
Linda Chapman, director of addiction services at Trinitas Regional Medical Center in Elizabeth, said they “fight the insurance company,” but if it does not pay, the family receives a bill.
THE SQUEEZE
“Of course you’re frantic to get him somewhere before he dies,” said Jennifer Kaupp, of Mendham.
She and her husband spent about $100,000 paying for treatment for their son Jack, who was in and out of several in-patient rehab facilities, including Summit Oaks where his insurance company paid for fewer days than the doctors requested.
Early last year, Jack's friend received six months in rehab for free because it was court ordered. Jack called the same facility to try and get admitted.
“We knew it would be a struggle because he wasn’t in enough trouble,” Kaupp said.
Two days after making that phone call, Jennifer and her husband found their son dead in a Morris Plains hotel room with a needle sticking out of his arm.
“It’s a visual that we will never, never get over,” she said.

Wednesday, February 13, 2013

Disparities Seen in Addiction Treatment

Black and Hispanic patients less likely to complete substance abuse programs, study finds

by DAVID CECERE

February 13, 2013

Roughly half of all black and Hispanic patients who enter publicly funded alcohol treatment programs complete treatment, compared to 62 percent of white patients, according to a new study by researchers from the University of Pennsylvania, Harvard Medical School and Cambridge Health Alliance. Comparable disparities were also identified for drug treatment program completion rates. The study, published in the latest issue of Health Affairs, shows that completion disparities among racial/ethnic groups are likely related to differences in socioeconomic status and, in particular, greater unemployment and housing instability for black and Hispanic patients.

The researchers analyzed data from more than 1 million discharges from treatment programs across the United States and found significant disparities between white patients and most minority groups in completion of treatment programs. The statistical differences roughly translated to 13,000 fewer completed episodes of drug treatment for black patients and 8,000 fewer for Hispanic patients, compared to white patients. Other minority groups, including Native Americans, also showed lower completion rates than white patients. Only Asian American patients fared better than white patients for both drug and alcohol treatment completion.

According to study co-author Benjamin Cook, assistant professor of psychiatry at Harvard Medical School and senior scientist at the Center for Multicultural Mental Health Research at Cambridge Health Alliance, the fact that racial and ethnic disparities in treatment completion persist even after adjustment for socioeconomic characteristics suggests that some patients are being treated differently because of their race or ethnicity.

Benjamin Cook, assistant professor of psychiatry at Harvard Medical School. Image courtesy Cambridge Health Alliance“Add to these results a host of other studies that identify mental health care disparities and racial/ethnic minorities’ higher likelihood of being incarcerated for drug abuse-related offenses, and we begin to see a picture of a substance abuse treatment system that is coming up far short in treating racial/ethnic minorities in the United States,” he said.

The researchers suggest that funding for integrated services and increased Medicaid coverage under the Affordable Care Act could help to dramatically improve access to treatment programs for minorities. “While health care reform holds promise for improving the substance use treatment of the nation, more attention needs to be paid to addressing disparities in care going forward,” Cook said.

Tuesday, February 5, 2013

“Inside Rehab”: How it could work better, and why it doesn’t

A startling new investigation of addiction programs says 28 days and 12 steps add up to inadequate treatment

BY LAURA MILLER

TOPICS: BOOKS, NONFICTION, DRUG ADDICTION, ALCOHOLISM, ALCOHOLICS ANONYMOUS, WHAT TO READ,EDITOR'S PICKS, PSYCHOLOGY, SUBSTANCE ABUSE, HEALTH CARE, INSIDE REHAB, ANNE FLETCHER,ENTERTAINMENT NEWS

Maybe Amy Winehouse had a point: However flippant that sounds, many a reader will be thinking it (or something like it) after finishing Anne M. Fletcher’s “Inside Rehab.” Fletcher visited 15 addiction-treatment programs, from the high-end to the bare-bones, and interviewed staffers, researchers, experts and over a hundred clients and their families. She collected data from an impressively wide range of studies and surveys. Nearly 3 million Americans seek help for substance-use disorders in speciality facilities annually (not including the nearly 2.5 million who opt for self-help groups like Alcoholics Anonymous) and we spend $35 billion on treating these disorders, so it’s surprising how little most of us know about what goes on in rehab.

Even more eye-opening, however, is what Fletcher discovered during her investigation. She learned that most people who recover from addictions do it on their own, by attending a self-help group or by working with a therapist rather than through a treatment program, and that most use programs are that outpatient operations, not residential. She found that a lot of the treatment offered in those programs, especially the residential ones, is known to be relatively ineffective and is, furthermore, often provided by people with little professional training or formal education in the field. The success rates of residential facilities are unimpressive and, whatever they say in their glossy brochures, many are not up on the newest developments in treating addiction. Many are overly wedded to the twelve-step method, which — gasp! — is not necessarily an indispensable part of getting and staying sober.

Fair warning: “Inside Rehab,” while informed and judicious, is no page-turner. Fletcher’s previously works have been solidly-researched self-help manuals. In this book, she never manages to smoothly integrate two distinct missions. One is to advise readers seeking help with addiction for themselves or loved ones. The other is journalistic, the intended illumination of an aspect of contemporary a society veiled in misconceptions and downright ignorance.

Still, while “Inside Rehab” can be a bit of a slog — if you don’t need the advice, the passages bogged down with recommendations and referrals get pretty tedious — the information and perspective Fletcher provides are indispensable. Whether we’re exchanging personal confidences or dishing about the latest wayward celebrity, addiction is a recurring topic in contemporary conversations. So it’s alarming that the conventional wisdom we bandy about is often wrong, and dangerously so.

As Fletcher relates, Alcoholics Anonymous, the template for most contemporary approaches to getting sober (regardless of the substance abused), arose during the mid-20th century. At that time, alcoholics and other addicts were regarded as moral weaklings and largely neglected by healthcare professionals. AA and the twelve-step programs it inspired are peer-group-based, self-help philosophies and practices that were developed by alcoholics themselves. Twelve-step-based treatment programs, whether residential or outpatient, are not the same thing as AA, even if they are often confused with it.

These programs may be shaped by the twelve steps of the AA movement, and many of them espouse the twelve steps as fervently as any fundamentalist sect, but “a good number of the principles and original teachings of AA,” Fletcher writes, “are inconsistent with many of the ways treatment programs employ AA in practice.” AA, for example, has no formal leadership, does not charge money from participants and was intended to be non-coercive. Many twelve-step-based treatment programs, on the other hand, accept clients who have had their arms twisted in way or another, often by drug courts and other facets of the criminal justice system.

Fletcher’s objections boil down to “the rehab industry’s long-standing failure to individualize approaches to meet diverse needs.” In the decades since the founding of AA, healthcare professionals and researchers cleaned up their own act and began both to evaluate addiction treatments and to design other approaches. (Some of these were created expressly for clients put off by the religious or quasi-religious aspect of the twelve steps.) Alternate techniques to help people stop drinking include cognitive behavioral therapy, motivational interviewing, contingency management, community reinforcement approach, medication and so on, many of which have been demonstrated to be effective in clinical studies.

These practices and other types of “evidence-based” treatments can work better for some people than the twelve steps (which have also been proven effective, for some people). The problem is, many individuals who seek professional help in battling substance abuse disorders never hear about these other methods, or are discouraged from trying them by true believers who insist that the twelve-steps are the only way to get and stay sober.

Furthermore, as Fletcher noted during her visits to various rehabs, many intensive programs used methods that have been shown to have no benefit. Clients in a residential rehab often have to sit through a lot of educational lectures — a consistent dud, especially with teenagers. Others are urged to mull over all the terrible things they’d done in the past, with the idea that this will force them face the seriousness of their problem. “They made me concentrate so much on all the negatives,” one woman told Fletcher, “that I was starting to get insecure and wanted to use more. They were not focusing on our strengths at all; they were just magnifying our weaknesses.” While the belief that addicts need to be “broken down” by confrontational tactics and other domineering gambits is fading, Fletcher found “vestiges” of this attitude in some facilities, even though there is much evidence that they are harmful.

Other classic twelve-step techniques, such a lots and lots of group therapy, work well for some patients and fail spectacularly for others; Fletcher has gathered and presents plenty of testimony from both sides. Yet part of the ongoing twelve-step-based culture within most treatment programs is to insist that if the program doesn’t work for a particular person, the person is at fault and can never be saved until he or she learns to properly “work the steps.” Especially heart-wrenching are the stories of parents who drained their life savings to send their children to rehab after rehab, in the belief that this was their only option and that they were paying for the best possible care.

In fact, one of Fletcher’s most fascinating findings is that publicly-funded addiction treatment programs in modest neighborhoods often provide better care than expensive private alternatives. “The wealthiest people are often getting no better than standard treatment approaches with a few embellishments,” she writes, while “facilities serving lower-income clients were reliant on grants requiring evidence-based approaches and documentation of follow-through.” As a result, the clients at, say, a community center in Madison, get “more comprehensive and more consistent” help in dealing with the challenges of sobriety, such as classes in life skills, trauma and mental-health counseling and family therapy — all services directed at the underlying problems that can send them back to drinking and drugs. Over and over again, Fletcher’s interview subjects told her that flexible, one-on-one counseling, rather than one-size-fits-all group treatments, was what saved their lives.

“Inside Rehab” is by no means a wholesale indictment of the twelve steps or even of residential rehab — although Fletcher believes that only a very small minority of addicts actually benefit from the latter. (Most, she concludes, need to learn to stay sober in “daily reality,” and outpatient rehab has just as high a success rate while costing much less.) But her book is a damning look at a reductive cult of the twelve steps that has emerged since the early days of AA. Anyone in the unfortunately position of needing her advice on how to find the best addiction treatment will find this book invaluable, but the rest of us have a lot to learn from it as well.

Laura Miller is a senior writer for Salon. She is the author of "The Magician's Book: A Skeptic's Adventures in Narnia" and has a Web site,magiciansbook.com.MORE LAURA MILLER.