Drug and alcohol abuse are widespread social, behavioral, and—if we are to believe the National Institutes of Health and most addiction professionals—medical problems. In fact, addiction medicine has evolved into its own specialty, and a large number of other allied health professionals have become engaged in the treatment of substance abuse and dependence.
If addiction is a disease, then we should be able to develop ways to treat addictions effectively, and the costs of accepted treatments can be used to determine how we provide (and reimburse for) these services. Unfortunately, unlike virtually every other (non-psychiatric) disease process—and despite tremendous efforts to develop ways to treat addictions effectively—there are still no universally accepted approaches for management of addictive disorders. And the costs of treating an addict can range from zero to tens (or hundreds) of thousands of dollars.
I started thinking of this issue after reading a recent article on abcnews.com, in which addiction psychiatrist Stefan Kruszewski, MD, criticized addiction treatment programs for their tendency to take people off one addictive substance and replace it with another one (e.g., from heroin to Suboxone; or from alcohol to a combination of a benzodiazepine, an antidepressant, and an antipsychotic), often at a very high cost. When seen through the eyes of a utilization reviewer, this seems unwise, expensive, and wasteful.
I agree with Dr Kruszewski, but for a slightly different reason. To me, current treatment approaches falsely “medicalize” addiction and avoid the more significant psychological (or even spiritual) meaning of our patients’ addictive behaviors. [See my posts “Misplaced Priorities in Addiction Treatment” and “When Does Treatment End.”] They also cost a lot of money: Suboxone induction, for instance, can cost hundreds of dollars, and the medication itself can cost several hundred more per month. Likewise, the amounts being spent to develop new pharmacotherapies for cocaine and stimulant addiction are very high indeed.
Residential treatment programs—particularly the famous ones like Cirque Lodge, Sierra Tucson, and The Meadows—are also extremely expensive. I, myself, worked for a time as a psychiatrist for a long-term residential drug and alcohol treatment program. Even though we tried to err on the side of avoiding medications unless absolutely necessary (and virtually never discharged patients on long-term treatments like Suboxone or methadone), our services were quite costly: upwards of $30,000 for a four-month stay, plus $5000/month for “aftercare” services. (NB: Since my departure, the center has closed, due in part to financial concerns.)
There are cheaper programs, like state- and county-sponsored detox centers for those with no ability to pay, as well as free or low-cost longer-term programs like the Salvation Army. There are also programs like Phoenix House, a nonprofit network of addiction treatment programs with a variety of services—most of which are based on the “therapeutic community” approach—which are free to participants, paid for by public and private funding.
And then, of course, are the addicts who quit “cold turkey”—sometimes with little or no support at all—and those who immerse themselves in a mutual support program like Alcoholics Anonymous (AA). AA meetings can be found almost everywhere, and they’re free. Even though the success rate of AA is probably quite low (probably less than 10%, although official numbers don’t exist), the fact of the matter is that some people do recover completely without paying a dime.
How to explain this discrepancy? The treatment “industry,” when challenged on this point, will argue that the success rate of AA alone is abysmal, and without adequate long-term care (usually in a group setting), relapse is likely, if not guaranteed. This may in fact be partially true; it has been shown, for instance, that the likelihood of long-term sobriety does correlate with duration of treatment.
But at what cost? Why should anyone pay $20,000 to $50,000 for a month at a premiere treatment center like Cirque Lodge or Promises Malibu? Lindsay Lohan and Britney Spears can afford it, but few else—and virtually no insurance plans—can.
And the services offered by these “premiere” treatment programs sound like a spa menu, rather than a treatment protocol: acupuncture, biofeedback, equine therapy, massage, chiropractic, art therapy, nature hikes, helicopter rides, gourmet meals or private chef services, “light and sound neurotherapy,” EMDR, craniosacral therapy, reiki training, tai chi, and many others.
Unfortunately, the evidence that any one of these services improves a patient’s chance of long-term sobriety is essentially nil. Moreover, if addiction is purely a medical illness, then learning how to ride a horse should do absolutely nothing to help someone kick a cocaine habit. Furthermore, medical insurance should not pay for those services (or, for that matter, for group therapy or a therapeutic-community approach).
Nevertheless, some recovering addicts may genuinely claim that they owe their sobriety to some of these experiences: trauma recovery treatment, experiential therapy, “male bonding” activities (hat tip to the Prescott House), and yes, even the helicopter rides.
The bottom line is, we still don’t know how to treat addiction, or even what it really is in the first place. Experts have their own ideas, and those in recovery have their own explanations. My opinion is that, in the end, treatment must be individualized. For every alcoholic who gets sober by attending daily AA meetings, or through religious conversion, there’s another addict who has tried and failed AA numerous times, and who must enroll in multiple programs (costing tens of thousands of dollars) to achieve remission.
What are we as a society willing to pay for? Or should we simply maintain the free-market status quo, in which some can pay big bucks to sober up with celebrities on the beaches of Malibu, while others must detox on the bathroom floor and stagger to the AA meetings down the street? Until we determine how best to tailor treatment to the individual, there’s no shortage of people who are willing to try just about anything to get help—and a lot of money to be made (and spent) along the way.
Seems to me the disease model evolved along with AA, probably with input from founder Dr. Bob. Just because we find it useful to classify a phenomenon as a disease does not mean it must have an effective treatment yet. As for costs you have completely ignored the cost of continued addiction. Opiate addicts can spend several hundred dollars on drugs in one day. The cost of buprenorphine induction and maintenance pales by comparison, and heroin addicts who stop buprenorphine or methadone often die. How do you value the life of a person with an addictive disease?
Addiction treatment is not unique in attracting quackery or an abundance of overpriced, often ineffective, treatments. Ain’t it awful.
So what are you suggesting? If we individualize treatment, the patient must be free to choose.
If you want a more interesting topic, research the patented Prometa protocol licensed by Hythiam for treatment of alcohol, meth and cocaine addiction with gabapentin, hydroxyzine and flumazenil.
Nice post, as always, and some interesting and important issues raised. Having worked in addiction treatment programs for over twenty years, it’s been my experience that whether or not someone “successfully” completes treatment is almost impossible to predict–making it very difficult to target addiction in a programmatic way. On that basis, I agree that an individualized approach is essential–in which I would include the idea that it’s almost impossible to define successful outcome based on a single treatment episode.
To elaborate a bit: if addiction is in fact a chronic medical condition, it is (like many other conditions) characterized by recurrence. There are accepted approaches to treatment of type 2 diabetes, yet with diabetics the outcomes are often quite poor (I don’t have any stats at hand). However, it seems much easier with diabetics (or hypertensives, or folks with other chronic diseases) to think of treatment in terms of an overall trajectory of improvement in HA1C or other relevant indicators–not in terms of perfect adherence to dietary and exercise regimens, perfect response to medication, etc. In other words, it’s understood that diabetics are flawed, and human, and that treatment is an ongoing process with an underlying goal of general improvement–progress, not perfection.
It’s been my experience that this perspective is not held with regard to addiction treatment, but rather that successful outcome is defined based on complete abstinence after a particular treatment episode–with significant moralistic judgment if this “success” doesn’t take place. To me, this kind of thinking is entirely inconsistent with the idea of addiction as a medical problem, but rather reflects what I think is the underlying moralistic perspective our society has on addiction–even if we somewhat reluctantly call it a disease (when convenient).
To be clear, I’m not arguing in favor of harm reduction, nor abstinence based treatment, nor any other particular approach. Rather, I think there’s a tremendous ego and economic investment on the part of treatment programs (and insurance companies) in the idea of “success” or “failure”–to some degree with purely mercenary motives, and to some degree from the perspective that well intentioned clinicians do want patients to do well. What I am arguing for is a shift in thinking about what successful outcome is, a change in what we realistically expect based on actual medical understanding of the phenomenon of addiction–based on what the disease really looks like and how it seems to function in reality, recidivism and all, not on moralistic fantasies of perfect success and abstinence based on a single episode of intervention.
Further, I would submit that our culture as a whole really doesn’t think addiction is a medical (or, more properly, public health) issue. In considering your points with regard to the expense of addiction treatment, I feel compelled to argue that in comparison to the funding, expense, and sheer weight of criminal justice intervention, the amount of money spent on addiction treatment is a mere pittance. Consider prisons, border patrols, courts, attorneys, and a variety of other people and institutions that continue to reinforce (and profit from) the criminalization of a public health concern. So, I personally don’t think the expense of addiction treatment is as much of an issue as the political ideology that keeps us believing that our current use of resources for non-medical intervention is somehow legitimate. This, to me, seems more like lip service than it does an actual commitment to medical treatment.
Finally, I have to take issue with your description of a variety of complementary, alternative, and integrative approaches to treatment as a “spa menu.” As an acupuncturist (as well as a psychologist) I’ve seen people benefit tremendously from CAM treatments for addiction, and am of the belief that in the right context any experience can be the transformative intervention that helps someone make a leap into recovery. I think you’ve said much the same thing, so your characterization of non-standard medical interventions (when you’ve said that there really is no standard intervention) is a bit puzzling. I do think the ways in which many treatment programs use CAM approaches is fairly superficial, and could easily be more substantive. I also think these kinds of approaches should be available across the board, not just to high-end programs for the affluent. But I have to argue with what seemed to me like denigration of CAM approaches in general. (And if that’s not how you meant your comments, apologies for my misunderstanding.)
So, again, thanks for the post, and for allowing me to rant…
moviedoc and Michael,
Thanks for your thoughtful comments. Michael, I agree that “success” in addiction treatment is a vague concept. To define it as complete abstinence is to condemn yourself (and your patients) to failure in most cases– regardless of the intervention employed (“medical” or otherwise). One solution is to describe the goals of treatment in terms of the complications (finances, relationships, health, employment, etc) that led to the treatment episode in the first place. [Frankly, I think we should look at all psychiatric treatment the same way, but I digress…] Just as we treat diabetes not necessarily to keep HbA1C below a certain level (even though that’s a good “biomarker”) but instead to prevent renal, ocular, neuropathic, and other complications, we might look at addicts the same way. Some alcoholics, for instance, can return to “controlled drinking” and suffer no further consequences. Admittedly, that’s anathema to most treatment programs.
Regarding my comments about the ancillary services provided by the more expensive treatment programs, you are right that some of them (if not all) can be therapeutic– if not curative– when properly employed. I simply wish to draw attention to the fact that they’ve typically been added as “amenities” or perks, when in fact they might provide precisely the dimension that a given patient needs to overcome his/her addiction. Unfortunately, we don’t know which patient. So as it stands right now, we throw a bunch of modalities at everyone who signs up (and pays their $30K-50K) and never really know what works for whom. With that approach, how will we (and our insurers) ever really know what’s effective?
To both moviedoc and Michael, I also agree that the money we spend on addiction treatment is minuscule compared to the amounts spent both within the drug trade itself and in our efforts to control it. But I deliberately avoided that part of the argument to focus instead on our health care dollars (which are finite and limited) and the intelligent, evidence-based appropriation of those funds for treating addictive disorders. The way it stands now, some spend a great deal and get nothing, while others spend nothing and achieve remission and lasting recovery. For the most part, we don’t get what we pay for. We can’t develop policy based on such findings.
Finally, moviedoc, as it happens, I almost took a job with the San Francisco Prometa Center in 2007, but I was (to put it mildly) unconvinced by their approach. The Prometa story will be, in my opinion, nothing more than a curious footnote in the history of addiction treatment.
Niacin (B-3) works well for sobriety.
Abram Hoffer, M.D., Ph.D. worked closely with one of the co-founders of AA, Bill Wilson. In fact, Bill Wilson was later inducted into the Orthomolecular Hall of Fame –
Bill Wilson used to drive around with pamphlets, telling people of the benefits of Niacin for alcholism. A video of Dr. Hoffer discussing, AA, Bill Wilson, and Niacin (B-3) therapy for alcoholism –
AA was as much a nutritional approach as a spiritual one in its inception.
I think the tenets of AA are good… the spiritual part, however the recovery rate is said to be about only about 5 percent. For anyone who is searching for alternatives to AA –
Duane Sherry, M.S.
Some additional links for nutritional and integrative medical approaches –
Community Addiction and Recovery Association –
Joan Matthews Larson, Ph.D., Health Recovery Center –
Neurofeedback and Addictions –
Duane Sherry, M.S.
In the event some of these links are quickly-dismissed (imagine)…
I don’t claim to have all the answers, but I am a retired counselor, with a master’s degree from the University of North Texas… Rehabilitation, Social Work and Addictions –
More importantly, I have been sober since February 1, 1987… I have taken 3,000 mg of Vitamin B-3, Niacamide (amide form of B-3) for years… along with several other nutrients.
Orthomolecular Medicine works.
In fact, it works well.
And it’s cheap.
The University of North Texas has had a Neurofeedback lab for years, and it has been part of the graduate curriculum for quite some time, where clients have received enormous benefit (including many people with “chronic mental illness”).
The classic definition of insanity: To keep doing the same things, over and over, and expect different results.
I’m for new ideas.
For taking mental health in a new direction.
A ‘recovery’ direction.
Duane Sherry, M.S.
How much should food cost? How much should housing cost? We still have a free market here, although health care costs subsidized by payers inflate fees. Addiction treatment is more complicated than you paint it. Rates of abstinence vary according to the drug and other factors. An addict with a major comorbidity will have a worse prognosis. Alcoholics probably do better than opiate addicts which is one reason buprenorphine forever makes sense for the latter, while benzos for alcoholics makes no sense. If you call addiction a disease we know there is no cure. A cure would entail converting an individual who cannot control his use to one who can. I have seen evidence of this happening with naltrexone. Abstinence is not cure, but it may mean success. Harm reduction like buprenorphine and needle exchanges can save lives. Is that success? Spiritual recovery through the likes of AA helps a lot of people, and cost is no barrier. Is it success? Is it treatment? Even if you define success as abstinence you must talk about duration, and you never know if you stayed clean until the day you die. And some achieve lasting abstinence after the first meeting or the first rehab while some take two and others ten, and still other die first.
I agree, a better question than “how much should treatment cost?” is “how much should we be willing to pay?” As it stands right now, some are prepared to pay a great deal for (I fear) the illusion of treatment. (By the same token, some are willing to take lifelong buprenorphine without ever exploring the interpersonal conflicts or trauma history that led to their compulsive use and subsequent addiction. Is that treatment? It’s debatable.) The point is, if we’re calling addiction a disease, and we professionals expect to be reimbursed fairly for the treatment we provide, and we expect those costs to be covered by a health plan, then we ought to have a sound evidence base upon which to base our treatment protocols. AA works for some, but not all. Some truly benefit from CBT, others from acupuncture, still others from niacin (according to Duane). I think we should understand what works for which people (and yes, define what we mean when we say treatment “works”) before asking patients or third-party payers to pay outlandish sums for what amounts to window-dressing.
There’s no more evidence that “interpersonal conflicts or trauma history” led to diabetes than to addiction. Compulsive drug use probably evolves out of the euphoric effect of the drug combined with the roller coaster of withdrawal and intoxication. Some are willing to take lifelong insulin rather than “exploring” fantasy causes, probably because it, like buprenorphine, works to forestall more devastating consequences of the disease (or whatever you want to call it). Some health plans still do not cover addiction or other psychiatric disorders the same as physical illness. This has been addressed to some degrees with parity legislation, which has also mandated, in my state at least, such treatments as massage therapy which probably have no better base of evidence. The question then is whether government should determine what and how much is covered, or competition between private insurers coupled with popular demand. If we end up with a single payer I believe we should cover illness/treatment according to a priority list like Oregon attempted a few years ago. But there should also be a private market where the wealthy can spend away on whatever snake oil or quackery they want to waste their money on.
It was great meeting you. I wish you’d concluded this post with the answer. And vitamin B-3 via Whole Foods dropped my cholesterol by 50 points, but I still drink wine with dinner sometimes.
There may be nothing better than B-3 Niacin for cholestorol.
It works well.
It’s cheap… without the fallout of statins.
To clarify to readers. Niacin lowers cholestorol, but not the amide form, B-3 Niacinamide (or nicotonic acid)..
Both forms can help with “severe mental illness”, but only Niacin for cholestorol. From the Orthomolecular Vitamin Information Centre –
Also, niacin (in either form) works best when certain culprits are elminated from the diet – namely, processed foods, sugar, etc, and a much healthier diet is introduced. Nutrients in the form of supplements are often successful when used in combination….
The work of Bonnie Kaplan, Ph.D., et al, Univeristy of Calgary. Dr. Kaplan is a pediatrician who was quite skeptical when first starting her research, but has since-found enormous success in the treatment of “bipolar” and other “severe mental illness” –
Duane Sherry, M.S.
Re: How much should addiction treatment cost
I don’t have the answers but I do have a question. How do we as a society pay for anorexia treatment?
To me, it seems that addiction and anorexia have several things in common: they both manifest as behavioral problems, they both require long-term treatment and perhaps life-long changes from the individual, they both seem to require intervention and supervision of some kind in the early stages of treatment, and they both could run up very big tabs.
So, I wondered if we had figured out how to treat anorexia cost-effectively because that may be a model for paying for treatment for addiction.
The American Psychiatric Association (APA) has a Caucus on Complementary, Alternative, and Integrative Medicine (CAIM) –
Surely, there are psychiatrists out there who are finding benefit with left/right brain integration (EMDR)?
If not, the ‘recovery’ movement is gonna have to take off without them.
In the event that a person has undergone trauma, and it is at the root of their alcohol or drug use…
Eye Movement Desensitization and Reprocessing (EMDR) gets high marks for trauma treatment from both the American Psychiatric Association (APA) and the U.S. Dept of Veterans Affairs.
I’ve met several integrative psychiatrists who use it, and have had good success with the treatment method.
From the EMDR Institute
Duane Sherry, M.S.
I’ve met several integrative ‘practitioners’ who use EMDR – mostly psychotherapists (not many psychiatrists)…
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