and specifically addiction treatment.
A colleague, (David Mee-Lee, M.D), was browsing the exhibit hall at a national conference this month. He asked one of the residential programs how much it costs per day.
The friendly service representative quoted me a multi-thousand dollar price for the 28-day program and said they don’t have a daily price. This was just like the fixed length of stay program I started nearly 30 years ago.
• A week ago, He listened to the anguish of a mother whose son had recently completed 28 days, and the 90 day extended care program, at a famous residential rehab. facility. She had high hopes for the next program: the 60 day wilderness program he had entered after his relapse. After 30 days there, the insurance company authorized continuing care, only at a less intensive level of care.
She was understandably concerned because, in her eyes, her son had received only half the program promised. No one had explained to her that addiction is a potentially chronic illness, and using a disease management approach addiction treatment involves a continuum of care, just like other behavioral and physical health disorders.
It could have been a rigid managed care company she was dealing with, but she told me the counselor had written very little clinical information to explain and justify the need for continued stay in their very intensive program.
• More and more is known about the neurochemistry of addiction as a “brain disease”. While it certainly is not all in the neurotransmitters, there is an expanding array of anti-addiction medications that can assist treatment and recovery. Yet Cable News Network (CNN) quoted spokespeople of two prominent, nationally known residential programs as saying at one program that “a small proportion of patients receive anti-addiction drugs” and at the other “No patients receive anti-addiction drugs as part of treatment.”
• Tom McLellan, Ph.D., Deputy Director, Office of National Drug Control Strategy (recently resigned), presented some sobering statistics at the American Society of Addiction Medicine Annual Medical-Scientific Conference in San Francisco, California. There are about 68 million people in the USA whose drinking can be classified as “harmful use”. About 2,300,000 people are in addiction treatment in specialty programs of which there are 12,000 programs. BUT:
-> 31% of those specialty programs treat less than 200 patients/year
-> 44% have no doctor or nurse
-> 75% have no psychologist or social worker
-> The major professional group is counselors who are paid the least in the clinical hierarchy and have a 50% turnover rate in a year.
-> There are about 5 million offenders in the community with about 50% having a Substance Use Disorder.
-> 700,000 offenders are released into the community.
-> There are opportunities to intervene at Pre-Arrest, Pre-Trial, Prosecution, Sentencing, Jail and Prison time, and Re-Entry into the community.
• The latest results from the 2008 National Survey on Drug Use and Health (NSDUH) found that 20.8 million needed (but did not receive) treatment for illicit drug or alcohol use. In the year prior to the survey, they found the following—
Of those aged 12 or older who needed treatment for illicit drug or alcohol use, but who did not receive treatment:
-> 95.2% Did not feel they needed treatment
-> 3.7% Felt they needed treatment and did not make an effort to get treatment
-> 1.1% Felt they needed treatment and did make an effort to get treatment
In 2010, with all we know about addiction, we reach a small fraction of people; and then many are the sickest of the sick. Imagine if we only treated people with breast cancer who were late stage; or people with hypertension who were heading towards a stroke; or those with diabetes who presented first for help in diabetic coma.
• Screening and Brief Intervention, Referral and Treatment (SBIRT) • Research-based Prevention strategies • Evidence-based practices like Integrated Dual Disorders Treatment (IDDT); Motivational Interviewing (MI) and Motivational Enhancement Therapy (MET); Client-directed, Outcome-Informed approach (CDOI); Cognitive Behavioral Treatment (CBT); Twelve Step Facilitation (TSF); Multi-Systemic Therapy (MST); Community Reinforcement Approach (CRA); Contingency Management (CM) and on and on • Genetic testing for personalized prescribing of psychotropic medications; and a variety of anti-addiction medications including extended release, injectable medications, vaccines, patches, therapeutic inhalants • Performance Improvement and Process Improvement like the Network for the Improvement of Addiction Treatment (NIATx) now also applicable to mental health agencies • Assertive Community Treatment and Intensive Case Management with a variety of housing, supportive employment and community supports for people with severe mental illness. • Computer-assisted CBT and internet-based support groups and chat rooms
Reference: National Survey on Drug Use and Health (NSDUH): National Findings and Results From the 2008 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration (SAMHSA). Published September, 2009.
David Mee-Lee, M.D Copyright 2010