Rehabing Rehab – How we can fix America’s addiction treatment system

When Charlie Sheen finally entered rehab, it wasn’t terribly shocking news. But what most people did find surprising was that instead of checking into a swanky Malibu addiction treatment center as he has done in the past, Sheen opted to receive in-home rehab. Immediately the media began criticizing his choice and questioning his commitment to getting sober.

There are undoubtedly certain challenges related to in-home rehab, but are you really guaranteed better care if you check into a treatment center?

Absolutely not, thanks to the lack of standardization in our current rehab system.

Seeking addiction treatment in The U.S.

Each year, about three million Americans seek help from a seemingly endless list of addiction treatment facilities. But who is ensuring these treatment centers are qualified to effectively treat them?

With a lax application process for state licensure and certification, there is little accountability placed on facilities, or their ownership, to ensure proper treatment is being offered. With more than 12,000 rehab centers in the country, the odds of finding the one that best fits your needs are next to impossible.

When treatment fails, which it often does, it is then assumed to be the addict who failed, when in reality it was often the addict who was failed by a flawed system.

This leads to a vicious cycle of relapse — a story all too familiar to families struggling with addiction, not to mention one we’ve seen repeatedly played out by Hollywood stars.

It is true that some don’t take advantage of their treatment and fail at sobriety on their own, but others simply weren’t given a chance to succeed.

The whole story is made worse by the fact that most rehab clinics market themselves as “all inclusive” — able to treat any type of addiction disorder — which most are certainly not. Addicts and their families are often so desperate to get help that they select a rehab clinic based on cost and availability, without understanding whether or not the care providers are properly certified in the type of addiction that affects them or are qualified to fulfill any additional needs they might have (including mental health needs).

This is especially true of first-timers (over 60 percent of those seeking addiction treatment are doing so for the first time). They don’t know what questions to ask or even what they are looking for out of a treatment center, making it nearly impossible to find the right option for their individual needs.

How to set standards for addiction treatment

We need to try and get some measure of standardization into the addiction treatment system so that we are able to match those looking for treatment with providers that fit their needs. Currently, there is essentially no oversight regarding the services addiction treatment providers report and their actual capabilities for providing those services.

In the place of a centralized federal or state-level vetting system, there are some private groups that provide directories. But it is not easy to tell how well these directories actually vet the treatment centers listed. It is critical for treatment candidates to know exactly what type of credentialed treatment services are provided. This should be provided by the public health departments, but until that happens, it’s basically “every man for himself.” (Here All About Addiction, we recently launched our own “rehab finder,” to provide a vetting system we think can help.)

We believe this is a crucial element for successful treatment; especially when you consider that more than 50 percent of addicts suffer from mental health issues, meaning they need special care by a trained professional. And while some may promise this, there is no verification process to ensure they are able to deliver on their promise.

In fact, a huge survey of the addiction treatment industry found that more than 20 percent of addicts entering treatment were missing crucial mental health services that they needed. (About 50 percent were missing other necessary medical services.)

Rehab is a business — a booming one, at that — and right now it is too easy to sell the idea of recovery. Because there is no model of care to follow, the system is compromised with clinics that don’t know how to do things better, some that limit their treatment due to dogma and other centers that are actually trying to “game” the system.

The bottom line is, without some level of standardization, treatment becomes nothing more than a crapshoot. You are left at the mercy of a broken system and never know what kind of treatment you are going to receive until it is too late.

Right now, you could easily check into rehab facility and find they offer nothing more than an expensive 12-step program. This is unacceptable. We have tools, like cognitive behavioral therapy and motivational enhancement therapy, which we know are effective, we just need to ensure they are part of the treatment model being offered to patients.

Add to that some very effective, if poorly utilized, medications and it’s clear we’re handicapping our patients, pun and all.

However, there is hope, and a better way of doing things, but it will require us to adopt a more progressive model of treatment.

Our society has too readily accepted the supposed “fact” that recidivism rates are high, and will always be high, for addicts. The fact of the matter is that the treatment process itself is deeply flawed and until we fix the model of care for recovering addicts, we will never be able to truthfully tell how many of them can recover. Addiction isn’t a death sentence. It is a treatable disease; we need to acknowledge that the way we are doing things doesn’t work and do something to change it.

After many years of trial and error, researchers and doctors have finally begun to grasp what works and what doesn’t in terms of treating addiction.

It is now our job and our responsibility to start developing a system that gets the proper treatment to the people who need it.

Any doctor will tell you, there are no guarantees with addiction. All we can do is give people the best shot at treatment, and sadly, right now, our system is failing at that.

Addiction during the holidays: Recovered or not, it’s important to be prepared

Holidays can bring on stress for someThe holidays are a stressful time for everyone. Between gift-giving, travel, and keeping up with all parts of the ever-complicated modern family unit, nearly anyone can find themselves driven towards the nearest coping mechanism, whatever that may be. However, for recovering addicts, or those still struggling with an active addiction, the holidays can be a particularly troubling season that can invite a destructive relapse. As with all mental and physical health issues, education and awareness are a powerful first line of defense. By going over some of the most frequently asked questions about addiction and the holidays, we can attempt to shed some light on these issues for addicts and their families to help combat them before, not after, they become bigger problems (like a relapse).

Why Are The Holidays So Difficult For Addicts?

Obviously, as just mentioned, the pressures of the holidays are difficult for everyone. But for addicts, these same issues of money, family and general stress are amplified, often because they are the same age-old issues that lie at the root of the addiction and the beginning of drug use and abuse in the first place. If the recovering addict has not had the opportunity to openly confront family issues in the past, either with the family itself or with a therapist or counselor, the potential for relapse can be great. A vast amount of research shows how stress can bring even long-dormant behavior back to the surface, which should serve as a warning to substance and behavioral addicts alike (like sex addicts or compulsive gamblers). On the other end of the spectrum, addicts without a stable family or group of friends are often left feeling alone and isolated during the holidays, another powerful source of the shame and boredom that can drive addictive behavior.

What Are Some Of  The Hidden Struggles That Can Intensify Addiction/Trigger A Relapse?

Most often, these struggles emerge from one of two likely scenarios. In the event of a still active addiction, attempts to hide the problem from friends and family and the resulting stress can, paradoxically, intensify the addictive behavior. And whether the addiction has been treated or not, gathering with family in a familiar place can frequently cause someone to face many of the underlying issues that can be the root causes of a drug addiction or compulsive behavior. To paraphrase Tolstoy, all unhappy families are unhappy in their own unique way, and whether one’s particular family is overly judgmental, enabling, angry, or whatever else, it can serve to restart self-destructive patterns of behavior. For some recovering addicts, there may be a family-imposed secrecy around the recovery itself, which can be trying at a time when the whole family is gathering, ostensibly to celebrate one another. Even the house (including the room where an addict used to act out) and certain family members (like that cousin they used to smoke weed with) can be important cues that may re-trigger cravings and old behavioral patterns. Additionally and importantly, if there is a family history of any kind of past abuse, this can obviously serve as a particularly powerful and insidious trigger for addicts, whether recovering or not. In fact, recent research suggests that these old, root stimuli may be much more powerful for drug addicts than re-experiencing the drug itself.

What Are Some Strategies For Surviving The Holidays?

First and foremost, one must be prepared. Since most people at least know and are aware of the potential issues that might arise within their own families, it is crucial not to try to “wing it.” If you know that your family is going to be asking lots of uncomfortable questions, practice some appropriate answers and don’t feel obligated to discuss any aspect of your recovery that you’re not comfortable discussing. If your family is overly focused on achievement or likes to bring up stories from the past that are triggering or shameful, rehearse your reactions to them. If you have a friend or significant someone who can help, do a little role-play trying out different answers and see how they feel as you actually say them out loud. It will never be exactly the same as you practice, but being prepared can go a long way towards taming the body and brain’s natural stress responses. Just as importantly, if you know you’re liable to encounter events or people that formerly facilitated addictive behavior, role play those likely scenarios and know how you plan on turning down or avoiding those substances or behaviors. For instance, figure out how exactly you’re going to tell your cousin you aren’t going to smoke in the basement with him before you have to actually do it. It will sound a lot less forced and strange the second time around and you will have already experienced some of the associated anxiety. If you’re going to be alone, make distinct plans for your activities and do the best you can to find healthy situations to participate in, even if they seem new or slightly uncomfortable at first. For instance, go ahead and join that group of strangers for a Christmas eve dinner or Christmas day movie instead of spending those times along. After all, uncomfortable or not, a new, healthy experience will be vastly preferable to sliding back into the same old destructive patterns of the past.

Should I Use New Years To Confront My Addiction?

Most everyone is familiar with the New Year’s Resolution as a method of planning major life changes. Of course, most everyone is also familiar with the limited success rate of these resolutions, and of the effectiveness of “going cold turkey” in general. Depending on the addiction, there are certainly things that individuals can do to help themselves- for example, research suggests that when trying to quit smoking setting a quit date and beginning to use replacement patches or supplements in anticipation of that date (in other words, while still smoking) can help reduce the amount of smoking while approaching that quit date, making it easier when the day finally arrives. If you’re planning to quit a “harder” drug than nicotine, you may want to set a whole schedule for reducing drug use prior to the quit date itself. The important thing is to be completely realistic in order for the change to stick. If you’re drinking a bottle of vodka a day, attempting to go completely dry within a week can be extremely dangerous to your health, and will not likely result in a permanent change. Once again, education and preparation are key. Prepare for any sort of quitting by looking online on sites like AllAboutAddiction and WebMD, and identify the medical and psychological issues that are likely to accompany your attempt. Look to see if your problem is one that you can handle alone, or if it is recommended that a doctor help you with the process. Remember that your goal should be lifetime change, not a temporary one. Though it might seem counter-intuitive, if your holidays promise to be especially difficult or stressful, you may want to hold off on trying to quit during them and look at them as a time to lay the groundwork for your post New Year quit attempt rather than going for a full on cold turkey try. Such pragmatism may well help you achieve your true goal.

“Addicted” – Recovered and Helping: The reality (tv) of addiction treatment.

With the success of shows like A&E’s Intervention and Celebrity Rehab with Dr. Drew, America has shown an almost insatiable appetite for television programs that deal with addiction. Whether this reflects the breadth and depth of the addiction problem in this country or a national appetite for tragedy and schadenfreude is open for debate, but regardless, TLC has now thrown its own hat into the ring with a new series, Addicted, that follows a trained family interventionist who is, herself, a recovering addict. Though the line between education and exploitation in such shows remains a debatable matter of personal opinion, it calls to our attention a crucial element in modern addiction treatment: the unique position of the recovering addict to make a positive difference in the lives of those still caught in the grip of dependency.

Hey, it’s what got me starting this website over three years ago.

Addicted on TLC – Addiction treatment reality

Kristina from the TLC show AddictedKristina Wandzilak, the main character of the TLC “Addicted” show, is a professional interventionist specializing in family-style interventions, targeted towards not only the addicts themselves but the families for whom having an addict as a family member has destabilized their lives and sense of control. The central philosophy of family-style intervention revolves around working not only with the addict but with the entire family to restore that feeling of control and healthy boundaries, after which, the theory goes, recovery of the chemically dependent individual can follow. Wandzilak’s faith in this style of addiction treatment is hard-earned; as a cocaine and methamphetamine addict, she cites her own mother’s ability to establish a firm boundary and “walk away” as the impetus for her to finally get clean.

Wanzilak’s story is a sadly common one. Falling in love with alcohol from her first drink at the age of 13, addicted to cocaine and methamphetamine by age 15, and in and out of treatment by 18, Kristina was clearly on the fast path to an early grave. Returning home after another escape from rehab, she was turned away at the door by her mother, a firm line she would later credit as the first step to her recovery. Though the next three years of her life would involve a continued spiral of cocaine and methamphetamine addiction, prostitution, and robbery, it was allegedly at a moment of complete rock bottom that her mother’s strength and grace in turning her away served as the inspiration for her to finally take control of her own life. After seeking her own addiction treatment, Kristina has now been sober since September 4, 1993 and calls this the greatest accomplishment of her life. In her words, she feels that if she helps families to embody the strength that her mother had in dealing with her, the addicts will be forced to “run into themselves” and thus find sobriety soon thereafter.

A note here – I’ve talked about the difference between positive reinforcement and punishment before, so I won’t go into it at length here, but I think it’s important to keep in mind the fine line between helping someone by keeping consistent boundaries and hurting them by refusing to help. With this show just starting, I really hope that this line is kep in mind and that the producers, and Kristina, don’t use it for ratings rather than helping those in need.

Where would addiction treatment be without recovered addicts?

The question stands- does Kristina Wanzilak’s or any other addict’s past with addiction make them more qualified to help those now suffering through the same issues? Many people feel that this is the case, including qualified specialists like Dr. Drew Pinsky, who takes most of the staff for his VH1 series Celebrity Rehab with Dr. Drew from a group of former addicts. Regulars on Celebrity Rehab with Dr Drew include technician Shelly Sprague and counselor (and program director of the Pasadena recovery center) Bob Forrest, both highly trained and qualified addiction specialists whose own experiences as addicts serves as a tool for understanding and gaining the trust of difficult patients, as well as promoting these people as living examples of the possibilities that await even the most seemingly hopeless cases. Sober houses are also overwhelmingly run by recovering addicts who can teach the newly sober a structured lifestyle and tricks to keeping focused on recovery. Our own Adi Jaffe, director of All About Addiction, is a recovering addict himself (check out his story on the Press tab). As we see recovering addicts step up to help those that remain trapped in a life of getting high, we are increasingly made aware of their unique ability to make a difference in lives that many had considered lost. Addicted on TLC is keeping that trend going.

Nevertheless, I don’t believe that having personal experience is necessary for becoming an addiction counselor or specialist, though it likely helps keep the motivation level high in a relatively stressful occupation. One thing is certain, seeing these examples of recovered addicts who are helping others is certain to do a lot of good to the addiction stigma I hate so much!

Twilight star Chaske Spencer reveals his drug addiction past

Kudos to Spencer, one of the stars of “Eclipse,” the most recent (and last?) movie in the popular Twilight series. Apparently, he told not only the rest of the cast, but now also People Magazine, about his addiction to alcohol, cocaine, and heroin. Like me, Spencer became one of the “recovered addicts” only after going to jail and then rehab, though unlike me, he’s also acting in multi-million dollar movies, so good for him.

In my recent article about the problem of anonymity in recovery, I alluded to the fact that if more people revealed themselves as recovered addicts, we could go a long way towards reducing the stigma of addiction and giving active addicts hope that their life could one day improve as well! I wasn’t counting on a Twilight star coming out right afterward, but I’m more than happy to have people add themselves to this mix!

Hopefully we’ll start seeing many more people coming out as recovered addicts (maybe even more Twilight actors???). We sure do need the good press!

Spencer, Twilight star, talks about his addiction problems

Addicts’ brains depressed but normal users… normal.

A paper that’s about to be published in the journal Science has found at least part of the difference between the brains of addicted individuals and those that use recreationally.

The question as to why only some people get addicted to drugs has been a difficult one to answer. Still, there’s no doubt that only a relatively small fraction of those exposed to drugs develop the compulsive, often destructive pattern of use we associate with addiction. The pattern holds in animal research too – even though all the animals in an experiment get the same amount of drugs, delivered in the same way, only some of them develop addictive drug taking. It seems there’s something different about addicts’ brains, but what is it?

What’s different about addicts’ brains?

We’ve found quite a few things that differentiate addicts’ brains from those of normal research participants. These include lower density of a certain type of dopamine receptor (D2), reduced activity in specific brain parts like the OFC (orbitofrontal cortex) that are important in decision making and behavioral control. Still, if we start with what is supposed to be a pretty similar group of rats and give them all the same drug, for the same time, in the same amounts, why do only some get addicted?

This recent study found that a specific neuronal process called LTD (Long Term Depression), that is important in learning (or what we call plasticity) is suppressed in addicted animals for far longer than in animals that end up not not displaying addictive behavior. Even though all animals displayed this sort of deficiency in LTD right after learning to take drugs, only the addicted animals showed it when tested two months later.

Since the difference was seen in an area of addicts’ brains called the Nucleus Accumbens, a very important area for learning about rewards, it seems likely that it plays an important role in addicts’ inability to change their behavior after they’ve started using drugs. Past research has already identified this as a problem with something we call “reversal learning” but it seems we may have just found at least part of the mechanism.

Now we have to figure out why some animals show this sort of pattern and others don’t. Genetic variability seems like a good place to start here.

Citation:

F. Kasanetz, V. Deroche-Gamonet, N. Berson, E. Balado, M. Lafourcade, O. Manzoni, P. V. Piazza, Transition to addiction is associated with a persistent impairment in synaptic plasticity. Science 328, 1709–1712 (2010).

NIDA and ONDCP – American policy on addiction research

At this year’s College on Problems of Drug Dependence (CPDD) Annual Meeting, I got to hear, and talk to, some of the most influential players in the American addiction research field. Here are a few highlights from their talks and our discussion:

Dr. Nora Volkow of NIDA talked about a shift from Genome Wide Association Studies (GWAS), which have been the most recent popular advance in genetics addiction research and into more Deep Sequencing work. The hope is that this will allow us to begin untangling some of the GWAS findings that have seemed counter-intutitive or puzzling. Deep sequencing should let us see what genes really are associated with addiction specifically, not just as markers.

Dr. Volkow also brought up the numerous issues of medications for addictions including the Nabi Nicotine Vaccine, Vivitrol (a Nalexone depot that helps opiate users who wouldn’t take it otherwise), and a host of new medications that are being developed or considered. An interesting idea here was the use of drug combinations which are showing great promise in providing enhanced treatment results (similar to HIV treatment that benefited greatly from drug cocktails). These include combining vernicline and bupropion for smoking and naltrexone and buprenorphine for cocaine (that’s not a type even though both have been typically thought of for opiate addicts).

Dr. Tom McLellan, who I personally believe is one of the most informed and thoughtful people we have when it comes to addiction research in this country, talked about our need to expand the reach of treatment to the drug abuse earlier in the problem cycle. While about 25 million people are considered drug addicts in this country, more than 65 million are drug abusers. By finding ways to reach those people in primary care (as in doctor offices) settings before they develop the full blown addiction we’re used to talking about we can do better. He also mentioned the idea of anonymity in recovery playing a role in the continued stigmatization of addiction, a topic I’ve written about recently.

Stay on the lookout for more amazing new addiction research knowledge!

Crystal meth and cocaine, Agassi and Gasquet- The reality of drug use in our society.

AgassiAfter Andre Agassi’s recent confessions in a tell-tale book about his use of crystal meth during his playing days, Richard Gasquet, who recently made it to the Wimbledon semifinals has just tested positive for cocaine.

He says he was contaminated with the drug when he kissed a woman who was using it.  Right. Unless the woman was covered in an inch thick layer of coke, or unless Gasquet drank about a pint of her heavily intoxicated saliva, we all know that’s a lie. I’m pretty sure the committee now deliberating will come to the same conclusion.

Drug use in our society

The bottom line is that drugs are everywhere, including our star athletes, night-club hopping starlets, and big-time business executives. And in case you haven’t figured this out, they’re not going away. The best we can do is to keep researching the problem so that we can:

  1. Educate the public (educational and dissemination research).
  2. Identify risky users earlier (assessment and genetics research).
  3. Figure out the most effective ways to get them into treatment (intervention research).
  4. Discover the best methods to treat them (clinical and pharmacological research).
  5. Repeat the cycle.

That’s it! That’s all we’ve got. Recreational drug use will most likely continue forever, and I for one think that’s the wrong problem for us to be focusing on.

Interdiction – Our current solution to drug use

Limiting the drug supply, which is a big part of how our government currently deals with the problem, drives up the price of street drugs. This in turn reduces their purity (dealers have to make money) and gets in the way of recreational drug use. So far so good. But guess what?

Addicts don’t care about the cost of drugs.

Trust me, I used to sell them and use. I used to know a lot of other people who did too. Addicts are not making rational decisions based on economic realities. They’ll sell their stuff, lie cheat and steal their way to more drugs. Their brains are no longer depending on rational thinking when it comes to their drug use. That’s pretty much the definition of addiction.

Decriminalization – Our next step

I’m going to write a post soon about the notion of decriminalization. Decriminalization is different from legalization. Making drugs legal is like sanctioning their use – making citizens think the drugs are okay. For the most part, they’re not. But decriminalization would take addicts out of our prisons and give them the treatment they need. I think it’s time we faced the music and dealt with drug use problems at their core, with the people most often negatively affected by them.