Barriers to Addiction Treatment Entry

By Dr. Adi Jaffe and Tariq Shaheed

How annoying is it to be running late for work unable to find your keys, wallet, or coveted smart phone? You check under the bed, between the sofa cushions, and in your useful phone valet, before giving up and calling in late to work (if it’s not your phone you’re missing). You ask your wife, who says she hasn’t seen it, and your child, who thinks it’s under the bed (you’ve looked, it’s not). Finally, giving up, you go to your car, where your phone sits smugly right on the passenger seat. As troubling and frequent as this story might be, it’s nothing compared to the difficult experience of over 20 million Americans who annually look for addiction treatment but don’t find it [2]. So what’s keeping so many Americans out of treatment?

Internal and external barriers to addiction treatment entry

Barriers to addiction treatment entry are plentyIn a study done in 2008, researchers surveyed a sample of 518 subjects varying in race and age, to find out about the barriers keeping them out of addiction treatment. [1] The study was conducted in Montgomery County Ohio, was a part of nationally funded “Drug Barrier Reduction” effort lead by the National Institute on Drug Abuse (NIDA). Most participants were using crack (38.4%), heroin (25.1%), marijuana (14.9%), and alcohol (11.2%). The researchers found a number of internal and external barriers that keep drug abusers from getting the help they need. Internal barriers included stigma, depression, personal beliefs, and attitudes about treatment, while external barriers (systematic or environmental circumstances that are out of a person’s control) include time conflicts, addiction treatment accessibility, entry difficulty, and cost of addiction treatment. [1]

The researchers concluded that both internal and external barriers can be addressed and improved, but that eliminating the external barriers to addiction treatment is most feasible and could substantially decrease the number of untreated addicts in the United States. Since addressing an internal barrier like “believing one can quit at anytime” (accounts for 29.3% untreated Americans) still requires the ability of the substance user to get treatment, it seems that addressing external triggers will be more immediately effective. Just as motivation to find an item such as keys, phone, or wallet is not the only factor in obtaining that item, a substance user with no internal barriers to treatment is still constrained by all those external barriers, and still not in substance abuse treatment.

The most commonly cited external barriers in the study were:

  1. Time conflicts – being unable to get off work for treatment, household obligations, busy schedules and simply not having time for substance abuse treatment.
  2. Treatment accessibility –  living too far away for treatment, not knowing where to go for treatment, having difficulty getting to and from treatment, and not understanding the addiction treatment options. Subjects reported that being wait-listed for a facility, and having to go through to many steps contributed to deterring them from seeking treatment.
  3. Financial barriers included inability to pay for treatment and being uninsured.

Some common internal barriers include:

  1. Stigma associated with the label of being call an alcoholic or an addict, or stigma regarding addiction treatment. Thus being unwilling to share problems and ask for help.
  2. Psychological distress such as depression and neuroticism which produces a lack of motivation among substance abuse treatment seekers.
  3. Personal beliefs
    1. Religion- God will remove the addiction at the right time
    2. Denial – User doesn’t believe they are an addict
    3. Doesn’t need treatment – For example 30% of heroin abuser believed they would recover without treatment.

Although getting substance abusers help is difficult, it starts by understanding the nature of the problem. While one person may not believe they are addicted, another may not understand how sliding scale payment for treatment works. Different individuals may need different helpful resources when it comes to understanding their options.

Thoughts and limitations regarding the research

As we pointed out in a recent article, it’s important to know who is participating in addiction research. In this case, the individuals recruited were reporting for substance abuse treatment assessment at a county intake center. This means the clients are likely from relatively low Socioeconomic Status (SES) groups, but also that they are for some reason motivated to find treatment. Those reasons themselves could be internal (decided to make a change) or external (got arrested), but it’s important to know that these findings do not necessarily apply to more affluent, insurance carrying, or addiction treatment uninterested, individuals. We are currently in the process of conducting a more general study to assess needs in that group.

Also, the time and costs constraints identified by participants can often be overcome by increasing flexibility in searches and by better tailoring the treatment referrals (see our Rehab Finder articles). Costs can be reduced while saving time by looking into outpatient, rather than residential, treatment options. Unfortunately, Americans have been exposed only to the residential treatment model (a la the Dr. Drew and Intervention television shows), but outpatient addiction treatment is effective, costs less, and truly a better fit for many clients (especially those still working, attending school, etc.).

Finally, not all of the internal beliefs can be written off as unreasonable barriers – indeed, it is likely that most individuals who do not seek official substance abuse treatment, and certainly most of those who never enter official substance abuse treatment, will still recover from their addiction without it. As we pointed out in previous articles (see here, and here), most people who use drugs do recover and many do it with no treatment per se, especially when looking at our biggest substance abuse problem – alcohol. That means that some people termed “in denial” and “not needing treatment” were actually either correct, lucky, or both. Recovery doesn’t have to look like we expect it to, it just has to result in a person who is no longer suffering with addiction.

A3 Plug (you knew it was coming)

At A3 we believe information is the key; by dispelling myths about addiction, removing stigma and anonymity, reviewing the latest research in treatment, and finding 21st century solutions to barriers, we hope to reduce the number of untreated. Join us in the fight to educate and treat addiction.

Citations:

1. Jiangmin Xua; Richard C. Rappa; Jichuan Wanga; Robert G. Carlsona. (2008) The Multidimensional Structure of External Barriers to Substance Abuse Treatment and Its Invariance Across Gender, Ethnicity, and Age.
2. An investigation of stigma in individuals receiving treatment for substance abuse

Antisocial personality disorder – Drug policy and court mandated addiction treatment

gavelA recent study conducted by a group at the University of Maryland found that court-mandated addiction treatment is especially helpful for those with Antisocial personality disorder (ASPD).

Using 236 men, it was found the overall success for participants without ASPD was high (85%) whether the treatment was court mandated or not. However, for those with ASPD, a whopping 94% remained in court-mandated treatment, though only 63% stayed in voluntary programs!

ASPD is relatively rare in the general population, but it’s estimated that its prevalence is relatively high (some estimate the prevalence as high as 50%) among addicts in drug treatment programs. I personally doubt that ASPD prevalence is that high even among treated addicts but it is certainly higher.

The Maryland team’s findings have two important implications for substance abusers with ASPD that should be noted:

  1. Judicial mandates offer a way to keep them in addiction treatment programs.
  2. Voluntary participants may require special interventions to keep them actively engaged in therapy.

Recently, a colleague shared with me some great insight about research into the effectiveness of mandated treatment: Mandated treatment can be effective if implemented well, which may sound simple but isn’t within a system that is used to putting down prisoners and not building them up. However, without aftercare, even the best mandated treatment loses its impact quickly. When it comes to aftercare, when trying to determine the best form of it (outpatient, residential , intensive, medical, etc.) the best thing to do is to ask the released client – if the match between the client’s desires and the treatment provided is high, the results are significantly better.

Citation:

The interactive effects of antisocial personality disorder and court-mandated status on substance abuse treatment dropout. Journal of Substance Abuse Treatment 34(2):157-164, 2008

The business of addiction treatment and health care

Whether it’s you suffering with addiction or a loved one, it’s easy to forget that at least in this country, treating the sick is a cash-money-business. This is true for health-care as well as for addiction treatment, and as the polls right before the passage of the recent health-care reform suggest, enough Americans like it this way that it’s likely not going to change in my lifetime.

I attended a networking event for Los Angeles area investors (LAVA) that focused on health-care and technology, especially in the post Obama Care era. Though they didn’t specifically talk about addiction, I brought the topic up and spoke to a few of the panelists after. Based on everything I read until now and what I heard this morning, there’s big change a-comin’ in the addiction treatment industry. Here’s where I think we’re heading and why:

1. Obama Care will add millions of new health-insurance clients to the mix, most of whom are exactly part of the vulnerable populations (poor, disadvantaged, less-educated) that more commonly need addiction treatment.

2. The Mental Health Parity and Addiction Equity Act passed in Congress a few years ago and now in effect means that all health-insurance policies that offer mental health and addiction treatment coverage have to include it at levels equal to those of standard physical care. This means billions of dollars added to the pool of money for addiction treatment. As of right now, the details about coverage of therapy, outpatient substance abuse treatment, and residential programs is being worked out, but it’s likely that all three will  benefit.

3. Health insurance companies want standardization of services, and for their money, they’re going to get it. Just like there’s a standard way to treat diabetes, addiction treatment is going to become standard among the larger providers that are going to begin doing serious billing with insurance companies. So while CBT, MI, and medications will see a lot of reimbursement there, we’ll have to see about mindfulness therapy, yoga, and other less conventional approaches. My guess is that the bigger 12-step centered providers will be part of the mix whether they offer residential or outpatient substance abuse treatment.

4. More people will get addiction treatment, especially now that the government is refocusing its efforts on the initial assessment for substance abuse problems being performed in primary-care physician offices. forget about 10% of 24 million addicts getting attention for their problem, I think we’re going to see something more like 25%-30% of 60 million people with substance abuse problem of varying degrees (not just full blown addicts) making use of the system.

5. Addiction treatment will focus more on outpatient substance abuse treatment than inpatient services. Not only do we not have the capacity to put everyone in residential treatment, but as we cast a wider net, a smaller percentage of individuals will need intense residential work. Hopefully this will mean that residential facilities will actually start adhering to NIDA recommendations and extend their average lengths of stay towards the 90 day minimum recommended.

That’s a lot of change, but I think it’s about time for all of this to happen. Addiction treatment has spent too much time as a small industry that doesn’t have much power behind it. We’re going to start seeing better results soon because people are going to want to get a piece of this pie, and in the U.S., that’s almost always the biggest motivator for change.

If you need help for yourself or a loved one make sure to try our Rehab-Finder or contact us directly!

Helping Addicts with medications for cravings

If we could make it so drug addicts could stop craving the substances that have brought them to their knees, would relapse rates drop and addiction-treatment success rates soar? I sure hope so!

Medications that stop cravings?

I’ve already written about a study by the renowned addiction researcher Barry Everitt showing that medications could be used in treatment to help addicts who are struggling with strong cravings and the effect of triggers (see it here). Still, in that study the researchers used a drug that blocked pretty much all memory formation and my original idea had to do with using a very common drug, one being used every day for hypertension, and more recently, in the treatment of PTSD.

Well, a study recently completed revealed that indeed, propranolol, a common beta-blocker, may be useful in greatly reducing the amount of time needed to overcome the sometimes crippling effect of triggers on behavior.

How this trigger to cravings study worked

The researchers trained rats to take cocaine, and after they were well trained, allowed them to press a lever for a light that had previously been associated with the drug. This is a common method to test the way animals react to triggers that have been associated with the drug. Even though the animals are no longer getting any cocaine when the light goes on, the fact that it had been previously associated with the drug makes the animals press the lever, like an addict triggered by something they’ve associated with their drug use.

The animals that were given propranolol immediately after every session took half as long to stop pressing for the drug-associated light. It took multiple administrations of propranolol (seven to be exact), but the effect was clear. The next step is to see if the same effect can be observed in people.

Helping addicts transition to outpatient substance abuse treatment

I’ve been claiming for the past few years that if we look in the right places, we can find many ways to help struggling addicts who are having a hard time quitting using currently available methods. I think that the notion that sticking to the “best method we have right now” is unwise given the fact that science has progressed quite a bit in the past 20-30 years. I agree, and am thankful, that the system works for some, but there’s no question that many still have trouble recovering from addictions that devastate their own lives and the lives of many close to them. I think these medications can offer some serious help.

The thing is, that if we could seriously reduce the impact of cravings on relapse rates, it’s possible that addicts would be ready to move from residential to outpatient substance abuse treatment  more quickly. Indeed, the main reason for keeping people in residential treatment is the thinking that they’re not ready to be in the world given the influence of triggers. My guess is that this is true for some addicts, but if we could provide an intervention, like propranolol, that would significantly reduce the influence of triggers, outpatient substance abuse treatment, which is a cheaper option, will be useful for many more. This would mean more people in treatment that truly works for them for less money. Sounds good to me.

Citation:

Ashley N. Fricks-Gleason & John F. Marshall (2008). Post-retrieval ß-adrenergic receptor blockade: Effects on extinction and reconsolidation of cocaine-cue memories. Memory & Learning, 15, 643-648

A million ways to treat an addict

When I was still attending my addiction counseling classes at UCLA, we often discussed the many different tools now available when treating drug abuse (CBT, 12 step, medications, rapid detox, etc.). Still, most of the class members focused on how many of these don’t work with everyone and how some have actually resulted in problems for certain patients. I think this is a mistake.

Like a physician treating any other chronic disease, I think that practitioners in the field of addiction need to come to terms with reality: Chronic conditions (and I don’t mean smoking good weed) are difficult to treat. Still, cancer treatment works by trying the best possible method, then the next, and then the next, until all options have been exhausted. In the addiction world, most therapists and counselors still stick to their guns with the method they believe work best.

Unlike with roses, an addict is not an addict, is not an addict… Different methods will work for different people. It isn’t hard to believe this when you consider the fact that while many addicts recover within outpatient substance abuse treatment settings, others need an intensive residential program, and some recover spontaneously with no real intervention.

It’s time to start focusing on results in this field and leave the moral dogma behind. If there’s a tool that can help, we need to put it into action. It’s that simple.