Death in rehab- What is wrong with California’s addiction treatment?

We at A3 have long been saying that there is something seriously wrong with the way addiction treatment is being regulated and with the addiction treatment system that has sprouted up as a result. Now, a government report created for the California Senate Rules Committee called “Rogue Rehabs: State failed to police drug and alcohol homes, with deadly results” (see here) supports our notion and extends them in alarming ways. Among the major findings:

  1. Over the past decade, the California department in charge of regulating residential drug and alcohol programs consistently failed to catch life threatening problems [with addiction treatment facilities].
  2. Many addiction treatment facilities in California are providing medical care in clear violation of their licenses and often by under-trained staff.
  3. Addiction treatment providers are accepting patients that are far too impaired (as in sick) for them to handle because they would rather take the money than turn away a patient.
  4. These problems have led to several deaths within the California addiction treatment system in the last decade.

Obviously these findings are extremely disturbing and cases like the one studies in the report of Brandon Jacques, a patient who died while under the care of MorningSide Recovery’s care,  could have been prevented with more attention and transparency in our system. The idea that addiction treatment facilities that are not equipped to handle severe cases are taking them just for the money is sickening and antithetical to the reason for their existence. As far as I’m concerned, such unethical flouting of patient care should lead to an immediate revocation of their license and a ban for the management from the field.

The most distrubing factor to my mind is the fact that many of these providers know that what they are doing is wrong. But they also know that more than 50% of people who are looking for addiction treatment are doing so for the first time and have no idea what to ask, what addiction services they need, or how to assess whether a facility is appropriate. That means they can take advantage of them with fancy websites and the use of terms like “holistic treatment” that mean little and promise much. It’s disgusting and flies in the face of everything our field is supposed to stand for. It’s also the main reason I worked so hard to develop our Rehab-Finder, which while far from perfect and in need of serious work that I can’t afford to put into it, tries to fix these problems by recommending treatment that is appropriate given the specific issues a client is dealing with. We are currently conducting a study with UCLA on the effectiveness of tools like this and I am committed to figuring out a safer way to help those in need find the right addiction treatment for them.

Importantly, the report also makes a number of recommendations:

  1. Allow for medical service provision at addiction treatment facilities but legislate strict oversight and accountability paid for by agency fees.
  2. Medical detox facilities should be required to have medical directors.
  3. Establishing requirements and procedures for death investigations at addiction facilities.
  4. Strict oversight of programs found to admit clients it is not fit to treat including immediate license suspension.
  5. Information sharing between addiction treatment licensing boards and medical boards.

We think it’s time that addiction treatment providers be held to the same standard that other medical facilities are held to. It might help finally close the gap in terms of recovery outcomes. Running as a relatively unregulated industry does not help patients, it does not help move the field forward, and although they can’t see it it does not even help the treatment providers who are behaving unethically since many of them are eventually forced to close and face lawsuits. It’s time to move forward on this.

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

A3 Verified – Matrix Institute on Addictions

A3 is doing its RehabFinder work this month and we have a brand new and exciting addition to our Verification roster – The West Los Angeles clinic of the Matrix Institute on Addictions (they can be reached at 310-935-1322). We’ve already featured one of the amazing founders of Matrix, Ms. Jeanne Obert, but during these past few weeks, we’ve gotten to have a more in depth look under the hood…

Matrix Institute on Addictions – Research based outpatient treatment

The Matrix Institute’s treatment protocol, manual, and method, were developed under a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), which we have mentioned many times in our writing on All About Addiction. Research  using the Matrix Institute manual has shown it to be successful enough that SAMHSA lists it on it National Registry of Evidence-based Programs and Practices (NREPP), a prestigious list of effective treatment approaches.

The Matrix Institute on AddictionsMatrix Institute is nationally and internationally recognized for its structured, outpatient treatments and research-supported elements and is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). The Matrix Institute is also a proud member of the National Association of Addiction Treatment Providers (NAATP). One of the best things about the Matrix Institute addiction treatment program is that they accept almost all insurance carriers and have an amazingly affordable cost of treatment of only $1,900 per month! For a treatment program with such a track record, these are amazing statistics.

The Matrix Institute and ongoing training and research

Matrix Institute is absolutely one of the leaders in the field of addiction treatment when it comes to working with researchers to  find new, effective treatments for substance abuse.  Research at Matrix has helped in the development of new treatments that keep patients in treatment longer, and help them have greater success.  Some of the research we have participated in has resulted in new medications for alcohol dependence, (Campral and Revia) and opioid dependence (Suboxone or Buprenorphine).

Currently, Matrix is working with the National Institute on Drug Abuse (NIDA) to find a medication to help people with methamphetamine dependence.

The Matrix Model has been developed, refined and evaluated through research over the past 25 years. This is why All About Addiction (A3) is proud to stand together with The Matrix Institute on Addictions in improving the kind of addiction treatment available by making standardized, affordable treatment a reality.

(Disclosure – Dr. Jaffe is a group facilitator and educator at the Matrix Institute in West Los Angeles)

Who is accountable for the treatment services addicts receive?

It’s not often that I let my opinions out freely rather than letting the data do the talking, but this issue’s been making me mad for a while and now it just has to come out. As part of our work on the A3 rehab-finder we’ve been trying to get some measure of standardization into the system so that when we match those looking for treatment with provides we get a good fit. The problem is that when SAMHSA collects this data there is essentially no oversight whatsoever regarding the services addiction treatment providers report and their actual capabilities for providing those services.

One of the most obvious examples of this has to do with providing services for clients who suffer from both mental health issues and drug and/or alcohol problems. This happens often and SAMHSA has a few specific fields that ask providers if they can handle these more difficult cases. Over 50% of addiction treatment providers claim they can, but since no one ever checks up on them, it’s just their word we’re supposed to count on. Well, as far as at least some of them are concerned, having a psychiatrist come by once a month for a few hours is enough, still other providers offer even less in terms of mental health provisions. Believe it or not, some who claim to offer mental health services do not allow the use of any psychiatric medication… I think that actually qualifies as negligence.

There is some research looking into this sort of stuff, including work from Dartmouth (and Dr. Mark McGovern) using an instrument called the DDCAT (Dual Diagnosis Capacity in Addiction Treatment). Unfortunately, as usual, the findings aren’t making it into the actual field. I think it’s due time that we hold providers accountable and set some sort of standard for each of these services that they claim to provide.

I mean seriously, could you imagine gynecologists being able to provide post-mortem examinations without training? Oh, I guess that’s happening too… Nevermind.