I recently talked with a Huffington Post reporter about the Real Tab for Rehab: Inside the Addiction Treatment Biz. In our discussion, I pointed out that to a large extent we still have an addiction treatment system that provides short-term (acute) treatment for a long-term (chronic) problem (this key point did not make the article).
In addition, the current system treats less than 10% of those who could benefit from some kind of intervention at a cost that will likely reach $34 billion by 2014, more than double the spending from 2005.
In my opinion, a lot of money is being spent on helping a minority of those who struggle with addiction, and sadly being spent on expensive residential treatment stays that research indicates is not more effective than less expensive outpatient care. Bottom line, the billions being spent could be invested in those who struggle far more wisely.
Outcomes for addiction treatment centers
Not too many years ago I was attending an addiction conference where a number of treatment centers were advertising their services. I struck up a conversation with one of the marketing reps of a well-known residential program.
She explained to me that because of the escalating cost of treatment, her team had developed a program that was only ten days in length, thus reducing the total treatment cost to about $15,000 while maintaining the effectiveness of a longer residential stay.
As I always do in these situations, I asked her about proof that the program worked. She had a well-rehearsed answer, but like most treatment programs, no reliable and valid measures had been employed to measure outcomes. Even if some had been used, we know that 10 days hardly scratches the surface of what needs to happen to help someone with addiction.
Am I opposed to residential programs?
Not at all. At times I believe these programs are life-savers and provide a strong foundation upon which to build a solid outpatient management plan. Many employ very skilled, compassionate, and hard-working counselors that know how to help patients stuck in addiction.
Some charge reasonable rates for their services and avoid the “spa-like” add-ons that contribute nothing to long-term outcomes. What I am opposed to is marketing that feeds on the vulnerabilities of the populations that seek out their help.
Many parents will go to the ends of the earth to help their addicted child and not think twice about mortgaging their home and draining their savings if someone tells them their program will save their kid. Even for those with money, the idea that one can “buy good outcomes” if just the right program is utilized is simply not true.
How to best spend treatment dollars?
First, learn about addiction and what the science has to say about treatment interventions. Then spend your money wisely on what will result in the best possible long-term outcomes.
This slide from a recent presentation provides you a quick reference point for understanding how a number of treatment interventions rank in terms of scientific evidence.
What ranks the highest?
- Brief interventions
- Addiction medications (Campral, Revia)
- Community Reinforcement Approach (CRA)
- Motivational enhancement interventions
What ranks the lowest?
- Residential treatment
- Alcoholics Anonymous (AA)
- 12-step facilitation therapies
- Psychotherapy
Note that it’s not that these things cannot be useful in overcoming addiction, they can be very helpful. But when you compare their effectiveness through the lens of science to other options, and take into consideration the cost of each, it is clear we could be spending the billions of treatment dollars far more wisely.
The goal is to maximize the best possible intervention outcomes over many years (and for some a lifetime), not a few weeks or months. To do this, we need to employ the best interventions at the lowest cost. Combining free community resources, outpatient therapists, medications, self-help groups, and motivational incentives will give you the biggest bang for your buck.
I agree with what Dr. Fitzgerald said about the rising spending on drug addiction rehab but not getting a very effective long term outcome. As we spend more and more on addiction treatment, it seems to me that the whatever programs out there are not really focusing on the root of the drug addiction, and this totally makes sense, because as a capitalistic country, I think (in my personal opinion) that the treatment centers (not all) are out in the market for a profit instead of really concerning about people’s problems with drug addiction. Thus, we need to have more “charity” types of addiction treatment programs to help the ones who are struggling and simply want to have a new beginning in their lives. However, besides the various types of treatment programs, i think that, first, we really need to ask the question why those people are “addicted”to the situations they’re at right now. This means that we should employ a broader aspect of solutions and techniques, including social, physical, psychological, family related,etc, to try to solve the problems instead of merely dealing with the after effects of a certain drug. For example, if an addicted 8th grader is smoking pott, and the police puts him in a juvenile rehab, he will probably get out of the addiction and maybe relapse back into the situation sooner or later, because he might have a unsolved family violence background that triggers him to use pott as a superficial route to avoid the unhappy feelings within him and maybe other types of circumstances. so the key point here is to fix this student’s family issue and the related psychological hardship of the issue, in order to achieve a greater success at helping him getting out of pott addiction!
I agree with this blog, treatments should be continuos over lifespan to overcome its nature of addiction. With acute treatments, the individual is receiving temporary treatment at high cost and a disadvantage for future. When an individual is released from acute treatment, they have a bigger concern on hand, which is being in the same environment as an addict. They are faced with dilemmas on how to live their lives with addiction surrounding them. Long term care is necessary at a lower cost so that the individual can receive the best intervention possible.
When compared with your full lifespan, what is a “short-term” intervention? I think the reason many people fall into addiction in the first place is this label and bucket approach we have toward interaction between human beings. How to spend the least teaching our kids, how to spend the least on student activities, how to spend the least time socializing at a networking event, how to spend the least on employee benefits…the list of way we try to maximize our benefit while minimizing our investment is endless. It’s good to remember that those laboring against their addictions are individuals even as they may fall into convenient categories, and that their treatment will require individual approaches. Long-term treatment is a compassionate and effective way to empower the patient with tools to kick their addictions. I agree with the post, too: ongoing intervention is best for those struggling with alcohol and drug dependency.
I have to agree with you about the price it costs to get people into a treatment center is so high that many people who really need it and want it, simply cannot afford it. The centers that people end up going to who can afford it are the mini resorts with the addons you spoke about. Also the need for continued support seems to be non existent. All too often people go to these rehab facilities and seem to be “cured” and then they get out and go back to the same plaes they came from and relapse. In a sense they can give their clients a false sense of security once they are done. A friend of mine was sent to one by his parents in California and he said it was on the beach and had really good food, but he never had the intention on quitting. A combination of a family intervention and medication like Antabuse (Disulfiram) or the GABA agonist is an in-expensive and could work very well for certain individuals
I think you talked about a key point in your blog when you talked about the cost of rehab being so expensive that the people that need it the most just simply cannot afford to pay for it. Sometimes i think its sad how some rehab centers seem more like vacation spots then real treatment centers. They are outrageously expensive, and alot of the people who end up going to these centers do not get the real treatment they need. I agree with you when you say that the billions we use on treatment centers could be used wisely on individual treatment.
I agree with the perspective this blog portrays regarding the aspects of increasing cost and very little effective outcomes. Though with treatment of any health related event I’ve found the lines have become blurred when finances come into play. From what Dr. Fitzgerald has stated I see these quick institutions as simple money generators rather then seeking effective treatment for their patients which can be correlated to the aspect of Medicaid mills in which some physician’s take multiple Medicaid patients and basically do quick diagnostics and quick treatments to gain a steady income similar to physician’s who don’t take as many government assisted patients. The quality of care is significantly reduced in my opinion when time with patients is reduced. Similarly with these quick 10 day residential treatments as Dr. Fitzgerald has stated regarding long-term effectiveness, patients have a tendency to rebound and go back to their previous ways. Through an ethical perspective it is down right immoral to provide treatment such as these due to the aspects of what medical treatment should be about. Going into any part of the medical field has become a focus of financial stability rather then proper treatment of patients. Overall as long as finances continues to spear head medical treatment, those who cannot afford it will be left with the short end of the stick. At the same time if there are no finances there will be no programs. It’s double edged sword that needs to be balanced with providers and patients.
I find it unfortunate that the clues for dealing with the issue of addiction are right there in front of us but it is as if we just don’t want to look at them. Your post as well as your presentation have completely opened my eyes as to the nature of addiction. While in the past our treatment methods may have been due to a lack of knowledge or understanding of the nature of addiction, I would venture that today the reasons for the methods used are a combination of “we’ve always done it that way”, and the expectation of instant gratification. In the case of the former, there are many laws and thoughts and rules in effect mostly because someone thought it was a good idea once and no one has bothered to question it or change it. It is just easier to leave it as is than to look objectively at it with fresh eyes and challenge whether it still makes sense. For the latter, we as a society generally expect things now and are not so good with due process and waiting. We want to convict from an arrest and skip the trial. We want someone to take a pill and to instantly feel better. With addiction I think we just want it to go away and when someone comes back from treatment we want them to just be fixed. Addiction is a very powerful and multifaceted thing and it needs to be dealt with from a point of understanding and tolerance as well as patience.
Well said – thanks for the feedback.
J
I agree with most of what has been written in this blog, re: short term rehabs are a waste of time, energy and money for MOST addicts/alcoholics. I say this from the perspective of an addict in recovery, a person who has experienced both, short term and long term. I am, today, successfully in a recovery lifestyle because I attended a 6 month rehab who helped me to see that my problem was NOT the drugs, but a Spiritual Malady, my lack of loving myself. It was not until that I realized My Higher Power….NOT RELIGIOUS, that I was able to “GET IT”. The cost of the rehab is inconsequental in respect to the recovery of the patient. I have direct knowledge of the high end rehabs in places such as Malibu and they serve a very unique purpose. They are in a “high end” area of “high end” clients who can afford and, for tax purposes, need there brand of recovery. For them, it is all about the write offs. In my case, the rehab wanted $5900 per month, but I was only able to pay $1000 and they excepted it and I spent 6 months going through their program. So, the falacy of not being able to afford rehab is not a realistic one, in this day and age. There is a rehab out there for EVERY level of payment….be it $0 or $50,000 per month. Society needs to realize that it is not, “The Drug of Choice”, rather “The Drug that CHOSE ME”….be it herion, crack, opiate’s, benzio’s, gambling, food or any of a dozen other addictions. AA has printed up 30,000,000 copies of the Big Book and they claim 3,000,000 members world wide…..that’s a 10% success rate, IF all of those 3,000,000 people are STILL clean and sober. We, addicts, need to change out lives to create a new me and to stay away from Old People, Places and Things……Just like we are taught !!
Thanks much for the feedback and reading my blog. I agree that spirituality and faith are critical to long term success, and that both outpatient and residential treatment can play an important role in helping one begin to connect to these important factors. I believe that “getting it” is not a one-time event, but rather that as you continue down the path of a healthy lifestyle, more and more layers of the onion are removed, deeper insights (“ah ha” moments) occur, and in many ways life can become more challenging. We need our faith for sure, and at the same time we need to access our creativity and find what makes our heart sing (or feet dance – just watched Happy Feet on the plane last night), learn how to manage our chronic problematic behaviors, and go after the deeper traumas that require resolution and hold us back from fully engaging in life.
J
This article has a good point about the rehab centers. As we all know that the addict spent a good amount of his/her money on the thing that s/he is addicted, there is usually very little money or nothing left for the recovery.
We need more treatment centers like Habilitat in Hawaii. the only long term treatment program I know of who offer free treatment and vocational training to qualified addicts who are motivated to change. Most of the people who really need the help don’t have thousands of dollars to throw at the problem… Often their families have exhausted their resources trying to help their loved ones. There is no real quick fix for a long term problem like severe addiction.
A couple of years ago my mother was caught in a horrible position that she had gotten herself into. Her drug addiction had cost her, her job, house and almost her family. In the middle of all the hype my sister and I tried very hard to find a residential treatment center that was cost effective. We were hitting brick walls with every call we made. Most residential clinic seemed to be more interested in the overall cost of the program then they were concerned with my mother. After finally finding a program to send my mother to she decided to leave after a couple of weeks. She said her main reason for leaving was the constant reminders of the pain she had cause herself and her family. Since leaving the residential program she has been sober with the help of her AA meetings and being faithful to her 12 step program.
This leads me to my point…..So many of these programs find success on others failures. And although I think that each individual has to find a program that works for them there is no cure for an individual’s addiction. There is no promise of an individual to stay clean and sober. The body works very hard to maintain homeostasis and as I have been learning most of the main issues my mother faces is the constant behaviors that she has associated with her addictions. As a society we try so hard to make sure our loved ones are healthy and safe but with the struggles of addictions there are never any guarantees in the life of sobriety.
Thanks for the comment. Glad to hear your mother found help through AA. As you say, there are no guarantees in life, particularly when it comes to addiction. Staying flexible, changing the approach or program when necessary, and focusing on what gives life meaning and purpose ultimately contribute to long-term positive outcomes.
J
I too agree that being able to accurately evaluate the needs of a patient seeking addiction treatment is tough, at best. When a person decides to take steps to change their life and to seek help for a drug or alcohol problem, these step are hard all in themselves. When you have an institution, whether it be government or public or private, you want the doors to be open to all individuals wanting to get help. However, often times cost of the program, waiting list to get in to certain facilities, screening certain patients to see if they are a good fit for the facility are all obstacles people face when entering treatment. It is not a smooth ride from the beginning. When you talk about realizing that certain individuals require longer durations of treatment, months or even years, or in some cases it is a lifetime, I really stepped back and tried to see the possibly of people being able to spend longer periods of time in treatment facilities. And I realized, and as you spoke about in your lecture, you had to continuously move funding around to keep just on person in treatment for years. This is the reality of the situation, addicts, and I would go as far to say as most addicts require longer than a traditonal 3 month 12 step program, and we need to work on providing services that fit the needs of people seeking treatment.
I have had a relative go to both short term and long term rehabilitation programs over the last 15 years and he is currently part of a 60 day program. I have noticed that the time frame between relapses were much closer together after going to a short term treatment center versus a long term treatment of 30 days or more. I’m sure that this may be common statistic among recovering addicts, but this is only from my personal experience with one individual.
It is an unfortunate thought that, like Dr. Fitzgerald stated, “parents will go to the ends of the earth to help their addicted child” no matter what the costs, that treatment centers will offer a cure or guarantee that their child will not relapse if they join in their program that ask outrageous financial costs. I’m not saying that these programs don’t work, but it seems different programs are effective for different people. Choosing programs that are scientifically proven to be more effective should be first step and where the money should go.
i agree with Dr Filtzgerald that we are spending lots and lots of moneyon drugs rehab and treatment centers but are not getting long term results. most of these rehab centers are provide short term treatment ,most of the people get short term treatment and than are left by them selve beleving that they will be fine. i belive that the people who go to these treatment centers are long term drugs abusers. since they are abusing drugs for really long the need long term treatment so that the get full treatment and don’t face any problem when they leave thease treatment centers. there is no quick fix we need to provie long term treatment center in order to get long term results.
This was a great article on utilizing effective addiction treatment programs. Too often, what is common practice is not necessarily the most effective practice. As a society we should use science and find out what the most effective evidence based practices are and utilize those practices. We owe that to those who are addicted and need help and to the taxpayers and others who fund those programs as well. I would never have thought that brief interventions would rank so highly on the list of evidence based practices let alone be number one.
Treatment center prices are completely outrageous. I think a huge part of treatment failing is from the lack of funds to continue treatment, or to enroll in a residential program in the first place. The treatment process itself is expensive, but when programs are adding on extra, unnecessary costs such as spa days, there is no way that drug addicts are going to come up with the needed funds. In addition, I believe that in most cases, a family member or friend is the one supporting this decision to get clean and helping financially to get their loved one into treatment. To then raise the prices of enrollment, residential, food, counseling, and whatever else they find mandatory, is quite unrealistic. Addicts do need counseling and extra care, but at what cost? I don’t think it should be so expensive that it effects the overall community in a way of taxes or fundraising. I think there should be an affordable option to help these people get clean and get there lives back on track. I agree that we, as a society, need to be careful about what programs we support.
I enjoyed your article and I have to say that I believe that all these approaches need to be put together in one package in treatment. This is why I feel that certain residential programs include the many things you pointed out in your slide such as , motivational therapy and other types of therapy. From experience I strongly feel that residential is the best source. It not only seperates you from your outside world but it places you in a situation where you must redefine and bulid a new identity. I just feel that outpatient is too risky in the beginning phases of treatment, it should be offered at the completion of residential as a part of maintaining sobriety. I do have to say that I agree that we need to use as many resources as possible to get more for your buck. I also feel that it is way too hard and expensive for those to get into treatment and the easiest way to get help is to be court mandated or be involved in the court system somehow. I worry for those who want treatment and cant afford it and are also not involved in the court sytem, what do thees people do for help?
I read the article and I enjoyed it very much. I agree with you that we should combine all the methods together, so we can have better results. I think people go to short term programs because they do not want to wait too much time until they see the results of the treatment. I see that if we put all of our efforts to a one special program, we will have better results. There are a lot of different programs of treatment which make people distracted about which one they should choose to help them in their addiction.
This article intrigued me because I have many friends and relatives that have alcohol problems. What I’ve seen in the behavior of my friends and relatives is that they don’t actually want to quit for themselves. They want to quit because people want them to or they’re required to by the law. I feel like what could be a big help is first let the person see that they need to quit for themselves. Then next of all take everything that reminds them out of their lives that reminds them of the drug. Including friends that they did drugs with. Also when you say that they don’t need the special pampered spa kind of appointments I wasn’t sure about that. Sometimes people need to see that there are also other things in life that they can do to relax and be happy. Maybe having a pampered kind of treatment could help in that sense. When I talk to the people about their addictions and how they feel they just feel hopeless and like there’s nothing else to do besides that drug to have a good time. That’s just from my own personal experiences though.
The idea of treatment is great and I think it can help other issues going on in the world today. For example since the War on Drugs, many people have been put behind bars for small, non-violent drug offenses. Some of these people even being first time offenders. I believe that these people could benefit from this kind of treatment. Having their life addressed to find the causes of why they are using or dealing drugs can help them to improve their life before getting into more serious trouble. Chances are they they will find other coping methods, understand the harm they are doing to their body and to others, and hopefully not recidivate.
Thanks for the feedback. Many who struggle with addiction have low self-esteem, so getting a massage, spa, or engaging in some fun or healthy activity I believe can be very useful and necessary in the healing process. But I also don’t believe doing these things needs to cost thousands of dollars. Money spent on expensive residential treatments can be used more wisely in my opinion. Of course if money is no object, than such programs may be beneficial.
J
Thanks for your blog. I would like to say not only low self esteem people get addicted, but hard life’s as well. The honest truth about programs that it cost a lot of money, and we should stop the programs that are not working and help the ones that are to flourish and help those in need.
I am middle class and go to aa but am still not sober (yes, prayer everyday, sponsor, the steps etc) and am hoping that making the immediate 6 week & 30k$ plus commitment I will go the long run wt sobriety this time. I am going to put together a comprehensive after care program and hope to quit this time. There is a change I will ultimately be fired from my job, yes I know not legal to do, but hope that being sober is risk that chance & the high price tag. In patient treatment is a risky and desperate move on my part but I am not changing in my own and am willing Robert something else. I hope to work very hard on myself in rehab.
Best to all,
Judy in Boston
Good luck Judy!
J
I am unsure the reason why the costs for treatment as risen so high, probably due to economic reasons. But If costs continue to rise at this rate, those with addictions will be limited to the help they need. Its true people question where these treatments work since addiction seems to be an individual problem that mainly only the individual to solve. It takes the individual to be self-motivating to want to change to make long term progression rather than being forced to change. But it is very important to see help for one’s addiction because sometimes people don’t know the first thing to do in quitting an addiction therefore it is necessary to have professional guidance for this. I agree with Fitzgerald that parents will pay at any costs to help their child be relieved of an addiction even taking out money that they don’t have. This could result is financial problems in the family so to spend wisely, families need to invest in treatments that have a proven record of being effective upon those dealing with addiction.
I have recently learned that there are 6 stages to consider when addressing behavior change. They are as follows:
1. Pre-Contemplative
2. Contemplative
3. Preparation
4. Action
5. Maintenance
6. Termination
Interestingly enough, there has been controversy surrounding the idea that people never actually move into the “termination” stage, and that maintenance becomes a lifelong effort to control the behavior. The idea of termination is that the old behavior is no longer a temptation, and that the new, healthy behavior is a fully integrated part of the subject’s life. Although this may be true, the idea of an addict coming to a stage of “termination” is perhaps not so clearly defined. As Dr. Fitzgerald has proposed, and research has supported, addiction is a chronic issue that is being treated like an acute problem. Maybe I’m just speculating, but to me it almost feels as though this could be happening as a result of society’s growing demand for “quick-fix” schemes and minute solutions.
A 10-day treatment plan costs less money and gets people the care they need quickly and efficiently without using as many resources, or so it seemed. Relapse rates tend to prove otherwise. It is the long-term programs that require deeper investment and greater effort that are working more efficiently to prevent addicts from relapsing. The concept of suddenly crossing a threshold into the “termination” phase of healthy behavior change is ludicrous considering the huge, continual effort required for the healing process of overcoming addiction. After an addict has lived a life permanently marred by addiction in which even the slightest provocation can trigger a relapse at any moment the truth stands that a 10-day treatment program is nowhere near sufficient enough to provide the care the addict needs.
People cannot be approached mechanistically or broken down to the micro-biological level and remedied or restored to proper functionality. The individual is an intricately interconnected system of mind, body and soul, and a treatment that focuses on the molecular make-up of a person’s existence rather than regarding the person as a holistic being will ultimately be flawed in its approach.
Rebecca, thanks for the nice feedback. You make some great points, and I like how you link the maintenance stage to addiction being a chronic condition. At the same time, it pains me a bit that the stages of change model continues to be taught, as there is little empirical support for this model. I have written about this in the Q&A link (see #11). It is a nice model and I will admit I used it early on in my work with patients. It made intuitive sense and patients liked it. But I have learned that change is very messy, chaotic, and does not follows rules. The stages are a nice idea, but because the evidence does not support the model I believe we should stop teaching it and continue our search for better ways to teach about the change process.
J
It seems extremely cruel that some of these programs are so expensive. Even more so that it seems there are scams out there, just designed to take vulnerable people’s money. I would be especially skeptical of programs like the ten-day one you mentioned. That just seems like it was made to have a quick turnover and be able to take more people’s money. I hope I’m not being too critical of it, it just seems insane to me that a life-long problem can be resolved in ten days. At the very least, I would hope that they offer their services past the ten days, should the patient need support in life outside of their treatment center. Not to bash too much on this one program, even longer term programs, which I imagine are more effective are not without problems. If a treatment program lasts thirty, or even sixty or ninety days, how many people can truly afford that? Who is able to take that much time off of work? Sure, if your job is willing to give you that time off and if your family can afford to take the financial hit of being without income during that time, of course it is worth the investment, but how many families or individuals are really in that position? My guess would be, not many. Just like so many other things, many forms of addiction treatment seem to be a business, looking out for a profit first and foremost, before helping those who need their services, which is awful, considering how vulnerable their clientele can be.
That’s too bad that the media gets to pick and chose what they want to quote you as saying. It reminds me that we always need to be critical thinkers when reading articles and think about what may be left out.
$15K for ten days of treatment that most likely won’t help someone in the long term?! Wow! That is outrageous! I never knew that was the cost of attending one of those “celebrity rehab” institutions. I really hope that in the future grants and other funding goes towards evidence based programs.
I am just starting a drug education course at my university and I found this post to be interesting. The chart showing the scientific evidence of effectiveness of various addiction treatments was new information to me. I was especially surprised that “residential treatment” was ranked at 40. The only context I have to think about that is when I hear of celebrities going to rehab. I kinda assumed that rehab, being expensive and seemingly popular with celebrities, was relatively effective. But apparently there are many other options that are more effective. I still need to learn was some of those are such as CRA and self change manual, but it is nice to know that there are these other options to treat addiction that are shown to be effective.
Yes, I encourage you to dig into the research and see for yourself what the studies show!
J