Archives for August 2017

Some Conclusions about Addiction from a Look at Some Numbers

Substance use disorders

Conclusion: Even when exposed to substances that can be used in ways that cause problems, most people don’t become addicted to them. Most people who develop addiction have problems already.

Note: For an individual, dependence, i.e. experiencing withdrawal symptoms without the substance, is not addiction, i.e. feeling compelled to persist in a behavior despite negative consequences.

Opioid use and opioid use disorder

  • 1 in 100 Americans, 12 and older, met the diagnostic criteria for opioid use disorder in 2015 (0.2 percent for heroin use disorder, and 0.8 for pain reliever use disorder). (Source)
  • 75% of people with prescription opioid addiction obtained the substance from a family member or a friend, not from a doctor. (Source)
  • 92% of people exposed to prescription opioids do not become addicted to them. (Source)
  • Heroin addiction is more than three times as common in people making less than $20,000 per year compared to those who make $50,000 or more. (Source)

Conclusion: Even when opioids – created by pharmaceutical companies – are prescribed by doctors, most people don’t become addicted to them. And socioeconomics matter.

Numbers from the New River Valley of Virginia

  • 16,000+ people in the New River Valley have alcohol and other drug problems. (Source)
  • According to local sources*, in 2015, the New River Valley had 34 cases of opioid overdose. Among those were 3 cases of heroin overdose, and 5 cases of fentanyl overdose.
  • According to local sources, in 2015, 11.4% of New River Valley high school students had misused prescription drugs in the past 30 days to “get high.” The national average is 3.2%. In 2015, 5.6% New River Valley high school students had used heroin at least once in their lifetimes. The national average is 3.2%.

Yearly death total statistics that make – and don’t make – the news in the U.S.

  • Marijuana overdose deaths: 0 (Source)
  • Terrorism-related deaths, U.S. citizens, overseas and domestic: 32 (2014: Source)
  • Opioid-related deaths: 35,000 (2015: Source)
  • Gun-related deaths: 35,000 (2014: Source)
  • Alcohol-related deaths: 88,000 (2015: Source)
  • Obesity-related deaths: 300,000 (Source)
  • Tobacco-related deaths: 480,000 (Source)

Conclusion: The selection of subjects covered by the media may not be due to high death rates.

*Grateful acknowledgement is made to New River Valley Community Services for synthesizing data from multiple sources for this post.

Laurel Sindewald contributed to the research for this post.

This post was prepared as part of a packet of handouts for a talk on the opioid epidemic by Anne Giles for the Montgomery County, Virginia Democratic Party on 8/17/17.

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

A Look at the Evidence for Addiction Rehab

In the U.S., when people think of addiction they usually also think of the 28-day addiction rehab, which was long popularized by the celebrities who used them to try to recover from addiction. As recently as 2013, the magazine People published a compilation of “celebrity success stories” who recovered with the help of traditional rehab.

Yet traditional 28-day rehab, based on the 12-step-heavy, Minnesota Model founded in 1950, is not effective at producing abstinence-based outcomes for people with substance use disorders (SUDs). In fact, scientists have known 28-day rehabs to be ineffective for over three decades. Relapse rates when leaving rehab are as high as 70%, probably higher.

“The position that residential treatment centers and their abstinence-only philosophies are superior to medication ignores overwhelming data and keeps families from seeking the best care. Let’s start with Pinsky’s patients: Nearly 13 percent who appeared on Celebrity Rehab died not long afterward; most had been addicted to opioids.”
Maia Szalavitz

Facing Addiction in America’s treatment recommendations are, in priority order, medical care, including medications, individual counseling, and support. Further, for some, treatment may not be necessary; spontaneous recovery rates are estimated to occur in 4 to 46% of people with diagnosable SUD.

We delved into the research on rehab and this is what we found:

“One of [the physicians interviewed] pointed out that you could book a room at a nice hotel for a month (let’s say at $150 per night), have all your meals there ($100 per day), see a psychiatrist twice a week ($300 per visit) and a psychologist three times a week ($275 per visit), get a membership at a fitness club for the month ($100), go to a massage therapist once a week ($100), and you still wouldn’t come out close to the $30,000 that a typical rehab costs for twenty-eight days. If you add it all up, plus throw in seeing an addiction counselor three times a week at a rate of $130 per hour, the grand total for the month comes to not quite $15,000, or about half the price of many a residential rehab.”
– Anne Fletcher (Inside Rehab 98)

  • People treated in outpatient programs are less likely to return to hospital or inpatient care, which further reduces costs of treatment over time. (Annis, 2008)

“Day clinic patients showed significantly fewer hospital readmissions and fewer days hospitalized during the one year follow-up period; this finding agrees with a growing body of evidence in the mental health field indicating that alternatives to inpatient programming foster lower subsequent rates of utilization of hospital beds.”
Helen M. Annis, Ph.D. (1985)

  • Most of the revenue (about 80%) for specialty addiction programs, including inpatient rehabs, comes from taxpayer-funded, government sources. (Kimberly & McLellan, 2006)
  • Once the dominant form of addiction treatment, the 28-day rehab is no longer well-supported by insurers. Most people who receive treatment for addiction are treated on an outpatient basis. (Inside Rehab 16)

“After numerous studies showed no difference in how people fared after going to residential versus outpatient programs, insurers and other funding sources drastically cut back on paying for residential rehab. Today, various forms of outpatient help comprise more addiction treatment experiences in the United States than residential stays.”
– Anne Fletcher (Inside Rehab 16)

“Of the types of care offered at these programs, 81 percent were outpatient, accounting for nine out of ten of all clients in treatment. About a quarter of the programs offered residential (nonhospital) treatment, which accounted for about one out of ten clients in rehab.”
– Anne Fletcher (Inside Rehab 22)

  • However, specialty programs (inpatient and outpatient) focused exclusively on addictions treatment, still comprise about 80% of the nation’s addiction treatment programs. The addiction treatment system is not well-integrated with the rest of medicine. (Kimberly & McLellan, 2006)
  • New science has shown that addiction is a chronic condition, requiring years of treatment.

“The idea that someone goes away to a thirty-day rehab and comes home a new person is naïve. Rather, there’s a growing view that people with serious substance use disorders commonly require care for months or even years, just as they would for other chronic medical conditions, such as diabetes.”
– Anne Fletcher (Inside Rehab 16-17)

  • Most rehabs in the United States rely heavily or entirely upon 12-step approaches for their curricula, which is not evidence-based as treatment for addiction. (Szalavitz, 2016; Sindewald, 2017)

“When I wrote Sober for Good, more than 90 percent of rehabs in the United States were based on the twelve steps. While the ratio appears to have dropped somewhat, most programs still base their approach on the twelve steps, include a twelve-step component, require twelve-step meeting attendance, and/or hold twelve-step meetings on-site.”
– Anne Fletcher (Inside Rehab 18)

  • The first inpatient rehab for addiction, Hazelden, which was responsible for creating the “Minnesota Model” of addiction treatment later adopted almost universally by United States rehabs, was founded by members of Alcoholics Anonymous. Alcoholics Anonymous is a religious self-help group founded by non-professionals in 1935, and is most known for the 12 Steps. (Anderson, McGovern, & DuPont, 1999; Wikipedia)
  • Inpatient rehab programs rely heavily on group counseling, which is not effective as a treatment for addiction. (Surgeon General’s Report, 2016)

“While group counseling is the staple approach in the vast majority of programs, there’s little evidence that the type of group counseling used at most of them is the best way to treat addictions.”
– Anne Fletcher (Inside Rehab 17)

“…if a client is a ‘group’ person, traditional residential rehab probably will agree with him or her; if not, too bad, because there’s some type of group counseling, education, lecture, or other group activity about eight hours a day–not including meals.”
– Anne Fletcher (Inside Rehab 83)

  • Some rehabs, particularly those with heavy 12-step emphasis, do not think people with addiction should be treated with drugs. (Szalavitz, 2016)

“Research clearly shows that certain prescription medications help people addicted to drugs and alcohol get sober and stay sober. yet many rehabs are unfamiliar with them or refuse to use them because of the old-fashioned notion that drugs should not be used to treat an addict–or that they should be used very sparingly.”
– Anne Fletcher (Inside Rehab 21)

  • Of inpatient rehabs, 54% do not have physicians or psychiatrists on-staff who could prescribe the medications evidence-based for treating addiction, and less than 25% have licensed social workers or counselors on staff to provide evidence-based behavioral therapies. (Kimberly & McLellan, 2006; Knudsen, Roman, & Oser, 2010)

“In many states, anyone can open a rehab program — no licenses or accreditation are required.”
David Sheff

  • Science has developed new treatments for addiction, but rehabs have been slow to adopt new methods and pharmaceutical treatments. (Miller et al., 2006)

“…people with alcohol addiction receive care ‘consistent with scientific knowledge’ only about 10 percent of the time.”
– Anne Fletcher (Inside Rehab 29)

When we looked at what the Surgeon General’s Report, Facing Addiction in America, had to say about inpatient treatment, we were surprised, after our research, to see that the report included residential (28-day rehab and similar services) and inpatient (hospital settings) services as evidence-based treatment for addiction.

“Residential services offer organized services, also in a 24-hour setting but outside of a hospital. These programs typically provide support, structure, and an array of evidence-based clinical services. Such programs are appropriate for physically and emotionally stabilized individuals who may not have a living situation that supports recovery, may have a history of relapse, or have co-occurring physical and/ or mental illnesses.” –Facing Addiction in America

  • In a study of 151,983 patients in England with opioid dependence, successful completion of treatment, including residential rehab, was not associated with a reduction in risk of fatal drug-related poisoning. (Pierce et. al, 2015)

We were unsuccessful in finding research studies demonstrating the efficacy of rehab for abstinence-based outcomes for people with substance use disorders.

Traditional, residential rehab programs are infamous for misrepresenting their treatments’ success rates, and for not following up with clients to determine long-term outcomes. Much of what we did find concerned inpatient (residential and hospital lumped together) vs. outpatient treatment settings. Our research unequivocally showed that the two settings yield comparable results, but that treatment on an outpatient basis is much more cost-effective.

Where does that leave us with regard to evaluating the efficacy of rehab? Right now, we don’t know.

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

More reports from Handshake Media are here.