#aren't these the kind of things that should be communicated with patients before they drive half an hour to see you

[scarletcomet]

just saw a new psychiatrist and he told me im too unstable for his practice and won't refill my meds

[bluewatsons]

Diana Rehm, Inside Addictive Treatment, DianeRehm.org (February 11, 2013) [continued]

Diane Rehm: And welcome back. Let's open the phones now, 800-433-8850. First to Central New Hampshire. Good morning, John.

John (caller): Good morning. I'm one of those -- I'm affiliated with AA and have been for a long time. And it's been really interesting to hear your speakers today because I fall into that category in the program they call high functioning drunks. And I spent 20 years going to lots of different meetings. And because I had not had all those hard negative consequences they were talking about, I hadn't lost a job, I was, you know, continuing to meet my goals. I hadn't gotten any DUIs, I drank following sort of a set of rules and yet I knew I still had a problem. . . But every time I went to an AA meeting in different groups and different states over 20 years I kept feeling like I didn't fit. And there weren't really the tools for me to make use of to address my high functioning -- you know, my drinking and addiction-based thinking. The AA's really good at putting people with a lot of problems that have had -- you know, that are in there true bottom stage and helping them climb out of that and having meaningful lives. . . But it seems to me that what ended up working for me, and I've been sober for seven years...

Diane Rehm: Congratulations.

John (caller): ...is that in the process the first thing you do is stop drinking, and then you're dry but you're not sober. And it's only through doing all the steps it seems to me that the anchoring process in the whole thing is based on relationships. And as far as most of the people that I know that are sober started like me and had a connection with somebody -- a meaningful personal connection with somebody who had some sobriety who could shepherd them. And in the program, we often called that a sponsor, but it may not be your actual sponsor. It may just be someone else that's in the program.

Diane Rehm: Sure. Sure.

John (caller): And then from that relationship you trust their judgment that they've accomplished something that you haven't. And then you accept a spiritual relationship. And it's from that acceptance of a true spiritual relationship that you actually get the help that -- to be sober.

Diane Rehm: All right. John, thanks for calling. That word spiritual may put some people off some programs, Anne.

Anne Fletcher: Well, yeah, it's what I said earlier. It's great when it works but it doesn't work for everybody. And it's not, you know -- Bill Wilson who found -- co-founder of AA never says that AA was the be all and end all. He said, you know, that he did not expect -- he doesn't like -- he didn't like dogma and that we found an approach that works for us, is what he said. And if you can find some other way then do it your way. So...

Diane Rehm: Here is an email from Nichole titled "My Father and Addiction." She says, "I know many inpatient programs will not accept alcoholics until they have been alcohol-free for at least a month. My father, a veteran, had to leave the State of Michigan to find an inpatient program to accept him. I feel this is a problem many are unaware of. Unless somebody wants to be a part of religiously affiliated program such as AA, there are few options." Dr. Seppala, is that a prerequisite at Hazelden?

Marvin Seppala: No, not at all. In fact our programs provide detoxication services and all medical and psychiatric services necessary to initiate treatment for folks. It would be an unusual setting that would require that sort of detoxification take place before initial care.

Diane Rehm: Dr. Seppala, tell me how much and, shall we say, an ordinary perhaps three-month stay at Hazelden can cost? And does insurance cover any or all of it?

Marvin Seppala: Yeah, I'm better off describing a one-month stay because that's a more common stay in our residential site and it would be 25 to $30,000. It's extremely expensive and that's why we describe it as tertiary care requiring good evaluation to determine the appropriateness of that level of care. When people don't meet, you know, the necessary requirements for that type of care, we'll send them to outpatient which is going to be more in the range of 5 to $7,000 for...

Diane Rehm: And does insurance cover any of it?

Marvin Seppala: Insurance covers both actually, both residential and outpatient care, but not all insurance. And what we've been seeing in the last year or so is that insurance is really limiting access to treatment of all types, both residential and outpatient in trying to -- on an outpatient basis where it is much less costly, even there to limit the length of time people could be involved. And when we discussed earlier that these are chronic illnesses, we need to be involved on an outpatient basis long term to help folks. . . And the entire treatment field and the insurance industry hasn't really recognized that and provided the type of care and structure necessary for that yet.

Diane Rehm: Anne, is that amount he mentioned typical of what you found?

Anne Fletcher: Yes, of the high-end kind of programs, yep. I found one program that I visited more kind of a celebrity rehab type place. It was really interesting. It was $38,000 whether you stayed one month or three. And actually it was quite a bargain for three months. And the reason they did that was because they wanted to encourage you to stay three months because the outcomes were much better for the people who stayed three months. ... But there really isn't -- this was a quote from one of the experts in my book -- there isn't any supporting evidence for -- I believe the way he said it was a short term burst of treatment that removes you from reality, that puts you away -- takes you away from your regular life. Yes, there are those few exceptional cases where somebody has a severe psychiatric problem. They can't stay sober. They've tried outpatient treatment many, many times. They may be suicidal and they do need to be removed from reality. But for the most part there isn't evidence supporting that model where you take people away. ... And, you know, there -- people don't realize, they don't -- just this knee-jerk reaction that you need to go away for treatment. You know, not only should people give more thought to outpatient treatment -- and by the way, there's no evidence that paying more money gets you better treatment. There are very good -- I found some very excellent community-based outpatient programs that had more state-of-the-art treatment -- now I'm not saying there aren't very good expensive programs out there, because I found excellent ones that were. . . But I also found excellent, very inexpensive, as I said, community-based programs that had masters-level therapists -- masters-degree level, that had very comprehensive programs that addressed the psychiatric and psychological needs as well as addiction needs, nutrition, getting people back to school, a whole life kind of approach.

Diane Rehm: So, Beth, what about the cost of a program like yours on an inpatient basis?

Beth Kane-Davidson: Oh, you mean -- for our patient, it's outpatient and so...

Diane Rehm: All outpatient.

Beth Kane-Davidson: Yeah, all outpatient. And of course that is less expensive. Our outpatient program runs around 4 or $5,000 for the intensive part. And then what's been brought up is, to me, the most critical part is the continuing care. We have continuing care which used to be in the old days a set time. You know, you would do 25 sessions. Now we've switched to open-ended. We want -- people need to come back, they need to stay engaged in treatment, they need the continued support.

Diane Rehm: And to what extent do the insurance companies step in?

Beth Kane-Davidson: They do step in. We have contracts with almost all of the insurance companies but I do echo what was said earlier. We getting a squeeze on our end. And we do have to get preauthorization and then continue authorizing the session so it's not like you just get a blanket, do what you need to do.

Diane Rehm: I see. Yeah.

Beth Kane-Davidson: And it goes back to, you know, this is a very complex treatment that we have to give. And so we do have to look at the individual and we do have to work within, you know, the perimeters of the insurance and what they're saying and what we need.

Anne Fletcher: But again we're talking, you know, about severe, severe cases much of the time. That's a small percentage of the people with substance problems. We also have not talked at all about seeing an individual therapist. Now most psychologists don't have training -- and physicians in addiction treatment and that's unfortunate. They don't receive that training in school. But you can find them, and I talk in my book about how you can find doctors and psychiatrists and psychologists with special training in the field to work with one on one. That's how I overcame my drinking problem, working one on one with a psychologist who had addiction training.

Diane Rehm: What's...

Anne Fletcher: And my insurance paid for it.

Diane Rehm: ...what's the difference, Dr. Seppala, of treating an alcohol versus a drug addicted individual?

Marvin Seppala: There are some differences specific to the type of substance that people use, but there's also remarkable similarities. We understand the neurobiology of addiction in a tremendous manner now than we did 20 years ago even. And it reveals the two aspects of brain function are dramatically altered. First, the reward center has been altered in a way that the person wants to continue to use the drug at a subconscious level. Drive states have been reprioritized so that in severe addiction people will risk their lives to get that drug and keep using or get alcohol and keep using. ... Even survival itself dropping down in priority secondary to the drive to continue to use that drug. In the prefrontal cortex where executive functions take place where we make decisions, think things through, look at the future has been altered in such a way that we can't recognize what is going on. We can't see the consequences. . . So even though I agree with many of the points made by Anne in her book, and she does help to describe a lot of the problems facing the addiction treatment field as a whole, she hasn't really described this function that we know from a neurobiological basis that limits people's own recognition of the problem and thus can undermine their attempts to seek treatment, let alone to get good treatment.

Diane Rehm: So it depends quite often on the people around you.

Marvin Seppala: It sure does. You really need people that care about you, that love you or even just a judge that knows you because of an illegal act, or an employer that's going to say, hey you need treatment. Hazelden did some studies actually almost a couple decades ago now, where they looked at how and why people enter treatment. Over 95 percent of people are coming in because of someone else in their life requiring that they address the issue. ... And they also -- we also looked at, you know, who did better, those that came of their own accord, which was a small group, versus those that were there because someone else insisted. And actually those folks that someone else insisted had slightly better outcomes than those that were there of their own accord, which we found to be unusual. But it's just what the numbers turned out to be.

Diane Rehm: Anne.

Anne Fletcher: I look at the literature of somebody who did a big, like, international look at the literature on kind of forcing people into treatment. And he said it's actually a huge national social experiment that we're engaged in in this country because we really don't know whether it helps people or harms people. But the most important point in all of this is by focusing on a small segment of the population, that's people with severe addictions, only 1 percent of the population in any one year has the kind of severe alcoholism that we think of as Nicholas Cage in "Leaving Las Vegas." Only 1 percent of the population. . . Most people with addiction don't have that kind of severe addiction, and that's what we're focusing on when we talk about people that we're talking about. More people would be helped if we had a broader approach, a less narrow approach to addiction.

Diane Rehm: And you're listening to "The Diane Rehm Show." Let's now go to Jefferson, Ind. Good morning, Terri.

Terri (caller): Good morning. My question is about my brother that's 43, and he's been doing drugs since he was a teenager. As a family we sat down and had an intervention with him and he actually was honest and said he was doing crack cocaine, and told us that we were enabling him. So we cut the cash off from him and a place to stay and dropped him off at a homeless shelter and was hoping that that would be his bottom -- his rock bottom. And actually he's been there for almost two years now. Actually he's homeless from the homeless shelter. So I guess my question would be what would be our next step?

Diane Rehm: What would you say, Beth?

Beth Kane-Davidson: I'd say look into the resources in your community. I think the point of individual addiction treatment counselor, therapist is a great way to go. Somebody that knows addiction and then can help you all figure out how to connect him to someone in the community that can begin helping him.

Diane Rehm: Dr. Seppala.

Marvin Seppala: Yeah, I would echo that. I think an initial evaluation's really essential and gaining some of the resources in the community rather than just a homeless shelter. He needs treatment of some sort to begin to examine the relationship that he has with drugs of abuse and look at some skills to get sober and stay sober.

Diane Rehm: Anne.

Anne Fletcher: There's not a simple answer to this question. it's very hard and sad as a family member when you're in a situation like this, and I feel for you. And I can't give you a simple answer. In both of my books I do talk -- and I have resources for family members -- but I'm going to give you one suggestion. One of the things that I found in doing my research is that there's a huge gap between science and practice. What the research shows to be effective and what's actually going on in many treatment programs in this county. And I only found one out of the 15 programs that is using scientifically-based family approaches, working with the family. ... They're doing a lot of psycho educational workshops educating families about addiction, the disease of addiction and, you know, talking to them about that. And kind of sitting around and talking about things you can and can't do to help the addict. There's a lot of focus on going to Al-Anon. And that's another 12-step-based group for families. And it does help families. There's research that it helps the family member but there's kind of this feeling that you can't really do anything to help the addict or get the addict into treatment. And that's not true. ... The CRAFT approach, which I mentioned earlier, which was developed by Dr. Robert Meyers, there is a book that I'm going to recommend, somebody's else's book called "Get Your Loved One Sober." And that has specific research-based strategies for family members of a loved one. "Get Your Loved One Sober," and that is published by Hazelden. And that is something that can help people with a loved one with an addiction, people who feel helpless like you.

Diane Rehm: And one last question. Terri said that they tried an intervention. Does a professional need to be present for an...

Anne Fletcher: CRAFT has been found to be far more effective than interventions in helping loved ones and getting them into treatment than interventions. Statistically I think it's 70 percent more effective. No, I know what it is. Seventy percent of people who participate in CRAFT in the research studies go into treatment. And those numbers are much greater than people who participate in intervention. It's striking. It's just striking.

Diane Rehm: Well, clearly lots of possible outcomes here, lots of resources. We'll have some of these listed at our website drshow.org. Thank you all so much. Anne Fletcher, her book is titled "Inside Rehab." Beth Kane-Davidson. She's at Suburban Hospital, John's Hopkins Medicine and Dr. Marvin Seppala of the Hazelden Foundation. Thanks for listening, all. I'm Diane Rehm.