Buyer Beware

We’ve previously discussed the benefits of at-home treatment for addiction, but what about out patient treatment in general? We’re taking a closer look at the benefits of out patient treatment with the help of the Recovery Research Institute‘s (RRI) research study titled “Buyer beware”: Treatment admissions practices and costs of residential treatment for opioid use disorder. We want consumers and families to have access to safe and effective treatment options and to know how to advocate for themselves and their loved ones. In order to have access to that, you need to know what effective treatment practices are and how to avoid being pressured into a treatment plan that isn’t the right fit. 

We know that in-patient treatment does not reduce the risk of overdose. We also know that continuous use of Methadone or Buprenorphine for at least six months cuts the risk of overdose in half. This is to say that in-patient and out-patient are just as effective for treating opioid addiction. The key is continuous use of an opioid substitute, usually in combination with an active recovery program. 

RRI’s study surveyed nearly 300 treatment centers and found that many admission practices are both deceptive and fail to follow ASAM practice standards, leading to unnecessary and costly in-patient admissions. Only a minority of treatment centers engage in questionable admission practices (this is more common among for-profit treatment centers than non-profit treatment centers), but the number is large enough to warrant educating consumers about these practices so they know what to look out for when they decide to seek help. 

Many parents exhaust their resources on in-patient treatment, believing it will be successful, only to realize later that it would have been better to pay for an effective post-treatment recovery management program. Some in-patient rehabs may cost around $6,000 for a 30-day program. Well-known centers often cost up to $20,000 for a 30-day program. For those requiring 60- or 90-day programs, the total average of costs could range anywhere from $12,000 to $60,000. RRI’s report provides further support for redirecting family attention from in-patient treatment to a combination of detox/out-patient treatment, medication and ongoing recovery plan oversight as a successful model for recovery from opioid dependence (as well as other substances).

The term treatment used in the report refers to traditional in-patient treatment, not to a short stay in a detox center. In my view, in-patient/hospitalization is good for detoxing from opioids, with successful recovery then dependent on taking opioid substitute medications for at least six months. Outcomes improve if users are also involved in a supervised active recovery management program, in addition to taking medication. But the bottom line is that in-patient treatment does not improve outcomes for opioid users unless combined with on-going medication for six plus months. Unfortunately, many parents are very aware of this fact only after paying for multiple treatments and enduring relapses when there was ineffective follow up to assure medication compliance. While the report uses the phrase, six plus months, our experience supports monitoring and oversight for at least three years.

Costs aside, our reasons for being wary of in-patient treatment centers are abundant… 

  1. Residential (In-patient) Treatment DOES NOT Reduce Risk of Overdose – When examining first treatment received after an opioid use disorder diagnosis, receipt of agonist medications such as buprenorphine for 6 or more months is associated with reduced overdoes risk, but residential treatment is not associated with this reduced overdose risk.Note that only a minority of treatment centers in the survey offered agonist medications (Methadone and Buprenorphine), so ask whether these medications are available when talking to in-take personnel at a treatment center.
  2. The Substantial Majority of Opioid Users do not Receive or Require Residential Treatment – …the substantial majority of people who resolve a substance use problem do not receive, nor require, residential treatment – which can be both costly and may unnecessarily remove people from their homes and work situations. Many respond well to less expensive outpatient level care…The key piece to understand here is that when seeking help, families are often directed to in-patient treatment as the first option, rather than seeking and starting with community resources. The study points to out-patient as an equally viable treatment alternative, assuming detox is successfully managed. Finding effective, competent community-based help can be a challenge. One excellent resource is ASAM – the American Society of Addiction Medicine – to find a qualified practitioner in your area. Because prescribing the correct substitute medication and managing medication use over time is proven to be successful in improving outcomes, why not start with a knowledgeable, trained professional?
  3. Many Residential Centers Offer Over the Phone Admissions w/o Screening or Intake Evaluation – 42% of for-profits and 20% of non-profits did not screen or perform an intake evaluation.Screening and evaluations are standard practices to make sure in-patient is necessary and the patient’s needs can be met by the treatment center. ASAM has established placement criteria that indicates whether or not a substance abuser needs in-patient or out-patient treatment. (For more on the ASAM criteria See my blog: Looking for Help – Who do you believe?)  But many centers do not follow ASAM placement guidelines. As the consumer, avoid these treatment centers at all costs. Their selling point is immediate admission, no questions asked. But an unscreened patient population is a big unknown. And if there are no evaluations, how does the center even know what kind of treatment is appropriate for each patient? This is not “best practices”, it is “worst practices”.
  4. Families Seek Residential Treatment on Their Own – …many desperate families and individuals seek residential treatment on their own.Despite the failure of in-patient to be successful in reducing relapses, families still spend a lot of time seeking in-patient treatment for their loved ones without going through their health care providers or addiction counselors in their community. Families often turn to the internet looking for help only to find treatment centers paying to promote their services, often with multiple websites. Shows like Intervention also create the impression that in-patient is the only option for families, who are usually in crisis, looking for an immediate solution, and are vulnerable to patient recruitment techniques. Perhaps, the self-help approach reflects a desire for privacy or fear that disclosing an addiction concern to a health care provider may lead to increased rates. Or families may not know that out-patient treatment, when combined with medication, is an equally effective alternative model. 
    • Practice Pointer: Your LO may be reluctant to go in-patient. Offer the option of going to an ASAM addiction medicine specialist – a doctor – and emphasize seeing the doctor as an alternative to traditional treatment.
  5. Patient Recruitment Techniques – these practices are designed to encourage a caller to sign up for in-patient care during the call. Practices include:
    • Immediate admission vs waiting a week or more (aka the “Buy now or lose your spot” psychological pressure tactic)
      • 79% of for-profit treatment centers offered same day admission vs a 7-day wait for a bed
      • 36% of non-profits offered same day admission vs waiting 23 days
    • Promoting luxury amenities
    • Justifying cost based on quality
    • Offering transportation assistance
    • Offering to talk to family members
    • Urging use of credit cards for payment
    • Referrals to interventionists who then use pressure tactics to get families to sign up for services. Some interventionists are said to overstate recovery rates and engender fear by telling callers their loved ones could easily die unless families sign up for an intervention
      •  Practice Pointer: If you are feeling pressured by these or other techniques, a good out is to say you have to talk to other family members or your “advisor” before making a decision. Get out of the emotional pressure cooker and contact your health care provider for a counselling referral.

The RRI Report reflects the tension between a prevailing in-patient treatment model versus the rising model of long-term, supervised recovery management in the community over many months, if not years. Critics of the in-patient model have long been concerned about these programs focusing on profits rather than quality of care. As the report states: While these findings concern a minority of (largely for-profit) treatment programs across the country, they nevertheless raise questions about the potential exploitation of a clinically and financially vulnerable population. In turn, such abuses point to ways that some programs are incentivized to prioritize profits over best-practices and high-quality clinical care.1

You and your loved one(s) deserve effective, quality care. Don’t settle for anything less. 

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