For readers of our newsletter, this post might feel “different” from the others. Usually we like to talk about what you can do to help yourself or your loved one when it comes to addressing substance issues and finding support or treatment that will help changes last. In this post we are going to do something different because we are angry and scared about the misinformation that consumers are faced with everyday as they look for treatment for themselves or someone they care about.
An estimated 2 million Americans are dependent on opioids. The Centers for Disease Control reports that 115 Americans died daily in 2016 from opiate overdoses (42,249 deaths, five times higher in 2016 than 1999), and that 40% of these deaths involved a prescription opiate. Despite this deepening crisis, there is hope that a number of FDA approved, evidence-based Medication Assisted Treatments (e.g., buprenorphine, naltrexone/Vivitrol, methadone) for opioid use disorders can help. Studies have found that these medications support long-term change (including abstinence from opiates) and significantly reduce overdose rates. Yet the traditional drug and alcohol treatment industry has been shockingly slow to support their use. Even more astounding is that many doctors in the treatment industry have not been educated about their effectiveness or trained to use them despite comprehensive efforts such as the Surgeon General’s Report last year reiterating the important role of these treatments.
Why the delay? There continues to be a strong belief in the public and among many treatment providers that if you utilize medication to recover from a drug problem, you are not “really sober”. This bias persists even though mountains of evidence from well-conducted research studies demonstrate that medication-assisted treatments (MATs, like buprenorphine and naltrexone) save lives. Despite their benefits, MATs have been adopted in less than half of private treatment programs. Even in programs that do offer MAT options, only about a third of patients receive them.
In an effort to understand this at the ground level, we decided to do a little experiment. We know that when a family reaches out looking for treatment for a loved one, they are usually vulnerable, scared, and desperate for someone to offer advice and some hope. And often, in their fear, they will take the advice of the first person they speak to, assuming reasonably that that person is educated in substance use and has a clear understanding of current effective treatments. So we did what many people do: an internet search! Just like many desperate families do when they are looking for help. We typed in “top rehabs in the US” and “best rehabs in the country”, created a list of 34 rehabs that came up on these searches, and called them.
We called looking for treatment for “our brother” who was “in trouble with heroin”. In these calls we asked each program the same series of questions about their use of MATs like Vivitrol and Naltrexone (opiate blocking medications), and Suboxone (an opiate maintenance medication), including their treatment policies and stance on these medications. (We asked them a bunch of other questions but that is for another post)! Our mission? To see if the treatment landscape was changing now that multiple studies (over many years!) have found these medications to be life-saving. What we found is disturbing.
Out of the 34 residential programs called, less than 40% (n = 13) of the programs would consider maintaining someone on Suboxone (buprenorphine) or discharging a patient on suboxone. The rest (n = 19) only used Suboxone during detox as a taper medication, while 2 rehabs “never use suboxone”. One of these programs said, “we want to get them off everything, otherwise he would be a hopeless opiate addict for life.”
Hopeless addict for life? Really? Buprenorphine, which is a partial opioid agonist, does activate opioid receptors in the brain but does not produce the maximal effects that full opioid agonists (e.g., heroin) do. It does not produce feelings of euphoria, but it will produce enough effect to quell cravings, provide relief from withdrawal, and satisfy the brain into thinking it is receiving a full agonist. It is protective in lowering overdose risk as it blocks the receptor sites in the brain that opiates would otherwise attach to. It allows many opiate users to build a stable life without fighting off cravings to use everyday and protects them from overdosing if they relapse to opiate use (both “street” opiates like heroin and prescription opiates) while on the medication.
In these 34 contacted programs (“best of the best”!), openness to using Vivitrol was a little higher, with 65% of the rehabs saying that they could consider discharging someone on it. Vivitrol is the intramuscular injection (like a flu shot, for example) of Naltrexone, a medication that blocks opioids from binding with the opioid receptors in the brain, thereby eliminating any sense of a high. It last approximately 4 weeks and multiple studies have found that it contributes to reduced overdose rates among opiate users. It is not an opioid itself (unlike suboxone or methadone), which may account for it’s slightly more positive reception in our surveyed rehabs, by countering some of the (unfounded and stigmatizing) beliefs that an opiate user wanting to be on opioid medication is “just a drug user looking for another drug”.
Unfortunately, of the 12 programs that did not discharge clients on Vivitrol, 4 of them did not even know what it was! One of the programs we called said “We really try and get patients off of everything and we would not want to discharge him on Vivitrol” and another said “I don’t know what that is, but if you spell it for me I can look it up and see if we will use it”. We ask you: does your diabetes doctor not know what insulin is? Does your cancer doctor not believe in chemotherapy?
Many of the inpatient/residential facilities we talked to made comments that showed they do not understand these life-saving medications, that they do not value clients’ experiences or wishes, and that they are using fear and scare tactics to pressure people into treatments that may not be appropriate for them. One intake coordinator said after a 5 minute description of the potential referral, “I don’t want to sound aggressive, but he could die today…” This kind of statement, made after a short phone call and aimed at a scared family, is preying on their fears in an effort to book a client. This is what you’d expect when you’re buying a used car, not what you’re hoping for when you’re looking for help for a life-threatening problem. Several of the programs used other tried and true sales techniques, like transferring callers to many different programs without explanation, or making suggestions that they close the deal and “get on a plane right now.” And others said the fictional brother clearly “needs a lot of treatment, possibly a year,” without offering to speak with him or gathering more information. And “he could die today”? The refusal to consider use of MATs will leave clients treated at these facilities more vulnerable to dying.
In fact, if you seek treatment for an opioid use problem, there is a significant risk that the treatment professional you speak with will either not offer these medications or have ideologically-based opinions about them that negatively influence how you feel about being prescribed them. As many opioid users will attest, there is a sense that you are “just an addict looking for another drug.”
We’ve had countless people come to us at CMC who have been in multiple rehabs and never once were encouraged to be on medicatIon assisted treatments. This is in spite of the data that suggests as many as 90 percent of people detoxed completely off opiates relapse within the first 1-2 months unless treated with these medications.
The takeaway? If you or someone you love is one of the two million Americans estimated to be dependent on opioids, please demand better. Our nation’s opioid struggle is an undeniable tragedy, and is one of the worst public health crises in the nation’s history. It is made all the more tragic by the fact that there are many viable, proven treatments for the problem yet treatment programs continue to refuse to look at the science. This must change if we are to stem the tide of opioid addiction in this nation and prevent more loss of life.
Anyone looking for treatment needs to really investigate the different programs and ask lots of questions. Many people do more research about which car to buy than which treatment program to attend. That needs to be reversed. And clients should enter this process expecting their questions to be answered and answered well! If you’re not sure about something you heard, then it’s probably not right (or the right place for you). Demand better service, and you will have a better experience.
To be a good consumer, you have to be an educated and informed consumer. Books like Beyond Addiction: How Science and Kindness Help People Change and Inside Rehab: The Surprising Truth About Addiction Treatment–and How to Get Help That Works by Anne Fletcher are excellent resources to educate yourself about substance abuse, treatment, and (especially in the case of Inside Rehab) what kind of questions you should be asking as a consumer.