You sigh as you see the name on the next chart. “Good grief, this poor woman,” you think as you place your hand on the doorknob.
“Doctor, I really tried. I really tried this time!” she sobs.
“Cheryl, I know you did. But you’ve got a disease, and you need treatment.”
“Doc, I can’t go back there again. I can’t. I can’t. I can’t. I’m going to lose my job. I can barely afford the payments. I had to put it on my credit card last time and…”
“Cheryl!” Both you and the patient are shocked by the harsh tone of your voice. There’s a pause where you both look down to the floor before you begin again, in a softer tone, “I see that in the last month, you’ve had four prescriptions filled from different emergency departments.”
“Doc, I had to! I ran out early again, and I was going to.”
“Cheryl, I’ve heard the excuses before. You have to go to rehab. At the rate you’re going, you’re going to die from this disease.”
“But I needed the insulin pens, doc. My sugars have been out of control. You said that my A1c was 12 last time. If you would just write me for a few pens, I know I can do it this time.”
“Cheryl, you have to go to diabetic rehab today.”
The idea of a primary care physician sending their patient to a quasi-medical facility for treatment of their type 2 diabetes seems absurd to us. No one would seriously suggest that a person with diabetes is better served by an inpatient stay in a poorly regulated, for-profit facility rather than their PCP’s office. But when it comes to substance use disorder, such treatment is sadly the norm.
There are few specialties of medicine more stigmatized than addiction medicine. Both patients and the physicians who attend to them are viewed with suspicion. To borrow a phrase from grade school, if I may, addiction medicine has “cooties.” Physicians turn away from patients with substance use disorder lest they be contaminated with these “cooties” in the eyes of their peers and society.
However, there is no good reason to treat substance use disorder differently compared to any other chronic disease. With proper treatment, substance use disorder patients have relapse rates similar to those seen in diabetic and hypertensive patients. Safe and effective medications, such as buprenorphine and naltrexone, are FDA approved for the treatment of opioid and alcohol use disorders, respectively.
It is true that addiction includes strong psychological and social factors, which must also be treated, but so do other chronic diseases; we all know of diabetic patients with poor glycemic control, not due to inadequate medication regimens, but rather due to stress eating due to depression, poor diet due to living in a food desert, lack of exercise due to a lack of access to safe outside spaces, and inability to obtain prescribed medications due to poverty.
Despite these seemingly intractable psychosocial factors, we physicians still try our best to treat these patients. The idea that we would hand their care over to a for-profit paramedical industry is anathema to our profession. You would never see “diabetic rehabs” or “losartan clinics,” but no one raises an eyebrow at the existence of drug rehabs and methadone clinics. Part of this is due to outdated public policies, such as those regulating the use of methadone for the treatment of opioid use disorder (thank you, Harrison Narcotics Act of 1914 and Narcotic Addict Treatment Act of 1974). However, indifference on the part of physicians is the prime reason that the predatory addiction treatment industry still exists.
Perhaps I am getting ahead of myself by using the term “predatory.” Allow me to explain.
There are respectable addiction treatment centers that exist primarily to help patients and follow guidelines for the treatment of addiction. These are the good ones. Sadly, these centers are not the norm, as the industry is largely unregulated. More often, treatment centers are owned by individuals with no medical training, whose chief goal is profit above all else.
These centers prey on vulnerable patients and their families during times of crisis in their lives. A common method of “generating leads” for these centers is a centralized 1-800 phone line that is staffed 24/7 with salespeople.
When a patient or family member calls the line, the sales agent on the other end takes down the patient’s demographics and insurance information. The agent then turns around and collects “bids” on the patient from participating addiction treatment centers. The center that bids the highest for the patient “wins” their contact information and then immediately calls the patient back in order to schedule an intake interview. These bids are not cheap either, costing $100 plus per patient. This should be illegal, but as these treatment centers are not viewed as medical facilities, there has been little motivation from regulatory bodies to prosecute this practice.
The debauchery does not end there. Once a patient is booked for treatment, these centers do everything in their power to generate the largest possible bill. A common scheme involves charging huge fees for “laboratory services,” which entail urine dipstick testing for drugs of abuse. A $10 POC urine drug screen is billed as a $1.000 laboratory test. If the patient’s insurance refuses to reimburse, the balance can be billed to the patient.
Overbilling practices are not limited to golden urine drug screens. Many centers make up for the poor reimbursement for addiction care by nickel and diming patients with a flurry of services. A morning check-up is billed as a depression screening. Daily AA or NA meetings are billed as group therapy sessions. Giving a dose of Suboxone generates a fee for the medication itself and the nursing fee for a staffer to hand it to the patient. The potential for up-charging is limited only by the imagination.
In some cases, treatment centers have even surreptitiously signed patients up for insurance benefits that they would not qualify for by falsifying the patient’s address and income in order to enroll the patient in insurance plans that reimburse the treatment center at a higher rate. They achieve this by using the “change in address” exemption to open enrollment periods by claiming that the patient has established a new address in the area near the treatment center.
What we’ve discussed so far harms the patient’s wallet more than their physical health. However, some practices can create physical harm. There is an entire sub-category of addiction treatment centers that advertise themselves as a destination for addiction treatment. These businesses advertise broadly to recruit patients to travel across the country to their center for treatment. After spending weeks or months as an inpatient, which costs as much as $50,000 a month, the patient is discharged into a strange city. Sometimes these patients are turned out with nothing more than the clothes on their backs and no way home.
Unsurprisingly, the risk of relapse in such a scenario is high. Since the patient’s tolerance is much lower after prolonged abstinence, their risk of overdose is naturally much higher. It has been demonstrated that opioid overdose deaths are measurably higher in counties with a high prevalence of addiction treatment centers.
If the destination treatment center is located in another country, as some are, the risks are even higher. These centers are not even subject to the scant regulations that the U.S. centers must abide by. These international addiction treatment centers are known to practice outdated and harmful treatments such as purgative therapy using emetics and laxatives and shock therapy in which patients with substance use disorder are forced to perform hard physical labor in adverse climates with extreme heat or cold. These harsh treatments are intended to “detoxify” the patient and have, unsurprisingly, led to deaths. The quackery does not stop there, as many of these international treatment centers adhere to a cult-like “spiritual” treatment model, which participants have alleged includes emotionally and physically abusive punishments for transgressions.
Religious-based treatment for substance use disorder is common in the addiction treatment industry. Even if you send your patients to a local center, it is possible that the center will either incorporate elements of religious treatment or be based entirely on religious treatment. The harms of religious-based treatment are not limited to the discomfort of your agnostic and atheist patients. Many religious treatment centers eschew modern medical teachings in favor of spiritual cures. These centers do not allow their patients to use scientifically proven treatments like Suboxone and methadone but rather preach that recovery must entail total abstinence from all substance use. These centers are mainly free from regulatory oversight and scrutiny because they claim that they are religious organizations.
Even nominally secular treatment programs can feature religious treatments, especially if inspired by 12-step groups such as AA or NA. As many are aware, a core tenet in AA and NA is “belief in a Higher Power.” While the nature of this “Higher Power” is never explicitly explained, it is clear from AA and NA literature that this refers to the god of the Christian bible. 12-step groups also have a strong distrust of medical treatment for substance use disorder and have traditionally taught that recovery from addiction entails eschewing all mind-altering substances, including Suboxone and methadone prescribed for opioid use disorder. This teaching has been walked back recently, and some groups acknowledge that the use of medication for opioid use disorder is a personal choice, but the dogma persists. Since each 12-step group is a decentralized organization, patient experiences vary.
The rampant growth of the addiction treatment industrial complex is largely due to therapeutic apathy on the part of medicine. We, physicians, have neglected this particular field for too long. Naturally, in a treatment vacuum, quackery and scams rush in to fill the unmet treatment demand.
We need to do right by our patients with substance use disorder and reclaim the field of addiction treatment. It takes knowledge and skill to manage substance use disorder, but nothing extraordinary compared to the other chronic diseases we treat on a daily basis.
Now that the X-waiver required for buprenorphine prescribing is no more, any physician with a DEA number can prescribe this drug for their patients with opioid use disorder. Learning how to prescribe and manage buprenorphine is a good first step. There are similar drugs for the management of alcohol use disorder as well, including naltrexone, which is not scheduled and is generally safe for most patients, even those actively drinking. The psychological and social components of addiction can be difficult to manage, but physicians can treat these as well by learning CBT skills or by referral to licensed therapists in their community.
We should resist the urge to refer patients to inpatient addiction treatment, as it is unnecessarily restrictive and overly costly for most. Patients also need to learn to manage their disorder in day-to-day life, and an inpatient stay rarely teaches them the tools necessary; it is easy to stay sober when locked in a facility where you don’t have to work or attend to the needs of daily living. As we discussed today, the paramedical addiction treatment industry is also a minefield of scams and quackery that exposes patients to financial, emotional and physical harm.
Thankfully, many patients with substance use disorder can be successfully treated in the outpatient clinic setting, just as we do for every other chronic disease. Those at high risk, such as patients with a high risk of complicated alcohol withdrawal, can be detoxified in a hospital or an inpatient detox associated with a hospital system.
If you are uncomfortable treating substance use disorder or need advice for complex cases, establish a relationship with a local addiction medicine specialist. Such a specialist can serve as an invaluable resource for patient care and also aid your own professional development. It may be difficult to find such a consultant, but it’s far better for your patients than the alternative. Many addiction specialists, such as myself, offer patient evaluations and liaison services at their clinic.
We must work to reclaim the field of addiction medicine for the good of our patients.
Jack McGeachy is an emergency physician and addiction medicine specialist.