David Lisonbee, CEO, Twin Town Treatment Centers

 

Though informing prospective patients and their families about prerequisite financial, emotional and time commitments and expenses prior to engaging in a course of treatment may seem inconvenient, counterproductive and potentially self-defeating, alternatives betray trust, which is the essential ingredient of any helpful relationship. To mislead and later to recant or to blame the third-party payer for untold costs is manipulative, dishonest and cowardly. For us in recovery, we long ago faced the need to curtail the practice of rationalization and duplicity so as to achieve and maintain sobriety. We also learned to practice these principals in all of our affairs.

 

Don’t fool yourself, staff and colleagues into believing that providing and billing for unnecessary services or length-of-treatment is justified. If you can’t provide meaningful and necessary services supported by ethical and legal utilization review and billing practices, find another model of rendering services or do something else for a living. When providers financially benefit from unnecessary tests (psychometric, urinalysis, DNA, etc.), experimental or unsubstantiated services (dietary, magnetic, electronic, digital, exotic) and extraordinary charges (out of network balance billing, PPO retail quotes outside of the community standard, etc.), your services and our profession loses credibility. You are also committing insurance fraud.

 

Paying or accepting fees for patient referrals creates a marketplace where human needs, human beings are being placed on the auction block. Auctions are a place for cars, art, real estate- putting someone and their insurance coverage up for bid through marketing and call-center processing destroys the very foundation of work. Rather than cherishing the humanity in each person in need, their vulnerabilities and financial assets are exploited. Such acts of exploitation corrupt any attempts at rendering help- trust is violated and people become as objects.

 

Treatment should be based on the elemental principal of effective therapy: TRUST. Building trust requires that our actions are always trustworthy. Respecting the people who ask us for help includes recommending services which are accessible, affordable and appropriate to their needs. Call centers and referral fees diminish patient identity and places patient need below financial incentive.

David Lisonbee, twintowntreatmentcenters.com

How do you help arrest a loved one’s decent down the destructive path of alcoholism and addiction? Is this the best time to address these problems? Can you pretend that everything is fine and that everyone is happy? Are you motivated by a benevolent care for your family or is self-defense or evening the playing field the goal? Are you acting from a place of concern and love, or are you reacting from the fear and pain of past injuries?

First take a look at yourself. Gauge your readiness for the task. Evaluate the present likelihood of success. Be realistic since all of these motives, both constructive and destructive are likely and legitimate.

I hope that this note provides you some helpful thoughts and strategies. It is normal to resent the very person you are striving so hard to help. Their behavior has harmed you and others for a very long time. Your anger, fear, and anxiety stem from constant anticipation of threat from the person who needs your help. You may have once relied upon for help yourself. Now they cannot be trusted. They have become unpredictable and unreliable. Repeated traumas have reinforced beliefs, ideas, feelings and behaviors that push your emotions out of control. You must protect yourself before becoming useful to anyone.

Even though the causes of addiction are innate and biological, continued regression versus recovery boils down to personal choice. The practicing addict is immersed in a world of immediate rewards and the avoidance of pain and emotional turmoil. Their reactions to you are constantly colored by their psychological and physical relationship with a chemical. That chemical has become centered and all-important in their life.

You can blame yourself. You can blame them. You can blame the chemical. Blame simply magnifies pain- your pain, their pain, our pain.

Set ground-rules or boundaries for yourself and keep them. If you react out of resentment or pain, you have become ineffective or destructive. Stop yourself and retreat.

Remember that you can only control your behavior. When you attempt to control others including addicts, you are acting to increase your pain, anger, resentment and fear. You set yourself up for failure. The futility of your actions result in worsening results. Stop!

Aggravating old problems and creating new ones does not improve the situation for anyone though this may feel natural at this point in your relationship.

Denial and rationalization are defenses which serve to maintain the status quo. Change is uncomfortable and creates fear, fear of the unknown. Accepting the reality of a situation is first stage of recovery. You must accept that you may lose your addicted loved one before you set out to help them. They must somehow arrive at the reality of their problem. Arousing their defenses defeats the purpose and blocks progress.

Rather than entangling the person’s drug or alcohol use/ inebriation, conduct any and all conversations while they are sober. During the holidays or weekends, these conversations will necessarily be made well before events and usually early in the day.

Draw a line in the sand that if the person drinks or uses, you will not associate with them during their use or while they appear under the influence. If you find them using or under the influence at your place, ask them to leave. If you are elsewhere, you leave. Make the agreement simple and hold to it.

When the loved one wants to engage or reengage in a relationship with you, set the expectation that they have to be sober and doing something to maintain that sobriety. Don’t step into the trap of accepting quick-fixes and temporary reprieves. If your loved one comes to realize that their relationship with you is important, they will allow you to hold onto your expectations.

Raising your voice, making threats, recalling shaming events are likely to arouse defensiveness in the addict and motivate even more chemical use. The chemical is used to avoid such situations and the emotions encountered from them. Set ground-rules about what you will tolerate and hold to them. Place accountability and responsibility back on the addicted loved one. Parenting creates childish behavior. Anger creates fights. Guilt creates shame.

Rather than submitting to the well-known and self-defeating habit of looking to blame, notice what is happening inside, and remember the routine and its consequences. Realize that your insides don’t feel well and seek more constructive remedies. Step away from the situation, go to an Alanon/ Coda meeting, talk with someone, write it down, change your focus, listen to different ways of viewing or thinking about the situation, but take action for yourself. Do what is uncomfortable- take the long-term solution. Take care of yourself and your loved one will do what they need to do.

Balancing work, home, leisure, recreation and physical exercise are essential toward maintaining resilience and to build energy from which action can be taken. Isolation, boredom, fatigue, frustration, anger are often results of encountering addiction in a loved-one. Realize when stress becomes greater than stress reducing activities. Seek social support, exercise, meditation, healthy diet, supportive social relationships, spiritual practices, rest…

Find a mutual support group, a treatment center, a professional therapist or an interventionist. Accepting the help of another contains potent medicine. Collaboration creates unity and connection. Addiction is the lonely disease for all effected.

The polarization of the treatment field between medication-assisted treatment (MAT) and 12-step drugfree treatment is gradually dissolving, according to experts interviewed by ADAW last week. “The problem is that some people view it as either/or,” said Philip L. Herschman, Ph.D., chief clinical officer of CRC Health Group. “Either it’s MAT and nothing else, or it’s 12-step and nothing else.”

At many treatment programs, including CRC and the Hazelden Betty Ford Foundation (the nation’s largest for-profit and not-for-profit treatment chains), it’s not either/or — it’s both. And the National Institute on Alcohol Abuse and Alcoholism (NIAAA) supports both as well.

Buprenorphine, methadone and Vivitrol are all proven medications that work, but not necessarily with the same patient, said Herschman. But other psychosocial treatments are necessary as well, including cognitive behavioral therapy (CBT).

“There are multiple evidencebased treatments, MAT being justone of them,” said Marvin Seppala, M.D., chief medical officer of the Hazelden Betty Ford Foundation. But MAT is an important one, especially because of the high overdose rate for opioid addiction. “If you neglect the literature and the science of addiction, you still have to look at the death rate,” he said. Hazelden added buprenorphine because so many patients overdosed after being discharged from treatment there (see ADAW, November 12, 2012).

“We try to differentiate between three different groups” for patients with opioid addiction, said Seppala — one treated with naltrexone (Vivitrol), one with buprenorphine and one drug-free.

The medications for alcoholism aren’t as good, and there are no medications for other drugs of abuse, noted Seppala.

Role of AA

“Hazelden is founded on the use of the 12 steps; it is one of the absolute tenets of treatment here,” said Seppala. “We are going to continue to emphasize the use of AA, CA and NA.”

Interestingly, Hazelden is “having really good outcomes on the people who refused medications but who stick around in our psychosocial therapy,” said Seppala. “the people on the medications are doing well.”

Physicians can’t predict who should be on medication and who shouldn’t, or who should be on what medication, said Seppala. “We’re trying to walk down the middle. What do you do with a 19-yearold who just started on oxycodone six months ago?” he asked.

But regardless of age, every patient who comes into a program should be informed that medications exist and may help, said Seppala. “I’m a psychiatrist and I was trained to give information — on what might work and on the risks,” he said.

There is adequate evidence to support the use of 12-step programs for people with addiction, said Seppala. Some critics claim that 12-step does not include a “manual” that has been proven by clinical trials (with the impossible placebo group) to work.

But even with CBT, the best therapists do not stick to a “manual,” said Seppala. “An experienced psychotherapist may have been trained according to a distinct model, but over time they realize it doesn’t work for everyone, and they alter their practice for different patients,” he said.

A good addiction treatment program should have a training system that helps their clinicians have a foundation in evidence-based practice,  said Seppala. “But to say ‘We’re going to use CBT and you have to do it with a manual’ — that’s nonsensical,” he said.

CBT alone isn’t adequate, and 12-step alone isn’t adequate, said Seppala. “It’s true that I can suggest that people go to 90 meetings in 90 days, and some of them will stay sober,” he said. “But we need to individualize treatment.”

Hazelden has a “stigma management” program to help patients who are on buprenorphine, because there is such a lack of understanding of MAT.

Alcoholics Anonymous and similar 12-step groups are “supports as part of a complete treatment plan for recovery,” said CRC’s Herschman. As a support system, AA is part of the treatment “that happens after an acute episode of treatment,” he said. “But in and of itself, AA is not treatment.”

‘Sobriety’ first

But David Lisonbee, president and CEO of Twin Town Treatment Centers in Los Alamitos, California, thinks that some programs are too reliant on pharmaceuticals. “We as treatment providers have allied with our clients and the interests of our clients, and our preferences and our goals have to do with long-term recovery and sobriety, which in heclassic terms means you’re coping with a minimum of assistance,” he said. Some people, he said, feel that the profit motive is behind the designation of buprenorphine as a maintenance medication instead of a detoxification agent (it can be used as either).

Many providers now accept that for some patients — the long-term heroin addict, for example — maintenance medication is appropriate, said Lisonbee. “Where we balk at maintenance is if it’s an occasional user or a young adult who has dipped into his parent’s medicine cabinet,” he said. “That person is suited to long-term sobriety.”

But, he acknowledged, the field is changing. “The field used to balk at antidepressants, but over the past 10 to 15 years antidepressants have been a treatment of choice when there’s a coexisting affective disorder,” said Lisonbee.

Evidence base for AA

There is evidence for the effectiveness of 12-step facilitation (AA) in Project MATCH, the NIAAA-funded comparison of CBT, motivational enhancement therapy and AA. That study concluded in 2001 but has been used for other studies showing the evidence of the effectiveness of AA (see ADAW, June 17, 2014).

“Excessive drinking is a heterogeneous disorder,” said Raye Z. Litten, Ph.D., associate director of the NIAAA Division of Treatment and Recovery Research. “That’s why one philosophy doesn’t work for everyone — but we think AA can work for some people.”

More studies have been done recently on AA, said Litten. “People do attend [AA], they stick with it, and they have improvements in drinking outcomes.”

“I’m happy to hear that they’re putting more of a menu of reatments” in addiction treatment centers, said Litten, referring to MAT. “If one medication doesn’t work, another one might.”

Litten recalled that last year at the ASAM annual meeting there was a special symposium on integrating AA and 12-step recovery into treatment.“There’s more going on here than meets the eye,” he told ADAW. “Some people have worked hard and found medication works in some people, and they are frustrated that more people aren’t using it,” said Litten. “But that doesn’t mean you should bash AA.” There are more than 50,000 AA groups in the United States, noted Litten. “Where else can you go for help that’s free and confidential?” Litten said.

Litten noted there is a stark difference between methadone and buprenorphine, the agonists used to treat opioid addiction, and acamprosate and naltrexone, which are medications approved to treat alcoholism. “Everyone who gets methadone or buprenorphine will have an effect from those medications,” said Litten. “But the alcohol medications don’t work for everyone.”

Still, it’s important to have the full toolbox to offer to patients. And Lisonbee agreed. “We are getting there,” said Lisonbee. “But we don’t want our treatment providers to be in it for the profit. We don’t want people to submit to a treatment industry that makes more dollars. We want to be client advocates.”

Alcoholism Drug Abuse Weekly, Vol. 26 Number 8, Feb 24, 2014, Allison Insinger