Addiction, otherwise known as “Substance Use Disorder” (SUD) is a relapsing, chronic disease which requires lifelong cognitive, behavioral, social and physiological change and maintenance. Outpatient treatment and “recovery management” are designed to prevent addiction related deterioration, morbidity, relapse, and death. Outpatient treatment and recovery management also provide solutions which guide addicted people toward resources designed to better meet their needs and away from inappropriate, costly, and restrictive levels of supervision such as residential institutions, hospitals, and jails.

Since the 1930’s it has been demonstrated that successful, lifelong recovery from the disease of addiction can be achieved by engaging in recovery promoting activity, social support and benevolent service. Attempts at providing professionally provided acute care medical and time-limited psycho-social interventions to this chronic disease as resulted in partial solutions and modest outcomes.

What appears to be missing in the current model of addiction treatment is long-term recovery follow-up and monitoring. Investments in thirty-day to nine-month courses of treatment in inpatient, residential or sober living settings are being lost when the patient returns home and/or over the course of time.

Cognitive and behavioral gains fail to generalize into normal life settings after discharge from a residential setting. Relapse often follows. In the absence of practicing recovery in real time, in real life, over time, recovery deteriorates. Recovery management aids to assess and supervise recover in the long-term.

The commercialization of addiction treatment and recovery has resulted in expensive services which result in occasionally good short-term outcomes. The motive for providing these services is too often fee-for-service profiteering. When the payor and payment for services is exhausted, there are no resource left for integrating clinical gains into real-life circumstances. Recovery management has been abandoned to “self-sustained” sobriety, sometimes with peer support.

“Shift by government and private sources from purchasing time, or session-limited units of service – to purchasing and integrated program of management and support for long-term recovery; shift in emphasis from treatment intensity (crisis stabilization) to treatment extensity (prolonged recovery maintenance).”(1)

Mutual support groups offer peer support on a voluntary basis. This has been an effective model for people who remain willing and open to recovery despite its challenges and demands for change. People who encounter periods of ambivalence, avoidance, defiance or other roadblocks benefit from professionally provided recovery management which is designed to anticipate and prevent incidents of recovery deterioration and relapse. Recovery management also offers professional contact, support and access to assistance regardless of the person’s level of willingness.

Outpatient treatment and recovery management differ from the “acute care model” in that a multitude of highly restrictive and costly resources is not required in the entry level of care, save medical detox in selective cases. Outpatient treatment and recovery management provides case management, coaching and support over the long-term, in the natural environment where the client resides.

The distractions, triggers and the wreckage from reckless drug/ alcohol influenced behavior must be encountered early in sobriety so that specific recovery skills are exercised in the context where they are needed. If a person new to recovery encounters these stimuli for the first time without the support and guidance of professionals and peers, relapse is likely.

Outpatient treatment and recovery management must be provided in “real time” during “real life”, to pursue “real life opportunities” and to cope with “real life events”.

“Treatment on an outpatient basis allows a more valid assessment of environmental, cognitive and emotional antecedents of drinking episodes and drinking urges on the part of the patient, and allows the patient to test new coping strategies while still within a supportive counseling relationship.

These conditions would be expected to foster greater generalization of learning in treatment to the patient’s natural environment” (2)

Learned ideas and behaviors are not applied in real life unless new skills are practiced and coached. (3) Studies reveal that didactic teaching provides participants no practical benefit. Didactic teaching which includes role-playing or in-class practice results in no lasting practical benefit. Only when teaching and practice are applied to real life situations followed by coaching and follow-up are behavioral improvements achieved. (4) (5)

Outpatient treatment of substance use disorders and recovery management allows for the practice and exercise of pro-recovery skills in the real world. Coaching and follow-up after real-world exercise allow for supportive, reinforcing and corrective steps toward strengthened recovery and guiding away from relapse towards greater resilience.

Patients develop the skills and self-confidence to cope with high-risk situations such as negative emotional states, interpersonal conflict, and social pressure to drink. The informal use of similar coping strategies may contribute to the success of 12-step self-help programs. (5)

References:

(1) White, W.L. & McLeallan, A.T. (2008) Addiction as a chronic disease: Key messages for clients, families and referral sources. Counselor, 9(3), 24-33.
(2) Annis, 1986, p. 183
(3) “Meta-analysis of Effects of Training and Coaching on Teacher’s Implementation in Classroom”, Joyce & Showers, 2002
(4) “Impact of Formal Continuing Medical Education- Do Conferences, Workshops, Rounds and Other Traditional Continuing Education Activities Change Physician behavior or Health Care Outcomes”, Dave Davis, MD, The Journal of the American Medical Association
(5) Kelly et. al. 2000
(6) “Evaluating Substance Abuse Treatment Process Models: I. Changes on Proximal Outcome Variables during 12-step and Cognitive Behavioral Treatment”, Finney, Moyes, Coutts, Moos, Journal of Studies on Alcohol, ‘98

You can pay $60,000 ($60K) per month in Malibu or West Palm Beach, $37K “Out-of-Network” from your insurance, $14K “In-Network” with your insurance coverage, or you can simply pay whatever your deductible and co-payment is for an average of twenty-five substance abuse/ addiction sessions at Twin Town Treatment Centers. Once an average of twenty-five billed sessions is complete, Twin Town provides four additional months of aftercare.

If you paid out of pocket, a five (5) month episode of substance abuse/ addiction treatment at Twin Town Treatment Centers would run approximately $4.5 K.

Optum Health, a nationally recognized behavioral health managed care organization published a white paper, which states the following:

“Sensing both demand for services and higher rolls of young adults on their parents’ insurance, entrepreneurs have opened new centers for treatment of substance use disorders. Many of these are in “destination” locales, in states far from patients’ homes. In our estimation, however, those are often not the most appropriate or effective settings for treatment for these reasons:

1. When individuals can be treated for a substance use disorder in or near their home communities, they often stand a better chance of long-term recovery. Their families and close friends can be part of their recovery, and the individuals in treatment learn how to be sober in the surroundings where they will continue their lives.

2. Close analysis of claims from some treatment centers bears witness to questionable practices in treatment protocols and in billing patients, families and their insurance companies. A particular area of abuse is in the use of and billing for drug screenings through laboratory tests that are being administered inappropriately, far more frequently than required, at rates well beyond the usual and customary charges.

CLAIMS COSTS FOR SUBSTANCE USE DISORDER TREATMENT IN FLORIDA

The costs of treatment in out-of-network facilities were, on average, three times higher than the costs of treating at in-network facilities.

Nearly 75 percent of the cases of young adults treated in Florida involved individuals who were not residents of that state.

Individuals from outside the state treated at out-of-network facilities were readmitted at higher rates — between 11 percent and 40 percent higher, depending on level of care — than Florida residents who used in-network facilities.

CLAIMS COSTS FOR SUBSTANCE USE DISORDER TREATMENT IN FLORIDA 18- TO 25-YEAR-OLD DEPENDENTS:

Out-of-Network (63% of members) per member $36,645

In-Network (27% of members) per member $13,692.”

Substance use/misuse and addiction represent a significant and substantial public health challenge. Data from the 2014 National Survey on Drug Use and Health (NSDUH) reveal that an estimated 27.0 million Americans aged 12 or older were currently illicit drug users (defined as using any of the following in the past 30 days: Marijuana/hashish, cocaine/crack, heroin, hallucinogens, inhalants, or non-medical use of prescription-type psychotherapeutics such as pain relievers, tranquilizers, stimulants, and sedatives) and 16.3 million were heavy drinkers (defined as drinking five or more drinks on the same occasion on five or more days in the past 30 days). Approximately 6.5 million people aged 12 and older reported currently using psychotherapeutics non-medically.

According to the 2014 NSDUH, 21.5 million Americans aged 12 or older had a substance use disorder in the past year. Among them, 14.4 million Americans had dependence or abuse of alcohol but not illicit drugs, while another 4.5 million had dependence or abuse of illicit drugs but not alcohol, and 2.6 million had dependence or abuse of both alcohol and illicit drugs. People with alcohol or illicit drug dependence or abuse were defined in the 2014 NSDUH as meeting the diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV).

The Affordable Care Act and new mental health parity protections are expanding mental health and substance abuse treatment benefits to 60 million Americans. Despite this historic expansion of health insurance coverage and other advances, too many Americans are not benefiting from treatment services. Based on the 2014 NSDUH data, although 21.5 million people aged 12 or older met the DSM-IV criteria for alcohol or illicit drug dependence or abuse, only an estimated 2.3 million received substance use treatment in the past year.

Drug poisoning (overdose) was responsible for about 47,000 deaths in the U.S. in 2014 (now the latest year for which national data are available). Furthermore, substance misuse (to include excessive alcohol use) and related disorders contribute to injury and chronic illness, lost productivity, family disruptions, and increased transmission of sexually and injection-related infectious diseases; are associated with higher rates of domestic violence and child abuse; and prevent many individuals from realizing their full potential.

The popularity of the “Dark Web” for purchasing illegal drugs is especially worrisome because it is increasing the availability and acceptability of drugs, according to an addiction psychiatry expert.

“After talking with people who use the Dark Web, I became very concerned that many of them have lost the appreciation that this is drug dealing, not just e-commerce,” says Karen Miotto, MD, Director of UCLA’s Addiction Psychiatry Service, who has studied the Dark Web, also known as the Deep Web or the Hidden Web. “Buying or selling heroin balloons in the park is clearly understood as an illegal activity; buying or selling drugs online may be construed as e-commerce without full appreciation that it is also illegal.”

The Dark Web refers to illegal online marketplaces that can be accessed by downloading the anonymous browser called Tor, and purchasing the digital currently bitcoin. In addition to illegal drugs, these websites sell passports, pornography and weapons.

The first and most well-known Dark Web site was Silk Road, which was shut down by the federal government in 2013.

The ease with which people can buy large quantities of drugs is creating a system with mid-level drug dealers, said Dr. Miotto, who discussed the Dark Web at the recent California Society of Addiction Medicine annual meeting.

She found people who use the Dark Web by asking students and colleagues for contacts, as well as through the website Reddit.

“We have a new drug distribution system,” Dr. Miotto said. “People can get drugs sent to them in a FedEx box right to their door with a sense of anonymity and confidentiality. There’s a sense of intrigue and excitement about getting drugs this way.”

Earlier this year, a study by Carnegie Mellon University researchers found illegal websites have sales that average $300,000 to $500,000 a day. The study found marijuana accounted for about one-quarter of sales, followed by Ecstasy and stimulants. These websites also sell significant amounts of psychedelic drugs, opioids and other prescription medications.

Dr. Miotto found that hallucinogenic compounds advertised as research chemicals are popular on Dark Web sites. “Some people believe they are performing a service by experimenting with these drugs and going online and writing about their experience,” she said.

When Silk Road was seized in October 2013, it had 13,000 drug listings. In June, the creator of Silk Road, Ross Ulbricht, was sentenced to life in prison. The government said over Silk Road’s three years in business, more than 1.5 million transactions were conducted on the site.

A number of new Dark Web sites have emerged since Silk Road was seized, including Open Bazaar, Silk Road 3.0 and Angora. “People write in testimonials about the drugs they purchase on these sites, just as you do on Amazon,” Dr. Miotto notes.

She said parents’ and physicians’ ignorance of the Dark Web makes it easier for young people to participate in the online drug marketplace. “Young people don’t always appreciate the risk they are taking in engaging in these activities,” she said. Parents can check to see if a Tor browser has been downloaded on their teen’s computer. Check packages that come to the house, and don’t allow your teen to have their own Post Office box. If your teen asks about Bitcoin, find out what he knows about it and why he’s interested in it.

“I worry about young people with disposable income and access to credit cards,” Dr. Miotto said. “Some of the most tragic cases I’ve seen are high school kids, or even younger, with a lot of discretionary income.”

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