Our look at treatment continues with a review of a recent Washington Post op-ed piece criticizing the 12-step program as being antiquated, ineffective, and not keeping up with advances in medication for addiction. Also gambling addiction and suicide. Dr Inaba comments.
Transcript (edited):
HOWARD: Howard LaMere here with Dr. Darryl Inaba and we are looking at news of addiction and mind/brain research and the impacts on society that addictions have. I see where the Craigs List killer apparently committed suicide – I didnt know he was addicted to gambling. I read something about how prone people who are addicted to gambling are, apparently, to suicide, more so than other addictions. And I also read that Asia Korea and China are experiencing a profound gambling upswing and its creating problems there. A story from the Washington Post is critical of 12-step program in particular and this doctors opinion is that the 12-step program is not very effective and that treatment ignores the efficacy of medication – there was quite a biting response to that. So Darryl, what do you think about the 12-step treatment controversy or any of the other things I mentioned for that matter?
DARRYL: Well, actually you mentioned two interesting topics. First I want to comment on gambling. I havent seen a more devastating compulsivity in addiction as gambling addiction. Pathologic gamblers, some view them to be different from drug abusers because of two big personality differences. Gamblers have a very powerful, very strong ego and an almost narcissistic belief that they can accomplish everything they deserve everything and that they are entitled – a feeling that they are due, winning is owed to them. Those traits are stronger in gamblers so I can understand why there are more suicides and more problems with gamblers. Ive always believed that the people I see on the road, hitchhiking or walking to their job here in southern Oregon have not lost the privilege to drive because of multiple DUIs but rather they are gamblers who actually lost their car actually lost their home actually are in debt to their ears and are in a place where they have no way of getting out of debt because of their gambling. Yet, any money they can scratch together, theyll sit back down at the poker machine or at the lottery machines or wherever and gamble their whole paycheck away again because theyre entitled. You know, theyre going to win.
HOWARD: The expectation of getting it all back, right.
DARRYL: And more. The expectation that theyre owed this and that theyre going to end up being very, very rich through their gambling is so great there that they continue to lose and continue to not accept the fact that whether its a state, a casino, or even an individual poker tournament, anything the thing is rigged! I mean its mathematics – youre going to lose and the house is going to win, you know. And the entity who organized the Lotto or whatever is going to win.
HOWARD: So theres some cognitive dissonance there. Why do people ignore the fact that they are going to lose?
DARRYL: Well, they think that theyre going to be that one person even though it is very, very rare with odds of a million and something to one that they are going to be the take home big lottery winner. And because that entitlement makes someone believe they are going to do it. So they keep investing a lot. So gambling is a very, very aggressive, encompassing, its a compulsivity in which people get so involved that they lose total sight of where they are and they have absolutely no way to get back. They owe so much money. They cant pay it back and then they look at themselves as being totally out of control because they cant blame it on drugs – some great reward isnt making them do it. Its just the expectation, so they end up, I think, having a higher suicide rate than other compulsive behavior and drug users.
HOWARD: That must be really hard to address from a treatment point of view. In this op-ed piece in the Washington Post, this doctor references celebrity Lindsey Lohan who is being released from an expensive treatment facility this week as the jump off point to critique the 12-step program. He says that most treatment is not effective and it is old it is quaint and ignores modern medication, modern research into drugs, medication. There are people a lot of people who strongly believe in the 12-step program, but there are components of it that make some people not want to go down that road. So, whats your thought on that?
DARRYL: Well, having reviewed the Washington Post article by Mr. Johnson, it certainly evoked in me a strong need to present a rebuttal, because he misses the point. Researchers and scientists and many lay people have been looking at and evaluating addiction for many, many years. These factors devalue his concerns, I believe he is missing the point his assumption is because Lindsey Lohan, is in her 4th rehab, – therefore it doesnt work.
HOWARD: Right thats an excuse.
DARRYL: But he fails to look at the research showing that just with alcoholism, it takes an average of 4 treatments before people can put together long-term recovery. And some people a lot longer, but for the average alcoholic, it takes about 4 treatment completions before they can do better. Lets compare that with other chronic persistent disorders, like diabetes. Lets look at treating asthma. Lets look at treating hypertension. There are more relapses with those conditions than with alcoholism or addiction. We dont sit around saying because somebodys blood sugar is out of control again or somebodys blood pressure just went up because they didnt stay on their low salt diet, or they didnt cut down on their fats or take their medication – we dont say theyre failures or treatment failures, we just recognize that thats part of the addictive process, part of the disease process and we need to develop a different intervention or new intervention or something to help promote this person maintain their goal in terms of treatment. Thats a big issue that needs to be looked at. He is correct in terms of treatment outcome studies. Outcome studies are all over the map because theres no consistency in how people report and evaluate a patients success after treatment. There is, I think, a built in bias about treatment programs or treatment protocols and procedures and medication – a desire to show the best results possible, so there may be some fudging to show the best results. There has always been a bias amongst funders and amongst insurance companies and amongst other people who dont appreciate treatment to show it in the worst light possible. And so, when you have those 2 polarities, you get results that are all over the map. And one of the things that needs to be accepted by critics of treatment, is that if a person is diagnosed by a physician to have diabetes, and the physician says okay, youve got diabetes, I want you to take this medication, I want you to lower your caloric intake, lower your carbohydrates. I want you to exercise more or whatever and patient never comes back or comes for an examination and the patient has high blood sugar both and isnt doing well and never shows up again – we dont consider that a horrible treatment failure on behalf of the doctor or on behalf of medicine its that the treatment didnt take. The person didnt accept that they have a condition that they have to do things differently. From the same standpoint, we cant hold people with addiction or alcoholism to a standard once we diagnose the problem, they come into a 12-step fellowship or treatment and then they split before treatment is completed. They leave after 1 or 2 visits. We should not call that a failure of the treatment, you know, or a failure of the person. Treatment never started. Many people look at reporting treatment outcomes in terms of: 3 consecutive visits to a 12-step meeting or 3 visits to the treatment program, outpatient, or stay at least 3 or 4 days in a residential program before the patient is considered in treatment. And then from that group, how many of them who stayed past 3 or 4 visits, managed to complete treatment? In 12-steps, you dont complete 12 steps. You engage in it for the rest of your life. So, we look at how many were able to persistently stay in a 12 step and were able to stay clean and sober. When you look at those numbers and put everybody on the same playing field, I think we will have real numbers and I think the jury is very strong in its verdict that effective treatment for addicts and alcoholics is one of the best things we do in medicine for effective outcomes. So that would rebut this guys statement on whether treatment works. Another thing he claims is that treatment is too expensive, asking why when we pay all this money for treatment, we get very poor outcomes and he quotes the Lindsey Lohan program, I guess and Hazelden and all of the high end celebrity rehab places when the vast majority of programs in this country, like the one Im working at now, the Addictions Recovery Center, is publically funded for the most part and for the most part totally underfunded. There isnt enough money to provide treatment and cover the costs of staffing, rent, legal,etc. So they need to raise their own money to supplement what the public is funding. And most of the formulas, even from San Francisco have an expectation of at least 40%. Youre going to raise 40% of the costs of treating this person by your own fundraising activity. But when you just look at the bare costs and not consider where the money is coming from or anything else like that and you ask how much does it cost us to treat one patient for a year? I think he was quoting something like $28,000 for the high end Hazelden type programs. To provide treatment for detox, for residential, then follow-up, is maybe $28,000 .
HOWARD: Actually that was for a month.
DARRYL: Well, thats for a month of the residential treatment. But some packages at places like Hazelden, thats for the follow-up, the aftercare, the continued work with the program for a year or so later up to a year later, so that a patient has a hope of maintaining recovery. If the initial package, is $28,000, and you compare that to the cost of keeping somebody in jail for a year – how much does it cost us if that person in jail is also suicidal or has a major underlying mental health disorder as well as an addiction disorder – youre talking about $28,000 to keep people in jail. Thats how much it costs us as a society. And if there are complications if this guy is suicidal, has a major underlying mental health or medical problem, then youre looking at astronomical costs added to that. So, if you compare those costs compare what it costs us to treat somebody for addiction, it comes out to be fairly cheap. As a matter of fact, the University of Pennsylvania did a metastudy, meaning they looked at over a thousand other outcome studies and tried to come up with equal criteria from each one to measure how they did and looked at one thing economics. How were these programs economically feasible? And out of over 1000 studies they couldnt find a single treatment that costs more to the community than what the community benefited in real dollars. Meaning that for every dollar a community spent treating an addict, the community made anywhere from maybe a dime 10 cents they made a dollar ten back to up to like 24 dollars back for every dollar spent on treatment. So, treatment is not expensive. One last thing he mentioned, I thought was interesting. He called it I dont know what he called it, but he noticed that with alcoholism, when people are alcoholic and they go on with their life that theres a certain maturation. We used to call it a maturing out process a certain amount of addicts get spontaneous ..
HOWARD: Remission.
DARRYL: Remission yes. Some people who have been heroin addicts for years just get tired of it. They dont go into treatment, they just quit and they dont go back. Studies show that about 10% of heroin addicts will have a self-remission later on in their life a maturing out process. And alcoholism, I think in the article he mentioned somewhere around 21% or so of alcoholics mature out of it and dont go back to it. Well that occurs, and then he says if you look at that factor, then youre going to get much lower results in treatment. But he doesnt realize the study is not about a maturing out factor, the study tracks people who are in the throes of their addiction, who havent matured out of it and are desperately trying to stop using. So, its apples and oranges.
HOWARD: Yeah, well it was an op- ed piece and so there was no incumbency to be truthful or factual. The author is coming out with a book in the next few months about medication treatment for addiction. So
DARRYL: Well, that part of it
HOWARD: Darryl, I think you should respond.
DARRYL: Sure! Do an op-ed rebuttal. You know something though? There are parts of this article I kind of agree with – where evidence based addiction treatment is moving and because of the Addiction Equity Act, there is a movement to put addiction treatment under primary care. Because after all, it is a medical condition. Its a condition of the brain – imbalances are going on. Maybe these regulatory programs are out of whack, in that, when you have evidence based medicine, the most rigorously tested evidence based treatment systems are medications. The FDA has a rigorous multi-phase process and multi-year process before they allow any medication to be sold to treat anything. So, when youre looking at that and realizing that were looking for a greater role for medicine to play and a greater role for the medical system to treat addicts where up to this point in time, the recovering addicts and alcoholics have played a bigger role. I think hes right. We should be seeing a growth in the use of things that can be effective in helping addicts and alcoholics enter into and maintain their treatment goals for a longer period of time.
HOWARD: And this discussion will continue. If you have comments or questions please get in touch. Check back soon for the next conversation in the series.