Put Me In, Coach!
This morning, as I read the latest stories about opioid overdose deaths, I was struck by a common thread in most of the tragic stories. One report after another had phrases like ‘she was in and out of treatment for years’ or ‘he died tragically one month after leaving treatment.’
I often wonder, if we treated opioid dependence as if we were treating any other fatal illness, would the death rate be lower? What practice measures would result from such an approach?
First, we would remove the veil of low-expectation that keeps us from realizing the ineffectiveness of ‘residential treatment.’ Once the low expectations are gone, huge questions would come to light. Why does something so ineffective continue to be seen as the gold standard for treating a potentially fatal illness?
We know that opioid dependence is a chronic condition, marked by relapse. What should be our measure of ‘success,’ when treating opioid dependence? Is the treatment in a given individual a success, if that person dies within a year? Within 5 years? Does cost matter? Should we expect better results for $50,000 then we would for, say, $2,000?
Expectations for good results with addiction treatment have been lowered over the years by the absence of other options, the assumption, conscious or unconscious, that addiction is more of a choice than a disease, and by an indifference to the loss of people who often turn friends, family, and society against them. Instead of seeing a loved one destroyed by illness, people see those with addictions as foolish people, hurting themselves. By the time death by overdose occurs, those close to an addicted person see death as inevitable; even as a blessed relief in some cases.
For decades, the public perception of residential treatment has benefitted from the fact that nothing better was available. ‘Send him to treatment’ has become a phrase uttered without thinking; a suggestion that implies a great deal, yet offers almost nothing. Perceptions of such treatments have also benefitted from abdicating responsibility for their failures. When patient after patient does poorly, those providing such treatments hide behind the assumption that failure was the patients fault. If only he ‘wanted it’ more!
What if we expected our teenage children to survive addiction? What then? Again, I think it is illuminating to substitute a different chronic disease, to get past the stigma that we all have over addiction. Would we expect insurers to pay $50,000 for a knee replacement that worked 10% of the time? Would we go to cancer doctors whose treatment approach had a 10% success rate? Maybe—but only if nothing worked better!
What if your asthma doctor took no responsibility for failing to effectively treat 90% of his/her patients? What if your doctor simply blamed you when the prescribed treatment failed, and you lost everything because of your illness? What if, when your child suffered brain damage from a diabetic coma, his doctor eschewed responsibility by saying that he just wasn’t ready for treatment yet?
As a physician, I’m frustrated that insurers will throw large sums of money at treatment approaches that rarely work, yet pay little or nothing for the intensive, medical care required to treat those with addictions. A $10,000 orthopedic bill is considered reasonable for the one-hour surgery to repair an anterior cruciate ligament. For $10,000, a psychiatrist could see an individual patient every week, for over a year! THAT level of intensity could truly result in positive change. It would appear to be in an insurer’s best interest to cover such treatment, as recovery from addiction would surely reduce overall healthcare expenditures. I try to avoid the cynical conclusion that insurers save even more by allowing treatment to fail, since those patients soon lose their job and coverage—- and cost the insurer nothing.
And then the rub: would a psychiatrist, seeing an addicted person weekly for a year, have a success rate greater than 10%? I guess that’s a good question. I just wish we could try!
Man with pills photo available from Shutterstock
Junig, J. (2012). Put Me In, Coach!. Psych Central. Retrieved on July 24, 2016, from http://blogs.psychcentral.com/epidemic-addiction/2012/09/put-me-in-coach/