Book Review: “Inside Rehab: the Surprising Truth about Addiction Treatment – and How to Get Help that Works,” by Anne Fletcher

Inside Rehab

This meticulously-researched book is excellent, and I highly recommend it to people entering treatment, and to their families. I also think everyone working in the field of addiction treatment needs to read the book and ponder the truths it reveals.

The book is more scholarly than I was expecting; the author researched studies, statistics, data, and talked to experts in the field of addiction treatment. She visited addiction treatment programs, and though half of them were located in her home state of Minnesota, she did investigate a wide variety of addiction treatment approaches. She talked with the people who worked at these programs and also talked to a large number of people seeking recovery from addiction. Some people had success with treatment, and some didn’t.

The “surprising truth” she refers to in her title isn’t surprising to anyone who read the milestone report issued last summer from Casa Columbia, the New York City think tank that studies addiction treatment. I did a blog on that report (see August 9th, 2012), one of the most important, evidence-based, exhaustive statements made about the state of addiction treatment in this country. I hoped this paper would be talked about and its conclusions taken seriously, but the addiction treatment field appears to have greeted CASA’s landmark paper a collective giant yawn, and gone back to business as usual.

Repeatedly, this author refers to CASA’s report, and her investigative book mirrors CASA’s findings closely. In fact, I would describe Ms. Fletcher’s book as an expanded, more interesting version of that CASA report.

“Inside Rehab” explains how addiction treatment has been abandoned by the medical field long ago. The lack of addiction science in past decades contributed to this exodus, as did the rise of the 12-step movement and the Minnesota Model. Doctors get very little training about addiction and its treatment, and the medical field views addiction not as a medical problem but as a social problem. Most doctors are happy to direct addicts to counselors rather than begin treatment with evidence-based medications. The author points out that even treatment centers rarely use or recommend medications that are proven to work, like naltrexone, acamprosate, disulfiram, buprenorphine and methadone. The author talks about how science takes a very long time to be implemented into real-life practices. This would not be tolerated in any other field of medicine.

The author says many treatment centers have not incorporated evidence-based treatment approaches, and have stayed stuck in the past, using the same treatments now as were used in the 1980’s. She’s right. Older methods that don’t show any benefit are still being used, like educational lectures, aggressive patient confrontation, and the like. The author points out how the addiction treatment field is still dominated by thinking that’s guided by folk wisdom, much of it from laypeople in recovery themselves, rather than science. Few programs offer evidence-based treatments like CBT (Cognitive Behavioral Therapy), MI (Motivational Interviewing), contingency management, community reinforcement approach, and even twelve-step facilitation. Programs promoting 12-step philosophy rarely use the actual Twelve Step Facilitation method as tested in research studies with demonstrated benefits. Instead, they use kind of a freestyle method. It may work; it may not.

The author correctly points out that workers in the field of drug and alcohol addiction treatment often have little training and may lack professionalism. Addiction treatment workers with little education can end up trying to treat people with some of the most complex medical problems, particularly people with addiction and co-occurring mental health issues. Counselors have been allowed to “grandfather in” and obtain certifications because of the length of time they’ve been working in the field, rather than returning to school for additional education.

The author talks about the lack of licensing requirements for the addiction counselors, and how certification organizations like CARF and JCAHO both only ask facilities to comply with state regulations. These organizations could instead call for higher standards for certification, including minimum standards for education.

She is rightfully critical of the “one size fits all” approach to people with addiction. Many treatment programs claim to individualize their treatment to fit the individual, but in reality, everyone gets assigned to the same groups, with little or no attention to specific issues. The claim of individual treatment in some cases appears to be more of a marketing ploy than an actual practice.

She criticizes over-reliance on 12-step recovery as a treatment for all people. I was happy to see Ms. Fletcher included the evidence showing 12-step recovery participation does improve the chances for abstinent recovery. But she feels patients shouldn’t be forced to go to 12-step recovery if they don’t want to go, and I agree with her. She also points out that non-12-step groups likely also improve recovery, though there’s been little if any research on them. She feels treatment programs need to offer these non-12-step options to patients in addiction treatment.

I agree with that too, but unless you live in California, those meetings are hard to find. Women for Sobriety, one of the groups she mentioned in the book, had eight meetings per week held in the state of North Carolina when I investigated that organization a few years ago, trying to find alternatives for a patient of mine who didn’t like 12-step meetings. That’s compared to 12-step meetings, which have hundreds, possibly thousands of meetings per week across the state. Alternative to AA and NA may work…but there are difficult to find, at least in my area. Online meetings may be of some help.

She made some insightful remarks about how when treatment facilities try to associate themselves with AA, it’s AA that suffers. That’s a good point. Some AA members aren’t happy to have their meeting flooded with patients from a local treatment center, who in some cases don’t really want to be there. Some meetings won’t sign attendance forms for a probation officer that’s forcing someone to go to AA. Some groups believe it’s against one of AA’s traditions that says people should come to AA because they’re attracted to it, not enticed or forced to go. I’ve heard AA members talk derisively about inpatient treatment rehabs where the only treatment offered is AA-type group meetings. They argue that people could do this on their own, for next to no cost. If someone seeking recovery lives in a big city, he could probably get to four or five meetings each day. One might wonder how much advantage is there to an inpatient program that costs tens of thousands of dollars where little more is offered than AA-type group meetings?

She has chapters devoted to the treatment of adolescent addicts, an area rife with controversy. Not all adolescent drug abusers will continue on their way to becoming addicts, yet some will. How can we tell who needs treatment and who doesn’t? We don’t have distinct answers yet, and it may lead to over- treatment of adolescents.

I do have a few minor complaints about the book. She’s quoted people who have been to treatment, who describe shoddy treatment they’ve received. I’ve no doubt much of it is true, but some of it sounds exaggerated, to say the least. I might take these descriptions at face value, but I’ve heard many patients tell exaggerated stories. For example, I had a patient (not an addict) tell me her last doctor beat her with a hammer. I was incredulous, but she insisted it was true. As I asked for specifics, it became apparent her previous doctor didn’t beat her with a hammer; he checked her reflexes with a small rubber mallet.

So…patient statements are helpful, but may not be as accurate as Ms. Fletcher believes. I understand the point Ms. Fletcher’s interviewed patients are making, and most of what they say may be true. Or it may not be true.

In one vignette, an addict criticized his doctor for not being willing to “help him out” with prescribed opioid medication to help him avoid opioid withdrawal and taper his opioid use. Unfortunately the book’s author pounced on that bandwagon, apparently unaware that it’s a crime for a physician to prescribe opioids from an office setting to treat addiction, unless it’s Suboxone from a licensed provider. I was sad she criticized the doctor, and that she seemed eager to believe the worst about the physician, when in fact the doctor could be charged with a crime if he complied with the patient’s request.

My other beef with her book is her relatively brief coverage of medication-assisted treatment with methadone and buprenorphine. She does mention these medications throughout the book, and correctly points out how traditional Minnesota model treatment centers aren’t using this evidence-based medication. But I think medication-assisted treatment of opioid addiction deserved a chapter of its own. It’s the most evidence-based treatment, possibly in all of medicine, and is actually being discouraged by most big-name treatment centers. That’s an outrage. (Even though Hazelden last year announced they would start to use buprenorphine, they are using it only for detox, and still discourage maintenance. See my blog post from Nov. 20, 2012.)

I had mixed feelings when reading the book. I agreed with most of what the author said, yet it’s hard to read about criticism of the field when I’m a part of it. I found myself wanting to be defensive, but in the end Ms. Fletcher has written some much-needed truths. The book is directed at the educated layperson, and the information is accurate. If addiction treatment professionals aren’t offering the best of treatments, patients need to take the initiative and get into programs that do offer the best, state of the art treatment. That’s the concluding message of this book. Ask questions before you go to treatment, and vote with your feet and your dollars.

It’s a great book. I wish all addiction treatment providers could read it, along with all medical students, doctors, nurses…OK, everyone should read it.

You can read more about the author of the book here: http://annemfletcher.com/

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5 responses to this post.

  1. Thanks for sharing 🙂 I am still in process of finding a treatment or doctor rather. This sounds like a great book- but I agree with you about the hammer 🙂

    Reply

  2. I still have yet to read this book but as a clinician working in the field of addiction in MN for the last ten years I have been frustrated time and time again by the lack of real understanding of and referral to evidence-based and harm-reduction modalities. They exist to a certain extent in MN but most of the ‘big names’ in the state are going to demonize and discourage people from utilizing them or simply won’t refer to them. Many people in MN rely on Medical Assistance along with Rule 25 County funding at least initially when entering treatment and many of the county assessors are not ‘on board’ with referrals to ORT facilities and I have seen many cases where County assessors at the top level (or Dinosaurs as I lovingly call them) step on referrals made to ORT facilities and turn them to referrals and funds only available for ‘detox’ rather than ‘maintenance’ and in some cases abstinence-based treatment 7-90 days and not ORT at all…I don’t feel by any means that ORT is the correct intervention for everyone I encounter but to not even have it on the radar as an option has likely contributed to the overdose deaths of thousands that could likely have been avoided with stable maintenance. We have 10 MMT facilities (a couple questionable, obviously J..) in the state and will likely have 12-15 in the next few years, we also have a growing number of DATA 2000 physicians, we have at least two wonderful and growing programs I’m aware of that are open-minded enough to actually create individualized treatment rather than just reference it in a pamphlet. We have two or three facilities licensed to use methadone in detox or start people on maintenance pre-ORT facility and at least a dozen facilities that contract with a DATA 2000 provider to utilize buprenorphine. Unfortunately, for the average Joe with no background in the field of addiction and no real contacts chances are that they are going to have the impression that the only option available are the 1980’s ‘abstinence-only,’ step-based facilities which is really tragic when you think about it.

    Reply

  3. I look forward to reading this book. In fact, I believe that this book has been around for a while now. As I have come by the title before. I personally like the book by Hester Reid and William Miller “Handbook of Alcoholism Treatment Approach. This is very academicals, and based on quite a bit of research. In fact Hester and Miller from the University of New Mexico had being doing review of the literature on Alcohol and Substance use since the mid. 1970s. They have done ample amount of surveys. According to them The best review I read on the book even though with some biases, I believe, was done by apparently a patient. Given that I read all three of the revisions and I own two of them, I agree with the reviewer’s accuracy http://lsrbooks.blogspot.com/2007/04/handbook-of-alcoholism-treatment.html the authors in essence were said that current dominant treatment approach if they had tried to intentionally assure that they could come up with the least effective modal; they could not have done it better (or is it worst).

    I have requested the Florida Department of Children and Family to consider doing a Mystery Shopper type program to establish real quality assurance. I have learned that whatever it is documented (some people really good documenter while being incompetent practitioners) in patient’s notes, their policies and procedures manual etc. It is not necessarily what is going on in treatment facilities. My posture is that “Paper holds whatever the ink can stain”. My sense is that we fear finding out that what we do can harm patients.

    I am in the field myself, I hold a master degree in Vocational Rehabilitation of people with disability (not necessarily substance use treatment, but I have substantial amount of transferable skills to figure out eventually what was happening) and I dropped out of PhD program. So I have some ideas of what was going on. I left the PhD partly because of frustration and lack of science and over all sense that practitioners think that we can make anything up (if it sound [or read] good and convince others and make claims that it is effective) then we can call it treatment. Just say things with sufficient authority and we can forget such petty thing as evidence.

    After becoming dependent on opiates (am not the only professional I have not seen the study, but I understand individuals in the health field are supposed to be the largest profession with substance use problems) In fact, the person who had a substantial influence to my beginning to use opiates was one of my classmates who I dated for a few years and had considered becoming a lot more attached. I give thanks to the gods we did not. Anyway after having trusted the professionals I thought they knew what they were doing and making a large contribution to devastating my life, I became psychophobic, a card carrying skeptic (not cynic) and a critic of the profession I used to trust. I know that there are some caring and competent professional out there that are doing excellent work and I acknowledge that we are missing quite a bit of information and research, but I cannot help notice and feel that the substantial majority (not likely intentional) have the potential of being hazardous to human mental health and life. Like they did mine, and I am fairly sure that am not alone, except that patients blame themselves when things do not work out or do not obtain the results they expected. We can really harm patients

    Reply

    • Nope, this book came out in 2013.

      I love Miller’s work. The third edition of “Motivational Interviewing” came out last year, with some great new stuff.

      Reply

  4. You are right, if I recall correctly it came out early in 2013. So I had seen the cover I just did not remember when. I have read it twice in the past three month and there was some good stuff in there, but I think she was too nice. Of course she was not bamboozled and misinformed like I did. I loved it when I read a few comments where it said that when the facilities do not get the outcomes, they blame it on the patients.

    I already knew that, most doctors don’t blame their patients when they do not get better they change the antibiotic or whatever modality they are using, but not in substance use disorder. They keep using the same rubbish expecting different results.

    I love the review of the literature done by Hester Reid and William Miller. a bit now of an old book(2003) I wished they revise it, but still the conclusions are still valid. If they (meaning residential facilities) would have tried to collect on purpose the most ineffective approaches they could have found and use them.They couldn’t have done it better.=<I paraphrased it). The most dominant approach, meaning the 12 Step facilitation, is the one with the least amount of evidence of effectiveness.

    I read about 3 hours a day of science, mostly psychology and related field I can assure you the gap between clinical practice and science is humongous. Am glad I am a healthy skeptic, because I have been hot air too much by clinicians. From what I can see you try real hard not to fool people. I can assure you there is a good number of clinician out there that act in bad faith. They seem to forget that there is a code of ethics they most follow. They are not bad people, they are just quacks. They do harm patients, and they are not rare. And as Dr. Scott Lilienfeld calls it, they are joyfully oblivious of their ignorance.

    Reply

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