Posts Tagged ‘review of Inside Rehab’

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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