Addiction treatment and the circuitous road to recovery

The Centers for Disease Control reports 116 people are dying every day in America as a result of opiate addiction.  Addicts say kicking the habit can be physically and psychologically draining. Some attempt to do it on their own. Others join traditional, free 12-step programs,  and still others check into $1,500- to $2,000-a-day rehabs, hoping to minimize the suffering of detox and increase the odds of beating addiction.

Taxpayer-funded resources in Southern Nevada, which generally provide temporary emergency care in what can be a revolving-door approach, are largely bereft of a treatment plan likely to result in long-term sobriety.  

What works?  What’s the future of addiction treatment? And what’s being done to end the insurance abuse that turns patients into commodities?    

”The backyard had an accumulation of mattresses”

Accountability is hard to come by in the drug and alcohol rehabilitation industry.  Measurements of success are inconsistent and vary among treatment providers. American Addiction Centers, one of the nation’s largest treatment companies, says 60 percent of its clients remain sober after a year.  That’s twice the industry standard, according to AAC’s website.

But critics contend for-profit rehab programs have little incentive for patients to succeed, but rather to fail and return, even multiple times a year.

“In general, sometimes I question whether their motive really is to get somebody clean and sober.  Some of them,” says Jeff Iverson, founder of Freedom House, a residential treatment facility.

Iverson’s concerns are well-founded.

The U.S. House Committee on Energy and Commerce is investigating allegations of widespread fraud in the rehab industry, including a deliberate scheme that “creates an incentive for relapse and profit rather than treatment and, ultimately, sobriety.”

Solutions Recovery, a Las Vegas rehab facility owned by industry giant American Addiction Centers, advertises “luxury amenities” on its website.  

A July 2015 inspection report from the State of Nevada revealed less than luxurious conditions at 3141 Pioneer Way, one of the homes owned by the company, and where 23 year-old Cody Arbuckle would be found dead two years later.

Observations by the state included multiple holes in ceilings, dirty conditions and damage to walls and doors:

“The dining room carpet had dirt/debris and large stains. – The backyard had an accumulation of mattresses, full trash bags, ciggarette (sp) butts on the ground on the south side of the yard near the trash cans. … Based on observation and interview, the facility failed to ensure the kitchen was maintained.The first aid kit must include, without limitation: (e) A shield or mask to be used by a person who is administering cardiopulmonary resuscitation. On 7/9/15 in the afternoon, the House Manager was not able to locate a shield/mask. This was a repeat deficiency from the initial state licensure survey dated 1/23/14.”

Inspectors also found the facility failed to meet tuberculosis testing requirements for five out of ten clients as well as its Director of Patient Care.  

State inspections of other Solutions homes revealed similar conditions, as well as furniture blocking exits, and “several piles of tree branches in the backyard and a pile of pipes.“  The facility was instructed to formulate a correction plan but not sanctioned by the state. AAC Las Vegas-based Vice-president David Marlon attributes the state of disrepair to a $2 million renovation.

The Bureau of Health Care Quality and Compliance (HCQC) oversees a broad range of health facilities, including 30 non-medical rehab facilities scattered throughout the state.  Seventeen addiction treatment facilities are in Las Vegas, eight are in Washoe County and two are in Elko. Carson City, Lincoln County and Churchill County each have one.

The State of Nevada has two supervisors – one in the south and one in the north.  The supervisors are responsible for scheduling and processing applications, inspections and investigations.

Consumer complaints are assessed to determine first if there’s a violation, and if so, the risk. Investigations into violations with the potential for substantial harm “may begin within 1 to 10 days.” An investigation into a violation with the potential for minimal harm may begin within 45 days, while a violation with no potential for harm but less than ideal conditions will be investigated “as soon as possible.”  Facilities receiving citations must respond with a correction plan. The state may impose a variety of sanctions, including fines, occupancy limits and license revocation. Results of investigations are made public by the Nevada Division of Public and Behavioral Health.

The revolving door

As the Current has reported, a Solutions Recovery executive admits the company helps clients pay insurance premiums.  The practice is not confined to Solutions, nor to the addiction treatment sector of the healthcare industry. It has been outlawed in some states and skirts the law in Nevada, according to insurance experts.

Georges Maalouf of Brown & Brown, a Las Vegas insurance brokerage, says insurers have the right to terminate coverage when providers purchase policies for patients.  

“In general, insurance fraud, fraud and abuse laws, as well as anti-kickback statutes can come into play. All of these things can be considered to influence or induce future utilization of facilities and could be considered insurance fraud,” says Maalouf.   “Providers can certainly encourage enrollment in a plan, however, they cannot pay for the services. If they are caught paying premiums we reserve the right to terminate coverage. We monitor how payments are made, who is writing the checks, what claims we get, utilization patterns, etc.”   

Iverson says success rates are unlikely to improve until the incentives for insurance abuse are eliminated and providers embrace a holistic approach to healing the entire person, not just ending the substance abuse.

He’s hoping to close the revolving door of “treatment” available to Medicaid recipients, who are often homeless and arrive in treatment saddled not only with their addictions but with a host of health problems, too.  Iverson’s new facility, Crossroads, across the street from University Medical Center, will serve as a psychiatric urgent care and medical detox facility, helping to alleviate the burden on hospital emergency rooms of treating patients suffering from mental illness and substance abuse.

At a recent Clark County Commission meeting, executives of Westcare, who operate the partially publicly-funded Community Triage Center in Las Vegas, admitted the facility has no follow-up plan for clients, who spend an average of two days in care.

Robert Vickrey, Director of Community Relations for Westcare, says the missing component is stable housing, which makes adherence to a case plan more likely.  

“We can only do so much.  If they don’t have a safe environment to go home to… they’ll go back to where they came from and all bets are off.  And we have to start from scratch,” says Vickrey. “I’m a licensed clinician. I know addictions fairly well. Just about everybody who comes through that detox for withdrawal management will have a co-occuring disorder of some sort.  Where do those folks go to get treatment?”

Vickrey says the Community Triage Center was designed to alleviate emergency room overcrowding, not provide comprehensive mental health and substance abuse treatment.  

By contrast, Iverson’s facility, Crossroads, intends to offer emergency detoxification treatment as well as long-range case management, including government-subsidized transitional housing within the facility.  

“You can’t take someone who has an addiction, treat them for a matter of days and expect them to survive on their own,” Iverson says.  “They need to be taught again how to live a responsible, productive life and that takes time.”

“I don’t know many alcoholics or drug addicts who in 30 days are able to even put very many clear thoughts together let alone grasp what it’s going to take to stay sober for any length of time.  I just don’t see that. What I see is recovery is a real process that people buy into slowly over a period of time.”

“We want to engage with them long enough to provide resources – enough education, enough opportunity – that somewhere in our continuum they’ll make this choice that this is the life they want.  Once this isn’t a punishment, once it’s a personal choice and something they want, the sky’s the limit.”

The annual cost of addiction in terms of health care, crime and lost productivity is estimated at $740 billion, according to the National Institute on Drug Abuse.   Some addictions cost more than others.

“Take a guy like me who was cooking meth ten years ago and gets burned by an explosion and has to spend a month in the Lions’ Burn Unit at University Medical Center at a cost of half a million dollars to taxpayers. That may be extreme but all addicts have similar circumstances that aren’t figured into the hard costs of addiction that we hear about,” Iverson explains.

Iverson says the future of addiction recovery appears to be medically-based, with drugs that can be implanted for months at a time in order to combat the cravings of addiction.  

“That was a tough realization for me, being an advocate of abstinence,” Iverson admits.  “Now, I see the people who survived because of medicine. If not for that, they may never have had the opportunity to embrace an abstinence-based recovery.”