Over the past year, the BB team has received over one and a half thousand different messages from users about their history of encountering drugs, as well as their problems with addiction.
Reports range from sad tales of overdoses and premature deaths to more encouraging accounts of recovery. Such stories have come from across the United States, as well as from Canada, the United Kingdom, Germany, Switzerland and Australia. Most of the stories come from people suffering from addiction, but also among them are stories from parents, spouses, siblings, and other family and friends of those struggling with the problem.
From all of these experiences, one common problem emerges: drug addiction treatment in the United States is an expensive and complex endeavor that is too often ineffective. With an opioid epidemic that has claimed more than 700,000 lives since 1999, the country's substance ***** system shows significant shortcomings.
Reports range from sad tales of overdoses and premature deaths to more encouraging accounts of recovery. Such stories have come from across the United States, as well as from Canada, the United Kingdom, Germany, Switzerland and Australia. Most of the stories come from people suffering from addiction, but also among them are stories from parents, spouses, siblings, and other family and friends of those struggling with the problem.
From all of these experiences, one common problem emerges: drug addiction treatment in the United States is an expensive and complex endeavor that is too often ineffective. With an opioid epidemic that has claimed more than 700,000 lives since 1999, the country's substance ***** system shows significant shortcomings.
The stories published by the BB team illustrate these problems. Jessica and Mason Davis (names have been changed) invested more than $110,000 in treatment for their oldest son, but most treatments were unsuccessful and he died anyway. Daughters Clover (name changed) underwent $200,000 worth of treatments for ten years before they finally found an effective method. Nancy Brown (name changed) went through a financial crisis after losing her oldest son to drug addiction and spent years trying to shield her surviving daughter from a similar fate.
Standard health insurance does not provide patients with enough protection against high costs and poor quality of care. Maureen O'Reilly lost her son to drug addiction when their insurance did not cover treatment at convenient facilities and he had to go to low-quality clinics in Florida, some of which later closed.
Standard health insurance does not provide patients with enough protection against high costs and poor quality of care. Maureen O'Reilly lost her son to drug addiction when their insurance did not cover treatment at convenient facilities and he had to go to low-quality clinics in Florida, some of which later closed.
Methadone can help overcome opiate addiction — evidence that evidence-based and supportive approaches can be effective. However, many face barriers related to stigma and strict regulations around the use of substances like methadone.
Here are a few factors that influence problems with medical care in drug rehabilitation.
Insurance problems lead to high treatment costs
Many people find it difficult to get insurance coverage for drug treatment. The reasons are often lack of health insurance or insurers refusing to cover the services needed.
This is a massive problem across the country. According to the National Survey on Drugs and Health, approximately 314,000 people in the U.S. in 2018 needed drug treatment but were unable to get it due to lack of health insurance or financial ability. About 100,000 people were unable to get treatment even if they had insurance because it did not cover the cost of services fully or at all. It's worth noting that there is overlap among these groups, as survey participants could choose multiple answers.
Here are a few factors that influence problems with medical care in drug rehabilitation.
Insurance problems lead to high treatment costs
Many people find it difficult to get insurance coverage for drug treatment. The reasons are often lack of health insurance or insurers refusing to cover the services needed.
This is a massive problem across the country. According to the National Survey on Drugs and Health, approximately 314,000 people in the U.S. in 2018 needed drug treatment but were unable to get it due to lack of health insurance or financial ability. About 100,000 people were unable to get treatment even if they had insurance because it did not cover the cost of services fully or at all. It's worth noting that there is overlap among these groups, as survey participants could choose multiple answers.
A recent report from the consulting firm Milliman found that the availability of commercial insurance coverage for substance ***** treatment is worsening, especially when compared to traditional medical care.
For example, in 2018, inpatient addiction treatment facilities were 10.1 times more likely to be out-of-network than medical or surgical inpatient facilities. This compares to 4.7 times in 2013. Similar trends were seen in outpatient facilities, making addiction treatment more expensive and difficult to access.
Maureen O'Reilly experienced these problems firsthand. Her son, Ed Fahey, tried to get help at local drug treatment centers in New Jersey. However, Horizon Blue Cross and Blue Shield, which administers his insurance, refused to cover these programs. Eventually, Fahey found treatment in Florida, which was covered by insurance, but fell into the «Florida mess» of substandard, poorly regulated treatment centers and sobriety homes. Tragically, he was the victim of an overdose and died in the sober house, which was later shut down by law enforcement.
This situation vividly illustrates the complex issues surrounding insurance coverage: insurers often shy away from funding drug treatment, which can be very expensive, without a clear understanding of what medical care is reliable and worthy of coverage.
For example, in 2018, inpatient addiction treatment facilities were 10.1 times more likely to be out-of-network than medical or surgical inpatient facilities. This compares to 4.7 times in 2013. Similar trends were seen in outpatient facilities, making addiction treatment more expensive and difficult to access.
Maureen O'Reilly experienced these problems firsthand. Her son, Ed Fahey, tried to get help at local drug treatment centers in New Jersey. However, Horizon Blue Cross and Blue Shield, which administers his insurance, refused to cover these programs. Eventually, Fahey found treatment in Florida, which was covered by insurance, but fell into the «Florida mess» of substandard, poorly regulated treatment centers and sobriety homes. Tragically, he was the victim of an overdose and died in the sober house, which was later shut down by law enforcement.
This situation vividly illustrates the complex issues surrounding insurance coverage: insurers often shy away from funding drug treatment, which can be very expensive, without a clear understanding of what medical care is reliable and worthy of coverage.
O'Reilly filed a lawsuit against Horizon and their behavioral health benefits manager, Beacon Health Options. Horizon called the allegations «false, baseless and unfair» in a statement, and Beacon declined to comment on the situation.
O'Reilly is not the only one facing similar difficulties. Many families of addiction patients who file lawsuits against their insurers have had significant successes: in Wit v. United Behavioral Health, for example, a federal court found that United unlawfully denied coverage for mental health and addiction treatment to tens of thousands of clients. While the decision is likely to be appealed, a successful outcome in the case could set a precedent for the entire field.
Insurers appear to recognize the problem. Companies like Horizon, Beacon, and United have worked with the advocacy organization Shatterproof to develop better standards for drug treatment.
All of this clearly shows why drug treatment in the United States is often so expensive. The insurance system is designed to protect Americans from enormous medical costs, but is often ineffective when it comes to addiction treatment.
Lack of information about drug treatment
Many academics and PhDs who study drug dependence in the United States answer the question about the evidence for the effectiveness of a particular therapy in the same way, «I don't know».
For example, some institutions use hippotherapy, in which patients interact with horses, but we have little research to support its effectiveness. The same is true of nature-based therapy based on outdoor activities, for which there is also a lack of reliable scientific evidence.
Lack of information about drug treatment
Many academics and PhDs who study drug dependence in the United States answer the question about the evidence for the effectiveness of a particular therapy in the same way, «I don't know».
For example, some institutions use hippotherapy, in which patients interact with horses, but we have little research to support its effectiveness. The same is true of nature-based therapy based on outdoor activities, for which there is also a lack of reliable scientific evidence.
This is not to say that these methods have been proven ineffective — we just don't know if they work. This raises questions, given that in healthcare, treatments are usually based on scientific evidence. Patients are unlikely to want doctors testing various techniques on them in the hope that something will work.
Unfortunately, a lack of evidence of effectiveness has become a common practice in addiction treatment. Most treatment facilities do not even track the actual results of their work.
Some claim that they do, but more often than not, they rely on follow-up surveys that are prone to bias and error. For example, a patient may claim not to have used drugs and the interviewer does not verify this information.
This is certainly an oversight in both the health care industry and the law. The Centers for Medicare and Medicaid Services «represents more than 4,000 quality indicators. However, there is not a single addiction program — zero» — states Tami Mark, an economist at the RTI International Research Foundation.
Unfortunately, a lack of evidence of effectiveness has become a common practice in addiction treatment. Most treatment facilities do not even track the actual results of their work.
Some claim that they do, but more often than not, they rely on follow-up surveys that are prone to bias and error. For example, a patient may claim not to have used drugs and the interviewer does not verify this information.
This is certainly an oversight in both the health care industry and the law. The Centers for Medicare and Medicaid Services «represents more than 4,000 quality indicators. However, there is not a single addiction program — zero» — states Tami Mark, an economist at the RTI International Research Foundation.
We also have limited data on the financial impact of addiction treatment on American families. There are extremely few studies on this topic.
Tami Mark, along with the advocacy organization Shatterproof, is trying to remedy the situation by creating a sort of «Yelp for Rehab». This project seeks to steer patients toward evidence-based treatment using provider surveys, insurance claims, and user assessments starting next year in at least some states.
Currently, however, patients are largely unaware of whether a treatment provider is actually evidence-based.
The game is not at full strength
There is a lot of information about drug ***** treatment that we unfortunately do not apply properly.
For example, studies demonstrate that opioid addiction medications such as methadone, buprenorphine, and naltrexone are highly effective. These medications can reduce the mortality rate among opioid-dependent patients by more than half and help people stay in treatment much more successfully than non-medication methods.
However, in the U.S., most rehab facilities do not offer medication-assisted treatment. According to federal data, only 42% of the nearly 15,000 facilities tracked by the Substance ***** and Mental Health Services Administration (SAMHSA) offer any medication for opioid addiction, and less than 3% provide all three federally approved medications.
In fact, many rehab centers may even oppose the use of medication based on the misconception that such medications merely replace one addiction with another. Ian McLoone said that RS Eden rehab center in Minnesota tried to convince him to stop taking methadone, and it was only through the support of his mother that he was able to continue taking it.
«It was by far the best decision I could have made. After that, I was able to complete my rehabilitation, get a summer job, and enroll in graduate school, which I successfully completed. I was able to build the life, family, and career I had dreamed of. Methadone really played a big part in that» — shared McLoone.
The reasons why treatment is not evidence-based reflect not only the decisions of the industry itself, but also public policy choices.
In fact, many rehab centers may even oppose the use of medication based on the misconception that such medications merely replace one addiction with another. Ian McLoone said that RS Eden rehab center in Minnesota tried to convince him to stop taking methadone, and it was only through the support of his mother that he was able to continue taking it.
«It was by far the best decision I could have made. After that, I was able to complete my rehabilitation, get a summer job, and enroll in graduate school, which I successfully completed. I was able to build the life, family, and career I had dreamed of. Methadone really played a big part in that» — shared McLoone.
The reasons why treatment is not evidence-based reflect not only the decisions of the industry itself, but also public policy choices.
Despite years of evidence and support from organizations like the American Medical Association, the Centers for Disease Control and Prevention, and the World Health Organization, the needle exchange program remains outlawed in much of the United States. Prescription heroin, which is provided to people with treatment-resistant addiction, is supported by solid research, including an extensive review from the RAND Corporation, but has received little attention from U.S. policymakers.
The bottom line is that unless we begin to utilize even the effective methods available, our progress in addressing the opioid crisis and the drug addiction problem in general will be extremely limited.
There's still a stigma
When I discuss issues related to addiction, I invariably come across the topic of stigma. This phenomenon is the nexus of the research I have conducted through various BB projects, or others.
I was struck by the situation in Vermont in 2017 as the state reformed its drug treatment system. When many people questioned officials about the challenges they encountered in implementing new models of care, everyone expected to hear about financial challenges-a common difficulty in policy development. However, officials noted that money was not the main obstacle.
The main problem turned out to be the stigma associated with addiction, based on the view that it is a moral failing, not a medical problem, and that people with addictions do not deserve public resources. Once this stigma was overcome, financial resources became readily available.
This is a major problem with the U.S. approach to addiction treatment in general. The long-term perception of addiction as a moral failing relegated to the criminal justice system, rather than recognizing it as a medical condition requiring public health resources, continues to plague the situation.
Why is information about addiction treatment centers and their outcomes so poorly available? How is it possible that alcohol addiction treatment remains so expensive and ineffective for so many? Why is the knowledge used not actually applied? Is there sufficient support for addiction treatment coverage from insurers?
The bottom line is that unless we begin to utilize even the effective methods available, our progress in addressing the opioid crisis and the drug addiction problem in general will be extremely limited.
There's still a stigma
When I discuss issues related to addiction, I invariably come across the topic of stigma. This phenomenon is the nexus of the research I have conducted through various BB projects, or others.
I was struck by the situation in Vermont in 2017 as the state reformed its drug treatment system. When many people questioned officials about the challenges they encountered in implementing new models of care, everyone expected to hear about financial challenges-a common difficulty in policy development. However, officials noted that money was not the main obstacle.
The main problem turned out to be the stigma associated with addiction, based on the view that it is a moral failing, not a medical problem, and that people with addictions do not deserve public resources. Once this stigma was overcome, financial resources became readily available.
This is a major problem with the U.S. approach to addiction treatment in general. The long-term perception of addiction as a moral failing relegated to the criminal justice system, rather than recognizing it as a medical condition requiring public health resources, continues to plague the situation.
Why is information about addiction treatment centers and their outcomes so poorly available? How is it possible that alcohol addiction treatment remains so expensive and ineffective for so many? Why is the knowledge used not actually applied? Is there sufficient support for addiction treatment coverage from insurers?
There is one popular answer to all these questions: stigma leads to distorted perceptions of addiction among the public and policy makers, who consequently do not do enough to change the current situation.
As Keith Humphries, an expert on drug policy at Stanford, noted, «These problems have been with us for a very long time. I haven't heard a single politician express outrage over the quality of alcoholism treatment in our community. It's almost unthinkable». The problem remains unresolved until a significant portion of society overcomes its preconceived notions about addiction.
However, there are positive changes — many people are willing to fight stigma (including our team). Project BB works every day to help drug addicts, as well as informing people about safe drug use and conducting drug harm reduction activities.
As Keith Humphries, an expert on drug policy at Stanford, noted, «These problems have been with us for a very long time. I haven't heard a single politician express outrage over the quality of alcoholism treatment in our community. It's almost unthinkable». The problem remains unresolved until a significant portion of society overcomes its preconceived notions about addiction.
However, there are positive changes — many people are willing to fight stigma (including our team). Project BB works every day to help drug addicts, as well as informing people about safe drug use and conducting drug harm reduction activities.