The term “rehab” is a Hollywood expression. Nobody refers their patients to “rehab” but we all have read about it in People magazine. Criticism of these programs is both well-deserved and unfair.
As a current addiction medicine fellow in Georgia, I find referral options are very limited for my patients. One prominent local facility rejected gabapentin for a patient with neuropathic pain. Many of these rehabs don’t allow pych meds either.
Hard to reconcile with the ASAM criteria, but ASAM is not in charge of everything.
If you read Matthew Perry's book, you would note that he decried rehabs and detox places as highly ineffective and that they taught him little. Detox is a waste of money without lengthy treatment after. I find it amazing that we put people through it and then send them on their way as if addiction was that easy. We must invest in programs that last longer in order to be successful. Between addiction and mental health, we have lost our way.
I am a retired pediatrician. There are many forms of rehabilitation for many ailments. Take morbid obesity. The record of successful treatment or rehabilitation after diagnosis is dismal. Alcoholics Anonymous has a better track record but, alas, its long-term success is likely not high. There is a deep and often unaddressed spiritual emptiness in many individuals with addictions to food, alcohol, sex, and drugs. Unless and until this spiritual vacuum is addressed, in my opinion, little success should be expected.
It was obviously the C19 vax that killed Matthew Perry.
For those that find the definitive nature of that comment offensive, and believe the C19 MRNA to be safe and effective, I intentionally worded my provocation to perhaps give a glimpse of how people like me felt when the majority of the world insisted with conviction that the new MRNA product, with no long-term safety data, was “safe and effective,” and then tried to force me and my family to be injected. A nadir moment in recent history in which Matthew Perry enthusiastically and commercially participated.
As far as addiction goes, the human brain is the final frontier. Maybe with a dose of humility, we’ll somehow make progress in our efforts to untangle. But given the Medical research communities’ fraudulent charade with Alzheimer’s over the last 20 years, you’ll hopefully forgive my cynicism.
"Somehow, a lengthy stay in a remote treatment “camp” – precisely the thing we decry as not evidence-based -- helped him turn the corner."
Emphasis on the word "lengthy," Doc.
As with confrontational techniques, the essential ingredient is temporal. We know from Skinner, Stoddard et al, the power of adaptive learning and association. It is the combination of reconstructive technique and removal from association that produce optimal results.
Regarding confrontation; I've seen it produce quite effective results in long-term residential settings, but there are degrees of confrontation beyond which one must not trespass; the breaking-down of emotional defense structures is, as you have noted, fraught with risk.
If you'll forgive the vernacular, those who recover from addiction without semi-permanently removing themselves to a supportive environment free of their learned association with their addictive behaviors, are unicorns.
Thank you for an astute and enlightening perspective.
Thank you for writing this. We experienced exactly this. When my partner needed to transition into a detox program out of the ER, none were available. All had minimum 6 to 12 week waiting lists. (Los Angeles, CA)
Nov 14·edited Nov 14Liked by Stefan G. Kertesz, MD, MSc
It is surprising that Dr. Kerstesz, with his considerable knowledge of addiction-related policies and practices, did not mention another significant hurdle to getting people into treatment programs. That obstacle is the ideology known as harm reduction.
Having witnessed the unfolding of the unmitigated disaster that is Oregon's ill-considered experiment with decriminalization, I have concluded that harm reduction is an antisocial form of activism that is bad for the community and bad for the user. Advocates for harm reduction pride themselves on their neutrality on drug use and addiction. "No judgment" is the mantra. In fact, that very abdication of a sense of right and wrong is what’s responsible for so much personal suffering and death among addicts. Furthermore, harm reductionists' purported neutrality on drugs masks their extreme hostility to the moral values meant to yield the sort of healthy and productive individuals who contribute to healthy and productive societies. Among harm reductionists, morality is a bad word.
People addicted to meth, fentanyl and other opiates have given away every last shred of personal and bodily autonomy they ever had. To pretend otherwise, which is the central premise of harm reduction, is a cruel farce. Harm reduction abets addiction while stigmatizing recovery and sobriety. As a society, we must stigmatize addiction and launch treatment programs that promote detox, rehab and sobriety.
I have a few views about the sort of rehab program Dr. Kerstesz discusses in his piece as a result of having been through treatment for two months at Hazelden's Newberg, Oregon, facility a decade ago and following the topic of addiction treatment more closely since then than the average citizen.
One of them is astonishment and dismay at the persistence of AA's 12-step program as the centerpiece of the treatment experience. As defined by the 12 steps and the Big Book, AA's method of treating addiction is at its core a religious practice. Paradoxically, AA's etiology for what it terms a disease is a pathology of the will and character. The cure is a lifetime of divining and following God's will. The sacrament is the bad coffee after the meeting.
AA does not work for me because I am an atheist who is incapable of accepting the gloss on the AA canon that urges atheists to make their higher power a doorknob. Since AA's theology holds that the higher power is an entity both greater than and outside of one's self, the doorknob is a nonstarter.
AA's "fellowship" does me no good because I have a lifetime of being a stranger among familiar strangers. In fact, while my rejection of AA's unscientific principles inclined me to leave, it was the familiar pain of not being able to connect with others that drove me to stop attending. Moreover, contrary to the way AA meetings are portrayed in popular media, they are not a space where addicts can grow by engaging in dialogues with one another. To attempt to do so would violate the firm rule against "cross-talk." Given a choice between medically assisted talk therapy and sitting through monologues for the rest of my life, I chose the former. To its credit, Hazelden was prescribing Subutex and Naltrexone even then.
It's high time to retire the 12-step program and replace it with an evidence-based approach that deals with the root causes of addiction. Rather than performing the fourth step's "searching and fearless moral inventory" of themselves (I found it to be a labor-intensive dead end), addicts would be better off working with a qualified therapist, preferably one who does not practice CBT. My problem doesn't lie in my will or my character; it's found in the history of the first 20 years of my life.
I have a different perspective on buprenorphine - I believe it’s useful but certainly not for life. I remember Salavitz’ promotion of opioids for CNCP denying addiction is possible when someone is using opioids for CNCP; so her credibility is no good in my world. I do believe in positive regard and support for lifestyle change necessary to recover, and treating it lifelong. Bupe is a big pharma drug and - like all opioids - will continue to be a big seller. Methadone has better outcomes and is cheaper. Bupe is overhyped and should be used cautiously. https://www.justice.gov/opa/pr/justice-department-obtains-14-billion-reckitt-benckiser-group-largest-recovery-case
Are you using PEtH levels in your practice for patients who are reluctant to pursue a higher level of care as an accountability measure for AUD?
I’m learning how complicated the road to recovery is for those who struggle with alcohol addiction, and it becomes tougher to stomach relapses when decompensated cirrhosis is present particularly once you’ve exhausted other AUD pharm and psych treatments.
I don't think it's quite justified to say that confrontational techniques are ineffective. Anecdotally they have certainly helped some people. Studies may have found them to be less effective than other techniques, but I think we have to be conservative when evaluating something as inherently difficult to measure as the effect of an extremely complex intervention that is not standardizable on an extremely complex problem (i.e. human brains and behavior).
I also disagree with your comparison here: "If we made getting treatment for heart attacks as difficult as we make getting treatment for addiction, there would be federal investigations." The 30-day mortality rate from untreated MI is at least in the double digits. And we are pretty certain that intervention for it is highly effective. Untreated addiction has a very low 30-day mortality rate, and there is quite a lot of uncertainty about intervention, as you describe here. I think it's entirely appropriate for it to be more difficult to obtain addiction treatment than MI treatment.
It has come down to the idea that all people who are not normal (however that is defined) now suffer from some disorder or addiction and therefore require intense treatments, mostly using drugs. The only "rehab" that is needed is within the entire medical complex as it must be dismantled and rebuilt with a foundation that excludes big pharma and the AMA and government.
When the student is ready the teacher will appear. We have multiple tools in our toolbox and some work some of the time, some don’t work at all. One size does not fit all. I have worked in the “trenches “ for 40 years and it is an honor to learn from my patients. If anything we have substituted harm reduction for treatment and that has been a total nightmare.
The same analysis can be used for our involuntary treatment of those that have a mental health issue. The evidence is against the use of polypharmacy, involuntarily committing individuals and just providing them dangerous psychotropics as the answer to an event in their lives.
I am surprised that you accept the statements suggesting that drug treatments are effective. It seems that the few long-term studies on addiction treatment suggest little to no benefit over free 12-step treatments.
“Rehab” for Addiction is a Problem and a Solution
As a current addiction medicine fellow in Georgia, I find referral options are very limited for my patients. One prominent local facility rejected gabapentin for a patient with neuropathic pain. Many of these rehabs don’t allow pych meds either.
Hard to reconcile with the ASAM criteria, but ASAM is not in charge of everything.
If you read Matthew Perry's book, you would note that he decried rehabs and detox places as highly ineffective and that they taught him little. Detox is a waste of money without lengthy treatment after. I find it amazing that we put people through it and then send them on their way as if addiction was that easy. We must invest in programs that last longer in order to be successful. Between addiction and mental health, we have lost our way.
I am a retired pediatrician. There are many forms of rehabilitation for many ailments. Take morbid obesity. The record of successful treatment or rehabilitation after diagnosis is dismal. Alcoholics Anonymous has a better track record but, alas, its long-term success is likely not high. There is a deep and often unaddressed spiritual emptiness in many individuals with addictions to food, alcohol, sex, and drugs. Unless and until this spiritual vacuum is addressed, in my opinion, little success should be expected.
It was obviously the C19 vax that killed Matthew Perry.
For those that find the definitive nature of that comment offensive, and believe the C19 MRNA to be safe and effective, I intentionally worded my provocation to perhaps give a glimpse of how people like me felt when the majority of the world insisted with conviction that the new MRNA product, with no long-term safety data, was “safe and effective,” and then tried to force me and my family to be injected. A nadir moment in recent history in which Matthew Perry enthusiastically and commercially participated.
As far as addiction goes, the human brain is the final frontier. Maybe with a dose of humility, we’ll somehow make progress in our efforts to untangle. But given the Medical research communities’ fraudulent charade with Alzheimer’s over the last 20 years, you’ll hopefully forgive my cynicism.
"Somehow, a lengthy stay in a remote treatment “camp” – precisely the thing we decry as not evidence-based -- helped him turn the corner."
Emphasis on the word "lengthy," Doc.
As with confrontational techniques, the essential ingredient is temporal. We know from Skinner, Stoddard et al, the power of adaptive learning and association. It is the combination of reconstructive technique and removal from association that produce optimal results.
Regarding confrontation; I've seen it produce quite effective results in long-term residential settings, but there are degrees of confrontation beyond which one must not trespass; the breaking-down of emotional defense structures is, as you have noted, fraught with risk.
If you'll forgive the vernacular, those who recover from addiction without semi-permanently removing themselves to a supportive environment free of their learned association with their addictive behaviors, are unicorns.
Thank you for an astute and enlightening perspective.
Thank you for writing this. We experienced exactly this. When my partner needed to transition into a detox program out of the ER, none were available. All had minimum 6 to 12 week waiting lists. (Los Angeles, CA)
It is surprising that Dr. Kerstesz, with his considerable knowledge of addiction-related policies and practices, did not mention another significant hurdle to getting people into treatment programs. That obstacle is the ideology known as harm reduction.
Having witnessed the unfolding of the unmitigated disaster that is Oregon's ill-considered experiment with decriminalization, I have concluded that harm reduction is an antisocial form of activism that is bad for the community and bad for the user. Advocates for harm reduction pride themselves on their neutrality on drug use and addiction. "No judgment" is the mantra. In fact, that very abdication of a sense of right and wrong is what’s responsible for so much personal suffering and death among addicts. Furthermore, harm reductionists' purported neutrality on drugs masks their extreme hostility to the moral values meant to yield the sort of healthy and productive individuals who contribute to healthy and productive societies. Among harm reductionists, morality is a bad word.
People addicted to meth, fentanyl and other opiates have given away every last shred of personal and bodily autonomy they ever had. To pretend otherwise, which is the central premise of harm reduction, is a cruel farce. Harm reduction abets addiction while stigmatizing recovery and sobriety. As a society, we must stigmatize addiction and launch treatment programs that promote detox, rehab and sobriety.
I have a few views about the sort of rehab program Dr. Kerstesz discusses in his piece as a result of having been through treatment for two months at Hazelden's Newberg, Oregon, facility a decade ago and following the topic of addiction treatment more closely since then than the average citizen.
One of them is astonishment and dismay at the persistence of AA's 12-step program as the centerpiece of the treatment experience. As defined by the 12 steps and the Big Book, AA's method of treating addiction is at its core a religious practice. Paradoxically, AA's etiology for what it terms a disease is a pathology of the will and character. The cure is a lifetime of divining and following God's will. The sacrament is the bad coffee after the meeting.
AA does not work for me because I am an atheist who is incapable of accepting the gloss on the AA canon that urges atheists to make their higher power a doorknob. Since AA's theology holds that the higher power is an entity both greater than and outside of one's self, the doorknob is a nonstarter.
AA's "fellowship" does me no good because I have a lifetime of being a stranger among familiar strangers. In fact, while my rejection of AA's unscientific principles inclined me to leave, it was the familiar pain of not being able to connect with others that drove me to stop attending. Moreover, contrary to the way AA meetings are portrayed in popular media, they are not a space where addicts can grow by engaging in dialogues with one another. To attempt to do so would violate the firm rule against "cross-talk." Given a choice between medically assisted talk therapy and sitting through monologues for the rest of my life, I chose the former. To its credit, Hazelden was prescribing Subutex and Naltrexone even then.
It's high time to retire the 12-step program and replace it with an evidence-based approach that deals with the root causes of addiction. Rather than performing the fourth step's "searching and fearless moral inventory" of themselves (I found it to be a labor-intensive dead end), addicts would be better off working with a qualified therapist, preferably one who does not practice CBT. My problem doesn't lie in my will or my character; it's found in the history of the first 20 years of my life.
I have a different perspective on buprenorphine - I believe it’s useful but certainly not for life. I remember Salavitz’ promotion of opioids for CNCP denying addiction is possible when someone is using opioids for CNCP; so her credibility is no good in my world. I do believe in positive regard and support for lifestyle change necessary to recover, and treating it lifelong. Bupe is a big pharma drug and - like all opioids - will continue to be a big seller. Methadone has better outcomes and is cheaper. Bupe is overhyped and should be used cautiously. https://www.justice.gov/opa/pr/justice-department-obtains-14-billion-reckitt-benckiser-group-largest-recovery-case
Great read! Very informative.
Are you using PEtH levels in your practice for patients who are reluctant to pursue a higher level of care as an accountability measure for AUD?
I’m learning how complicated the road to recovery is for those who struggle with alcohol addiction, and it becomes tougher to stomach relapses when decompensated cirrhosis is present particularly once you’ve exhausted other AUD pharm and psych treatments.
Thanks for the article! It was informative.
I don't think it's quite justified to say that confrontational techniques are ineffective. Anecdotally they have certainly helped some people. Studies may have found them to be less effective than other techniques, but I think we have to be conservative when evaluating something as inherently difficult to measure as the effect of an extremely complex intervention that is not standardizable on an extremely complex problem (i.e. human brains and behavior).
I also disagree with your comparison here: "If we made getting treatment for heart attacks as difficult as we make getting treatment for addiction, there would be federal investigations." The 30-day mortality rate from untreated MI is at least in the double digits. And we are pretty certain that intervention for it is highly effective. Untreated addiction has a very low 30-day mortality rate, and there is quite a lot of uncertainty about intervention, as you describe here. I think it's entirely appropriate for it to be more difficult to obtain addiction treatment than MI treatment.
Hmm so what about the EMTs saying "heart attack" and Perry's advocation for the recent vaccine ??
Nothing to see here, huh?
It has come down to the idea that all people who are not normal (however that is defined) now suffer from some disorder or addiction and therefore require intense treatments, mostly using drugs. The only "rehab" that is needed is within the entire medical complex as it must be dismantled and rebuilt with a foundation that excludes big pharma and the AMA and government.
When the student is ready the teacher will appear. We have multiple tools in our toolbox and some work some of the time, some don’t work at all. One size does not fit all. I have worked in the “trenches “ for 40 years and it is an honor to learn from my patients. If anything we have substituted harm reduction for treatment and that has been a total nightmare.
The same analysis can be used for our involuntary treatment of those that have a mental health issue. The evidence is against the use of polypharmacy, involuntarily committing individuals and just providing them dangerous psychotropics as the answer to an event in their lives.
I am surprised that you accept the statements suggesting that drug treatments are effective. It seems that the few long-term studies on addiction treatment suggest little to no benefit over free 12-step treatments.