The opioid epidemic in the United States has led to a boom in substance abuse treatment centres – in 2015, it was believed to be a $35bn market in the US alone – but that growth has not been without practical and ethical, not to mention legal, hiccups. It also has not been sufficient or sufficiently funded by the government.
US National Recovery Month
In the US, September has been dubbed National Recovery Month for the past 27 years by the Substance Abuse and Mental Health Services Administration (SAMHSA). It is a time to reflect and focus, “to increase awareness and understanding of mental and substance use disorders and celebrate the people who recover.” This year’s theme is “Join the Voices for Recovery: Strengthen Families and Communities.”
President Donald Trump himself proclaimed in September 2017, the National Alcohol and Drug Addiction Recovery Month, with the similar sounding goal to “emphasise to all those suffering that recovery is possible.” In August he even declared the opioid epidemic a “National Emergency,” though his specific policies seem to be more targeted at increased law-enforcement efforts to put drug dealers and abusers in prison, and stopping the flow of illicit drugs from abroad (mainly through the southern border with Mexico, thus further justifying his border wall) rather than increasing access to treatment. He also proposed a variation on the “Just Say No” campaign of the 1980s.
The Best Substance Abuse Treatment
Trump’s Health and Human Services Secretary Tom Price, himself a physician (though not an expert on addiction) has belittled one of the most effective addiction methods, medication-assisted treatment (MAT) through maintenance drugs, such as methadone and buprenorphine (Suboxone). Earlier this year, Price said, “If we’re just substituting one opioid for another, we’re not moving the dial much.”
Instead, Price praised less effective (and less expensive) faith-based programmes, such as Alcoholics Anonymous and Narcotics Anonymous. These 12-Step programmes are fellowships – a type of support group – where alcohol and drug abusers meet to share stories and reinforce each others’ resolve to not drink or use drugs. They’re informal, self-regulated and financed, meeting in churches or public buildings. No doctors or trained therapists are on hand, unless they are fellow members.
Unfortunately, while they often are included in most substance abuse rehab facilities’ programmes, they are not in themselves addiction treatments. They cannot work as the primary means of treatment. They offer no detox or MAT, and have a success rate that’s difficult to determine (they are anonymous, after all), but may be as low as 5 per cent.
More Rehab Facilities Needed
Whether the HHS secretary or the President agrees, there clearly is a need for more alcohol and drug rehab facilities. The market has complied, spurred in part by the US Mental Health Parity and Addiction Equity Act of 2008 – which requires most health care plans to cover mental illness and substance abuse – and the Patient Protection and Affordable Care Act (“ObamaCare”) , which enshrined mental health and substance abuse coverage as “essential benefits.” The $15,000-$30,000 a month rehab clinic can charge for treatment helped, too.
One place where there’s been a flurry of new substance abuse treatment facilities is Palm Beach, Florida, where there is now a $1bn market and is the US rehab capital. Three-quarters of its rehab clients were from out of state. At least until the recent Hurricanes Harvey and Irma, Florida looked like a pleasant place to recover from addiction.
More Regulation Needed
Florida also has had an increasing number of qualms and scandals – some horrific. The problem is that the industry is largely unregulated. Rehab used to be a calling, non-profits run by recovered addicts or their family, not a business. Now some predatory investors are becoming ‘Big Rehab’, behaving like a typical ‘big business’, looking to buy up smaller properties, peel off their most profitable programmes – in this case, the in-patient beds at such rehab facilities – and discard the rest. This is short-sighted and dangerous.
For example, Acadia Healthcare grew from six facilities in 2010 to nearly 600 by 2016, including in the United Kingdom. In 2014 it paid Bain Capital $1.18bn for 100 or so inpatient centres, offering detox and rehab, and another 110 methadone clinics.
Another unnamed firm tried to buy Gosnold, a not-for-profit centre in Massachusetts, but this attempted purchase was limited to the inpatient detox and rehab arm only (not including aftercare and prevention).
All that money has attracted not just investors and opportunists – more than $2.2bn has been invested in drug rehab facilities by private equity firms between 2006 and 2016 – but also outright crooks. Kenneth Chatman, a “body broker,” allegedly (he was convicted) kept addicts supplied with drugs, faked daily medical tests and forced some into prostitution so he could bilk their insurance companies. (Florida also is a good port to bring in illicit drugs, with no wall or prospective wall to circumvent.)
The View from Europe
In Europe and the United Kingdom, methadone and buprenorphine maintenance is called opioid substitute treatment (OST) and is the most common treatment for opioid dependence. It also is the most effective, according to a Wiley Online report. “Patients who received only psychological support for opioid dependence in England appear to be at greater risk of fatal opioid poisoning than those who received opioid agonist pharmacotherapy.”
According to a 2011 European Monitoring Centre for Drugs and Drug Addiction report, Europe spent more than €800m on opioid substitution treatment, €367m on outpatient counselling, and €112m on inpatient treatment in 2006.
A December 2016 report from the Advisory Council on the Misuse of Drugs (ACMD) on Reducing Opioid-Related Deaths in the UK concluded that OST reduces the number of overdose deaths from heroin. It also stated that OST should at least be maintained at the present levels, but that greater access to healthcare services are needed to treat the mental health and chronic physical pains that can lead to, or accompany, substance abuse.
Europe’s largely government provided healthcare means that private alcohol and drug rehabilitation facilities are not as needed as they are in the US, and thus have not grown as fast or become as costly. In the US they’ve grown for two reasons: the country has let them, and needs them. Now, they must regulate them.
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