September 5, 2019

He died of an overdose—after $110,000 in addiction treatment

Daily Briefing

    In August 2017, Sean Blake died of an overdose, after nearly a decade cycling in and out of addiction treatment programs that cost his family $110,000—a story that highlights the flaws in the U.S. addiction treatment system, German Lopez reports for Vox.

    How to design a substance use disorder (SUD) treatment facility

    Sean Blake's story

    Sean's problems started more than 10 years ago, in high school, when he began to use alcohol and marijuana. As Sean got older, he started abusing alcohol and using cocaine and opioids, Lopez writes. By age 20, Sean had started using heroin. He was discharged from the Navy where he'd trained to be a submarine electrician, and without an income, began stealing from his family to get money for drugs, Lopez writes. It was then his family said he had a choice: receive treatment or move out. After a brief stint away from home, Sean agreed to treatment in October 2010.

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    But finding a residential rehab facility was easier said than done. At the time, few residential treatment facilities existed in Vermont, Lopez writes.

    Sean eventually went to the Hazelden Betty Ford youth program in Minnesota, which cost over $36,000 for a five-week stay. The Blakes' employer-sponsored health insurance from Blue Cross and Blue Shield agreed to pay around $28,000 for Sean's treatment, leaving the Blakes to pay more than $8,000.

    But in November 2010, Sean was kicked out of Hazelden for fighting and later went to New Found Life, a different rehabilitation facility in California. A few months after leaving New Found Life, Sean was homeless and using drugs in Los Angeles, Lopez writes.

    Over the next six years, Sean went to six different treatment centers, some of them multiple times. Each time he went to a treatment center, his family paid the bills, which ranged from hundreds of dollars to tens of thousands of dollars, Lopez writes.

    It wasn't until 2012 that Sean, and his family, learned he had an underlying condition: bipolar disorder. After years of going in and out of rehab facilities, Sean ended up in the Rikers Island jail in New York City for stealing. It was in jail that Sean was informed he likely had bipolar disorder and started receiving treatment for it, as well as methadone for his opioid addiction.

    According to Lopez, many of the rehab facilities Sean cycled in and out of prior to his arrest either did not offer or actively discouraged medication-assisted treatment for opioid addiction. In some cases, the stigma around these medications kept Sean from taking them.

    John Brooklyn, an addiction doctor at the Howard Center who occasionally saw Sean, the stigma against these medications led Sean to think "that he should be able to do it on his own," despite Brooklyn's recommendations that Sean take buprenorphine or methadone.

    But the providers at Rikers weaned him off of the "potentially lifesaving" methadone medication because local methadone clinics in his home state of Vermont were virtually inaccessible, Lopez writes.

    In August 2017, at 27 years old, Sean died of an overdose involving alcohol and fentanyl. In addition to the emotional toll of Sean's addiction, the Blakes had spent about $110,000 on Sean's treatments. To pay for the treatments, the Blakes drained their retirement savings and the college funds they'd saved for Sean and his younger brother.

    "If he had survived, we would have said it was money well spent," Blake's mother, Kim, said. "There's no question."

    The flawed US addiction treatment system

    The Blakes' story is indicative of a misguided addiction treatment system in the United States, Lopez writes.

    The system is dominated by the 12-step approach, popularized by Alcoholics Anonymous, which is effective only for some people who misuse alcohol and lacks a strong evidence base when it comes to other addictions, Lopez writes. And while many 12-step programs purport to treat addiction as a medical condition, "they often take a moralizing view toward addiction—one that feeds into stigma," Lopez writes.

    This type of program is often coupled with other approaches that are supported by even less research, Lopez writes, including wilderness therapy, equine therapy, and the confrontational approach—a method built around punishments and "tough love" that research suggests can actually make a situation worse.

    According to Tami Mark, a health economist at RTI International, CMS "has over 4,000 [health care] quality measures" but "[t]here are none for addiction programs—zero."

    Mark added, "The problem in the industry isn't that we have a few bad actors …. It's that a large portion of the addiction industry isn't providing the type of care that we know leads to recovery."

    Namely, addiction is a chronic condition, Lopez writes, that requires long-term care.

    "The science is very clear on what works," Mark said. "You have to keep people in care for a long enough period of time. And it's not happening—and it ends up wasting billions of dollars."

    Brendan Saloner, a health policy researcher at Johns Hopkins University, said, "We have allowed this system to evolve so that there's a lot of great treatment out there that people don't know about, and a lot of predatory treatment that will basically rob you blind."

    Steps going forward

    In recent years, the public health focus on the opioid epidemic has prompted many states to increase  access to evidence-based addiction treatment, but in many places quality care is hard to access, Lopez writes. According to the U.S. Surgeon General, just one in 10 people with a drug addiction receive specialty treatment, and the majority of treatment facilities don't offer medications proven to help opioid addiction.

    In order to fix this, experts say a large investment in addiction treatment is needed nationwide that is focused on evidence-based care, meeting high-quality standards, and tracking outcomes for patients, Lopez writes (Lopez, Vox, 9/3).

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