Discussion Will elected officials ever realize that forcing a person that doesn’t want to get clean into rehab is basically throwing money away?

[LucidSDreamr]

Every US solution I see in liberal areas to address drug use and homelessness associated with it is severely flawed. (Red states just cage you and torture you like a demented child torturing an animal to death - obviously no hint or facade of rehabilitation there)

It operates under the assumption that forcing the addict or homeless person to go to rehab will fix everything.

Any drug addict or person in recovery know immediately that you might as well burn your money and smoke it through an crack pipe than send an addict that doesn’t want to get clean or had underlying pain or mental issues causing them to never want to get clean. It’s a total waste of money and the person will relapse 99% of the time.

The only way ppl get clean is when they themselves decide to get clean.

It’s maddening that we are still staking a punishments approach that is even far more expensive than jail (treatment) to throw at this problem when the science amd statistics have shown it doesn’t work.

Imo many ppl on hard drugs like heroin or merh
Could continue to work and contribute to society if we simply allowed them to and made their drug legal (and thus cheap).

Sure they likely aren’t going to be curing cancer in a Harvard lab (but you’d be surprised, trust me) but they can do manual labor or service jobs on drugs (like a great percentage of the active workforce from laborers up to intellectual jobs like law or tech, isn’t already on drugs).

Is this being done because the rehab industry, like the law enforcement industry. Realizes their solution will never fix the problem and just create a revolving door of bodies to use as an excuse to steal tax dollars?

Or are they actually just that stupid that they haven’t realized or nobody has told them “an addict will NEVER get clean unless THEY want to". No amount of forced rehab prison or torture will get someone clean.

 

[tryptakid]

Most of recovery services available, regardless of whether you associate the regions they are in as 'red' or 'blue', is outpatient treatment with a medication component whenever possible as well as associated toxicology screening. This generates revenue from multiple sources:

1) Visits with prescribers
2) Visits with nurses
3) Behavioral Health visits
4) Prescription fills (many community health centers have 340B pharmacies, where drugs are dispensed at a steep discount, and those pharmacies whether independent or co-owned by the health center) share some of the profit with health centers for each prescription filled.
5) Lab testing - billable for both the health care provider as well as from the lab
6) Federal/State/local grants that fund services and are frequently able to remain as part of the annual contribution allocated to service providers from these funding streams. While initially they are indicated specifically to hire addiction treatment providers, purchase things needed to provide care, etc. - after the years of service are completed they may then roll that total amount into the base funding without any spending requirements attached.

For opioid treatment, this is pretty common - especially given the variety of drugs used in OBAT (Office Based Addiction Treatment) programs - Suboxone (or subutex to a lesser degree), Naltrexone (Vivitrol - 1x/month injectable)), and Sublocade (Buprenorphine which is present in both suboxone and subutex, but can be administered 1x/ month by injectable implant). Urine screens are typically required at each visit, and for newer patients that is often 1x/week, while long-established patients who are stable are seen 1x/month or less.

For stimulant treatment, we don't have an analog for medications like buprenorphine (suboxone) - though there has been an increase in the use of a combination of Contingency Management using a similar, nurse focused delivery of care, while also prescribing medications like Vivitrol (potentially disrupts rewarding aspects of stimulant use) antipsychotics for reducing the risk of psychosis when using, and stimulants like strattera, wellbutrin, or occasionally methylphenidate or dexamphetamine (in an attempt to replace the use of stimulants in a way that could be linked to self-medication.)

Alcohol treatment tends to be more fluid, though components of this model may be seen in outpatient alcohol treatment.

Additional supports come through community supports such as 12-step groups, SMART Recovery, or other types of peer-based support. One non-abstinence based approach that has become more common lately is called Harm-Reduction Works. It would be more in line with what you're talking about.

For inpatient treatment, it's incredibly difficult to even get into detox, let alone into longer term care. At most, you're looking at a weeklong detox, maybe a 2-4 week short term residential, and 6 month half-way house, each less restrictive and more focused on reintegration. There are very few remnants of the former long-term hospital system that once existed during the institutional era. Folks are most likely to be treated while incarcerated, demonstrating the conclusion of the transinstitutionalization of people with addiction and chronic mental health conditions. For comparison, it costs about 10-15,000/year less for a person to be incarcerated vs housed in a state hospital.

The way I see it, I agree with what you're saying, and I also believe that we need to reinvest in long-term care facilities for people with mental health and addictive disorders. The big thing I advocate for is that if we build hospitals or residential programs, they need to be the kinds of places that people actually want to go to. If you build programming that is appealing to people, people will use it, find success, and pass that along to others in their communities.

At the same time, people may not want to abstain from drug use. We should give them access to safe supply, and we should provide them a place to use drugs so that it isn't something that causes risk to come to other people in the community. The last person who should be responding to an overdose is a midday staff member at a Dunkin Donuts. People shouldn't be using syringes to inject drugs in public parks. There are people ( like me) who want to provide space for folks who want o use drugs, so that the larger society doesn't have to.

Through the creation of risk-reduction sites, you can provide a variety of services including medical care, case management, education, legal clinics, day shelter space, vocational rehabilitation, while also providing safe supply and consumption space as well. I think the worst thing we frequently do is lead by calling sites "supervised consumption sites". Those should not be the title nor the primary focus. It simply gives ignorance a platform to voice opposing views or vote against.

We need to untangle recovery care designed around abstinence from harm reduction. Right now, many programs offer inpatient/residential/outpatient services that are not focused on one or the other, so while some folks may be trying to legitimately stop using opioids, others are there to reduce harm and have somewhere to stay. I'm grateful that I got clean in 2008 and this wasn't something that was common - despite overall being a personal and professional proponent of risk reduction/harm reduction. They just need to be offered separately from abstinence based recovery services.

All I can do is keep planting seeds and hope that they spread. I was on a local advisory committee for a Supervised Consumption initiative which was pretty cool, and I'm hopeful to see what that initiative will evolve into and ultimately become.

 

[tryptakid]

Is this being done because the rehab industry, like the law enforcement industry. Realizes their solution will never fix the problem and just create a revolving door of bodies to use as an excuse to steal tax dollars?

Or are they actually just that stupid that they haven’t realized or nobody has told them “an addict will NEVER get clean unless THEY want to". No amount of forced rehab prison or torture will get someone clean.

Most people making policy or overseeing service delivery have very little personal exposure to addiction in a meaningful way aside from possibly in a clinic setting. My experience is that most clinical providers working in addiction have significant deficits in their fundamental understanding of addiction, and support things that 'feel right' but frequently miss the bigger picture. Coupled with the rapid increase in deaths during the rise of fentanyl and the trauma that has left us with ( I cannot count how many of my own patients of have died, let along people I used with when i was getting high, people I was in treatment with, people I knew from 12-step meetings, people I grew up with, etc.). There are just not that many people coming into the field with fresh ideas like there were even a decade ago. CoVID did a number on staffing as well, people are just burnt out.

For the most part, there are very few providers that generate revenue on a fee for service model - we're almost all salary, and the reimbursement rates for services rarely cover one's salary. If anyone's making money, it's the medication manufacturers, the insurance companies, the labs running all of the tox screens, and clinical researchers who find ways to absorb grant dollars into whatever they're studying which may be tangentially connected to addictions, or of limited usability.

I can't speak to for-profit health settings because I've never worked in that environment as they rarely prioritize behavioral health as a part of what they offer. They are, for the most part, the same as the pill mills that got us into this mess on the oxycontin side, just using buprenorphine instead.