The National Council on Alcoholism and Drug Dependency estimates that over 23 million Americans (age 12 and older) are addicted to alcohol and other drugs. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), just under 11% (2.5 million) received care at an addiction treatment facility in 2012. SAMHSA also estimates that the market for addiction treatment is about $35 billion per year.
The vast majority of addiction treatment is based either partially or entirely on the 12 Steps of Alcoholics Anonymous (AA), but is there scientific evidence to support AA as a clinical treatment? Should addiction treatment centers make enormous profits by simply funneling substance abusers into the free fellowship of AA?
These are the primary questions behind The Business of Recovery ‒ a new documentary that opened earlier tonight at the Newport Beach Film Festival. Like many documentaries, there are some startling statistics ‒ including this provocative one delivered early in the 81-minute film.
I became the Director of the Alcoholism Treatment Unit at Harvard’s McLean Hospital. I’ve probably treated a couple of thousand people who have one addiction or another. Almost all residential treatment programs in the United States are 12 Step based, so their effectiveness will depend entirely on whether 12 Step programs work and the statistics for AA are not good. It is helpful for 5‒10% and that’s a good thing. That’s 5‒10% of people who are being helped by A.A. ‒ it’s a lot better than zero percent ‒ but it shouldn’t be thought of as the standard of treatment because it fails for most people ‒ for the vast majority of people. Lance Dodes, MD ‒ Addiction Expert & Author ‒ Harvard Medical School Graduate in The Business of Recovery
As a part of the annual film festival in Southern California, the film is being shown again Tuesday evening and the producers are working toward a broader, public release later this year. The critical assessment of addiction treatment is both timely and sobering.
12 Step programs are very popular, but if you’re looking for figures and randomized trials and scientifically rigorous studies of how they work and for how many people they work ‒ you will not find those studies. You will find anecdotal evidence ‒ for people that it did work [for] ‒ but unfortunately we don’t have the scientific basis to say how many of all those people that tried a 12 Step program ‒ how many of those did not succeed. Ruben Baler ‒ Health Scientist, National Institute on Drug Abuse in The Business of Recovery
The film is timely because the market does seem poised for accelerated growth based on a number of key attributes.
- A real‒estate component that can easily scale to any size ‒ including the private, single family residence (called “sober living homes” ‒ by one estimate over 10,000 in Arizona alone).
- Freshly minted federal mandates for payment parity with other chronic or acute health conditions like cancer or diabetes.
- Almost no federal, state or municipal oversight for credentials or treatment pricing.
- Advertised success rates of 80% (or higher) with no scientific evidence.
This last one is the most troubling since addiction is often couched in clinical terms like “disease” and “treatment.” The AMA first defined alcoholism as an illness (1956) and then a disease (1966), but there’s little scientific evidence to support a disease diagnosis. That also makes it challenging to categorize any program based on the 12 Steps of AA as clinical treatment ‒ even if there is a billing code.
AA is not really a treatment ‒ it’s a fellowship. If you go to your doctor to be treated for cancer or heart disease you expect your doctor to be doing what the science says is the best treatment available for what you have. That has not been the standard in addiction treatment. William R. Miller, PhD ‒ Emeritus Distinguished Professor University of New Mexico in The Business of Recovery
Two events last year (not included in the documentary) also signal a healthy and growing commercial industry.
The first was the merger between two iconic treatment brands ‒ the world-renowned Betty Ford Center and Hazelden (founded in 1949). The combined non‒profit entities are now simply the Hazelden Betty Ford Foundation. As with many non‒profits, there are no outside investors to satisfy, but the salaries of key execs are often in the high six‒figures (and well above averages for even practicing physicians ‒ any specialty).
The second event was the IPO last fall of AAC Holdings, Inc. ‒ which is really the first attempt at a publicly traded company exclusively for addiction treatment (the AAC stands for American Addiction Centers). The quoted price range for a 30-day “treatment plan” (again ‒ revolving largely around AA) was $15,000 to $26,000. The Hazelden Betty Ford Foundation is easily twice that amount and other, more exotic treatment facilities (often catering to celebrities in swank resort‒style locations) can easily run into the low six‒figures.
As a publicly traded company ‒ something that Betty Ford and Hazelden have both intentionally avoided ‒ AAC has already hit some significant headwinds in the form of accusations, short‒sellers and legal scrutiny. One of the reasons is that a sizable source of high‒margin revenue appears to be urine testing which can be used in high‒volume and is relatively easy to game for serial revenue and profits.
On March 3, 2015, SeekingAlpha published an article asserting, among other things, that AAC Holdings: (i) conducts unnecessary urine drug tests that contribute to its outsized margins; and (ii) lowered its provision for doubtful accounts after acquiring a revenue management company from its CEO and president’s spouses, which boosted its net income before its IPO. On this news, shares of AAC Holdings fell $3.54 per share or over 10% from its previous closing price to close at $30.37 per share on March 3, 2015, damaging investors. The Rosen Law Firm (announcing its investigation into potential securities claims on behalf of investors)
The lack of certification also supports a very low barrier to becoming an addiction treatment counselor.
There is no mandatory national certification exam for addiction counselors. The 2012 Columbia University report on addiction medicine found that only six states required alcohol and substance-abuse counselors to have at least a bachelor’s degree and that only one state, Vermont, required a master’s degree. Fourteen states had no license requirements whatsoever ‒ not even a GED or an introductory training course was necessary ‒ and yet counselors are often called on by the judicial system and medical boards to give expert opinions on their clients’ prospects for recovery. Gabrielle Glaser ‒ The Irrationality of Alcoholics Anonymous (The Atlantic)
So we developed this history of providers being people who are themselves in recovery ‒ originally with no educational requirement at all. In New Mexico, we now have a Bachelors degree required to be a substance abuse counselor and it was quite controversial to do that. I don’t know of any other life‒threatening illness where it’s controversial if you should have a college education to treat it, but it has been in the addiction field. William R. Miller, PhD ‒ Emeritus Distinguished Professor University of New Mexico in The Business of Recovery
Even the judicial system contributes to the confusion by often mandating AA attendance to offenders who arrive in court as the result of criminal charges associated with substance abuse (most commonly driving under the influence).
It is completely inappropriate and dangerous for courts to be mandating AA treatment. This amounts to malpractice. It’s medical malpractice by the judge. It’s as foolish as if the judge said to you ‘ok ‒ you have an infection ‒ I mandate that you take penicillin because I believe that’s the effective drug. Lance Dodes, MD ‒ Addiction Expert & Author ‒ Harvard Medical School Graduate in The Business of Recovery
Outside of AA, newer alternatives are also gaining broader awareness, acceptance ‒ and real scientific evidence of efficacy (JAMA meta‒analysis here).
I made the documentary One Little Pill to help spread awareness about a treatment for alcoholism that literally saved my life. It’s called the Sinclair Method and it’s based on using the FDA approved generic drug naltrexone to create an effect known as pharmacological extinction. The success rate is very high ‒ nearly 80%. I also started a non‒profit called the C3 Foundation as a more direct way to help people find the clinical information and doctors that support the use of this life saving treatment. Claudia Christian ‒ Actress
New drugs will also challenge the conventional wisdom around AA being the primary ‒ often only solution to substance abuse. There is also the very real possibility that AA is not helping people with other mental or behavioral disorders that can be easily masked by substance abuse. The AA mantra of “more meetings” could well be counterproductive to many who arrive at the fellowship with a wide range of psychological, behavioral and other clinical issues.
Ultimately, whether AA is scientifically effective ‒ for whom and how many ‒ is a secondary issue. No one argues that it has helped to destigmatize substance abuse and it definitely helps some. Unlike for-profit treatment plans, however, AA has never had fees or dues of any kind since its inception in 1935 ‒ and likely never will. The real issue then is a $35 billion a year industry that’s largely based on funneling substance abusers into the free fellowship of AA ‒ or simply providing large doses of AA meetings themselves.
To be sure, there’s a lot of hand‒waving, glitzy marketing and pseudo‒science to justify the enormous cost associated with treatment plans, but little proof of scientific efficacy. Court mandated attendance isn’t profitable, of course, but it does legitimize the process of funneling people into A.A. in ways that also benefits the industry at large.
As highlighted through several tragic stories in the documentary, family members are naturally eager to spend whatever money they have ‒ and often money they don’t have ‒ in desperate attempts to save loved ones from the harsh realities of substance abuse and addiction. Preying on this strong desire is the very real and profitable business of recovery ‒ and one that the documentary exposes with clear‒eyed and sober detail. I do hope the film finds a way to a larger public audience. There’s still so much we don’t know about substance abuse and addiction ‒ except ‒ at least according to one compelling film ‒ how to turn it into a very lucrative business.
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