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The following is a rather long article because I didn’t want to try and oversimplify the problem of addiction treatment brokers. This isn’t a subject that can be discussed in a paragraph or explored in a 2 minute sound bite. This issue is complex and I want to avoid the “throw the baby out with the bath water” approach that many, including Google have proposed and implemented because that approach, as expedient as it may seem, may lead to an even more tragic outcome for those in need of addiction treatment.

As an addiction treatment professional it is gratifying to see that the disease of addiction is finally receiving the attention it deserves – from the media, from the public and most importantly, from politicians who are empowered to fund treatment and prevention programs. Most of these programs are of high quality, staffed by competent and compassionate counselors and medical personnel who work in this field not for financial remuneration but because they want to make a difference. In fact, as a primary care physician who chose the sub-specialty of Addiction Medicine as opposed to other more lucrative choices, I knew I was trading better pay for the privilege of helping those in need put their lives back together.

For several years I have worked with addicted patients and have advocated for the field of Addiction Medicine, largely through my work with ASAM (the American Society of Addiction Medicine) and NYSAM (the New York Society of Addiction Medicine). I can’t tell you how many of my letters and phone calls to politicians and policy makers went unanswered from 2000 through 2010 – as I tried to sound the warning about the opioid epidemic as loudly as possible. Then I watched helplessly as well-meaning politicians with little understanding of addiction hurriedly passed laws and enforced regulations that although well-meaning, drove patients from prescription opioids to heroin increasing rather than decreasing the rate of overdose. These consequences may have been a surprise to lawmakers but they certainly were not a surprise to my Addiction Medicine colleagues and I.

Now I fear that a new development and the proposed response to it may once again hurt more people than it helps. Since the field of Addiction Medicine is finally getting the respect and funding it deserves, we have run into a new problem: the emergence of opportunists who see a way to make money by marketing themselves as a gateway to treatment. What I am referencing here are treatment “brokers” and the way they have used Google search and Adwords to create a business model that I believe is immoral and unfair. By dominating Google search (through a combination of web design savvy and their willingness to pay enormous sums for addiction-related keyword bids), they insert themselves as middlemen between addicts and treatment centers, making it difficult to find actual treatment centers or addiction medicine professionals without going through them first. Moreover, their presence drives up the price of advertising through Google Adwords to the point where actual addiction specialists and treatment programs can no longer afford to advertise treatment services as such programs usually operate with small budgets with little or no profit margin.

In other words, when it comes to advertising for addiction treatment the playing field is most certainly not level. Treatment brokers have little or no overhead as they don’t actually provide treatment. They don’t need a building or counseling staff. They simply build a flashy website and hire an operator who answers the phone and refers patients to the treatment programs that can afford to pay huge sums to brokers for such referrals. Those treatment programs are not recommended by the broker because they are good and most appropriate for a given patient, but because such treatment programs pay dearly for such referrals. Of course, a program that must spend large sums for such referrals cannot also afford to hire the best professionals to provide evidence-based addiction treatment so it faces a choice: either it can raise the cost of treatment to the point where most people can’t afford it (it is not unheard of for a month-long treatment to exceed $30,000) or hire cheaper staff who are less competent and qualified.

Although I imagine that Google was unaware of this practice until recently, their bid-based advertising model has made them complicit in this scam. After the following New York Times article exposed this business practice and Google’s active although unwitting complicity – https://www.nytimes.com/2017/09/14/business/google-addiction-treatment-ads.html – Google bowed to pressure and reacted by pulling virtually all addiction treatment ads for their site. However, this un-nuanced, all be it well-meaning knee-jerk response – could actually have more tragic repercussions for addicts than making no changes at all as it “erases” legitimate treatment programs as well as these brokers. In other words, as Google, for all practical purposes, has a monopoly on search, removing all ads for treatment professionals and programs will likely result in the addict or his/her family believing that no quality addiction treatment is available locally, when, in fact, that is not actually the case.

What Google is attempting to do here is to wash its hands of the problem so it can focus on less controversial industries. I understand the company’s reasoning but In my view, that approach is not acceptable. The bidding war for keywords (which is a direct result of the Google Adwords model) created this problem. As a socially responsible company (which, I believe, it tries to be) Google itself must directly address this issue. By taking a small percentage of the legitimate profits Google can generate from the advertising of qualified treatment professionals and treatment programs, Google can help to “police” itself and the addiction treatment industry, providing links to legitimate treatment providers while excluding the treatment brokers that have tarnished its reputation.

The issue at hand is how to most efficiently and fairly vet treatment providers so the legitimate ones are given a Google “good housekeeping” seal of approval, allowing them to advertise and publicize their services through the search engine. I realize there are no easy solutions here – but if treatment professionals and the advertising professionals at Google are given the chance to work together, I am sure we could create an effective and equitable system where providers are vetted before their ads go “live”.

In terms of physicians, this vetting process is relatively easy because much of the work has already been done. First, physicians are required to file a lot of paperwork to maintain licensure to practice medicine. In addition, in my view, anyone who calls himself/herself an addiction specialist should be Board Certified by the American Board of Addiction Medicine or the American Society of Addiction Psychiatry, two credible organizations that require physicians to stay current in this rapidly developing field.   As medication assisted treatment for opiate dependence is now the “standard of care”, any addiction specialist should also have the SAMSHA waiver to provide buprenorphine. Lastly, a treatment facility wishing to advertise on Google should employ an Addiction Medicine physician as its medical director and Medication Assisted Treatment should be an option for patients who request it.

On the counseling side, treatment programs should be required to hire qualified counselors who are licensed by the state in which they practice. In New York, for example, counselors may have a social work license, a psychology license or be Certified Alcohol and Substance Abuse Counselors. Of course, every state has different licensing requirements so criteria will have to be tweaked depending on program and provider location.

My point here is that this is not rocket science. With a well-thought strategy, Google can help the addiction treatment industry to police itself, removing the few bad actors who do not adhere to high treatment standards. This is not to say that we need Google to be “Big Brother”. There are certainly different legitimate evidence-based approaches to care and there is no need for every provider to practice addiction treatment in exactly the same manner. From diversity comes innovation and I understand that. However, as in other fields of medicine, I think we can agree on some broad guidelines. Medication Assisted Treatment is good. Putting leaches on someone to cure his/her addiction is not. Agreed?

In my view, we all need to step out of our bubbles for a minute. Treatment providers and technology giants like Google must work together to guide those suffering from the deadly disease of addiction to safe and reputable care. Opportunists hijacked technology to create the problem. Trusted treatment providers and software engineers working together can solve it.

When I am at a gathering and it is known that I am an addiction specialist, dinner-party conversation always seems to veer towards my views on marijuana use, particularly in teens. It is clear that people feel strongly about the subject. However, often the evidence for what they are saying is poor or nonexistent.

To begin, we need to separate the legalization question from the medical question of whether the benefits of its use outweighs the risks. As far as legalization is concerned you may be surprised to know that I favor making marijuana legal for a number of reasons. First, I do not believe in a nanny state. Second, I believe the law should be consistent. If the government is to dictate our behavior, than all dangerous behaviors and substances should be made illegal. Alcohol would have to come off the shelves along with cigarettes, sodas and candy. Moreover, as the era of prohibition proved quite clearly, making a substance illegal may affect total consumption of a product, but does not affect the rate of addiction to that product. This makes sense, of course, because addiction, by definition, involves the loss of the effect of the negative consequences (such as getting arrested) of a given behavior upon the use of the drug.

That being said, there is a body of emerging scientific evidence implicating marijuana in negative behaviors and health outcomes.
Here is some data that I find pretty interesting.Early marijuana use (before the age of 21) appears to be more dangerous than use after that time. This makes sense given the fact that the prefrontal cortex is still developing in one’s late teens and early twenties.
For more information look here: https://www.sciencedaily.com/releases/2017/03/170328105901.htm

What is also becoming clear is the adverse effect of marijuana on school performance. This has been seen anecdotally for years but it is good to see some objective data on student grade point averages to support the claim.
For more information look here: https://www.sciencedaily.com/releases/2017/03/170308144728.htm

Then there is the issue of whether marijuana may actually cause or be associated with physical problems such as osteoporosis. This is of particular concern in heavy users.

For more information look here: https://www.sciencedaily.com/releases/2016/10/161012132657.htm

And now there is evidence from rat studies indicating that marijuana use can affect not only cognition, but the willingness to tackle cognitively difficult tasks.
For more information look here: https://www.sciencedaily.com/releases/2016/08/160824144033.htm

To be clear, I don’t think it very productive to debate whether marijuana is good or bad. There are studies showing its benefits and we hear about them every day. However, now it is becoming clear through objective studies that there are some very real risks here as well.

I always find it interesting how bewildered most people are – including physicians and healthcare administrators – when asked about the opioid epidemic. Most point to societal factors and unstable family structure as primary causes and there is ample evidence to support this view. However, a significant factor – and one that is not often discussed – is the role of physicians, their administrators and medical practice guidelines prevalent in the 1990’s.

 

I am not going to try and simplify things. Honestly, there are many causes of the opioid epidemic. However, one often overlooked fact is that changes in the practice of medicine that took place in the 1990’s – changes that really were well-meaning – actually contributed to opioid addiction. Moreover, these changes were tied to reimbursement – particularly for hospitals – so physicians and hospitals had to “play the game” or risk losing funding and employment.

 

Back in the 1980’s when I was training to become a doctor, we probably under-treated pain. Pain medicine was used to “take the edge off” but neither patient nor doctor expected the medication to remove pain entirely. As training physicians in an urban setting, we were aware of the risks of addiction and definitely subscribed to the “less is more” philosophy of pain management.

 

Things changed a lot during the 1990’s. Probably the most significant change was the adoption of a well-meaning but soon to be abused phrase – put forward by the American Pain Society in 1996 – PAIN IS THE 5^th VITAL SIGN. In other words, in addition to Pulse, Blood Pressure, Temperature and Respiratory Rate every patient had to be assessed for pain. In theory, this wasn’t a bad idea as it prevented under-treatment of pain. However, as is often the case, the pendulum swings too far in the opposing direction. All of a sudden, this slogan became more of a mantra.

 

This mantra echoed in the halls of Congress and soon a patient’s perception of pain management became tied to Medicare and Medicaid reimbursement. Hospitals were told that to receive maximum payment for their services, patients had to complete surveys indicating whether their pain was managed appropriately in the hospital. Poor scores on this metric would lead to poor reimbursement rates. This would “trickle down” to lower salaries, less resources, etc.

 

What happened as a result? Hospital administrators pushed physicians (particularly those working the Emergency Department) to prescribe more pain medication. As one hospital administrator (who will go unnamed) once said to me “Over-treat don’t Under-treat Pain. A patient who is overmedicated and/or asleep doesn’t complain.”

 
Sadly, as physicians, we didn’t stand up to this clearly misguided rhetoric. Medical training is similar to military training in many respects. You don’t question your superiors, especially hospital CEO’s. You just do as you are told. And so we did. ER docs started prescribing Percocet like water, Dilaudid became the new Tylenol, etc. Patients completed their surveys and went home with prescriptions for Percocet and other opioids. The resourceful ones even “threatened” ER docs and staff with a poor review if they didn’t get the prescriptions they wanted.

 

… And so a new generation of addict was born. This was not the heroin addict of the 1960’s – injecting bags of dope in bad neighborhoods. This was blue collar and white collar men and women with large mortgages and little savings running on the hamster wheel of economic prosperity who were simply overwhelmed. They wanted a magic pill to make their problems go away – at least for awhile. And they got it – in the form of semi-synthetic opioids.

 

The question is not how we got here. It is how do we get away from here.

Most of my other blogs focus on the addict. In this one, I want to focus on the addict’s family because it is often a family member who contacts me first about treatment. What becomes clear in just about every conversation is that the addict has altered the family’s dynamics over a period of months or years, creating a state of disequilibrium that has all family members on edge.

The presence of addiction in a loved one, in particular one’s child, inspires a myriad of feelings that leave family members disturbed, if not downright depressed. In the many family sessions I have done (where I meet with the family with and without the addicted individual), family members describe intense feelings of guilt. Would the addict not be an addict if we didn’t move when he/she was a teen? Why didn’t we see the warning signs early? How did I allow myself to be so manipulated? Why did I enable my son’s/daughter’s addiction for so long?

To make matters worse the addict, although impaired, is often very perceptive when it comes to his/her ability to cause emotional pain in others to get what he/she wants (money, a place to stay, etc.). He/she may say horrible and hurtful things to those he loves, trying to “unload” his personal pain on others around him. On an intellectual level we know that it is the drugs that are talking – that our addicted son or daughter doesn’t really mean what he/she is saying. Nevertheless, it hurts – especially when we want so much to help our loved one.

My Approach To Addiction In A Young Adult

In addiction treatment, we have spent far too much time looking for a silver bullet – that curative medication or approach that will simply make the problem disappear. We want something simple, something that is standardized and guarantees results. Of course, there is no magic tool, just a number of approaches that, along with hard work on the part of the patient and family, can free the addicted individual from the chains of addiction.

Given all the frustration and intra-family turmoil caused by the addicted individual and our wish for a simple solution it is easy to understand the attraction of the “tough love” approach. If the addict is manipulating the family and causing emotional pain to family members, simply cut him or her off. Kick him/her onto the streets. The theory is that he/she will hit “rock bottom” and then reassess his/her life, leading him/her back to family and a productive existence.

From the standpoint of logic this makes sense. If a family is enabling the addict then go to the opposite extreme – “tough love”. However, in my experience this is a very dangerous approach. Anecdotally it may have saved a few lives (I’m sure we have all seen some variation on this approach on television at some point), but it has also ended the lives of many addicts leaving family members with guilt and shame.

What is wrong with an approach that seems so “logical”? The answer is simple. The addicted brain does not follow the rules of logic. Without slipping into the complex world of neurobiology (you can look at some of my other published articles and blogs for that), we can make the general statement that drugs of abuse “highjack” normal brain function. Control is transferred from the pre-frontal cortex (the center of logical thinking) to the ‘nucleus accumbens’ (a center of emotion).

Once this hijack of the brain takes place, the well-intentioned “tough love” approach does more harm than good. A logical brain faced with a decision weighs the options appropriately. If I steal this, I end up in jail. Therefore I won’t steal it. This kind of logic is the basis of law enforcement. The addict’s brain doesn’t work like that. It is completely preoccupied procuring the drug at all costs. If that means hurting others, participating in illegal activities and putting oneself in dangerous circumstances, the addicted brain will still move ahead. If an addict is offered a choice between maintaining his/her housing and family ties but without the drug, and being homeless on the street with an ability to buy the drug (often as a result of illegal and immoral activities), he/she often makes the seemingly illogical decision to maintain the addiction.

So what works? A measured and structured approach, individualized for every patient with numerous supports from several disciplines including general medicine, psychiatry, psychology, social work and recovery coaching. It is not a miracle and it doesn’t lend itself to catchy sound bites or engrossing videos. It is hard work. In summary, the team leader (who could be from any of the above disciplines) puts together a team that will best suit the patient’s needs. A physician handles detoxification and ongoing psychiatric treatment, a psychologist does therapy (generally cognitive-behavioral or psychoanalytic) and a social worker or recovery coach provides sobriety strategies and sobriety-focused teaching and counseling. At ‘Detox at Home NY’ we work together as a team not only to maintain sobriety, but to address psychiatric and social concerns as well as family dynamics. Everyone’s path to recovery is a little different. However, the key to success is maintaining honesty and open communication between all family members, repairing the rift that addiction has caused.