Finding the Best Treatment

If you are reading this before a loved one is in a life-or-death situation, then you have some time to plan. Think about it like researching where to send a kid to college: You will want to figure out which kind of programs are the best fit; get detailed information; interview administrators; visit the campus; determine how much it will cost and how you will pay for it.

If the crisis is now, get help now! Just be prepared for, to put it gently, an extreme learning experience that will likely be layered with frustration. There is no easy way around that.

Mainbar: What addiction science says about getting – and staying – off opioids

Where should you start?

Most counties in Pennsylvania have what is known as a single-county authority on drugs and alcohol. All of them have trained staff that can act as consultants in the quest for treatment, said Deb Beck, president of the Drug and Alcohol Service Providers Organization of Pennsylvania.

Experts caution that most physicians – including most psychiatrists – have little training in addiction.

"Asking a friend who had a successful treatment outcome is not a bad way to go about it," Beck said. "I would ask everybody and their mother before I made a decision."

Mainbar: What addiction science says about getting - and staying - off opioids

Finding facilities

The Pennsylvania Department of Drug and Alcohol Programs' Care Provider Search tool can help. New Jersey's Department of Human Services lists programs by county. A more sophisticated tool is SAMHSA's Behavior Health Treatment Services Locator, run by the federal Substance Abuse and Mental Health Services Administration. Only licensed centers pop up in the government tools.

Philadelphia has a network of Behavioral Assessment and Crisis Response Centers; several are open 24 hours a day and will see anyone in crisis, regardless of insurance.

Inpatient/outpatient/etc.

Every patient is different. First rule of thumb: the longer the addiction, the more difficult the recovery, the more intensive the treatment needs to be.

Second rule of thumb: The more complicated the outside life, the bigger the need to wall out that life when starting treatment, said Beverly J. Haberle, executive director of the Council of Southeast Pennsylvania, the regional affiliate of the National Council on Alcoholism and Drug Dependence. "Somebody whose marriage is falling apart, lost a job, a new father," is in the criminal justice system or just has "a lot of stuff going on in their lives," said Haberle, would likely need the extra stability of an inpatient unit.

And if the patient is detoxed – a painful process taking a few days to several weeks, depending on the substance abused – the next phase is particularly dangerous because the body's tolerance is gone but the brain still responds to triggers such as stress. A locked unit means "I'm not running around trying to find where I'm going to get my next fix," said Haberle.

Beck puts it this way: "With opioids you really need to get away from yourself. It is really hard to get clean on an outpatient basis."

It may be part of the long step-down process, however – from intensive inpatient to outpatient to recovery house to regular meeting, with other steps in between. And some people's choices may be limited due to financial reasons or the complexities of life and children.

Haberle, a certified intervention specialist who oversees a staff of 60 at the Council and has been in recovery from alcohol for decades, regularly coaches families about how to choose a treatment center.

Questions to ask:

What is their expertise in co-occurring issues, which are frequent in people who have become addicted, particularly long term. Many facilities deal with only one issue – substance abuse – and may not accept or be a good fit for a patient with physical disabilities, trauma, issues around sexual identity, or any number of mental health diagnoses. Others serve specific groups – children or pregnant women or adults who are working.

How do they help manage pain? People who are addicted to either prescription pain pills or heroin may have started in an attempt to relieve pain. While the drugs may be doing far more harm than good, stopping them might nevertheless bring back chronic pain that in some cases may be excruciating. What approaches does the facility use for pain management?

What is the current population of the center? "They don't like to talk about that," Haberle said."But if you have an 18-year-old and you are sending him into a place where everybody is 50 he is not going to identify well." Recovery in a treatment center is not like getting over an infection in a regular hospital bed. Relationships, trust, and support are essential to success.

Are they accredited, and by whom? Centers listed in government search tools are licensed and accredited. Many others are not. Recovery houses can be safe and supportive places to live during the months or years following more active treatment, but their levels of professionalism vary widely.

Does your insurance cover it? Is it in-network or out-of-network? Do you have the sense that the center will stand up to insurance companies that try to end treatment too soon? "You need to find facilities that will fight for their patients," Haberle said. "Sometimes families don't understand their rights." Several new federal laws intended to guarantee "parity" between coverage for physical conditions and behavioral ones are beginning to show results. Pennsylvania also has comparatively strong requirements for private health insurance as well as Medicaid. But enforcement lags.

All three groups of medication significantly increase success of treatment and reduce overdoses by at least 30 to 50 percent. Which medication is suitable for which patient is a highly personal decision. Most accredited treatment centers now offer at least one type of medication; some have all three. Haberle's organization publishes an online Consumer Guide to Medication-Assisted Recovery.  SAMHSA also has detailed information on Medication and Counseling Treatment, which are effective only when used together – the medication prevents relapse of substance abuse (either by substituting a safer opioid or by blocking the effects of any) while counseling helps patients learn new behaviors that will eventually, it is hoped, allow them to stay clean on their own.

How treatment centers discuss these medications can be a clue to their overall care, says Adam Brooks, senior vice president of research and a senior scientist at the Treatment Research Institute in Philadelphia, which studies the effectiveness of substance abuse treatments.  "The true mark of quality is these programs is their willingness to be upfront and talk about how well they manage the medication portion of their treatment across various stages of recovery," Brooks said. "If they say these medications are bad and we will give them only as long as necessary and then you can live risk free . . . That is not good care. It is not the whole story."

The epidemic of opioid addiction and overdose deaths has brought an unprecedented degree of attention and funding to the long-ignored area of addiction. "There is a whole growth industry and there are very slick marketers that are getting into the business," said Haberle.

Some private physicians are getting trained and certified to prescribe buprenorphine but may not have the essential behavioral elements in their program, Brooks said. And they may work only with cash.

Comprehensive treatment centers with long histories are more likely to include all the necessary elements, he said. They also include many different programs, each tailored for different needs. Which one (if any) is appropriate would be determined at an assessment.

The clinician, said Beck, should be asking about family history, listening for biogenetic predispositions and previous treatment by family members -- a positive, she said, because it indicates a stronger support. "If mom and dad are using drugs," on the other hand, "that is the opposite," she said. And "if mom and dad don't know anything about drugs," she said, then that means there is a lot of work to be done. Levels of education may indicate how quickly a patient will be able to learn about his or her disease; personal interactive skills also play a key role.

A sort of perfect storm has stretched the treatment system to the limit, Beck said. The opioid epidemic has meant a dramatic increase in number of people needing treatment at the same time that Medicaid expansion under the Affordable Care Act has dramatically increased eligibility and parity laws are requiring that insurers cover longer stays.

After years of declining support, government funding has suddenly increased – and lots more is under consideration at both the state and federal level – but it will take a while to increase capacity. "We're moving people all over the state trying to find detox beds," Beck said. And those turn over far more quickly than other treatment spaces.

Release from treatment is the beginning of the most challenging phase, when people must create and find the necessary support structures, sometimes moving to other cities to ensure that they don't fall back with the same crowd. It is also the most important time to continue on treatment medication (and the least likely time to actually be prescribed it, according to a recent study) because of the risk of overdose after a period of abstinence.

Haberle recommends finding a "recovery support specialist" in the community – someone who has been in longterm recovery and can help with everything from decision-making to impulse control. Good treatment programs can set up the connection, she said. Government drug and alcohol authorities may be able to help. Her organization provides them for Medicaid patients. It also runs several Recovery Community Centers around the region, with services ranging from peer support to computer training and sober movie nights. And there is a lot more help out there.

"In the drug and alcohol field there are traditional services and there is also an underground," Haberle said. The underground will tell you: "Who is the barber who will cut somebody's hair for a job interview? Who will hire someone in recovery? How do i explain the gaps in my employment record," she said, adding that a coach may suggest addressing the question directly: "Here is what I learned through that experience. And this is what I can bring."

dsapatkin@phillynews.com

215-854-2617

@DonSapatkin