HealthyGamerGG - The TRUTH About Rehab...

Episode Date: November 22, 2022

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If I recruit someone for your fancy rehab, what that kind of means is that I'm going to get a kickback. Also, you'll have different rehabs that will kind of keep patients there because they want to stay full. They want to make money. There's all kinds of really shady stuff going on. And I wish I could say I'm just a conspiracy theorist here. But unfortunately, that's really not the case. Let's talk a little bit about rehab centers. So I want to talk to all about rehab centers because I think that in a sense, rehab centers seem to be the gold standard.

for overcoming addiction, right? When we see people who are struggling with addiction, when we're thinking about addictions, even celebrities or people like that, they'll say like, oh, this person is in rehab. So when addictions kind of get out of control, the idea is that the best thing that we can do is go to rehabs. Now, there are a couple of things that are kind of interesting about rehab centers. So I've worked in a couple of rehab centers myself. I really enjoy kind of working there. I'm going to share that a little bit with you all later. But unfortunately, there are a lot of things that are not ideal about rehab. centers and some things that are actually wrong. And I'd love to talk to you all about that today. So part of the reason that I want to talk about this is that if you think about people who are

struggling with addiction, what usually happens is we struggle for a while. We try to get it under control. We try to cut back. You know, our family or loved ones, friends, people will sort of tell us, hey, like, you need to get this under control. You need to cut back, whatever. So you try a little bit of this. Maybe you sign up to see a therapist. Maybe you call a psychiatrist. They give you an appointment out in 2023, you know, which is like six months away, whatever. And so we try to do a lot of stuff to overcome addictions. We watch videos on the internet, like, whatever. And it seems to not work a lot of times or we'll get a lot of pressure for family. And sometimes family is like incredibly desperate, right? So especially with some of these like there's a, there's an opioid crisis in the United States right now. A lot of people are overdosing. Things like heroin and other drugs are getting cut with fentanyl. People also have struggled with alcohol and stuff like that for a long time. You know, there are all kinds of problems that these substances. will create, addictions will create. They'll destroy marriages. They'll cause people to lose their jobs. They'll, you know, cause people to become physically hurt in accidents, have, you know,

physical side effects, get HIV from sharing needles. There are all kinds of high stakes when it comes to addiction. And so what we've got is people who are struggling to handle this on their own or handle it at home. And then we've got a bunch of people who really, really care about you. And the stakes are really high and sometimes including death, right? So what that sort of creates, is this system where people, so what that creates is an incentive to sort of start residential treatment. And residential treatment is like a 30-day rehab or two-week rehab or whatever. And you're going to go there and they're going to fix you. And you've got lots of loved ones who are who really need you to be fixed, right? And you yourself need to turn around your life.

You can't be addicted anymore. So since it's intensive, you go there, you stay there for 30 days. That makes it expensive. And since frankly, people are desperate. That makes it expensive. So I've worked at rehabs. I've heard lots of stories about this from patients, you know, even in my outpatient practice. They'll do things like mortgage their house. They'll do things like take out loans. They'll do go fund me's. They'll raise money. They'll say raise $30,000, $50,000. I've heard of some rehabs even costing $100,000 for one month of treatment. And people are actually willing to pay it. The reason they're willing to pay it is because they're desperate, right? This is like we're talking about life and death here. So I've seen parents that we're talking about my son's life.

And in order to save his life, we're willing to spend $70,000 for one month of treatment to get this under control. And so when we've got a vulnerable population, when we've got a desperate population, when we've got high stakes and a high intensity of treatment, that leads to a lot of money. And this is where, unfortunately, what I've seen is a lot of rehabs that I think don't really do a good job. Now, part of the reason they, I'd like to believe that part of the reason they, I'd like to believe that part of the reason they, they don't do a good job is because is not like predatory in nature. I'd like to think that they think they're doing the best they can or they have particular beliefs about what makes the best rehab kind of treatment. But unfortunately, the truth is that a lot of these places are actually quite predatory.

And so I've seen, so I worked at two rehabs predominantly. One was an insurance-based rehab that, you know, patients pay very little or almost nothing out of pocket. So it's kind of a different sort of place. A lot more patients. I was responsible for 28 to 29 patients usually on a given day. So over the course of, let's say, one week, maybe like 10 of them will leave and I'll get 10 new patients. So I'm caring for about 40 patients a week.

The other rehab that I worked at was a private pay rehab that cost a lot more was one of these like really nice. Both of them were actually in really beautiful locations, but had really nice facilities. I took care of like CEOs and other like important people, celebrities, stuff like that. That place was a way higher price tag. there were maybe about 10 patients there at a given time. So about a third to 25% of the size. And what I really found, what I heard from a lot of those CEOs is that they've been to other rehabs.

And their experience is that they go to this really nice place that's like out in Florida, right, where they like, it's on the beach. They go there. Everyone's really caring. They get massages. It's kind of this luxury rehab where it's focused on like wellness. There's a lot of meditation and a lot of yoga and like we're going to kind of like sober you up over 30 days.

You're going to do like some. kind of work, but it's almost like this luxury vacation kind of rehab thing. And the basic problem is that people will become sober over 30 days. And why will they become sober? Because they're in a facility where you're being watched 24-7, right? So you wake up in the morning and there's something going on and you go to bed at night and there's something going on. You stay in this particular room. You don't leave the campus at all. You have no access to drugs or alcohol. So over the course of 30 days, it's really easy to get sober when it's impossible to physically use. Then what happens is these rehabs do very little aftercare. We'll talk about what that means later. But in the worst cases, what they'll kind of do is,

like, you feel great, right? After detoxing and being pampered for 30 days, you feel amazing. You've got a nice tan. You're going swimming every day. You're doing yoga. You feel mentally really, really, really well. And so you're like, wow, I feel amazing. I've conquered this addiction. And then you go back out. You go home with very little aftercare, right? So there's not really much of a plan in place. work stress starts building up, home stress starts building up. You haven't really done a whole lot of deep emotional work. You basically took a 30-day vacation. And so three months later, you're back to using again.

Back to drinking. All that kind of stuff comes back. So a lot of these rehabs will create an artificial environment where like it's really easy to be sober. And then they'll send you back into the environment where you crash. And then what happens? What happens is that now after you crash a year later, people are like, man, things were so good when you came back to that place.

And you yourself realize, man, I felt so good when I left, I just screwed up. So what am I going to do? I'm going to go back. Pay another $70,000 because it worked so well, right? And at the end of 30 days, you feel amazing. You're like, wow, this is it. This time I'm going to do it. And you kind of go back out.

Maybe you're sober for a couple months and then you kind of relapse. So some of these places, unfortunately, I do think it's part of their business model. We'll look at some data in a minute that actually encourages people to like come back, right? And I know that sometimes there are conspiracy theorists out there that'll say like, oh, like doctors, want to keep people sick because that's how they make money. My experience as a doctor has been that there's way, way, way more patients out there than I will ever be able to see and that I can help people get better and there's no shortage of people needing medical care. I really don't think that's true for most people in medicine and I even don't think that's true for the majority of rehabs I'd like to think.

I don't think they try to keep people dependent on their services. But I do think that for some of these places, they actually don't prioritize long-term sobriety. What they really prioritize is creating a really awesome 30-day experience. And it turns out that this is not just me kind of thinking this, right? So it's not just conspiracy theories. So let's actually look. So in the New Jersey state legislature, there's actually an investigator. This happened, let me see if I can find the exact date. So this happened 10 days ago. Okay. So these kinds of practices have been going on for a long time. There's a lot of money to be made in addictions because people are desperate. So let's take a listen to the New Jersey state legislatures, state commission of investigation on rehabs. Let's hear what they actually

kind of say. Okay. So this is like a committee that is, they're going to publish a report probably in the next couple of days. So this is not just Dr. Kay's opinion on things. This is like literally the results of investigation. Let's take a look. It's in the federal government and it makes it easy for unethical practices to exploit people who are already in a vulnerable situation frequently with little consequence. And it can be an overwhelming time and an unclear time to navigate the addiction rehabilitation process. We'll listen to about two minutes of this.

So the recovery industry theoretically exists to help people overcome their addictions and get them back to healthy and productive lives. So listen to that. The recovery system theoretically exists to help people with their addictions and get back to their lives, right? But the reality is that many addictive. individuals and their families are victimized by the very system that's supposed to help them recover and rebuild their lives.

Unfortunately, insurance payments that are involved also becomes more of a focus and the remuneration rather than healing broken lives. Fueling this vicious cycle is often immoral and illegal practices that you'll hear about today, one known as patient brokering, where corrupt players in the industry, steer patients to a specific treatment center in exchange for some sort of financial payoff. And this system is growing increasingly, and it's getting more sophisticated as brokers are finding ways to circumvent laws and banning practices and operating within great areas of the law as well.

So you'll hear testimony today about the type of care patients are receiving for addiction treatment and how it may not be based on the services the individual actually needs in order to recover from their dependents and the quality of their private insurance coverage may play more of a role than the quality of care that they need. And you'll also hear testimony today about some treatment operators and recovery industry employees here in New Jersey who engage in potentially unlawful practices to ensure patients have extended insurance paid stays at their facility. Some manipulate drug tests or keep patients in the most intensive level of treatment, even if no longer necessary for prolonged periods of time.

So we're going to pause there. They go on to talk about a lot of stuff, but like basically what this commission is discovering is that, so like we said, there's big money to be made, right? So what's actually happening is people will like, if I recruit someone for your fancy rehab, what that kind of means is that I'm going to get a kickback. Also, you'll have different rehabs that will kind of keep patients there because they want to stay full. They want to make money. There's all kinds of really shady stuff going on.

And I wish I could say I'm just a conspiracy theorist here. But unfortunately, that's really not the case. And there seems to be actually a lot of data that there are a lot of problems with addiction recovery. So what I'd love to do today is go through a couple of things. First is explain a little bit about why addiction rehabs don't consistently have good outcomes as a field. Second thing I want to do today is talk about the different kinds of rehabs that I've sort of seen. And you can blend them a little bit. So like why are things the way they are right now?

What are the different kinds of rehabs? I want to share with you all a little bit about like what actually happens in rehab. So what are the stages of rehab and like what is like successful rehab treatment look like? Then I want to share with you all the four things that in my experience is a clinician, like if we take one patient who's successful and one patient who isn't successful, what's the difference? and what is a successful course kind of look like and what does an unsuccessful course look like? And hopefully what we'll do is equip y'all with some information so that if you ever do need to seek addiction rehab treatment or a loved one needs to seek rehab treatment, that you're equipped with some information so that you can sort of tell who's good and who isn't. Because unfortunately what happens

is a lot of people will be like, yeah, we're really expensive. We've got really great. We've got this beautiful facility. We'll make things work. You know, 99% of people are sober when they leave. And so like you don't really know, So like, these people seem to know what they're talking about. They're wearing fancy suits. They're charging a lot of money. You know, they're talking a big game. So, like, let's mortgage our house and send our son. So let's start with why are things, why is it hard to sort of tell what makes a residential

treatments? Actually, let me scrap that question. So let's start with this, which is why is it that there are a bunch of rehabs out there? And we're not clear, first of all, whether they work really well or, you know, what works and what doesn't. So the first thing that we have to understand is that. research on addiction rehabs is very, very, very crappy, to be blunt. So even if you look at the number of studies that are published, there are very, very few peer-reviewed studies. They tend to have very,

very low-quality evidence. And why is that? It's because a study that involves measuring someone for 30 days and then following them for a year is really, really hard to do. The other thing that I think is a little bit nefarious is that I think some of these rehabs don't have a vested interest in actually having third parties look at their outcomes, right, because they may not actually be very good. So it's really hard to study residential treatment. The other issue that we tend to have is that rehabs tend to be quite different, and a lot of them are not really very evidence-based to begin with. So a lot of rehabs will be based on 12-step kind of models, and we'll look at some date on that. And 12-step models can be really good. They can help a lot of people, but they don't necessarily work for

everyone, and they're not necessarily the standard of care when it comes to addiction treatment. So part of the reason that addiction rehabs are the way they are is, first of all, it's really hard to study them. And secondly, there's a lot of stuff that they do that is not really like scientifically based. So let's take a couple of, a look at a couple of papers about rehabs, okay? And then we'll kind of illustrate this. So first, the effectiveness of residential treatment services for individuals of substance use disorders, a systematic review, let's kind of look at their major findings, okay?

With caution, results suggest that the best practice rehabilitation, treatment integrates mental health treatment and provides continuity of care post-discharge. So this is what I've kind of discovered as a provider is you can do whatever you want to for 30 days. But unless you fix their outside environment or help them with the outside and environment that they're going back to, the chance of relapse is very, very, very high. Okay. So even then, if we kind of look at this, so between January 13 and December 2018, so over five years, there were only 23 studies published worldwide in the English language on rehabs, which is a very, very low level of studies.

Eight were methodologically strong, five were moderate, and 10 were weak. So we've only got eight studies on rehabs over a five-year period. So it's hard to study and what we kind of know, that the one big takeaway is aftercare, which we'll get to. So now I'm going to share with you all something from, I think this is from JAMA or NEDEM. So Journal of the American Medical, association. So first, let's start with this. There's something called opioid agonist treatment,

which if someone is addicted to opioids like heroin, the standard of care is to actually provide an analog of an opiate that people can sort of maintain so they don't go through withdrawal and don't have cravings and stuff like that, but it's hard to abuse. So there's this medication called Suboxone, which makes it hard for it to be like injected and stuff like that. It's chemically a little bit different. But the key thing is that the standard of care for opioid use disorder, like according to all the science we have, the most effective treatment for opioid use disorder is opioid assisted treatment. Okay. Now, for people kind of saying like, okay, but wait, if I'm prescribed an opioid and I have like a heroin addiction, isn't that just like

replacing one addiction with another? And the answer is sort of, but generally not really. So my experience is that you got to give someone something in a controlled way, in a measured way, so they can't use more, they're not necessarily using less. And then like when someone struggles with addiction, usually their life is falling apart. And it's really hard to get a job and fix your relationships and stuff like that when you're dealing with cravings every single day. So opioid assisted treatment, and this is according to the data, right? This is what seems to work the best.

My experience with opioid assisted treatment is that I'll use it for some amount of time. And then eventually when they sort of get their life settled, I will advocate or at least have a discussion for getting off of opioid agonist therapy. And if they want to stay on it, that's okay, but I'll be like, okay, hey, if things are stable, like, what do you think about this? Like, now that one year out, you've got a stable job, your marriage is repaired, you're done with family counseling. What do you think about stopping this medication now? And we'll kind of have an ongoing discussion. And hopefully eventually, I'm, as a psychiatrist, I advocate for the minimum possible medication use.

Sometimes people need it, and that's totally fine. So let's take a look at the standard of evidence, the standard of care, best available evidence for, what is effective at helping heroin addicts get off of heroin. Nationally, 107 programs, 29% offered opioid agonist therapy with the option of continued maintenance. An additional 31% offered opioid assisted therapy for short-term detoxification, which we'll get to in a second. 60% of people will offer opioid agonis therapy. 39% did not offer opioid agonist therapy, and 78 programs, 21% actively discourage the use of opioid agonist therapy. So this is really interesting, right? Because what this is sort of suggesting

is that 60% of people are unclear, may not necessarily use it, or will actively discourage the best scientifically valid treatment for addiction, right? I want you all to think about that for a second. Now, there are good, arguable good reasons for this. So almost all programs offered some form of 12-step program, right? So 92% of rehabs will offer some 12-step components. And And in the 12-step tradition, many of those people are very, very anti-aginous therapy. These are not scientists, though. They're not medical doctors. It doesn't mean that they don't have value.

They bring a lot to the table. And 12-step programs have been shown to be effective at helping people overcome addiction. But oftentimes, those kinds of things will clash. So the best rehabs, and we'll get to this in a second, that I've seen sort of offer a spectrum and really try to create an individualized approach. The downside that I've seen with 12-step programs, a lot of these people are believers, right? They're like, AA is the only way. And they start with, it's very kind of like a lot of it will have like religious connotations to it.

And there's like a higher power and it's sort of based on like the Christian ethos and things like that. And like a lot of them are like really, really hard liners. And it's kind of my way or the highway. And if it's not working for you, the reason is because you're not trying hard enough. That's my complaint with some people who do 12-step stuff is that they don't acknowledge. that, hey, maybe it's like our intervention could be better. They don't acknowledge that. If there's a failure, it means you're not working hard enough.

Next thing. So this is a paper that talks a little bit about, you know, what are the components to success in recovery? So let's take a quick look at that. So good rehabs will provide information and skills, promote a working alliance. What does that mean? That means that we're going to work together.

Addiction is not something that you have to conquer on your own. We're going to help you. It's a team effort. role modeling recovery. So this is really interesting. But like what does it mean to be sober? What would your life be like to be sober? What does it look like to be sober? And having people that you can kind of look up to and sort of see like, oh, this person has their life together. They maintain their relationships. They have a job that they find fulfilling. They're like in good touch with their kids. That's really important at helping people become sober. And this is really important. Increasing choice. Right. So like this is where if we look at kind of the science on what leads to successful recovery, giving empowering. people who are struggling with addiction with choice actually correlates with increased recovery. And the challenge here is that when we go back to some of these 12-step programs, right, this is not 78% of people don't give patients a choice.

It's our way or the highway. And since we don't have good data on these kinds of things and they're not really very well regulated, like a lot of people are doing what they think is best and I kind of don't fault them for that. But a lot of it is frankly like pretty ineffective. That's kind of a quick review of the evidence. Why are things as bad as they are? I think that's, we've sort of seen why.

Because a lot of these rehabs are not actually based in science. They're kind of based in peer recovery, which is really important. It's a really important aspect of the model. But what we sort of know is that creating a personalized, tailored approach to recovery, because it worked for 1,000 people does not mean it worked for you. And the most success that I've seen in addiction recovery is when we sort of create a personalized approach. So now let's take a quick look at the types of rehabs. Okay.

So this is just like, according to Dr. Kay. So in my experience, there are multiple types of rehab. The first is an evidence-based rehab. So this is where, I know it sounds kind of weird, but they use things like science. They offer medical treatment. Okay? So I worked at two evidence-based rehabs. So maybe I'm biased there, but, you know, the reason I work there is because there's data that shows that it's the best way to do things.

And so what that sort of means is that, like, you know, you're going to see a psychiatrist, you're going to see a therapist. They'll teach you evidence-based techniques like mindfulness, maybe motivational interviewing. the people there will be trained in scientifically valid techniques that help people overcome addiction. Second kind of rehab that we have is a 12-step program. Now, these are not mutually exclusive, but some of these will be very, very evidence-based and have minimal on 12-step stuff, whereas a lot of places will be heavy, heavy on 12-step stuff, and will actually discourage evidence-based medicine, as we already saw. So these are rehabs that are oftentimes started by people who are in recovery themselves. So I struggled with addiction for 30 years. I've been

sober now for 20 years, I want to make it my life's work to help other people, which is totally great. Love that mission. Love that you want to give back. And they create a program. The challenge is that you can learn a lot from personal experience, but I think it's not as effective as combining science with peer support. Even in terms of what we do at Healthy Gamer, so we've sort of built in on this kind of peer support program. Like our coaching program is a peer support program, which is what the United Nations kind of recommends, World Health Organization recommends. We sort of see that these have value, but they shouldn't be done exclusively, especially when it comes to treating diseases.

That's my kind of opinion here. Third kind of rehab that we have is the luxury rehab. And what is the luxury rehab? These are places that are not even like 12-step-ish. They may have 12-step stuff, but they're not like hardcore 12-step programs. These are places that are essentially like 30-day vacations, right? So they're like more like wellness spas. They may have a doctor, but the doctor or therapist are going to have like,

an excellent bedside manner and may not necessarily offer like good clinical care, right? So some of them do, some of them don't. And we're not saying that there aren't evidence-based luxury rehabs as well. But some of these places are going to focus on like yoga. And the key thing about these luxury places is that you're kind of enforced sobriety. So you're going to get sober because you have no choice. But they're not going to build skills. They're not going to do the deep emotional work that is necessary. We're going to give you a really nice vacation where you can recharge. And then when you go back, there's a decent chance you're going to relapse, and you had such a positive experience here. You give us five out of five stars, so you're going to come back and we're

going to get ourselves another 70K. Easy. Okay. Now, you can blend these. So there are, like I said, I worked at one insurance place, one sort of cheaper rehab and one really expensive rehab that had some of these luxury things. So like they were, you know, they had yoga and stuff in the morning, which is totally fine. I'm not, you know, I'm clearly not against yoga. But you really want like a blend of this stuff. And some people are more focused on the luxury than they are on the evidence-based side. So next up, we're going to talk about what happens when you're trying to get sober. So the first thing to understand is the first step of sobriety is detox. So this is detox is usually a physiologic and psychological thing. So when we're addicted to a substance, a substance does two

things for it has two kind of effects. One, it offers an emotional coping strategy. So if we're feeling bad, I can pop a pill and I can feel good. But then the other thing that happens as we develop an addiction is we develop a physiologic dependence. And even if you've never been addicted to a substance, maybe I'll use caffeine, right? So you can think about someone who's like addicted to caffeine. Like half the population is addicted to caffeine when they wake up in the morning, they feel non-functional without caffeine. So the first stage of sobriety is detox. And this is when your body is going through a physiologic withdrawal. And this is so physically everything from painful to dangerous that people will seek out the substance. So for example, I've had a patient who has had stage

four metastatic cancer and has been on chemotherapy and radiation therapy and has like cancer pain and their bones and stuff like that. And they've been addicted to opiates. So I was asking them, What's worse? Having cancer all through your body and pain and like taking these medications and getting literally irradiated or going through opiate withdrawal. And they said 100% opioid withdrawal. I'd take cancer any day of the week over opioid withdrawal. So in opioid withdrawal, you get really, really nauseous. You feel pain all over your body. Like your body just starts to hurt. You can start to have diarrhea and sweatiness and your like your nose is leaking all the time. You've got the chills, shakes. Apparently it just. feels absolutely awful. And so when people start to feel those things, it can be so physically impairing that like the only relief you can get is from the opioid. Different kinds of substances will create different kinds of withdrawals. So one thing that's really important to note is that alcohol withdrawal and benzodiazepine withdrawal, these are medications like X or Valium, can actually be life-threatening. So as our body goes through a physiologic withdrawal from

alcohol, it causes, it can potentially cause seizures and arrhythmias. So alcohol is a CNS central nervous system depressant. And what that means is that it kind of suppresses our nerves. It's an oversimplification. And so what happens is when we take the alcohol away, our nerves have adapted to alcohol being in the system and they've kind of compensated for that. So let's say a nerve normally works over here. And then what happens is we add alcohol. And when we add alcohol, it sort of suppresses our nervous function. And then what happens over time is our brain adapts. So we're back at baseline. Right. So this is what we think of as a functioning alcoholic. They actually are drunk. They're like they've got a high blood alcohol level, but they appear completely normal. Cognitively,

they're normal. You know, like they're completely normal. And so then when you remove the alcohol, okay, what ends up happening is their nerves become hypersensitive. Because now we're removing this depressant effect over here. And then when their nerves become jittery, they can actually have a seizure and can sometimes even go into cardiac arrhythmias, and it can be lethal. So detox feels awful for the most part and can also be like medically dangerous. So sometimes detox has to happen in a hospital. A couple of other things. So when people talk about, oh, marijuana isn't addictive. Part of what they mean when people say marijuana isn't addictive is that we don't generally speaking develop a very strong physiologic tolerance.

to marijuana. It doesn't mean that it isn't psychologically addictive. So we still kind of marijuana can be an emotional coping strategy for sure. But you're not going to have, at least I don't have, I've never heard of anyone having seizures after like withdrawing from marijuana. Okay. So that stage one is detox. So usually the detox stage lasts anywhere between, let's say, three and seven days. It depends on what you're detoxing from. And during that time, it's like hard to do like much therapy and things like that because physically you just feel awful. So usually detox needs to be managed medically. So when I'm helping patients with opioid detox, I'll give them various medications. So I'll give them, like, low paramide so that they don't have diarrhea 15 times a day.

So we try to make the detox as manageable as possible. Sometimes when people are detoxing off of alcohol, we'll use things like benzodiazepines to help them safely detox off of it. So you'll administer things like Larazapan and other kinds of medications to prevent people from having seizures and stuff like that. And you kind of detox them off, hopefully, pretty smooth. The second stage is kind of our residential treatment. And this is when we start doing things like therapy, right? Because now you're detox, you're physiologically kind of back to square one. So you can start doing things like therapy.

You're starting to like build skills. We'll talk about what this kind of stuff is. So this is like the 30-day rehab part, right? So maybe you detox at a different facility and then you go to a 30-day rehab. But generally speaking, let's say we're going to do this for about three weeks. And so that's like when you're doing the work of rehab, you're going to into different groups, you're talking about your feelings, you're talking about substances, maybe you're going to 12-step meetings, you're learning how to meditate, you're getting

therapies, maybe now that the substances are out of your system, now a psychiatrist can actually like diagnose you with something because you can't diagnose someone with a mood disorder if they're actively using substances. So maybe you're bipolar, maybe you're not, maybe it's all the cocaine and alcohol that you're using that makes you look bipolar, whereas you're not actually bipolar. But once you get kind of cleared out, once the substance is clear out of your body, then what the doctor can do is evaluate for other psychiatric illnesses, things like that. Okay. So this is like the, you know, you're in rehab. We'll talk more about what that is. And then we get to the third stage, and this is what I think is the most important, is aftercare. And in my opinion, the biggest thing that

separates good rehabs from bad rehabs, aside from people who are like, you know, openly predatory or unethical, is the aftercare plan. So what I see in these 70K luxury rehabs is that they do a very bad job, or some of them, do a bad job of aftercare. And aftercare is like, I don't want to say this, but it's easy to be sober when you're like in a residential facility where you have no access to alcohol and drugs and people are helping you detox and you're hanging out with other sober people all the time. You don't have your work stress. You don't have your school stress.

You don't have your family stress. You don't have your home stress. You're kind of in a stress-free kind of environment where you can just focus on working on yourself. Then what happens is you go back into your old environment, you go back into the stress, and then it becomes really easy to relapse. So good programs will set up aftercare. And so what is like an aftercare plan from the places that I work look like? It's like, okay, we're going to, where are you going to go? Where will you live? Are there any risk factors there? Do you have roommates who get like use every day, right? Where are you going to get psychiatric help? So they'll help

you make appointments, and they'll make even like sort of make appointments. And if I'm calling from a rehab and I'm making an appointment, I can usually get people in faster. So the key thing here is they'll like set up appointments for you. So that two weeks after discharge, you're going to go see this psychiatrist and you're going to go see this therapist. And so they set it up for you so that you've got psychiatry appointments, you've got therapy appointments. Are you going to do some sort of peer support recovery, right? Are you going to go to 12-step meetings? Are you going to do refuge recovery, which is kind of like a Buddhist-inspired peer support program? Right? So it's not about the higher power and sort of like God-oriented stuff. It's like more about

mindfulness and like discovering whatever kind of spiritual stuff and things like that. But they'll help you set all this stuff up. In some cases, the aftercare will also involve things like, you know, helping you find alternate housing. We'll help you do things like thinking about, you know, work or professional things, including doing things like providing letters to your bosses that protect your privacy, but also like, you know, explain to your boss that, hey, this person may need like a graduated return to work, things like that. So for example, when I'm at rehab, like sometimes we'd get students. So 21 year old, then I'm going to write a letter to his dean. And I'm going to say, hey, the kid needs to like have a halfway. Kid needs to take, his course load needs to be reduced by 50%

over the course of this next semester because he's got all this other crap to do. He's expected to do A, B, C, and D. Right? He's going to go see therapists. He's going to go see psychiatrists. And we sort of write that in a way that is privacy protected. But an official, you know, letter comes from a doctor saying, hey, like, y'all need to cut this guy some slack. He's trying to put his life together or she needs to try and put her life together. Aftercare can also involve starting a lot of these conversations around relationships. So like 30% of the patients at rehab that I worked with is just a rough statistic are going through a separation or divorce, a third. And so are we patching that up? Are we proceeding with divorce? Like, what's going on there? Because that's a

major stressor. So the key thing about aftercare is it's about preemptively thinking about all the stresses that you could have to go back into and your treatment team at rehab starting to work on that kind of stuff. So we don't want to send like if you're going through a divorce and we discharge you after like giving you a massage every day and going for a swim on the beach for 30 days in a row and then you're going back to your spouse who you haven't talked with except for a little bit and you're like, yeah, I'm sober like it's all good. I conquered my addiction. Your spouse is like awesome. And if your therapist hasn't had like conversations with them, whereas like we meet with people like once a week. We meet with family members if they want to once a week. We're like,

hey, what are the problems that are going on? Like what's the stress in your marriage? How is the alcohol affected? Both of y'all? How do you feel about that? How do you feel about that? How does that make you feel? How does that make you feel? I play referee. You know, so like if things get too heated, I'm going to like calm things down. I'm going to ask one person to step out of the room. We're going to work on it in the intervening week. Like we're going to do some solid family therapy, individual work. We're going to all it together so that when you leave here, we recognize that saving your marriage is an uphill battle, but we kind of know what we're dealing with. Instead of, yeah, it's 30 days, I'm sober, I feel really good, I got daily massages, and it's all good, okay? Aftercare is crucial. So now,

what I want to do is talk to you all a little bit about what leads to success in sobriety. So this perspective is kind of like my take on when people do a good job at rehab, what changes for them. Like when someone comes in on day one and they leave on day 30, what's different? And it comes down to four things. The first thing is awareness of triggers. So substance use is highly environmental. Like we kind of know this. And so a key thing about staying sober is like controlling your exposure to triggers. So triggers can be everything from roommates who get high every day to X's, who use heroin and who will hit you up. It can be even things like, you know, work-related stress or family-related stress. Every time my parents ask me, like, you know, when am I going to

move out of the house? When am I going to move out of the house? When am I going to move out of the house? Every time my wife or husband nags me about a particular thing, it makes me want to forget and use. And like, it's really, really stressful. So you have to know what are the things that trigger your desire to use and trigger cravings. Now, we're not saying that you have to avoid all of those things because some of that stuff may be necessary, but you have to have an awareness of your triggers. And I know it sounds kind of simple, but like a lot of times we don't think about that in addiction. There are even studies that kind of show that sometimes if you ask people, okay, why did you relapse? They'll say, I was doing fine.

I was doing fine. I don't know what happened. I just slipped up. And the more than I tunnel down into it, it's like, what do you mean you just slipped up? So walk me through the sequence of events. You've been sober for 12 weeks. You were sober on Wednesday morning. And then you had a binge over the weekend.

How was Thursday? Thursday was fine. What about Friday? Well, Friday at 6 p.m. I got a text from my ex. They're asking like, hey, you want to hang out? And then they sent me a provocative picture. And I was like, sure, right?

And then we started texting back and forth. I met up with my ex on Saturday night. And then I used for 24 hours. Okay, well, right? So like, what are your triggers? Second thing that happens. This is what I call deep emotional work. This is what leads to success.

So if you look at addictions, the most common feature of all addictions, is that they're coping mechanisms. So if we look at a human being and they're psyche, right? So there's like, if there's like really toxic stuff down here that I can't manage, I'm going to need to like add a substance to kind of quiet that out. So we can think about, okay, what are the triggers? But then what we also want to do is like empty out some of this stuff.

Empty out some of like the deep emotional work. Right? So that this stuff kind of like leaks out the bottom. And then we start to like feel better. So this is where like if you look at like the history of childhood abuse, for example, correlates with addiction. And so like as you start to feel really, really ashamed of yourself, right? I'll give you all just like an example of a thought that people who struggle with addiction will have. I'm a worthless piece of crap.

So why not use? It's not like I'm going to accomplish anything anyway. Might as well get some joy out of life. Like I don't deserve to be happy. So why not just screw up? Like, why not just screw up my life, right? It's not like people give a shit about me. These are the kinds of thoughts that you'll have.

I don't think that that's true. I think people do care about you and I think you do deserve to have a good life. But that involves that deep emotional work. You can't massage your way to sobriety. You got to actually like do that hard work, ask those hard questions. What do you want to be in life? What is this addiction done to you? What's the harm you've caused?

Do you deserve to be happy in life? Who taught you that you don't deserve to be happy in life? These are like these deep, cathartic conversations, which sometimes you'll see on stream. Next thing that leads to sobriety is development of co-executive. coping skills. Okay? So development of coping skills is remember that we're going to have to face some triggers. We can't avoid all the triggers. And we can do some of this deep emotional work, right? We can empty this out a little bit. But at some point we're going to be in a situation where we feel emotionally bad or emotionally stressed. And we've got to have some kind of alternative

as opposed to the substance that will help us emotionally cope. Now, this is really important. It's very hard to develop coping skills when things are on fire. So the thing about developing coping skills is when you first start to use a coping skill. Let's say that y-axis is emotional relief and x-axis is time. Okay? If I start meditating today, what do you think the emotional relief that I get from meditation is? So this is interesting. When you're developing a coping skill, this is what the curve looks like. Because this first segment of time, it's not like you feel instant relief with meditation, right? Actually, at the beginning, meditation is even more stressful because you're not even doing it, right? It doesn't help you at all. So it's like you're paying a cost, you're not even getting a

benefit. Then things start to turn around. And then after like two weeks of meditating, you really start to get the hang of it. And we know that clinically, for example, we see statistically significant improvements in psychiatric diagnoses, usually by like the six to eight week mark in terms of mindfulness interventions. So it's like really hard to like, you can't develop an alternate coping skill while you're detoxing. Right? You got a detox first, be in a good place, be stable. It's kind of like trying, like, so I see this a lot where like people will be actively using, right? They're like they're using and they need to learn how to meditate because that helps with addiction. It's like trying to learn how to swim in the middle of the Arctic Ocean.

You got to learn how to swim in quiet waters, right? Like learn how to swim in a kiddie pool. Learn and then you can start to swim in like like bigger, bigger, bigger, bigger waves. So a key part of that 30 day course is when I have a patient who comes in for 30 days of rehab. I'm thinking to myself, okay, like, what are the coping skills that they're going to need 30 days out? And we've got 30 days to teach them how to swim. Last thing is environmental planning. So we've kind of talked about this a little bit already. But this is where, you know, as a psychiatrist, it's kind of like, I'm responsible for this person here, right? And this is one of the other reasons why I think a lot of rehabs are not affected because they're like, my job is to take care of you here. It's not to find you

a new roommate. The good rehabs will help you work through that kind of stuff. But the key thing is that when we think about these triggers and we think about coping skills and stuff like that, the truth of the matter is that a lot of substance use is associated with life stressors. So, for example, in New York, maybe 30 years ago, in order to get public or subsidized housing, government housing, you had to be sober because they're like, we don't want addicts using it. Like, you got to get sober first and then we'll give you housing for free. This is what we need you to do. And then someone realized that it's really hard to get sober while you're homeless.

So New York Institute of this awesome program called Housing First. We're like, we don't care if you use or not. We're going to give you a roof over your head. And lo and behold, when people like aren't homeless, it's actually easier to get sober, as opposed to the other way around. So there has to be environmental planning involved. So what's your work situation like? What's your family situation like? What's your intimate relationship situation like?

What's your friend's circle like? What are your roommates like? and thinking about all of these stressors and helping someone craft a plan. Okay, so I'm going to like avoid talking to my mother-in-law for one month after I leave because that's just too much to handle. I'm going to focus on getting back into work.

I'm going to focus on rebuilding my relationship with my significant other. And I'm going to try to move out. That's when I'm going to, and mother-in-law comes later. And I'm going to go to meetings. I'm going to see a psychiatrist. I'm going to see a therapist. You have to like plan things out

in a lot of environmental planning. And when people do these four things, They become aware of their triggers. They do the deep emotional work. They start to develop coping skills. And they do some amount of environmental planning. This is when, oh, sorry. This is when I tend to see success with rehabs.

Last thing that we're going to do is go through a couple of examples. So here's person one. Goes to the luxury rehab. Okay. So what they usually do is they do, let's say, like, days one to five, they do detox at a hospital. Locked inpatient psychiatric unit. So they detox off of alcohol. They don't like it there.

The food sucks. They're crazy people there. Then on day five, they move to the luxury rehab. I get a big screen TV. I get a private room. I start taking walks on the beach. And then for the next kind of like, let's say, 25 days, they're doing some work. They go to a couple meetings.

Meetings are optional. There's no restriction on things like cell phones or devices or stuff like that. so I can hang out in my room and be on my phone if I feel like it. I'm going to have a private chef. I'm going to do some yoga. I'm going to kind of detox. I'm going to talk some about my feelings. People, since I'm paying $70K, I'm the boss.

So I'm paying $70,000 to be here. What are they going to do? Kick me out on week two if I don't show up to some meeting. So people show up, like as I start to slack off, people show up and they're like, hey, like you should really come to this. Like we want you to come to come this. You're like, yeah, okay, I'll come. You come the next day.

Day after that, you don't come. You do the yoga, you go for the beach, you have some, you know, you have a lot of people kind of like, that are very like ego supportive. So like they're very compassionate and they're listening to you. You go and you vent about your problems, right? You do a lot of venting. And there's like staff that's very, very compassionate. They're like, oh, it's so hard to be you, bro. It's so hard to be you, be you girl.

Oh, like your husband is abusive. Like, oh, your wife is abusive. They're so neglectful. Like, life is hard for you. You're such a beautiful person. They don't challenge you. They don't be like, hey, like, it takes two to ruin them. marriage. And it's kind of great. And then you leave with a tan. You leave feeling good,

like you're going to take over the world. You've kicked the addiction. You've conquered it. They don't tell you, hey, this is a lifelong journey and you're going to continue to struggle and like let's set up a psychiatrist or therapist. Yeah, you don't need that kind of stuff. You're fixed. Option number two. Okay. So you do detox. Let's say at an inpatient locked facility at day five, you move over. And then people start to ask you questions. So like people are compassionate, but they're also challenging. They're a little bit more strict in terms of attendance. Like, they're kind of like, hey, you're here to get sober. You're not here to be. This isn't a vacation. They're going to emphasize skills building. You start doing deep emotional work. You really connect with a therapist. You really like

them a lot. You see a doctor a couple times a week. You know, so multiple psychiatry appointments. Meds change if they need to. They're willing to offer opioid assisted therapy if you need it. And then, you know, at week two, you're also doing things like doing family therapy. You're also doing things like figuring out work-related stuff. You're having tense conversations with your partner about the state of your marriage and divorce. They're not pleasant. They're not fun. But you're starting to do the work here.

You're doing a lot of challenging work with a lot of support. And then people on week two start to develop aftercare plan. You've only been here for two weeks. This is the halfway point. And we're going to start planning. for you to leave. It's kind of weird, right? Because that's what it takes to set up good aftercare. And while we're setting up aftercare, I want you to go to a 12-step meeting. I want you to go to an AA meeting. I want you to go to a Refugee Recovery meeting. I want you to go to a smart meeting.

So on Tuesday, Wednesday, Thursday, this week, and Tuesday, Wednesday, Thursday next week, you're going to go to both of all three of those meetings. So one meeting a day. And you're going to tell me which one you like, as opposed to these guys who are like, oh, by the way, like, you can go to AAA if you want to. And then you go to A.A. And you're like, yeah, that's not really for me. But then what? You go two weeks after discharge, you go to your first A meeting, you decide it's not for you. And then you're like, I don't need it. I'm sober. Whereas here people are like trying things. This is what a good successful rehab experience looks like. And then hopefully you've set up good aftercare. And when you leave, like, you're not, it's not a vacation. It's that you've been fighting a war and losing all this time. But now finally, like you have a plan of attack. You recognize who the enemy is. You recognize what your vulnerabilities are. You recognize that you have some deep emotional work that you've started on, but that you have a long way to go. You've developed some coping skills to replace substances. The challenge is that when it comes to rehabs, they're not incentivized to do all this stuff. In the worst cases, people are actually incentivized to set you up to fail, but love them.

I don't think that's the majority, but I wish I could really say that with 100% confidence. And there's also a lot of other reasons why a lot of rehabs are not effective. And that's because people show up with the best of intentions, right? I've been sober for 20 years at work. for me, it's worked for hundreds of people. But it also hasn't worked for hundreds of people. But this, it's my way or the highway. It's like, this is the way to sobriety. And if you guys have done like work with sobriety, y'all will meet these people where they're like super hardcore, right? Incredibly rigid. And so the problem is even if you go to one of those rehabs, like those people will say like, yeah, if you show up here and you do the work, half of the people

wash out. And they say it like it's a point of pride. It's the people who are serious enough who will be sober. And so either you make the cut or you don't make the cut. And I don't think that that's like effectively the best way to help people with sobriety. It works for some people temperamentally. And so the big challenge with rehab is that we have a lot of people who are desperate and the stakes are high. And it is an intensive treatment. And the more that we sort of combine those, when you've got a resource intensive thing in a group of desperate people, that's when you get mortgages. That's when you have people taking out loans.

That's when you have people selling cars. That's when you have people who are like trying to like borrow money from all their friends and family. to fund $50,000 for 30 days of residential treatment that may not even be scientifically valid. And when you have a system like this that doesn't measure outcomes, that doesn't hold rehabs accountable, you end up with what you have in New Jersey, which is a situation where you've got a bunch of rehabs that are at the worst predatory, and unfortunately a lot of them are probably just negligent. Half of whom don't actually use the standard of care, the best evidence-based treatment for things like opioid addiction, in a country where we have an opioid crisis.

national health emergency and half of our residential treatment centers are not even using the best tool that we have. The truth of the matter is that residential treatment is like rife with all kinds of problems. There aren't really good checks and balances. A lot of people, in my opinion, don't really know what they're doing.

You can maybe argue that it's ignorant for me to make that criticism because I've only, you know, I only worked at two rehabs. I worked there for like two to three years. It's not like I have 30 years of experience under my belt. So fair enough, if you want to say my perspective isn't as valid as those other people's. But there's a lot of data to support this.

And so if you're interested in rehab, what I'd strongly recommend is if you call a place, you ask questions like this. Ask them, what's your treatment philosophy? Do you see psychiatry, like, do you all have mental health clinicians there? What kind of clinicians? Do you all use a nurse practitioner? Or do you have a medical doctor? Or is it a team of both? Do you all have therapists? How often will I see a medical doctor? How often will I see a nurse practitioner? How often will I see my therapist? What kind of things do therapists work on? What kind of therapy do you use? Do you all, what do you emphasize in your program? How much of it is 12-step? How much of it is coping skills? And this is really, really crucially important. What does aftercare planning look like at

your facility? Hopefully, if you ask these questions, you'll be able to tell because all of them will have the same price tag, 50K,000, 60K,000, sometimes, or they can be a lot cheaper in insurance-based, but even if you're talking about insurance-based ones, like you can ask them these kinds of questions. Because what we also learn from the New Jersey Commission is that a lot of these places that are insurance-based, they'll just keep you there, including up to and including falsifying drug tests. So you're not allowed to be discharged. And when people are falsifying drug tests to keep you there, do you think they're actually trying to help you? Of course not. You're a prisoner.

And every day you're at the prison, the facility is being paid $800,000, $1,200. So ask these kinds of questions before you go. And hopefully, you know, places that can give you good answers are places that I would trust a little bit more. So that's kind of my take on rehabs. It's a place that's rife with bad information because a lot of this stuff isn't published. It's hard to research. A lot of these places are for-profit. So they don't really publish their outcomes.

They're not really vetted by third parties. There's no peer-reviewed research publications and things like that. So you got to be careful, which is unfortunate, because the stakes are high when it comes to addiction.