MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Alcohol and drug addiction is a major public health issue, but far too few patients are able to get effective treatment. Joining me in the studio to talk about this challenge, health and medical writer Anne Fletcher. She's the author of a new book titled, "Inside Rehab: The Surprising Truth About Addiction Treatment And How To Get Help That Works." Also in the studio, Beth Kane-Davidson, director of the Addiction Treatment Center at Suburban Hospital in Bethesda, Md. And by phone from Portland, Oregon, Dr. Marvin Seppala. He's chief medical officer at the Hazelden Foundation.

MS. DIANE REHMI do invite you to be part of the program. Join us on 800-433-8850, send us your email to drshow@wamu.org, follow us on Facebook, or send us a tweet. Good morning to all of you.

MS. BETH KANE-DAVIDSONGood morning.

MS. ANNE FLETCHERGood morning, Diane.

DR. MARVIN SEPPALAGood morning. It's a pleasure to be here today.

REHMThank you so much. It's good to have you all with us. Beth, let me start with you. How big a problem in drug and alcohol addiction in this country today?

KANE-DAVIDSONIt's huge, and I've been working in addiction treatment since 1978, which dates me a little bit, but it's been an amazing field, and one of the things we're seeing is more and more people needing treatment and even needing treatment at younger ages.

REHMPeople -- experts argue that addiction is really a chronic disorder. Is that how you see it?

KANE-DAVIDSONAbsolutely. That is our philosophy at Suburban Hospital Johns Hopkins, that it is a chronic disease which needs treatment on all sorts of levels. It's very complex. So one size treatment does not fit all.

REHMAnd how would you define addiction?

KANE-DAVIDSONI'd define addiction -- actually the new definition the American Medical Association has talked about is a brain disease, and it is chronic, and you can really look at early symptoms and middle symptoms as consequences, continuing to use the drug despite adverse consequences.

REHMAnne Fletcher, you've brought personal experience to the writing of this book. Tell us about that.

FLETCHERWell, first of all, you were asking about the numbers. There are 22 million people in the United States with some kind of drug or alcohol problem. Only one out of 10 of those people go for help. So one of the reasons I wrote "Inside Rehab" was to try to reach out and try to understand, number one, why aren't more people getting help, and to try to look at why and how we might be better meeting the needs of the people who are not getting help.

FLETCHERSo I went to go inside rehab to visit the places that are providing addiction treatment, interviewed people for their stories, some of them who had been to rehab as many as 20 times, to understand what their experiences were, why some of them weren't being met, and to look at the rehab system to try to understand. One of the things too that people need to understand is that the people who go into treatment represent -- treatment programs, represent a very small percentage of the people with substance problems.

FLETCHERThey're the people with very severe disorders. Most people with addiction don't have that -- or substance problems, drug and alcohol problems, don't have severe problems, and their needs are not being met.

REHMSo what is it that finally takes a person into treatment? If there's such a small number seeking help, what is it that finally turns the corner?

FLETCHERWell, we don't know exactly what it is. I think it's different for different people. We know that a large number of people are coerced into treatment either by family members, by the legal system, by their employers, and often that is not an effective way to get into treatment. We do know that there are effective strategies, many of which aren't used to get people into treatment. One of the most effective approaches is called CRAFT that gets people into treatment.

FLETCHEROf the 15 programs I visited, only one of them was using that approach. It's an acronym for the Community Reinforcement and Family Training Approach. But many programs are not using approaches like that. Approaches like intervention have not been found to be all that effective for getting people into treatment. Often it's a tipping point when people see that the costs of their using drugs and alcohol are outweighing the benefits, what they're getting back from it.

FLETCHERAnd there are approaches, motivational interviewing, motivational reinforcement, which some programs are using now to get people into treatment, and that helps people see earlier that you don't have to hit bottom to get there.

REHMAnd Dr. Marvin Seppala, I gather AA has been tremendously important in your own life.

SEPPALAYes, it has, actually. And I'd prefer to speak to 12-step programs in that manner. But, yeah. At 17, after dropping out of high school, I ended up at Hazelden, unusually enough as the first adolescent there. Strange notoriety, but certainly one I don't mind now that I'm the chief medical officer of the institution.

REHMThat's really extraordinary that you were there at age17 and now you've become the first medical director who, as an adolescent, served there. How did that progression occur for you?

SEPPALAYou know, I got -- at the time in the early seventies when I went to treatment, I got the information I needed and that was that I had a problem. They called it a disease and yet no one could describe what that meant, and even at 17 I knew that they had little ability to tell me what kind of disease it was, which now we can. Now we were vast neuroscience information about addiction as a disease, and we understand it that way, but then we did not, and yet they gave me an opportunity to take a look at myself and see that I had the same patterns of behavior, the same sort of uses as all the other men actually on the unit that I was involved in.

SEPPALAAnd I fit the mold very well. I just hadn't had as much life experience at that point. And I had deteriorated really rapidly, and it was clear to me that going down the same path was going to result in even worse experiences. So I didn't actually get sober immediately after treatment. In fact, I joke with my peers at Hazelden, especially the research department, that I was a treatment failure because I went back to the small town that I grew up in in southern Minnesota, and there was no AA or any kind of 12-step programs in that town, and so I didn't go.

SEPPALAI had never heard of it before. I had never even heard of treatment before. So it seemed like a long way to drive to Rochester, Minnesota, a larger town, 11 miles away, to actually attend something I had never heard of, so I just didn't do it, and fell right back into old patterns.

REHMDr. Marvin Seppala. He's chief medical officer at the Hazelden Foundation. Here in the studio, Beth Kane-Davidson, director of the Addiction Treatment Center at Suburban Hospital Johns Hopkins Medicine, and Anne Fletcher. She's the author of a new book titled, "Inside Rehab." We are going to open the phones shortly. I look forward to hearing your comments and questions.

REHMBeth, it's interesting that in a recent New York Times piece, Jane Brody wrote that people usually do more research when they're getting ready to buy a car than they do when they are seeking treatment. Do you see that as the case?

KANE-DAVIDSONI absolutely do, and that's why I'm excited about the book being out, and excited to be on the program because what generally happens is people get into a crisis and they want help right away, and they pick up the phone, or they go on the Internet and they see a treatment and they call it and they're, you know, they're ready. They want to come. They want help. And what we try to do at Suburban is say, okay, let's take this step by step.

KANE-DAVIDSONYou know, people really do need to investigate treatment programs. They do need to make sure that people are -- the staff there have the credentials to treat addiction, that, you know, they know how to figure out the criteria before -- between inpatient and outpatient. Is there a family program? What kind of support is there? Extremely important to look at what that treatment center is about.

REHMAnne what kinds of variations are there in these treatment programs?

FLETCHERWell, there are huge variations, and I found that people were not asking the questions. They weren't asking questions about credentials. I interviewed more than a hundred people who had recent experience with the treatment system, and I would ask them questions like what were the credentials of the people who treated you? It didn't occur to them. Well, I just assumed that the person had training. There are 30 states in this country that do not require people to have at least a bachelor's degree to be an addiction counsel.

FLETCHERSo that means that 30 states in the country you could have no degree, an associate's degree --

REHMHang out a shingle.

FLETCHERThat's right. That's right. So that was a huge surprise to me. Many people don't know -- most people don't know that there is no evidence that residential treatment is more effective than outpatient treatment where you go to treatment and you go home at night. Everybody's knee jerk reaction is that you go away to residential treatment. So I found that from studying the scientific literature, talking to experts in the field.

REHMThere's no difference?

FLETCHERGenerally, when you look at literature. The experts I talked to said that resident -- certainly there's some people who cannot stay sober on their own, but one of the models that a lot of people talked about being effective is if you can find a good sober home to live in, but one of the problems is that sober homes are not regulated and licensed. But go to outpatient and live in a good sober home where you're monitored.

REHMAnne Fletcher, She's author of a new book titled "Inside Rehab: The Surprising Truth About Addiction Treatment And How To Get Help That Works." Stay with us.

REHMAnd welcome back. We're talking about addiction, be it drugs or alcohol. We have three people with us in this hour. Dr. Marvin Seppala is chief medical officer at the Hazelden Foundation. Beth Kane-Davidson is director of the Addiction Treatment Center at Suburban Hospital, Johns Hopkins Medicine. And Anne Fletcher is author of a new book titled, "Inside Rehab: The Surprising Truth About Addiction Treatment and How to Get Help That Works.

REHMDr. Seppala, can you give us a brief outline of the treatment program at Hazelden?

SEPPALAWell, we have an entire treatment system with multiple locations around the country and all the basic levels of care that would be associated with addiction treatment. So, you know, Anne Fletcher mentioned residential treatment. That's the type of treatment where people would go and stay for several weeks usually at a time. We have outpatient treatment where people would attend about three evenings or three days a week for a few hours.

SEPPALANow we have day treatment. So I can give you a sense of residential treatment. I guess that the most common form...

REHMSure.

SEPPALA...that people talk about.

REHMSure.

SEPPALAResidential treatment, the individual would come in and, in most cases, have detoxification prior to entering the treatment program itself.

REHMI gather that can be rather difficult.

SEPPALAIt sure can. When we think about the high risk periods associated with addiction and treatment, the first is detoxification where alcohol detoxification, alcohol withdrawal can actually kill people. So a safe detoxification is very important. And the second high-risk period is the first 12 to 18 months people are actually attempting to stay sober, because that's the most common time that relapse occurs.

SEPPALASo when you mentioned chronic illness earlier, that's how we look at addiction. If it's chronic, we have to treat it over a long period of time. And if we can help people through especially that first 12 to 18 months, much more likely they're going to stay sober for the long term.

REHMSo are you suggesting that a residential program would require a stay of 12 to 18 months?

SEPPALANo, not at all. In fact, it's just way too expensive for such a thing.

REHMSure.

SEPPALAWe think of residential treatment as tertiary care, like a level 1 trauma center at the hospital who takes care of the worst sort of difficulties associated with any illness that if someone's going to come in to residential care, they should do it for a distinct period of time related to severe illness, either severe addiction or a combination of addiction with psychiatric illness or addiction with a medical illness, or proof that they have been unable to attend outpatient treatment and gain from it.

REHMAnd who determines the length of time that's appropriate?

SEPPALAYou know, it's really a combination, Diane, that our staff really looks at what we believe is a necessary period of time for that high-level of care that, you know, residential care and it will be influenced by information from the family, information from the patient, that degree of the illness itself -- just how bad or how limited it might be. And then insurance companies, the payers themselves, of course, like any hospitalization for any illness have a vested interest in how long people stay.

REHMOf course. Beth, how does what Dr. Seppala has described is it similar to or different from what the Suburban Hospital, Johns Hopkins offers?

KANE-DAVIDSONIt's very similar. And what we do, if somebody needs inpatient, we assess that and we refer them out. We try to do appropriate match. But we do the outpatient, intensive part. And basically, and the question I always get when a person calls in, a family member or actually the potential patient, him or herself is, well, what do you do? And so, quickly, when somebody comes to our program and they're admitted into the intensive outpatient program, they come to the Suburban Center for four hours every day, Monday through Friday.

KANE-DAVIDSONAnd what they do is they have a variety of different groups, and the groups are led by a multidisciplinary staff.

REHMI would think that detoxification is much more difficult on an outpatient basis than on an inpatient basis, am I wrong?

KANE-DAVIDSONNo. You're absolutely correct. And if somebody needs detoxification, then we look for the hospital to do a short medical detox if appropriate.

REHMHave you, by this time, determined whether addiction is in fact the case and wouldn't each and every person who's labeled an addict have to go through detox?

KANE-DAVIDSONNot necessarily a medical detox within the hospital walls.

REHMI see.

KANE-DAVIDSONAnd we do assess that when the patient comes in for their evaluation. We determine medically, number one, what do we need for the safety of the patient. If they don't -- and a fair amount of people that come to us are not in need of an inpatient medical detox -- then we get them into the program as quickly as possible because the window of opportunity is very small. So the crisis is happening, we know that they are going to be an appropriate for our outpatient program.

REHMSo how can you be sure with the person who comes in for four hours a day that that person is not continuing the addiction the other 20 hours of the day?

KANE-DAVIDSONGreat question. One of the things that we use as a tool is drug screenings and breathalizations. So that is part of the treatment program. Certainly, as was already mentioned, it being a chronic disease, there can be relapses. And one of the things that's important about treatment is longevity. The longer we can keep people engaged in the program, the better for their recovery.

REHMSo, Anne Fletcher, this is where the statement you made earlier comes into play that it's not clear whether inpatient or outpatient treatment is the more successful.

FLETCHERRight. And Beth is talking a lot about the importance of individualizing care, seeing each person as an individual. And one of the things that was probably the most striking to me in writing the book was lack individualizing care. There's a lot of individualizing in assessment, looking at individual needs. And as Dr. Mark Willenbring, who is very prominent at the NIH years ago but now back in Minnesota where I live, said as we do a highly individualized assessment and then we give the same treatment to everybody in the country.

FLETCHERAnother expert said to me, our number one intervention is group. And if you don't like group, we do more group. I was surprised that at many prominent 12-step high-end treatment programs where people are paying as much as $25,000 a month for treatment, they're in groups, some kind of group treatment, education or therapy up to eight hours a day. I did not expect to see that.

FLETCHERI thought there would be much more individual treatment, one on one. They may be getting three to five hours of individual treatment a week. The other thing that I saw over and over again was 12-step based treatment, disease model treatment, which is fine when it works. We do know that people who go to AA or some kind of 12-step program get involves. That means get a sponsor, go to meetings regularly.

FLETCHERGet involved and socialize with people afterwards. They do tend to do better. But we also know that five to eight out of every ten people who go to AA after treatment when they're referred drop out within nine months. That's what the research shows. They're not told about other options. So the sad thing to me were the stories that I heard over and over again of going to these kinds of treatment programs, 10, 20 times.

FLETCHERIn fact, one of the last people I interviewed for the book, he was referred to me by a non-12-step treatment program. And the person who referred me said, you really want to talk with this guy. He's been to rehab 20 times, spent $500,000. I said, you know, I can't do another interview. I've already conducted a hundred. I've been to 15 rehabs for the book. And I said, I just, you know, I have enough interviews.

FLETCHERAnd he said, no, you really want to talk to this man. And I interviewed him and it was heartbreaking because he was still looking. He was still trying. And at the end, I sat down and interviewed the entire staff of doctoral level psychologists at the non-12-step based rehab, where the man finally went for help. And I said, why did this have to happen? Why did he go to these places over and over again when he said the 12 steps don't work for me?

FLETCHERAnd he was told over and over that something was wrong with him. And he wasn't told about alternatives. And he had (word?) psychological problems that were never addressed in all of the times that he went to rehab. I heard these stories too many times.

REHMAlternatives like what?

FLETCHERWell, instead of having the treatment focused on the 12 steps and getting to accept that he had a disease, you could have treatment that was based in a completely different way. Things called cognitive behavioral therapy, which don't focus on the 12 steps but are more skills based. Having you focus on -- now, 12-step based programs do incorporate some of those strategies but they are not the focus of the treatment.

FLETCHERLearning new ways to deal with your thoughts, your depression, your ways of handling stress. That sort of thing. Treatment that introduces you to alternative support groups. You don't have to just go to AA, you could go to SMART Recovery. You could go to Women for Sobriety. I talked to treatment program staff who had never heard about these support groups that are similar to AA in that they provide support in the community but they have a completely different philosophy.

REHMBeth, are there also chemical interventions?

KANE-DAVIDSONSure. There are now, you know, pharmaceutical aids out there that can help with craving. And, again, it comes back to individualizing treatment. And we have found the same thing at Suburban in terms of offering different options for people for SMART Recovery. We actually have a SMART Recovery meeting on-site, Tuesday night.

FLETCHERFantastic.

KANE-DAVIDSONWe have a small alumni AA meeting. You really -- and again, I'm dating myself as that starting in this field in 1978, fresh out of college, it was 21-day, 28-day programs.

FLETCHERIt's probably how you were trained, right? That everybody goes to AA and that's what you were told.

KANE-DAVIDSONThat's what it was, yeah. And if you didn't go to AA, then you were out of the program. And so now we really have -- you know, there's still the program stuck in the old model. But I believe this is an exciting time where science is on our side. We are helping patients look at alternatives -- behavioral, you know, thoughts, cognitive behavioral therapy, different people running the groups. We have a nurse that comes up and talks about nutrition.

KANE-DAVIDSONWe have a clinical psychologist that comes twice a week. We have addiction therapists. We have licensed clinical social workers. It's a mix. So you really get to -- what is going on with this person and how can we address it? How can we help?

REHMDr. Seppala, how many patients -- how many individuals is the better word -- who come to Hazelden, how much time do they spend in groups? How much individual attention are they given?

SEPPALAYou know, if they're in one of our residential sites, they're going to have group therapy approximately three hours a day. They'll meet with their individual counselor a couple of times a week for a half hour to an hour per session. And they'll have psychologic testing upon admission to the program. And if there's a need for mental health intervention, they'll see a psychologist on a regular basis.

SEPPALAThat could be anywhere from once a week to several times per week and they'll see a psychiatrist on an individual basis. So we have multiple options within the course of their treatment at our sites.

REHMDr. Marvin Seppala of the Hazelden Foundation. And you're listening to "The Diane Rehm Show." Here's a wonderful email from David who says: How does one assess whether he or she should be seeking treatment? I have a steady job. My drinking doesn't really affect my personal or private life, but it seems to me excessive compared to most other people. Anne?

FLETCHERWell, I've written another book on alcohol recovery called, "Sober for Good." And a lot of times when I talk with experts for that book -- and I don't pretend to be an expert but I personally had a drinking problem. And one of the things I did and a lot of -- again back to the experts, because I talked to so many experts and looked at the scientific studies -- look at the connection between your substance use and the problems you're having in your life.

FLETCHERAnd if it all keeps coming back to the substance, that's a pretty good sign. I also encourage people to go for an assessment. Ideally, with somebody who's not affiliated with the treatment program. Many people don't realize that -- and I say that because often, you know, the treatment program has a vested interest in admitting you into that program. And, again, this is advice coming from experts who I interviewed.

FLETCHERAnd there are, I can think of, I live in a small university city in rural Minnesota. Well, in that small city, off the top of my head -- and I'm sure there are more -- there are two independent, both people with psychological expertise and addiction expertise who you could have an independent assessment from who could tell you whether you had a true alcohol or drug use disorder. So that would be abuse or dependence. So they could tell you the extent of your problem.

REHMBeth?

KANE-DAVIDSONI just want to chime on -- we talked about addiction being a huge issue, and 22 million Americans dependent. But right now, there's a highlight on the amount of people which is actually about six million that drink in a harmful way. And I would suggest this listener, Google Rethinking Drinking.

FLETCHERAbsolutely great.

KANE-DAVIDSONIt's a campaign that's going on to address exactly that question that we as adults should be asking. Rethinking Drinking. Maybe we're not meeting the criteria for addiction, but the amount of alcohol that one person might be consuming could be to the point where they need to rethink their drinking. And so, that is something I'm very passionate about right now that, you know, it's out there. Rethinking Drinking, it's a campaign to help people look at their ways that they are using alcohol.

FLETCHERYou can have a problem without being an addict or an alcoholic.

KANE-DAVIDSONExactly.

REHMAnd here's an email from Jane in Cincinnati who says: How do I know if my husband is an alcoholic? He drinks most nights, usually two to three drinks a night, sometimes up to a bottle of wine in one night. On weekends it can be more. He doesn't believe he has a problem. His doctor said he doesn't. What do your guests think? Beth?

KANE-DAVIDSONWell, again, I would direct her to Rethinking Drinking. And we see this fairly frequently where somebody -- I just actually had a patient that had gone to an emergency room and had some liver abnormalities and it wasn't addressed. And then the wife came in to talk to us because he was drinking more and more. So you can't always rely on what a physician or history and physical is saying. You have to get an expert and get an assessment.

REHMBeth Kane-Davidson, director of the Addiction Treatment Center at Suburban Hospital, Johns Hopkins Medicine. Short break. Your calls and the cost involved when we come back.

REHMAnd welcome back. Let's open the phones now, 800-433-8850. First to Central New Hampshire. Good morning, John.

JOHNGood morning. I'm one of those -- I'm affiliated with AA and have been for a long time. And it's been really interesting to hear your speakers today because I fall into that category in the program they call high functioning drunks. And I spent 20 years going to lots of different meetings. And because I had not had all those hard negative consequences they were talking about, I hadn't lost a job, I was, you know, continuing to meet my goals. I hadn't gotten any DUIs, I drank following sort of a set of rules and yet I knew I still had a problem.

JOHNBut every time I went to an AA meeting in different groups and different states over 20 years I kept feeling like I didn't fit. And there weren't really the tools for me to make use of to address my high functioning -- you know, my drinking and addiction-based thinking. The AA's really good at putting people with a lot of problems that have had -- you know, that are in there true bottom stage and helping them climb out of that and having meaningful lives.

JOHNBut it seems to me that what ended up working for me, and I've been sober for seven years...

REHMCongratulations.

JOHN...is that in the process the first thing you do is stop drinking, and then you're dry but you're not sober. And it's only through doing all the steps it seems to me that the anchoring process in the whole thing is based on relationships. And as far as most of the people that I know that are sober started like me and had a connection with somebody -- a meaningful personal connection with somebody who had some sobriety who could shepherd them. And in the program, we often called that a sponsor, but it may not be your actual sponsor. It may just be someone else that's in the program.

REHMSure. Sure.

JOHNAnd then from that relationship you trust their judgment that they've accomplished something that you haven't. And then you accept a spiritual relationship. And it's from that acceptance of a true spiritual relationship that you actually get the help that -- to be sober.

REHMAll right. John, thanks for calling. That word spiritual may put some people off some programs, Anne.

FLETCHERWell, yeah, it's what I said earlier. It's great when it works but it doesn't work for everybody. And it's not, you know -- Bill Wilson who found -- co-founder of AA never says that AA was the be all and end all. He said, you know, that he did not expect -- he doesn't like -- he didn't like dogma and that we found an approach that works for us, is what he said. And if you can find some other way then do it your way. So...

REHMHere is an email from Nichole titled "My Father and Addiction." She says, "I know many inpatient programs will not accept alcoholics until they have been alcohol-free for at least a month. My father, a veteran, had to leave the State of Michigan to find an inpatient program to accept him. I feel this is a problem many are unaware of. Unless somebody wants to be a part of religiously affiliated program such as AA, there are few options." Dr. Seppala, is that a prerequisite at Hazelden?

SEPPALANo, not at all. In fact our programs provide detoxication services and all medical and psychiatric services necessary to initiate treatment for folks. It would be an unusual setting that would require that sort of detoxification take place before initial care.

REHMDr. Seppala, tell me how much and, shall we say, an ordinary perhaps three-month stay at Hazelden can cost? And does insurance cover any or all of it?

SEPPALAYeah, I'm better off describing a one-month stay because that's a more common stay in our residential site and it would be 25 to $30,000. It's extremely expensive and that's why we describe it as tertiary care requiring good evaluation to determine the appropriateness of that level of care. When people don't meet, you know, the necessary requirements for that type of care, we'll send them to outpatient which is going to be more in the range of 5 to $7,000 for...

REHMAnd does insurance cover any of it?

SEPPALAInsurance covers both actually, both residential and outpatient care, but not all insurance. And what we've been seeing in the last year or so is that insurance is really limiting access to treatment of all types, both residential and outpatient in trying to -- on an outpatient basis where it is much less costly, even there to limit the length of time people could be involved. And when we discussed earlier that these are chronic illnesses, we need to be involved on an outpatient basis long term to help folks.

SEPPALAAnd the entire treatment field and the insurance industry hasn't really recognized that and provided the type of care and structure necessary for that yet.

REHMAnne, is that amount he mentioned typical of what you found?

FLETCHERYes, of the high-end kind of programs, yep. I found one program that I visited more kind of a celebrity rehab type place. It was really interesting. It was $38,000 whether you stayed one month or three. And actually it was quite a bargain for three months. And the reason they did that was because they wanted to encourage you to stay three months because the outcomes were much better for the people who stayed three months.

FLETCHERBut there really isn't -- this was a quote from one of the experts in my book -- there isn't any supporting evidence for -- I believe the way he said it was a short term burst of treatment that removes you from reality, that puts you away -- takes you away from your regular life. Yes, there are those few exceptional cases where somebody has a severe psychiatric problem. They can't stay sober. They've tried outpatient treatment many, many times. They may be suicidal and they do need to be removed from reality. But for the most part there isn't evidence supporting that model where you take people away.

FLETCHERAnd, you know, there -- people don't realize, they don't -- just this knee-jerk reaction that you need to go away for treatment. You know, not only should people give more thought to outpatient treatment -- and by the way, there's no evidence that paying more money gets you better treatment. There are very good -- I found some very excellent community-based outpatient programs that had more state-of-the-art treatment -- now I'm not saying there aren't very good expensive programs out there, because I found excellent ones that were.

FLETCHERBut I also found excellent, very inexpensive, as I said, community-based programs that had masters-level therapists -- masters-degree level, that had very comprehensive programs that addressed the psychiatric and psychological needs as well as addiction needs, nutrition, getting people back to school, a whole life kind of approach.

REHMSo, Beth, what about the cost of a program like yours on an inpatient basis?

KANE-DAVIDSONOh, you mean -- for our patient, it's outpatient and so...

REHMAll outpatient.

KANE-DAVIDSONYeah, all outpatient. And of course that is less expensive. Our outpatient program runs around 4 or $5,000 for the intensive part. And then what's been brought up is, to me, the most critical part is the continuing care. We have continuing care which used to be in the old days a set time. You know, you would do 25 sessions. Now we've switched to open-ended. We want -- people need to come back, they need to stay engaged in treatment, they need the continued support.

REHMAnd to what extent do the insurance companies step in?

KANE-DAVIDSONThey do step in. We have contracts with almost all of the insurance companies but I do echo what was said earlier. We getting a squeeze on our end. And we do have to get preauthorization and then continue authorizing the session so it's not like you just get a blanket, do what you need to do.

REHMI see. Yeah.

KANE-DAVIDSONAnd it goes back to, you know, this is a very complex treatment that we have to give. And so we do have to look at the individual and we do have to work within, you know, the perimeters of the insurance and what they're saying and what we need.

FLETCHERBut again we're talking, you know, about severe, severe cases much of the time. That's a small percentage of the people with substance problems. We also have not talked at all about seeing an individual therapist. Now most psychologists don't have training -- and physicians in addiction treatment and that's unfortunate. They don't receive that training in school. But you can find them, and I talk in my book about how you can find doctors and psychiatrists and psychologists with special training in the field to work with one on one. That's how I overcame my drinking problem, working one on one with a psychologist who had addiction training.

REHMWhat's...

FLETCHERAnd my insurance paid for it.

REHM...what's the difference, Dr. Seppala, of treating an alcohol versus a drug addicted individual?

SEPPALAThere are some differences specific to the type of substance that people use, but there's also remarkable similarities. We understand the neurobiology of addiction in a tremendous manner now than we did 20 years ago even. And it reveals the two aspects of brain function are dramatically altered. First, the reward center has been altered in a way that the person wants to continue to use the drug at a subconscious level. Drive states have been reprioritized so that in severe addiction people will risk their lives to get that drug and keep using or get alcohol and keep using.

SEPPALAEven survival itself dropping down in priority secondary to the drive to continue to use that drug. In the prefrontal cortex where executive functions take place where we make decisions, think things through, look at the future has been altered in such a way that we can't recognize what is going on. We can't see the consequences.

SEPPALASo even though I agree with many of the points made by Anne in her book, and she does help to describe a lot of the problems facing the addiction treatment field as a whole, she hasn't really described this function that we know from a neurobiological basis that limits people's own recognition of the problem and thus can undermine their attempts to seek treatment, let alone to get good treatment.

REHMSo it depends quite often on the people around you.

SEPPALAIt sure does. You really need people that care about you, that love you or even just a judge that knows you because of an illegal act, or an employer that's going to say, hey you need treatment. Hazelden did some studies actually almost a couple decades ago now, where they looked at how and why people enter treatment. Over 95 percent of people are coming in because of someone else in their life requiring that they address the issue.

SEPPALAAnd they also -- we also looked at, you know, who did better, those that came of their own accord, which was a small group, versus those that were there because someone else insisted. And actually those folks that someone else insisted had slightly better outcomes than those that were there of their own accord, which we found to be unusual. But it's just what the numbers turned out to be.

REHMAnne.

FLETCHERI look at the literature of somebody who did a big, like, international look at the literature on kind of forcing people into treatment. And he said it's actually a huge national social experiment that we're engaged in in this country because we really don't know whether it helps people or harms people. But the most important point in all of this is by focusing on a small segment of the population, that's people with severe addictions, only 1 percent of the population in any one year has the kind of severe alcoholism that we think of as Nicholas Cage in "Leaving Las Vegas." Only 1 percent of the population.

FLETCHERMost people with addiction don't have that kind of severe addiction, and that's what we're focusing on when we talk about people that we're talking about. More people would be helped if we had a broader approach, a less narrow approach to addiction.

REHMAnd you're listening to "The Diane Rehm Show." Let's now go to Jefferson, Ind. Good morning, Terri.

TERRIGood morning. My question is about my brother that's 43, and he's been doing drugs since he was a teenager. As a family we sat down and had an intervention with him and he actually was honest and said he was doing crack cocaine, and told us that we were enabling him. So we cut the cash off from him and a place to stay and dropped him off at a homeless shelter and was hoping that that would be his bottom -- his rock bottom. And actually he's been there for almost two years now. Actually he's homeless from the homeless shelter. So I guess my question would be what would be our next step?

REHMWhat would you say, Beth?

KANE-DAVIDSONI'd say look into the resources in your community. I think the point of individual addiction treatment counselor, therapist is a great way to go. Somebody that knows addiction and then can help you all figure out how to connect him to someone in the community that can begin helping him.

REHMDr. Seppala.

SEPPALAYeah, I would echo that. I think an initial evaluation's really essential and gaining some of the resources in the community rather than just a homeless shelter. He needs treatment of some sort to begin to examine the relationship that he has with drugs of abuse and look at some skills to get sober and stay sober.

REHMAnne.

FLETCHERThere's not a simple answer to this question. it's very hard and sad as a family member when you're in a situation like this, and I feel for you. And I can't give you a simple answer. In both of my books I do talk -- and I have resources for family members -- but I'm going to give you one suggestion. One of the things that I found in doing my research is that there's a huge gap between science and practice. What the research shows to be effective and what's actually going on in many treatment programs in this county. And I only found one out of the 15 programs that is using scientifically-based family approaches, working with the family.

FLETCHERThey're doing a lot of psycho educational workshops educating families about addiction, the disease of addiction and, you know, talking to them about that. And kind of sitting around and talking about things you can and can't do to help the addict. There's a lot of focus on going to Al-Anon. And that's another 12-step-based group for families. And it does help families. There's research that it helps the family member but there's kind of this feeling that you can't really do anything to help the addict or get the addict into treatment. And that's not true.

FLETCHERThe CRAFT approach, which I mentioned earlier, which was developed by Dr. Robert Meyers, there is a book that I'm going to recommend, somebody's else's book called "Get Your Loved One Sober." And that has specific research-based strategies for family members of a loved one. "Get Your Loved One Sober," and that is published by Hazelden. And that is something that can help people with a loved one with an addiction, people who feel helpless like you.

REHMAnd one last question. Terri said that they tried an intervention. Does a professional need to be present for an...

FLETCHERCRAFT has been found to be far more effective than interventions in helping loved ones and getting them into treatment than interventions. Statistically I think it's 70 percent more effective. No, I know what it is. Seventy percent of people who participate in CRAFT in the research studies go into treatment. And those numbers are much greater than people who participate in intervention. It's striking. It's just striking.

REHMWell, clearly lots of possible outcomes here, lots of resources. We'll have some of these listed at our website drshow.org. Thank you all so much. Anne Fletcher, her book is titled "Inside Rehab." Beth Kane-Davidson. She's at Suburban Hospital, John's Hopkins Medicine and Dr. Marvin Seppala of the Hazelden Foundation. Thanks for listening, all. I'm Diane Rehm.