The Business of Recovery
film

Greg Horvath has produced a very disturbing documentary called The Business of Recovery, shining an unflinching light on an industry that is “selling hope to families in crisis” and making a fortune in the process, fleecing desperate parents and addicts of hundreds of thousands of dollars while getting less than stellar results. He interviews a slew of addicts who have been to treatment upwards of 10 times (some of whom died from addiction after the filming), as well as some top addiction experts and a few of the rehabs themselves.The Fix sat down with Horvath to ask him some questions.

What made you decide to make this film? Are you a recovering addict or have you ever been in rehab? Or do you have family or friends that have spent a small fortune to no avail?

I have experience with [the] 12 steps, rehabs, and worked in the industry for many years. I felt the way we were treating addiction wasn’t working nearly as well as was portrayed. I wanted to dispute or confirm this feeling.

How did you hook up with Adam Finberg (the director)? His background seems to be as an editor of reality and documentary TV.

Adam and I met at the Sundance Film Festival about 12 years ago. We have collaborated on a couple of other projects over the years. He is a very talented filmmaker and I hold him in the highest regard.

You interview a lot of experts and also laypeople on the street regarding the nature of addiction. What is your personal belief about addiction?

That’s an interesting question, always sparks heated debate, and that’s why we put it in the film. The one thing I noticed over my years of working with addicts was that they never wanted to debate with me whether addiction was a disease or not…they just wanted to get clean and/or sober.

I’ve been in quite a few rehabs (which might make your point). Most seem to be owned or run by people in recovery who actually believe that the 12 steps work because it worked for them. Do you think all these places are corrupt or do some have a true desire to help but it gets murky when profit is involved?

I have never questioned the passion or commitment of most of the people who work in the industry that believe that 12 steps work, because it worked for them. Just like I have never questioned the passion and commitment of most nurses and other medical staff that work at hospitals. However, if you had a child that has cancer, would you want them treated by nurses and medical staff who believe in a particular support group, or would you want your child treated by someone who is using what the science says is the best treatment for the cancer your child has?  

You mention in your film that 10% of US rehabs are not 12 step-based. What is their main methodology? What is their claimed success rate? 

Actually we did not say that, we said that 90% of the treatment in the US is 12 step-based.

How do you feel the rehab industry has changed now that many of them take insurance?

No opinion.

There are free treatment centers like Freehab or religious fellowships. What are your thoughts on those? 

I think they are great options for indigent people.

You mention the problem with addicts, who aren’t stable, treating or supervising other addicts. It’s definitely risky. Many people, new in recovery, choose to work in recovery because they’re so gung ho or they have no other real training or education or possibly a criminal background. How can we minimize risks aside from mandatory training or do you think treatment centers should only be run by medical professionals without addiction backgrounds?

I go back to education. I really don’t care if the nurse or doctor that is treating my cancer has had cancer, as much as I care about their professional credentials. And to be clear, a six or 12-month certificate and a year or two of sobriety is not a credential.

What kind of changes would you ideally like to see made to the rehab industry aside from offering non-12 step-based methodologies and some type of accountability or policing from government agencies? Refunds if the client relapses or leaves? 

I never said that I want the rehab industry offering non-12 step methodologies. As a matter of fact, that’s one of the fundamental flaws that annoys me the most about treatment. Support groups are not treatment, they are support groups. We need to stop referring to it as treatment. 

Why do you think the rehab industry has such a loyalty to the 12-step model when you elucidate via many researchers that it is only effective for a very small percentage of people? 

It’s a free program, and a free after-care program.

I must say I was pretty horrified by the salaries (from $200,000 -$900,00) that many of the executives at these “nonprofits” were making. It reminded me of religious organizations. How many of these places offer scholarships or sliding scale? 

Most of them offered some scholarships.

I was amazed that so many of the rehabs that you interviewed seemed to just fall into the trap of saying exactly what would support your points that a) they were primarily 12-step based and that b) they have no way of truly proving their success rate aside from self-reporting and that c) there was no real data supporting 12 step but that it does work. What did you tell these rehabs that your movie was about to get them to go on film? 

There were no traps or hidden agendas. We told them exactly what we were doing, we were making a documentary about the treatment addiction. And they agreed to talk to us about their methodology.

There are over three times as many treatment centers now as there were in 1986 but drug overdose rates have tripled. Why? 

I think there are some strong factors associated with JCAHO declaring pain as the 5th vital sign in 1999. However, if what we were doing was working so well, and we tripled the number of facilities doing it, would the death rates be tripling? By comparison, in the same time period that overdose death rates tripled, cancer death rates have gone down by 22%. That should really shock anyone still clinging to the myth that the current addiction treatment modalities are working.

The accreditation companies of rehabs are themselves nonprofits that appear like government agencies and look very official but they only look at building codes and documentation, not the efficacy of treatment. How can parents, friends or partners make more educated decisions regarding choosing a rehab? 

Two words: “Buyer beware.” If the accreditation companies do not look at whether the treatment offered by a facility works or not, it is an absolute roll of the dice to think you can pick a “good" facility. A facility is much like a used car salesman, they are going to tell you everything that’s right with their facility, I would be more concerned with what’s wrong with it. Buyer beware…ask questions about educational requirements, refund policy, do they drug test their staff, are they treating you with science/empirical treatments, or just teaching how to do a support group. If they answers are vague, move on. Buyer beware.

Many addicts go into rehab and come out worse. I certainly have had that experience but is that the rehab’s fault or just a matter of having addicts living together, just like some inmates get worse in prison? 

You kind of answered your own question. However, the rehab has to own its share of the problem/failures. You can’t expect a much different outcome when all you offer are quasi-scientific treatments, administered by unqualified staff, in a largely unregulated industry.

If you had a loved one who had an addiction problem, what would you do? Where would you send them?

I would need much more information before I could even attempt to answer this question. And that’s the greater problem, addiction is far more complex than just a matter of: “Where should I send them?” 

Many of these rehabs have paid referrals and kickbacks but one of the rehab-heads defended it by saying it’s a “relationship-based industry.” How much does this compromise the integrity of the whole system? 

People we interviewed were absolutely shocked that it went on, and thought it was one of the most shameful practices in the industry. Please refer to the Stark Legislation, it was passed for a very good reason. It is a dangerous conflict of interest for a doctor to be prescribing a treatment he owns or gets paid to prescribe.

Many of these rehabs pay more in public relations and ads than they probably invest in their actual programs. It’s all marketing and reputation. Although this is a terrifying way to pick a treatment for a condition that can kill you, it doesn’t seem like science has all the answers yet. 

That’s an interesting comment, you would first have to “ask” science a question, in order for science to “have” an answer. Having said that, predatory and misleading marketing is a large part of the problem as well. We have to start with some honesty in the industry about expectations.

In the light of all of this, if you could construct your ideal rehab, what would it be like?

1) The use of science-based treatment (empirical, not evidence-based). 

2) Better educated professionals in charge of treatment. 

3) Regulations that have value to the addict and that are in line with the medical field.

Amy Dresner has been a columnist at The Fix since 2011. She recently wrote about the documentary "The 13th Step."

The Fix talks to Greg Horvath about his unflinching examination of the rehab industry and its reliance on 12-step facilitation.
By Amy Dresner
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USA

The ultimate accusation we can seemingly make about something today is that it is addictive. Like heroin is. Consider the fate of cigarettes in that regard. Talk now is about sugar being addictive. And what about marijuana?

But aren’t we awash in a sea of addictions? Aren’t we all addicted, more or less?

Horrifying!

In the 19th century, opiates were used by virtually every man, woman, and child in America. A tinctured opiate solution, laudanum, was sold everywhere over-the-counter, and was used to help babies through teething and in order to sleep.

Horrifying!

But opiate addiction was not considered a special problem in 19th-century America. There are two possibilities: One possibility is that people socialized their use (keep in mind that opium and coca have been consumed in Afghanistan, Asia, and South America for eons) so that opiates were taken in a traditional, controlled manner and people were rarely addicted to them. 

The second possibility is that, if everyone around you is addicted to something, you can’t recognize the substance’s addictiveness or your own addiction. Was this the case for 19th-century opiate use?

Moving into the 20th century, consider smoking. When cigarettes were considered harmless—were even marketed for their health effects—people smoked relentlessly, in all settings, indoors and out. (Consider Mad Men.)

Horrifying!

When the Surgeon General’s Report indisputably showed smoking caused cancer in 1964, there was an immediate, shocked reaction. About half of all smokers quit over the next decades, cutting smoking rates in the United States from roughly 40 to 20%.

Some people continue to smoke—oddly enough, less well-educated and poorer people with fewer resources, despite the rising cost of cigarettes. Still, no one today considers smoking healthy, and everyone recognizes that nicotine is addictive. Those who continue to smoke are now, in many places, social pariahs.

But let’s conduct a mind experiment: What if coffee and tea were discovered to cause cancer? Many people would quit making coffee in the morning or going to Starbucks—let’s guess half of all regular coffee drinkers. Others would say they wished to quit, but couldn’t just yet. And a defiant minority would say, “I don’t care if coffee causes cancer—life is unbearable without it!”

It turns out coffee isn’t dangerous (it is actually remarkably healthy). Its worst consequence is contributing to the apparently universal insomnia that grips America. So most people don’t have to (or don’t want to) quit.

But is coffee (caffeine) addictive? Don’t be absurd! On the other hand, as Archie Brodsky and I wrote in Love and Addiction:

“The sufferer is tremulous and loses his self-command; he is subject to fits of agitation and depression. He has a haggard appearance…. As with other such agents, a renewed dose of the poison gives temporary relief, but at the cost of future misery.” 

The drug in question is coffee (caffeine), as seen by the turn-of-the-century British pharmacologists Allbutt and Dixon. Here is their view of tea: “An hour or two after breakfast at which tea has been taken … a grievous sinking … may seize upon a sufferer, so that to speak is an effort. … The speech may become weak and vague…. By miseries such as these, the best years of life may be spoilt.”

What seems dangerous and uncontrollable at one time, or in one place, becomes natural and comfortable to deal with in another setting. 

Let’s turn to the present. Is there anything that people do seemingly compulsively all around us, which they don’t regard as addictive?

Have you been in a park, or airport, or bar lately and watched people check their smartphone or equivalent gadgetry incessantly, going back to their email, text messages, phone messages, personal newsfeed—what have you? They hardly ever look up at the sky outside, or to talk to the person next to them—sometimes the person they entered the space alongside, like their partner or children!

What about people taking these gadgets (and others, like iPods, iPads, whatever) to bed? There are two possibilities: Either they sleep alone, and the instrument becomes their main companion, one that never leaves their side. Or else they sleep with someone, but pay nonstop attention to their electronic companion instead of their real-life partner!

Horrifying!

What is that exactly? What would happen—what happens—when occasionally they lose this gadget, or aren’t allowed to use it, or their battery runs out? How do people cope with their life and time without this crutch? Are they tense, at loose ends, almost unable to bear the passing time? Isn’t that withdrawal?

A few people point out serious negative health and life consequences from these electronic addictions. Some medical publications are even considering this seriously—if perhaps a little bit tongue-in-cheek. And there is rehab for smartphone addiction, just as there is for video game addiction.  

But if everyone is addicted to their cellphone, Facebook page, Instagram (whatever the hell that is), who really cares? And if everyone drinks coffee at breakfast, can it really be called addictive? Or does normalcy protect us from the label “addiction?” Or are we not really even interested in addiction? Do we really only care about what are acceptable and unacceptable addictions?

Or is there a clinical justification for focusing on some addictions because they harm us?

As my fellow addiction psychologist and the president of SMART Recovery, Tom Horvath, recently wrote:  “I suggest that everyone has addictive behavior, and some have problematic addictive behavior (at various levels).” I wrote a paper about marijuana’s addictiveness entitled, “Marijuana is Addictive—So What?” My point was we only worry about some of the myriad addictions in our lives. Something’s being addictive, taken by itself, doesn’t concern us.

By the way, do you know that psychiatry’s manual, DSM-5, recognizes only one addiction: compulsive gambling. No drugs are called addictive in the DSM-5. And only one more activity is being considered currently—electronic games. (No sex, or porn, or love? None of those can be harmfully addictive? Who makes these things up?)

That’s not horrifying; it’s unbelievable!

As for your personal concerns about an addiction, as Archie and I say in Love and Addiction: “Practically speaking, we can only make the personal decision to treat something as an addiction on the basis of how much we see it hurting us, and how much we want to be rid of it.”

For those seeking the definition of addiction in brainwaves, there can be no meaningful answer to these questions. Only when society (or you in your own life) considers an addiction harmful and disapproves of it will the red flag for addiction go up. That labeling process can change, sometimes quite rapidly.

So, to borrow some phrases from literature: Addiction, where is thy sting? (William Shakespeare) Never send to know who is addicted; it is you. (John Donne)

And that old classic: Addiction is as American as apple pie. (H. Rap Brown)

Stanton Peele, Ph.D., is the author of Recover! Stop Thinking Like an Addict. He is the recipient of career achievement awards from the Center for Alcohol Studies and the Drug Policy Alliance. His Life Process Program for treating addiction is available online. He last wrote about memoirists and alcoholism.

When does something veer off from being normal and accepted to being called addictive? The answer isn’t in our neurosystems.
By Stanton Peele
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drive safe

According to The National Highway Traffic Safety Administration: “Drunk driving deaths spike during the holidays. Every 51 minutes, someone in the United States dies in an alcohol-impaired driving crash. Be responsible—don’t drink and drive. If you plan to drink, choose a sober designated driver before going out.”

As the Memorial Day holiday weekend approaches there will be more traffic on the roads, and more people will make the devastating decision to drink and drive.  

The concept of the "designated driver" began in Scandinavia. It was adopted as a formal program by Hiram Walker and Sons, the distillers of Canadian Club Whiskey in Canada, in the 1970s and became a buzzword in the North America shortly after. Mothers Against Drunk Driving (MADD) became the self-declared champion of the designated driver in the 1980s. But designated driver programs, when instigated by groups of people drinking, had its problems. If the driver wasn’t designated the driver before travel, often the designated driver didn’t stay sober. Equally, if complete abstinence is not required, someone would end up driving drunk.

Several volunteer programs across the country focus on college students' weekends and the excellent HERO program vows “...to register one million designated drivers and make having a designated driver be as automatic as wearing a seatbelt.”

Now 35 years old, MADD, the support and advocacy group for the victims of drunk driving, has long been aware that young people between the ages of 21 and 24 are most at risk of being involved in a fatal crash involving alcohol. The group aged 25-34 are the next highest.

Incidentally, the two age groups most at risk, are the most tech savvy. The Pew Research center says: “Younger adults—regardless of income level—are very likely to be smartphone owners.”

So is there an app for that? You bet there is. Uber’s wildly successful 2009 launch into the closed shop of private transportation caused a storm of protest from taxi drivers across the country. But the "ride-sharing" service that connects independent, non-commercial drivers with their own cars with people in need of a ride has been hugely popular with an urban generation raised on technology and the convenience of the Internet. As the taxi app that crowdsources private drivers quickly became a ubiquitous part of modern life, it became a no brainer that Uber (and other ride-sharing start-ups, Lyft and Sidecar) would be the first choice for getting home late at night from a party or bar.

Ride-sharing, for MADD, couldn’t have come at a better time. And both Uber and Lyft have made donations to the charity through the use of promo codes. Over the July 4th weekend in 2014, they began their partnership by giving $1 ($10 for new riders) for every ride taken between 6am on July 4 and 6am on July 5. The cooperation continued over the New Year’s holiday.

But was the new app making a genuine dent in DUI deaths? And was it changing attitudes toward drunk driving?

Back in 2014, Uber looked at publicly available data on DUI arrests in the time before and after Uber’s Seattle entrance in 2013. They noticed a drop in DUI arrests in the city.

Inspired to learn if their business was having a genuine impact on public safety in other markets, they looked at Pittsburg and Miami and noticed a temporary and unusual spike in requests for drivers at closing time in the two very different cities. Satisfyingly, that’s exactly how it looked. Coincidence? Maybe, but in a follow-up look at requests in Chicago, they dug a little deeper—looking into the distance of a request from a bar or restaurant, and sure enough, 45.8% of rides requested came from or near these locations during the peak drinking hours of 10pm and 3am, compared to 28.9% at off-peak times.

But these were only small slices of time, a year at most, and not necessarily hard proof of a change in the habits of young drinkers.

In January 2015, Uber teamed up with MADD to look at California. The California Highway Patrol (CHP) covers the entire state’s highway and county road system. Its publicly available data on DUI crashes, gives a snapshot of activity from across approximately 2,335,000 miles of paved roadways. Uber used this information and looked at the time when the "Uber X" ride-sharing model was introduced into various parts of the state. Uber X is the basic service, where private individuals share their car to people in need of a ride.

As they hoped, in their report, “More options. Shifting mindsets. Driving better choices,” alcohol-related crashes were fewer in parts of the state where Uber X had been introduced—particularly in the key group of those under 30. They conclude:

“...We believe there is a direct relationship between the presence of ‘Uber X’ in a city and the amount of drunk-driving crashes involving younger populations.”

Good news, of course, but what about the attitudes of these young drivers? Were they changing? MADD wanted to see if part of their mission: “to create major social change in the attitudes and behavior of Americans toward drunk driving,” was being accomplished. They commissioned a survey to find out how seriously people wanted to end drunk driving.

“The results of our survey show that the availability of additional, reliable transportation options is shifting mindsets and driving people to make better, safer choices."

"88% of respondents over the age of 21 agree with the statement: 'Uber has made it easier for me to avoid driving home when I’ve had too much to drink.'”

"78% of people say that since Uber launched in their city, their friends are less likely to drive after drinking."

"57% of transportation network service users agreed with the statement: 'Without Uber, I’d probably end up driving more after drinking at a bar or restaurant.’”

And after hearing about Uber’s impact on drunk driving already, 93% of people would recommend a friend take Uber instead of driving, if the friend had been drinking.

Neville Elder is a regular contributor to The Fix. He's also a photographer and writer. Originally from the UK, he's lived in the unfashionable end of Brooklyn for 13 years. He last wrote about the forgotten victory in the War on Drugs and how the DEA under Michele Leonahrt was rotten to the core.

Memorial Day driving could be safer this year, due to an unlikely alliance.
By Neville Elder

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