How should dependence on a drug or substance be characterized—a choice or a disease? The latter, as addiction is defined as “a mental illness” that “changes the brain in fundamental ways … resulting [in] compulsive behaviors that override the ability to control impulses despite the consequences,” according to the National Institute on Drug Abuse.
The increase in substance misuse and use disorders is a national epidemic—in the U.S., alcohol and drug abuse totaled 67 million and 27 million people, respectively, according to a 2016 report by the Substance Abuse and Mental Health Services Administration. Orange County residents are hardly immune. The county has seen a significant increase in alcohol and drug-related overdose deaths, 41% and 61% over the last 12 years, the OC Health Care Agency reports.
The addiction surge is reflected in OC’s nearly 420 licensed residential facilities and other programs, reports the state Department of Health Care Services. The growth of the facilities is largely driven by the Affordable Care Act, which expanded coverage of mental health and substance abuse disorders, bringing both conditions under the banner of behavioral health.
Even large health systems are paying attention to the space. OC hospitals have come up with their own one-stop addiction treatment programs involving varying degrees of partnership with third-party treatment center operators.
Hospitals
“What we’ve all watched change over the last five to seven years was a huge increase in patients [ages] 18 to 30,” said Marshall Moncrief, noting the patient population at Hoag Memorial Hospital Presbyterian’s Chemical Dependency Recovery Center in Newport Beach, part of Hoag Neurosciences Institute. He serves as regional executive director of St. Joseph Hoag Health’s Institute for Mental Health & Wellness. “In those [cases], almost every case, they are admitted for addiction to opioids. Many of them got started with pot, moved quickly to prescription narcotics and then moved to IV [intravenous] heroin,” he said.
Hoag’s 21-bed residential treatment facility, SolMar Recovery, opened in 2015. It is the first and only residential treatment facility in California on an acute-care hospital campus. The arrangement allows patients access to the nonprofit hospital’s resources, including emergency room, inpatient detoxification unit, and psychiatrists to treat the depression and anxiety that often come with addiction. It offers 30-, 60- and 90-day stays.
The residential program is part of St. Joseph Hoag Health’s broader addiction continuum treatment program, which also involves St. Joseph Hospital of Orange and Mission Hospital in Mission Viejo and Laguna Beach.
While all three hospitals are equipped with detox and rehabilitation capabilities, Moncrief said each facility has its own geographic segmentation and clinical capability. Broadly speaking, St. Joseph Orange’s strength is in mental health, Mission Hospital’s in “dual-diagnosis”—offering addiction and psychiatric treatments—and Hoag’s is in long-term rehabilitation.
“We do not see ourselves as the one-size fits all, one-stop shop. We just want to offer an alternative,” Moncrief said.
Chronic Illness
The type of care outlined by Moncrief has a lot to do with the shifted perception of addiction.
Mary Eno, chief of addiction medicine at Kaiser Permanente overseeing the South Bay and Southern California regions, cautioned against characterizing addiction as a weakness. “[Alcohol and other drug] use disorders share many features with other chronic diseases, [including] environmental and genetic influences,” she said.
Treatments for the chronically ill include medication, managed diet and exercise.
But seeing addiction through the same lens as chronic health conditions, such as heart disease, stroke, cancer and Type 2 diabetes, isn’t a view that everyone shares. Moreover, substance abuse appears to be primarily a “luxury disease” for those with higher incomes.
The U.S. comprises only 5% of the world’s population but consumes more opioids than any other country—roughly 80% of the world’s opioid supply, according to a December 2014 Express Scripts Holding Co. report.
Physicians and treatment center executives told the Business Journal that the overwhelming majority of patients they see are Caucasians with middle- or upper-middle and above incomes—“78% of drug- and alcohol-related hospitalizations were among non-Hispanic Whites,” according to the OC Health Care Agency. The agency also noted that affluent areas like southern and coastal cities in the county have the highest hospitalization rates, including Dana Point, Laguna Beach, Laguna Woods and San Clemente.
But to Eno, “Addiction is chronic, and it should be treated [as such],” she said.
Kaiser provides inpatient and outpatient programs using the 12-step program used by Alcoholics Anonymous and Narcotics Anonymous. It provides residential services through contracted third-party providers. “We provide group or individual therapy, counseling … but when it comes to residential inpatient treatments, hospitals may not be the best place to take on these patients. We partner with facilities that have the special expertise,” Eno said.
MemorialCare Health System’s flagship Long Beach location offers an addiction-medicine program.
Trouble
But while nonhospital operators provide alternative residential options, such as gender- or age-specific, not all facilities are created equal.
“There are good operators out there, don’t get me wrong, but there are also bad ones, and there are no state regulations to monitor … it’s a choice whether we participate or not [to be certified and accredited],” said Rebecca Flood, chief executive of New Directions for Women Inc., a privately owned nonprofit operator in Costa Mesa that provides rehabilitation treatment services for women suffering from alcoholism and substance abuse.
Facilities need licensing from the Department of Health Care Services to provide 24-hour residential nonmedical services, but the agency offers “a voluntary certification” to programs that provide the following services: day treatment, outpatient and nonresidential detoxification. Some residential facilities, those referred to as sober living homes, transitional housing or alcohol and drug-free housing, don’t require licensing as long as those cooperative living arrangements are free from alcohol and other drugs.
Flood said that because addiction is now treated like chronic illnesses, needing multilevel care as opposed to a one-time detox, more scrutiny should be demanded. OC-based operators make up 50% of the Department of Health Care Services’ list of suspended and revoked programs—22 out of 44 facilities in California. Flood estimated that among the 200-plus facilities in Costa Mesa, only about 10% are certified.
New Directions has five facilities totaling 36 beds—30 residential-rehab beds and six sober living beds. Alcohol abuse is the most prevalent, followed by prescription opioids and street drugs like cocaine and methamphetamine.
Innovation
As for Michael Castanon, chief executive and founder of Luminance Health Group Inc. and Luminance Recovery Center, treatment centers can value-add using technology. The company, opened in 2015, is developing Triggr, an app designed to prevent relapses once patients leave their addiction treatment programs.
Castanon, a former addict himself, said aftercare in the years of recovery is extremely critical when it comes to preventing relapses. “Getting through an addiction treatment program is great, but it is not the end of the story,” he said, adding that up to 50% of those who make it through a program will later relapse.
Triggr aims to measure quantifiable outcomes by tracking patient compliance, including whether patients are attending their after-care appointments, going to the gym for a workout, or heading to danger zones where they can fall into using that substance again.
“We want to reduce readmission rates,” Castanon said.
Luminance has five facilities in OC, including locations in San Clemente, Ladera Ranch, Laguna Niguel and Dana Point totaling 30 beds. Castanon said there are about 110 employees, and Luminance totaled $14 million in revenue last year.
Treatment begins with detox followed by a 30-, 60- or 90-day inpatient recovery program. Patients pay either through insurance, a preferred provider organization plan, or self-pay. The ratio is about 85% insurance to 15% private pay, and Castanon said the company plans to increase its private-pay percentage.
