March 18, 2016
Evelyn Pringle and Martha Rosenberg
Addiction psychiatry, essentially treating drug addicts with other drugs, has become a hugely profitable industry.
Addiction treatment has become big business. If you haven't noticed it yet, investors certainly have. The U.S. Substance Abuse and Mental Health Services Administration projected the market for addiction treatment at about $35 billion for 2014.
Since 2006, private equity firms have invested more than $2.2 billion in substance abuse treatment companies. The private equity firm Bain Capital paid $720 million for CRC Health in 2006 only to turn around and sell it for $1.18 billion to Acadia Healthcare Company Inc. in 2014. Acadia operates 76 facilities with about 5,800 licensed beds in 24 states, Puerto Rico and the U.K.
Why are addiction treatment companies so lucrative, with profit margins of over 20 percent? Largely because of the booming specialty of addiction psychiatry, which has exploded and muscled its way into standard rehabilitation and monetized it.
“The insurance companies told the rehabs they would no longer pay for inpatient rehab for heroin, cocaine or alcohol unless there was also another Axis 1 psychiatric disorder like bipolar disorder or major depression,” explains psychiatrist Phil Sinaikin, author of Psychiatryland. “I was working in a drug treatment facility when the change happened. Since addicts typically complain of anxiety and depression, a completely understandable emotional response to their toxic lifestyles, it was no problem to add a new label and throw a few psychiatric drugs at their now relabeled ‘dual diagnosis.’”
Unlike older treatments for alcoholics and addicts, addiction psychiatry treats substance abusers much like primary care physicians treat physically ill patients—with drugs, even though their problem is drugs. As illogical as it may seem, the practice of harm reduction is addiction psychiatry’s standard operating procedure, substituting one or several drugs for the original substance with the goal of stabilizing the patient, not necessarily recovery. The treatment model essentially tells patients nothing really can be done about their addiction except to provide them more drugs, sometimes for life.
Helping the increase in drug patient pools, in 2013 the American Psychiatric Association loosened the definitions of alcohol use disorders, eliminating “legal problems” but adding “craving.” (The APA’s financial links to Big Pharma have been widely reported.) The problem with the harm reduction/maintenance model is obvious; the substance abuser never recovers, but simply stays hooked on another or multiple drugs, while Big Pharma cashes in.
“This basis for [such harm reduction] treatment has its analogy to other chronic disorders,” psychiatrist Stefan P. Kruszewski at the Center for Drug Safety and Effectiveness, Department of Mental Health, at Bloomberg School of Public Health and John Hopkins University Medical School, told us in an interview. Addiction is thought of “like often-cited diabetes and hypertensive heart disease, with the following logic: chronic conditions need chronic care and we have drugs that can treat those conditions.”
But the parallel doesn’t hold up, Kruszewski says. “We use insulin and antihypertensives to treat those metabolic conditions,” he explains but, "psychiatric co-morbidity stemming from drug and alcohol use may do far better without further psychiatric drugs that often do nothing more than treat symptoms and produce new ones."
“While so many psychiatric drugs have little to offer drug and alcohol abusers, many of them nonetheless cause problems," he explains. "Opioid maintenance drugs cause their own dependence and serious withdrawal states and other drugs used to treat alcoholism may blur the baseline mental status and delay recovery.”
“The best care for an alcoholic is to not drink,” he emphasizes.
Anne M. Fletcher, author of Sober for Good, agrees, noting that pricey residential centers do not necessarily help patients more than no-frills state-run centers. Alcoholics and addicts may not need to go to a rehab center at all, Fletcher told theNew York Times. “The truth is that most people recover 1) completely on their own; 2) by attending self-help groups; and/or 3) by seeing a counselor or therapist individually,” she said.
Substitute Drugs for Addiction Expensive and Can Cause More Abuse
The FDA has approved three drugs for treating alcoholics: naltrexone, acamprosate and disulfram. Disulfram, marketed as Antabuse, produces unpleasant effects such as vomiting, hypotension and facial flushing when a person drinks alcohol while taking the drug. Never a popular drug, it costs as much as $136 at Walgreens and $117 at CVS for a month’s supply, according to GoodRx.com.
Naltrexone was approved for the “treatment of alcohol dependence" in 1994 and had already been approved for opioid dependence since it blocks the “effects of exogenously administered opioids.” In pill form, naltrexone, marketed as Revia and Depade, costs approximately $137 at Rite-Aid and $124 at Walgreens. Its once-monthly extended-release injectable formulation is marketed under the trade name Vivitrol. According to GoodRx.com, an injection of Vivitrol is $1,310 at Walmart and $1,356 at CVS with a $500 off coupon. Without a coupon, its monthly price is as high as $2,430, according to GoodRx.com.
Finally, acamprosate was approved in 2004 “for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation.” A month’s supply of acamprosate, sold as Campral, sells for $252 at Walgreens and $245 at Rite-Aid, GoodRx.com reports.
For opioid addiction, buprenorpine, marketed as Suboxone, has been a success story for Pharma and Wall Street though not all patients. Intended to replace opioid/heroin addiction, Suboxone is notoriously difficult to quit, some users and drug counselors say.
A former addict who is now an addiction counselor and does not want to reveal her name, says, "pharmaceutical companies are profiting at the expense of human lives and the disease of addiction. The way Suboxone is prescribed, manufacturers have a captive audience,” she explains. “The ridiculous high dose being prescribed and the long-term use makes it almost impossible to get off of.”
“The withdrawal is absolutely brutal and lasts from 30 days to months compared to 7 to 10 days for oxycodone or heroin acute withdrawal,” she says. Most people "go back to buying Suboxone legally or illegally because they cannot stand the cramps, sweats, diarrhea, no sleep, inability to regulate body temperature, depression, lethargy and no affect.”
“The people on it over a month, and at the high dose, get all these symptoms, even with a slow taper-off of the drug,” she notes. “And it lasts weeks to months. If you are not addicted to opiates and you take a Suboxone, it’s very, very strong.”
Another user in a study of Suboxone misuse in Ohio in 2012 by the Center for Substance Abuse Research at the University of Maryland, said, “People are being introduced to opioids through Suboxone now because, if they were not Suboxone users, the buprenorphine…the active agent in Suboxone is giving them the opiate effect, and now they’re looking for stronger opioids."
Suboxone sells for $560 at CVS and $553 at Target for a 30-day supply, according to GoodRx.
Abuse of Suboxone has become an epidemic, like abuse of opioids and heroin. 2013 statistics "show sharp increases in buprenorphine seizures by law enforcement, in reports to poison centers, in emergency room visits for the nonmedical use of the drug and in pediatric hospitalizations for accidental ingestions," says the New York Times.
In addition to the legal problems and medical emergencies, "an unmet demand for treatment has created a commercial opportunity for prescribers, attracting some with histories of overprescribing the very pain pills that made their patients into addicts," the Times noted.
Many prescribers have checkered pasts. The Times article reports that in 2013, "Nationally, at least 1,350 of 12,780 buprenorphine doctors have been sanctioned for offenses that include excessive narcotics prescribing, insurance fraud, sexual misconduct and practicing medicine while impaired. Some have been suspended or arrested, leaving patients in the lurch."
Drug Problem? Take a Drug
Clearly, the drugs used to treat addiction have become a big revenue stream for Big Pharma. And not surprisingly, many of the medical groups dedicated to addiction psychiatry have strong Big Pharma links.
The American Society of Addiction Medicine (ASAM) has received $47,500 from Pfizer since 2013, according to Pfizer reports. The company that sold Suboxone at the time, Reckitt-Benckiser, paid "at least $100,000 in dues to the American Society of Addiction Medicine," the New York Times reported.
ASAM also published a consensus statement in the December 2011 Journal of Addictive Medicine titled, "Statement of the American Society of Addiction Medicine Consensus Panel on the Use of Buprenorphine in Office-Based Treatment of Opioid Addiction," that was supported "by an unrestricted educational grant to ASAM from Reckitt-Benckiser Pharmaceutics Inc, manufacturer of Subutex and Suboxone." No conflict of interest there.
At least six board of directors at the American Academy of Addiction Psychiatry (AAAP) have financial links to Pharma companies including three who actually serve on drug makers’ speaker boards.
These Pharma-funded groups also receive our tax dollars. The program for AAAP’s 25th Annual Meeting thanks the Center for Substance Abuse Treatment, Substance Abuse Mental Health Services Administration, National Institute on Alcohol Abuse and Alcoholism, and National Institute on Drug Abuse, all federal agencies, for their financial support.
There is also a group whose entire purpose is buprenorphine/Suboxone promotion. The National Alliance of Advocates for Buprenorphine Treatment (NAABT), which admits it has "received donations from pharmaceutical companies" says its mission is to "Educate the public about the disease of opioid addiction and the buprenorphine treatment option; help reduce the stigma and discrimination associated with patients with addiction disorders; and serve as a conduit connecting patients in need of treatment to buprenorphine treatment providers."
NAABT aggressively defends Suboxone sales as science-based and strikes back at news outlets reporting their downsides. "We are allowing the critics and the uninformed to frame the discussion about medication-assisted treatment," and “negative hype about buprenorphine," it says.
Drugs Meant to Help Lead to Costly Lifelong Addiction
To doctors and reporters who remember when the treatment for drug and alcohol addiction was not an expensive substitute drug, the popularity and monetizing of rehab is disturbing. Many addiction patients are young and do not realize that treating addiction as a life-long illness requiring expensive drugs is a relatively new and extremely lucrative contrivance of Big Pharma.
Nor have many tried to quit their substitute drugs yet, as Stacey Pope told us she did after she became addicted to pain medications prescribed during several surgeries and wanted to avoid going through withdrawal by taking Suboxone. In order to get the drug prescribed, she had to pay a doctor an initial charge of $600, and another $100 fee every month to get her prescription refilled. Each prescription was $412 for a month’s supply and the costs were not covered by her insurance. “The terrible thing about Suboxone was that my doctor didn’t have a plan for me to get off it,” Pope said.
Pope remained on Suboxone for seven months and decided to try to go off the drug herself. “After watching a show on heroin, I realized I was no different than they were,” she said. In an attempt to wean herself off Suboxone, she started cutting down the dose and canceled her monthly appointments with the doctor.
“They called to see how I was and when I told them I was great and wouldn't need to come in for a refill for another month, I was told I had to come in monthly to stay in the program,” she said. “I knew they could care less about me. They wanted my $100 but I never went back.”
Sadly, there is more to Pope’s story. "I was under the impression you wouldn't be sick coming off Suboxone," she said. "But my pharmacist said no matter how low my dose, I would go through withdrawal."
Pope endured the withdrawal side-effects for months, including anxiety, chills, sweats, sleeplessness, body aches, restless legs and depression. She also relapsed on pain medications a few times and had to suffer through withdrawal again from those drugs. Several months after going off Suboxone, Pope “stumbled with alcohol” off and on for some time. Now she says, “I’ve come to realize there’s a reason they say abstain from all drugs."
Evelyn Pringle and Martha Rosenberg
Addiction psychiatry, essentially treating drug addicts with other drugs, has become a hugely profitable industry.
Addiction treatment has become big business. If you haven't noticed it yet, investors certainly have. The U.S. Substance Abuse and Mental Health Services Administration projected the market for addiction treatment at about $35 billion for 2014.
Since 2006, private equity firms have invested more than $2.2 billion in substance abuse treatment companies. The private equity firm Bain Capital paid $720 million for CRC Health in 2006 only to turn around and sell it for $1.18 billion to Acadia Healthcare Company Inc. in 2014. Acadia operates 76 facilities with about 5,800 licensed beds in 24 states, Puerto Rico and the U.K.
Why are addiction treatment companies so lucrative, with profit margins of over 20 percent? Largely because of the booming specialty of addiction psychiatry, which has exploded and muscled its way into standard rehabilitation and monetized it.
“The insurance companies told the rehabs they would no longer pay for inpatient rehab for heroin, cocaine or alcohol unless there was also another Axis 1 psychiatric disorder like bipolar disorder or major depression,” explains psychiatrist Phil Sinaikin, author of Psychiatryland. “I was working in a drug treatment facility when the change happened. Since addicts typically complain of anxiety and depression, a completely understandable emotional response to their toxic lifestyles, it was no problem to add a new label and throw a few psychiatric drugs at their now relabeled ‘dual diagnosis.’”
Unlike older treatments for alcoholics and addicts, addiction psychiatry treats substance abusers much like primary care physicians treat physically ill patients—with drugs, even though their problem is drugs. As illogical as it may seem, the practice of harm reduction is addiction psychiatry’s standard operating procedure, substituting one or several drugs for the original substance with the goal of stabilizing the patient, not necessarily recovery. The treatment model essentially tells patients nothing really can be done about their addiction except to provide them more drugs, sometimes for life.
Helping the increase in drug patient pools, in 2013 the American Psychiatric Association loosened the definitions of alcohol use disorders, eliminating “legal problems” but adding “craving.” (The APA’s financial links to Big Pharma have been widely reported.) The problem with the harm reduction/maintenance model is obvious; the substance abuser never recovers, but simply stays hooked on another or multiple drugs, while Big Pharma cashes in.
“This basis for [such harm reduction] treatment has its analogy to other chronic disorders,” psychiatrist Stefan P. Kruszewski at the Center for Drug Safety and Effectiveness, Department of Mental Health, at Bloomberg School of Public Health and John Hopkins University Medical School, told us in an interview. Addiction is thought of “like often-cited diabetes and hypertensive heart disease, with the following logic: chronic conditions need chronic care and we have drugs that can treat those conditions.”
But the parallel doesn’t hold up, Kruszewski says. “We use insulin and antihypertensives to treat those metabolic conditions,” he explains but, "psychiatric co-morbidity stemming from drug and alcohol use may do far better without further psychiatric drugs that often do nothing more than treat symptoms and produce new ones."
“While so many psychiatric drugs have little to offer drug and alcohol abusers, many of them nonetheless cause problems," he explains. "Opioid maintenance drugs cause their own dependence and serious withdrawal states and other drugs used to treat alcoholism may blur the baseline mental status and delay recovery.”
“The best care for an alcoholic is to not drink,” he emphasizes.
Anne M. Fletcher, author of Sober for Good, agrees, noting that pricey residential centers do not necessarily help patients more than no-frills state-run centers. Alcoholics and addicts may not need to go to a rehab center at all, Fletcher told theNew York Times. “The truth is that most people recover 1) completely on their own; 2) by attending self-help groups; and/or 3) by seeing a counselor or therapist individually,” she said.
Substitute Drugs for Addiction Expensive and Can Cause More Abuse
The FDA has approved three drugs for treating alcoholics: naltrexone, acamprosate and disulfram. Disulfram, marketed as Antabuse, produces unpleasant effects such as vomiting, hypotension and facial flushing when a person drinks alcohol while taking the drug. Never a popular drug, it costs as much as $136 at Walgreens and $117 at CVS for a month’s supply, according to GoodRx.com.
Naltrexone was approved for the “treatment of alcohol dependence" in 1994 and had already been approved for opioid dependence since it blocks the “effects of exogenously administered opioids.” In pill form, naltrexone, marketed as Revia and Depade, costs approximately $137 at Rite-Aid and $124 at Walgreens. Its once-monthly extended-release injectable formulation is marketed under the trade name Vivitrol. According to GoodRx.com, an injection of Vivitrol is $1,310 at Walmart and $1,356 at CVS with a $500 off coupon. Without a coupon, its monthly price is as high as $2,430, according to GoodRx.com.
Finally, acamprosate was approved in 2004 “for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation.” A month’s supply of acamprosate, sold as Campral, sells for $252 at Walgreens and $245 at Rite-Aid, GoodRx.com reports.
For opioid addiction, buprenorpine, marketed as Suboxone, has been a success story for Pharma and Wall Street though not all patients. Intended to replace opioid/heroin addiction, Suboxone is notoriously difficult to quit, some users and drug counselors say.
A former addict who is now an addiction counselor and does not want to reveal her name, says, "pharmaceutical companies are profiting at the expense of human lives and the disease of addiction. The way Suboxone is prescribed, manufacturers have a captive audience,” she explains. “The ridiculous high dose being prescribed and the long-term use makes it almost impossible to get off of.”
“The withdrawal is absolutely brutal and lasts from 30 days to months compared to 7 to 10 days for oxycodone or heroin acute withdrawal,” she says. Most people "go back to buying Suboxone legally or illegally because they cannot stand the cramps, sweats, diarrhea, no sleep, inability to regulate body temperature, depression, lethargy and no affect.”
“The people on it over a month, and at the high dose, get all these symptoms, even with a slow taper-off of the drug,” she notes. “And it lasts weeks to months. If you are not addicted to opiates and you take a Suboxone, it’s very, very strong.”
Another user in a study of Suboxone misuse in Ohio in 2012 by the Center for Substance Abuse Research at the University of Maryland, said, “People are being introduced to opioids through Suboxone now because, if they were not Suboxone users, the buprenorphine…the active agent in Suboxone is giving them the opiate effect, and now they’re looking for stronger opioids."
Suboxone sells for $560 at CVS and $553 at Target for a 30-day supply, according to GoodRx.
Abuse of Suboxone has become an epidemic, like abuse of opioids and heroin. 2013 statistics "show sharp increases in buprenorphine seizures by law enforcement, in reports to poison centers, in emergency room visits for the nonmedical use of the drug and in pediatric hospitalizations for accidental ingestions," says the New York Times.
In addition to the legal problems and medical emergencies, "an unmet demand for treatment has created a commercial opportunity for prescribers, attracting some with histories of overprescribing the very pain pills that made their patients into addicts," the Times noted.
Many prescribers have checkered pasts. The Times article reports that in 2013, "Nationally, at least 1,350 of 12,780 buprenorphine doctors have been sanctioned for offenses that include excessive narcotics prescribing, insurance fraud, sexual misconduct and practicing medicine while impaired. Some have been suspended or arrested, leaving patients in the lurch."
Drug Problem? Take a Drug
Clearly, the drugs used to treat addiction have become a big revenue stream for Big Pharma. And not surprisingly, many of the medical groups dedicated to addiction psychiatry have strong Big Pharma links.
The American Society of Addiction Medicine (ASAM) has received $47,500 from Pfizer since 2013, according to Pfizer reports. The company that sold Suboxone at the time, Reckitt-Benckiser, paid "at least $100,000 in dues to the American Society of Addiction Medicine," the New York Times reported.
ASAM also published a consensus statement in the December 2011 Journal of Addictive Medicine titled, "Statement of the American Society of Addiction Medicine Consensus Panel on the Use of Buprenorphine in Office-Based Treatment of Opioid Addiction," that was supported "by an unrestricted educational grant to ASAM from Reckitt-Benckiser Pharmaceutics Inc, manufacturer of Subutex and Suboxone." No conflict of interest there.
At least six board of directors at the American Academy of Addiction Psychiatry (AAAP) have financial links to Pharma companies including three who actually serve on drug makers’ speaker boards.
These Pharma-funded groups also receive our tax dollars. The program for AAAP’s 25th Annual Meeting thanks the Center for Substance Abuse Treatment, Substance Abuse Mental Health Services Administration, National Institute on Alcohol Abuse and Alcoholism, and National Institute on Drug Abuse, all federal agencies, for their financial support.
There is also a group whose entire purpose is buprenorphine/Suboxone promotion. The National Alliance of Advocates for Buprenorphine Treatment (NAABT), which admits it has "received donations from pharmaceutical companies" says its mission is to "Educate the public about the disease of opioid addiction and the buprenorphine treatment option; help reduce the stigma and discrimination associated with patients with addiction disorders; and serve as a conduit connecting patients in need of treatment to buprenorphine treatment providers."
NAABT aggressively defends Suboxone sales as science-based and strikes back at news outlets reporting their downsides. "We are allowing the critics and the uninformed to frame the discussion about medication-assisted treatment," and “negative hype about buprenorphine," it says.
Drugs Meant to Help Lead to Costly Lifelong Addiction
To doctors and reporters who remember when the treatment for drug and alcohol addiction was not an expensive substitute drug, the popularity and monetizing of rehab is disturbing. Many addiction patients are young and do not realize that treating addiction as a life-long illness requiring expensive drugs is a relatively new and extremely lucrative contrivance of Big Pharma.
Nor have many tried to quit their substitute drugs yet, as Stacey Pope told us she did after she became addicted to pain medications prescribed during several surgeries and wanted to avoid going through withdrawal by taking Suboxone. In order to get the drug prescribed, she had to pay a doctor an initial charge of $600, and another $100 fee every month to get her prescription refilled. Each prescription was $412 for a month’s supply and the costs were not covered by her insurance. “The terrible thing about Suboxone was that my doctor didn’t have a plan for me to get off it,” Pope said.
Pope remained on Suboxone for seven months and decided to try to go off the drug herself. “After watching a show on heroin, I realized I was no different than they were,” she said. In an attempt to wean herself off Suboxone, she started cutting down the dose and canceled her monthly appointments with the doctor.
“They called to see how I was and when I told them I was great and wouldn't need to come in for a refill for another month, I was told I had to come in monthly to stay in the program,” she said. “I knew they could care less about me. They wanted my $100 but I never went back.”
Sadly, there is more to Pope’s story. "I was under the impression you wouldn't be sick coming off Suboxone," she said. "But my pharmacist said no matter how low my dose, I would go through withdrawal."
Pope endured the withdrawal side-effects for months, including anxiety, chills, sweats, sleeplessness, body aches, restless legs and depression. She also relapsed on pain medications a few times and had to suffer through withdrawal again from those drugs. Several months after going off Suboxone, Pope “stumbled with alcohol” off and on for some time. Now she says, “I’ve come to realize there’s a reason they say abstain from all drugs."
