Comedian John Oliver took on Rehab during this recent show on HBO. Oliver is from that branch of comedy that uses shock tactics to draw attention, a la Richard Pryor and Lenny Bruce. Hopefully viewers aren’t so distracted that they miss the very serious issues he brings up.
Those issues are familiar to people in the addictions field, many of whom are just sick about it. Not least because they know they will inevitably be tarred with the same brush.
I want to address just one of the issues that Oliver brings up. I’ll return to others in future posts.
A lack of regulation of treatment providers – this deserves closer scrutiny than Oliver has time to give it. For one thing, he lumps all categories of treatment together, from inpatient all the way down to mom-and-pop recovery homes. But in reality, certain levels of care are highly regulated, while others are largely ignored.
As with so many other functions, the Federal Government has left the problem of regulation to the states. One result: some states have too few regulations and others arguably suffer from too many. I know of a number of state governments that have taken steps to improve their standards, and to make them more consistent across the board. That means changing the law, which is never easy.
The real issue, in my experience working with providers, is the absence of consistent monitoring and enforcement of those standards. In their eagerness to reduce the size of government (a frequent campaign promise), states have stripped away staff who would otherwise make onsite visits to ensure compliance. One monitor, recently retired from the state during a reduction in force, was recruited back a year later as a contractor to do essentially the same job. His Department had fallen hopelessly behind when it came to investigating complaints and monitoring essential functions. There was a need.
I questioned him about the wisdom of this– layoffs and buyouts, followed by rehires. Didn’t that just unnecessarily interrupt the agency’s functions, and create a bunch of new problems? He readily acknowledged that. But there had been political pressure to downsize during one year, followed by a spate of critical incidents during the next. That had drawn public criticism, something all politicians wish to avoid. Faced with a crisis, the easiest solution was to rehire people who already knew the job. “Plus we don’t show up on the HR reports as regular employees,” he went on to say, “so it doesn’t look like the government is adding positions, which would tick off the budget hawks.”
The challenge of enforcing compliance is analogous to enforcing drunk driving laws. The efficiency of the process is more important than the severity of penalties. The goal is to catch violators and impose consequences without delays. Same with treatment providers: it’s important to monitor compliance regularly and consistently, and to administer penalties as soon as possible after a violation is discovered.
To do so, you need people in the field. That means adequate staff. Which in turn means money in the budget. And that’s where politics can interfere.
In a sense, this is one if those problems that’s self-created. The remedy is a government and a political process that simply works the way it should.
Nowhere is this problem more critical than in medication assisted treatment.