Longer Treatment Programs Now Being Recommended

[Ursus]

Los Angeles Times
At addiction centers, longer treatment programs are proving key to ending the relapse-rehab cycle

Thirty days' treatment is the norm, but more facilities are offering programs to patients that extend to 45 days, 90 days and even longer.
November 10, 2008

By Shari Roan >>> We love quick, tidy solutions in this country. With health problems, in particular, we're impatient. Pills to ease each and every symptom? Great. Same-day surgery? Terrific. A scheduled cesarean section? Bring it on.

But in the case of drug and alcohol dependence, it's becoming increasingly clear that there is no such thing as get-well-quick therapy. Instead, with scientific evidence showing that the longer the treatment, the better the chance of lasting sobriety, addiction centers nationwide are lengthening their programs and firmly discouraging patients from early checkouts.

For more than a year, the Betty Ford Center in Rancho Mirage has offered a 90-day residential treatment program, in addition to shorter programs, that attracts about one-third of all clients. Promises Treatment Center in Malibu now provides more than half of its clients with 45- to 90-day treatments and last year extended its young-adults program from 30 days to 90 days.

Visions, which provides adolescents with addiction treatment in Malibu, increased its program's length from 30 days to 45. Hazelden, the legendary treatment program based in Minnesota, has added beds in nearly all of its facilities over the last two years to meet a growing demand for treatment programs of 90 days or more.

Addiction experts say that longer treatments -- with the length of stay based on the client's specific needs -- will lead to fewer people cycling between 30-day hospitalizations and relapses for years on end. From 40% to 60% of people relapse after drug treatment, according to the National Institute on Drug Abuse.

"Treatment is dose-related," says Dr. Harry Haroutunian, director of the licensed professional program at the Betty Ford Center. "More is often better, depending on what you do with the time."

Treatment programs of 28 or 30 days are still common. But this template was never based on medical evidence, says Dr. David Lewis, Vision's medical director. Lewis, who in the 1970s helped establish the first addiction treatment program in the U.S. Air Force, says 30-day stays were scheduled for bureaucratic reasons -- men and women didn't need to be reassigned if they were away from duty for no more than 30 days. Other treatment centers followed suit, and insurers adopted the standard of 28 or 30 days of inpatient care.

Today, addiction experts recognize that it's foolish to treat every patient the same way.

"There was a belief that 30 days was the right number," says Dr. David Sack, chief executive of Promises and an addiction psychiatrist. "But there was absolutely no data to say 30 days was the right number. . . . The programs were cookie cutters. What we're seeing now is this much broader view for how to manage addiction. There isn't this naive optimism that people will reach 30 days and they'll be fine."

Relapse rates

In fact, data suggest 30 days aren't nearly enough.

• Research published in 1999 by Bennett Fletcher, a senior research psychologist at the

National Institute on Drug Abuse, has shown that though 90 days isn't a magic number, anything less than that tends to increase the chances of relapse. One study, of 1,605 cocaine users, looked at weekly cocaine use in the year after treatment. It found that 35% of people who were in treatment for 90 days or fewer reported drug use the following year compared with 17% of people who were in treatment for 90 days or longer. The study was published in the Archives of General Psychiatry.

• Another study, part of an NIDA-funded project called Drug Abuse Treatment Outcome Studies, followed 549 patients who had several problems in addition to their drug use and who entered a long-term residential program. Those who dropped out of treatment before 90 days had relapse rates similar to those who stayed in treatment only a day or two. After 90 days, however, relapse rates dropped steadily the longer a person stayed in treatment.

• Studies of youth also reflect the connection between longer care and a greater chance of recovery. A 2001 UCLA study of 1,167 adolescents receiving substance-abuse treatment found that those in treatment for 90 days or more had significantly lower relapse rates than teens in programs of 21 days.[/list]

Some of the earliest evidence emerged from high success rates in treatment of addicted health professionals, says Haroutunian: The Federation of State Physician Health Programs has long recommended 90-day treatments and continued follow-up care for doctors who abuse drugs.

Longer treatment reflects the fact that addiction is a chronic, relapsing disorder, says Lisa Onken, chief of NIDA's behavioral and integrative treatment branch.

"The more you have a treatment that can help you become continuously abstinent, the better you do," she says. "You have to figure out how to be abstinent. You still have cravings. You still have friends offering you drugs. You still have to figure out ways not to use. The longer you are able to do that, the more you are developing skills to help you stay abstinent."

Additional time in treatment allows people to learn to handle stress, develop ways to cope with environmental cues that could trigger drug use and improve relationships that are needed to sustain recovery.

However, time alone isn't a solution. Many addicts stop using for long periods of time while incarcerated but relapse after being released.

"There is no real evidence that just locking someone up, denying someone access to drugs alone, will cure an addiction," Onken says. "It's not just length of treatment that is important. It's length of treatment that is working."

28 days later

The first month of treatment is now viewed as a first step, Fletcher says. It often consists largely of coping with withdrawal symptoms and establishing a relationship with a therapist.

"People are often detoxifying for 28 days," Haroutunian says. "Their mind is not right. Their temperament is not right. They have emotional instability, poor judgment, physical complaints, sleep problems -- things that keep them in a very delicate state of vulnerability to coping with life stresses. If they are out there in the world after only 28 days and get flooded with these things, they are vulnerable to relapse."

Brain scans of recovering addicts support the idea that changes are still taking place three months or more after treatment. Chronic drug use damages the brain, such as reducing the number of dopamine receptors, chemical pathways that allow for normal brain functioning. Changes in the brain during recovery correlate to clearer thinking and more honesty on the part of the patient, Haroutunian says. It's often only at that point that therapists discover other problems, such as physical or mental-health problems, eating disorders, gambling issues, relationship problems or a history of abuse or molestation.

"If that is not identified and treated, it can easily bring someone back to their original drug of choice," he says.

Haroutunian notes that Alcoholics Anonymous, founded more than 70 years ago, recommends: "90 meetings in 90 days."

"I think the founders of the 12-step program were divinely inspired in their wisdom, which science and data are now supporting," he says.

Trying to get clean

Drug abuse became a way of life for Steve Owens at age 11. After being molested as a child, he says, "I found drugs the only way to have comfort."

Owens abused cocaine, alcohol and prescription drugs, and later, heroin. By age 21, after numerous arrests on drug-related charges, he entered a 30-day treatment program. It was the first of 34 hospital stays he would experience over the next two decades, each time relapsing after the month-long treatment ended.

"They would clean me up and I would start to get back on my feet again, mentally, physically and spiritually," he says. "Then I would get out and go right back where I came from -- the same friends and the same places. With these rehabs, you just get started before they let you go."

At one point, Owens, who is now 50, stayed clean for seven years. But after his brother died unexpectedly, he relapsed. He was living in Atlanta at the time and heard of Promises in Malibu. Twice he entered for 30-day stays -- stints that were followed by relapses. When he flew to Los Angeles for a third try -- about five years ago -- he was so addled by drugs that he got on the wrong plane and ended up in restraints in a hospital psychiatric ward. He was released to Promises and told a therapist, "If you let me stay here, I'll do anything you say."

He agreed to 30 days of hospitalization followed by five months in a sober-living house from which he was free to come and go but where he also received daily counseling. After leaving the sober-living house, he attended a nine-month intensive outpatient group and completed a 12-step program.

The year he devoted to getting well "was the best thing that ever happened to me," says Owens, who now lives in Los Angeles and runs a nonprofit group that supports rehab for people who are homeless, as well as women with children. "I got a chance to get on my feet the first 30 days and then I got a chance to get used to being clean and sober and staying away from the people I used to drink and use with. I was able to let go of the past and apologize to the people I've hurt. I became a free man."

However, it's tough to convince some addicts or their family members that three to six months of treatment offers the best chance of success. People argue that they can't leave their jobs, school or families for that long, Sack says. They want to put the problem behind them as quickly as possible.

"They want to believe it will be fixed up very quickly and they can go back to normal and not have to talk about it," he says.

Instead, he compares addiction to any chronic disease, such as heart disease or diabetes, in terms of the attention and perseverance needed to remain healthy.

Longer-duration treatment doesn't necessarily mean a hospital or residential stay, experts say. Some treatment centers and hospitals offer transition to a sober-living residence, where residents are free to go about their lives but also receive daily counseling. The Betty Ford Center has about 15 houses, with six people to a home, to continue long-term care. The residences are designed to allow clients to return to more normal lives while offering support and advice in remaining drug-free.

"The supervision is light," Haroutunian says. "They go into the community. But they more or less report in every day for their program."

Coverage varies

Some people would like to commit to a longer period of treatment but can't afford it.

Most states, including California, have laws mandating that group health insurance plans include addiction-treatment coverage, but insurance programs vary widely in the amount of inpatient care that is covered. Some plans cover 30 days of inpatient care per year, although other insurers will discontinue inpatient coverage after a week or two if a patient is physically stable. A few will pay for treatment that lasts more than 30 days.

Care is typically most expensive in the first month, Haroutunian says. At Betty Ford, the first month of inpatient treatment costs $24,000; the second and third months cost $8,000 each.

People without insurance coverage often pay out-of-pocket. The cost is overwhelming to most people, he acknowledges. "But we tell them it may save their life. Most people see the wisdom in that."

Intensive outpatient programs are becoming more common for people who cannot afford the steep price of long inpatient or residential care, Fletcher says. Successful care of that nature, he says, "means, on average, at least every other day having contact with a group or therapist."

In his counseling work, Owens says, he encounters resistance to the idea of spending three months or more devoted to nothing but recovery. People view it as a sacrifice, but he tries to reassure them they'll gain more than they lose.

"Even if you have to lose a job, so be it," Owens says. "You're trying to save your life. And what comes next could be the best part of your life."

Roan is a Times staff writer.

[email protected]

[Anonymous]

I should start selling drugs right outside the exit door of those places.

I think business will be good

[Ursus]

Join Together picked up that story, and there are a few interesting (and revealing!) posts in the Comments section (scroll down; I've included them).

-------------- • -------------- • --------------

Longer Treatment Stays Prove Beneficial
November 12, 2008

News Summary

Lengthier treatment stays for addiction have better rates of success, research shows, and some traditional 28-day programs have extended their programs to up to 90 days, the Los Angeles Times reported Nov.10.

The Betty Ford Center in Rancho Mirage, Calif., for example, now has a 90-day residential treatment program. More than 50 percent of the clients in Promises Treatment Center in Malibu are in 45- to 90-day treatment programs; the young-adult program at Promises has been extended from 30 days to 90 days.

Visions, an adolescent addiction center in Malibu, increased its program length from 30 days to 45. Hazelden also is expanding to meet the demands for treatment programs of 90 days or more.

Although 28- or 30-day treatment programs are still common, addiction experts say that longer treatment programs will help to curtail the cycle of hospitalization and relapse.

"There was a belief that 30 days was the right number," said David Sack, chief executive of Promises and an addiction psychiatrist. "But there was absolutely no data to say 30 days was the right number. What we're seeing now is this much broader view for how to manage addiction."

Recent research suggested that programs of 90 days or longer have a significant impact on relapse rates. A 1999 study published in Archives of General Psychiatry found that 35 percent of cocaine users who were in treatment for 90 days or less said they used drugs the following year, compared with 17 percent of those who were in treatment for 90 days or longer. Similarly, a UCLA study on adolescents found that those in treatment for 90 days or more had significantly lower relapse rates than teens in 21-day programs.

"The more you have a treatment that can help you become continuously abstinent, the better you do," said Lisa Onken, chief of the National Institute on Drug Abuse (NIDA) behavioral and integrative treatment branch. "You still have to figure out ways not to use," Onken added. "The longer you are able to do that, the more you are developing skills to help you stay abstinent."

Bennett Fletcher, a senior research psychologist at NIDA, said that the first month of treatment is now viewed as a preliminary step consisting of learning to cope with withdrawal symptoms while establishing a relationship with a therapist. This theory is supported by brain scans of recovering addicts which show that changes are still occurring three months or more after treatment.

The cost of longer treatment stays is out of reach for some patients, however. Although most states have laws mandating that group health insurance plans include addiction-treatment coverage, programs vary in the amount of inpatient care covered. Some plans cover 30 days of inpatient care per year; other insurers will discontinue inpatient coverage after a week or two if a patient is physically stable; some pay for treatment lasting more than 30 days.
 
———————————————————————————
COMMENTS ON THIS ARTICLE:

Posted by Jere Bunn, Saranc Lake, NY on 13 Nov 08 09:13 AM EST
Having been in the field during the time of the transition from literally no "funding" to the initial acceptance by Insurance Co. to cover alcoholism (first - then drugs later) I clearly remember the "number of treatment" days was a decision made the third party payers rather then the clinicians.

Posted by Pete on 13 Nov 08 11:30 AM EST
Here's another example where many of these insurance plans are being "penny wise and pound foolish." If the evidence supports that 90 days or more of treatment leads to much lower relapse rates, the cost-savings over the LONG TERM should more than justify the higher intial outlay. Sadly, if single-party (government) healtcare comes to pass, there will probably be even more such decisions being made by people other than the clinicians directly involved with the patients.

Posted by Guido iovinella on 13 Nov 08 11:36 AM EST
I regret to say that despite the data treatment stays are shorter. This has been driven by the insurance companies and remains a concern for all providers

Posted by David H. Kerr on 13 Nov 08 11:38 AM EST
Here is another piece of the puzzle to our society's growing awareness about the disease of drug addiction. The LA Times reports on the growing research saying "Lengthier treatment stays for addiction have better rates of success.." One of the most accurate statements comes from our National Institute on Drug Abuse (NIDA) "The more you have a treatment that can help you become continuously abstinent, the better you do," said Lisa Onken, chief of the National Institute on Drug Abuse. The article quotes recent research calling for 90+ days of treatment but then goes on to say that most insurance programs won't cover this. From our experience, recovery and a drug free lifestyle is a lifelong commitment. Treatment is only the catalyst to this lifestyle change. Long term lifestyle changing programs like our Integrity House residential Therapeutic Communities, followed by a halfway house to give the new recovering addict support in finding a job, housing, school, more stable relationships and other longterm positive directions is the best approach to promote a drug and alcohol free lifestyle. Hard core addicts need to start with a 5 year continuum of treatment and recovery.

Posted by Robin McCrae, Community Human Services on 13 Nov 08 01:54 PM EST
Our experience in 4-6 month residential treatment is that 30-35% of admissions get clean and are still clean and sober at the 6-month follow up -- a great outcome that makes a good case for long-term treatment.

Posted by johnedwin on 13 Nov 08 02:17 PM EST
The long term treatment for our health is keep smiling.As to humour, surely right that it is possible to see having a sense of humour as a virtue, especially when it allows us to laugh at ourselves; for in this case humour enables us to get a distance on ourselves and, perhaps, if we are lucky, to grow in an ethical sense.The laugh is help to improve our health in longer term of the conditions.It will be the best long term medicine for the treatment of our health. ----------- johnedwin dating

Posted by Robert on 13 Nov 08 04:01 PM EST
The entire premise about length of stay being THE important determinent in long-term sobriety is wrong. It merely perpetuates the same, old discredited psyho-social approach to addition care. The truth is relapse rates approach 80% or more in the vast majority of such cases. Addiction needs to be treated as a primary neuro-biological social disease. Repeated studies have shown, as in the success of buprenorphine care, that too often the hard sciences are ignored in favor of social sciences.

Posted by Been there on 13 Nov 08 04:34 PM EST
For over 60 years the social model movement originating in California, by way of recovery homes, has known the longer an addicted person stays in the treatment environment, the better their overall chance for long-term rewarding abstinence. Recovery homes and halfway houses usually got short shrift and labeled unprofessional, paraprofessional or looked at as tertiary placement after "real" treatment took place. What happened is the insurance coverage ended and the person still needed help. These programs found that recovery from alcoholism usually didn’t require hospitals, doctors or therapeutic counseling. The medical model looked askance at such a notion. Social model programs created an environment allowing recovery opportunities to occur through everyday living absent the use of substances. Recovery from addiction is viewed from a public health model. (Read Social Model Alcohol Recovery an Environmental Approach by Sandra Shaw and Thomasina Borkman). Unfortunately, now that research is showing a small, but very significant piece of social model methodology has worked for all these years, the model itself is near extinction. At least the length of stay issue has come to light.

Posted by John from Oceanside on 14 Nov 08 11:00 AM EST
Been there I just wanted to tell you that Social Model is still alive in San Diego. We have 21 County funded Recovery Houses and probably 10 to 15 that are funded in other ways all doing great work. We have some that are 40 to 50 years old now. Maybe with these lean times the policy makers will look back to what works and is cost effective.

Posted by drgray on 15 Nov 08 09:43 PM EST
The current treatment system is outmoded and ineffectual as the insurance companies see it. They want results. A genetic/dependency neurobiopsychosocial model is science and evidence based. It has worked very well long-term. As short-term detox and long-term highly individualized outpt Tx at 1-2 sessions per week to start going to bi-weekly and monthly based on progress extending from 1-2 years works long-term. Current technologies make 60-90 day inpt and high-tech Tx as above noted is very workable. Insurance companies want more bang for their buck. They demand it and it can and is being done with long-term positive outcomes. Existing programs can be modified to science/evidence based. "Don't throw the baby out with the bathwater." Use high tech modification. Use the ATTC's for training existing counselors. High tech is here to stay and improve on a daily basis. Patients and families get well. Cost to insurance is a $ saving investment.

Posted by verhelst recovery house on 17 Nov 08 02:28 PM EST
meaningless in the face of the demands for 30 and out by our local agencies and state (AZ) licensing requirements which have bankrupted us. Now we're at 30 years of service and out of service

Posted by Marilyn Lewis on 17 Nov 08 02:34 PM EST
Extended lengths of stay may work for some, but may not be feasible for women with children. Compared to men, women who enter treatment for cocaine have been found to use cocaine more frequently and to use greater amounts. They also have responsibility for more dependent children at treatment entry. Men are more likely to use alcohol,and have lost custody of their children. They may benefit from a 90-day stay, but many women try to stop on their own because they don't want to lose custody. While we are on the right track, one size doesn't fit all.

Posted by bisbee verhlst house on 17 Nov 08 02:35 PM EST
meaningless and obvious to the casual observer. after more than 30 years of service, we are broken by virtue of demands for 28 day programs by local agencies and the cost of state (AZ) licensing requirements. When are you going to help small rural local service providers? For 25 years we ran on no government funds, but when we went legitimate, we couldn't get the money. Staff is working without pay and you're reporting that longer stays work better than 28 days at what, compared to us, is a bleeping resort?

Posted by Woods on 17 Nov 08 04:04 PM EST
I think the followup after residuntial treatment is very important regardless how many days of treatment. The number of days depends on the individual needs which is overlooked. There is no silver bullet or required time. The time stay should be paitient driven in an ideal world not isurance.

Posted by Emmett Kelly on 17 Nov 08 04:27 PM EST
All of this means nothing until "rates of success" and the traditional, i.e., "30 day" treatment outcomes are compared with persons receiving "longer term treatment" to maintain sobriety. Naturally this comparison will be based on hard numbers and a large participant group in each category over a long period of time Without such data, this is just more hype from two of the most expensive, private treatment centers on the West Coast. Did either "Betty" or "Promises" mention rates of relapse or extended periods of continuous sobriety? Hello.

Posted by [email protected] on 17 Nov 08 07:48 PM EST
There has been long time conventional wisdom that what this report states is true. But, there are so many other variables that it isn't really very usefull. Add to the fact that "Recovery" has been poorly defined, as has been Relapse, Lapse...and the choice to use certain substances and not others e.g. wine but not cocaine and to do so without problems...AND of course, in this best of all possible worlds who is going to pay for this long term treatment, who will maintain the mortgage, the child care etc. This report no doubt made someone some money and I hope they spend it well, I am sure that they needed it. At some point we have to get away from the "car wash" mentality of rehab and develop some reality based treatment.

Posted by Richard on 18 Nov 08 09:02 AM EST
Longer $tay$ are also benefit treatment center$ and their owner$$$$$$$$.

Posted by nelsontdi on 18 Nov 08 10:40 AM EST
Long-term stays are better, it is common knowledge, but let's not forget the importance of a good aftercare plan. At least a month in intensive outpatient followed by aftercare and then individual treatment for at least one year, of course with self help involvement. Also, one must assess and treat the family, see and treat what's going on systemically. And let's not forget a good mental health assessment and psychiatric treatment if needed. Also, are we assessing for appropriateness of referral to medication protocols, Suboxone, Vivitrol? I believe 30 day stays and even shorter stays have their place. Longer-term placement, if the client is not ready, may be contradictory. The long-term stay for adolescents may be more effective for the second placement. There are just so many variables, needs should to be assessed on an individual bases. Studies need to take into account the many variables. It would be great if the insurance companies recognized the need for longer-term treatment in at least some instances. For me I believe we need to advocate for longer-term care when appropriate.

Posted by Dr. Doyle on 18 Nov 08 12:15 PM EST
Remember when the mantra was that outpatient was as good as inpatient for the employed, motivated, supported addict with a home? Those few studies (with EAPs, I believe) ruined discussion regarding longer inpatient stays for the next decade. I recall myself trying to spin the situation to desperate addicts citing those studies, knowing "it just don't make sense..." I'm glad the pendulum has swung back.

Posted by jrzshor on 19 Nov 08 11:11 AM EST
having worked in this field for 20 yrs I can say that "longer" in tx is a really silly notion. It is no the length of time spent but how it is spent, If a client does not learn how to deal with life as is (which is pretty daunting for any sober person), then nothing can or will help.

[Ursus]

A related article, which dates from a year prior to the above two:

-------------- • -------------- • --------------

Los Angeles Times
The trouble with rehab, Malibu-style
Lawsuits and violations reveal problems in a luxury cottage industry for the addicted.
October 09, 2007 | Paul Pringle, Times Staff Writer

Hollywood rehab can produce unhappy endings, even when the patient isn't named Lindsay or Britney.

That's what Kelly Logan learned when he sought treatment for a methamphetamine addiction at Promises Malibu, detox destination to the stars.

Logan's brother, Garfield, says he paid $42,000 up front to admit the former professional surfer for a month at Promises' canyon-top Mediterranean-style home. Five days later, he says, Promises kicked Logan out for belligerent behavior but kept all the money.

"They're scam artists," said Garfield Logan, a plaintiff in one of four consumer-rights, breach-of-contract and unfair-business-practice lawsuits filed against Promises Malibu and its Westside branch in the last year. Promises has denied the allegations.

The suits and state licensing violations reveal a little-seen side to the high-end rehabilitation centers that have become a Malibu cottage industry and -- thanks to such patrons as Promises alums Lindsay Lohan and Britney Spears -- a tabloid feeding ground.

The legal problems also reflect how the Malibu properties -- the area has one of the densest concentrations of rehab retreats in the nation, experts say -- can differ from industry norms, as represented by the Betty Ford Center, Hazelden, Phoenix House and other leaders in addiction treatment.

All of the Malibu centers are for-profit enterprises in a field dominated by not-for-profits. With luxury as a principal appeal, many charge far more than the going rate for residential care. Court records indicate that Promises' fee is more than double the $23,000 cost for a month at Betty Ford.

At the same time, Promises and fierce rival Passages Addiction Cure Center make sweeping claims on their websites about their clinical successes and reputations, purporting to have few or no equals in the world. Addiction researchers say the boasts are virtually impossible to substantiate.

In addition, Promises, Passages and other Malibu rehab firms have identified on their websites a number of psychiatrists and other physicians as staff members, even though the centers are not licensed to provide medical care.

Instead, they are limited to offering services such as detox monitoring that does not require medical treatment; group and individual counseling; and addiction education, state officials say. Over the last few years, Promises and several other centers that do business in Malibu have been cited by state regulators for providing medical services outside the scope of their licenses.

Until recently, the Promises website said the center had a medical staff led by Jack Kuo, director of psychiatry; and Robert Saltzman, medical director. The site no longer refers to a medical staff, and it describes Kuo and Saltzman as "independent affiliates" with the title "independent detox specialist."

The changes occurred after The Times inquired about Promises' operations. The center did not respond to questions about the physicians, and attempts to interview Kuo and Saltzman were unsuccessful.

Two doctors, Robert Waldman and M. David Lewis, have been listed as staff internist and psychiatrist, respectively, and sometimes "addictionologist," on the websites of at least three of the 11 centers that run rehab houses in the Malibu area. Renaissance Malibu described Lewis as an "adjunct" staffer; Waldman was listed as the "medical director" of Cliffside Malibu, but his staff designation has been changed on the website to "M.D./detox."

Bruce Moorman, intake coordinator at the Canyon, a center that identifies Waldman and Lewis as staffers, said there was nothing misleading about the characterization. "They take care of our clients," Moorman said. "They're on site more than not."

Don Grant, director of Harmony Place, whose website also lists Waldman and Lewis under the staff heading, said they do not provide medical care but "monitor the detox" of patients. The state cited Harmony in 2005 for advertising "medical detoxification services" on its website and contracting with physicians.

Grant said Harmony now strictly adheres to the state rules and that Waldman and Lewis are part of the center's "ancillary staff."

"They are not paid by us," he said. "Our clients contract with them independently."

Asked about the website staff listings for several Malibu centers, Lisa Fisher, spokeswoman for the state Department of Alcohol and Drug Programs, which licenses the firms, said the agency planned to investigate. "There should be no medical staff," Fisher said. "No medical services."

Fisher said the Malibu centers are allowed to recommend doctors to patients but that they should not create the impression that they have in-house physicians available to prescribe and administer drugs or provide other types of medical care.

Similarly, physicians are permitted to serve as counselors at rehab centers, but even in that role, they must refrain from practicing medicine as staff members, said Rebecca Lira, deputy director of licensing and certification for the alcohol and drug department. "I have never seen a physician who is only a counselor," Lira said.

Since 2002, the state alcohol and drug agency has cited nine of the centers that operate in Malibu for a total of about 20 substantiated licensing violations, records show. These included improper administering of medications and TB tests; contracting with physicians; operating beyond patient capacity; failing to have staff members trained in first aid and cardiopulmonary resuscitation; and for an employee's having sex with a patient.

State officials said the problems were corrected.

By contrast, the four Phoenix House centers for adults in Los Angeles and Orange counties -- which together have about 230 beds, compared with 167 in Malibu -- have received no citations in that five-year period.

Malibu Ranch Treatment Center closed in January after regulators said they found that alcohol and illicit drugs had been taken onto the premises; it had no licensed or registered counselors; staff members did not supervise residents; it exceeded its treatment capacity; and its sewer line was clogged.

Malibu Ranch director Jerry Schoenkopf said the violations were technical.

"We didn't close down because we were running a substandard treatment center," he said. "We were having economic problems."

Schoenkopf said his center was an affordable alternative in Malibu, with a monthly fee of $15,000, and that it treated many low-income patients free of charge.

In recent years, clean and sober retreats have mushroomed in the privileged environs of Malibu. The firms licensed in Malibu operate more than two dozen rehab houses there. Some are clustered in adjoining or nearby residences.

"What is taking place in Malibu is rather unique," said Michael Cunningham, chief deputy director of the state alcohol and drug department. He said most communities have a dire shortage of rehab beds. "Clustering is not the norm."

Some of the Malibu centers are known for lavish accommodations, including 500-thread-count sheets, gourmet meals and ocean views. Passages offers multiple mansions; marbled baths; 65-inch flat-screen televisions; and massage, acupuncture and hypnotherapy rooms.

Many of the Malibu firms typically demand a month's payment in advance and refuse to refund any portion if the patient leaves treatment early or is expelled. No-refund policies at more traditional centers often apply to just part of the fee -- $5,000 in the case of Betty Ford, for example.

Cynthia Moreno Tuohy, executive director of NAADAC, the Assn. for Addiction Professionals, said such no-money-back rules are an exception and "a shame."

"People do leave programs, they do get expelled from programs when they act out," said Tuohy, whose organization has about 11,000 members. "That's not a reason not to be reimbursed for services that aren't received. It's important not to take advantage of someone who is ill."

Promises and other centers say the stringent financial terms motivate patients to complete their treatment and are spelled out in admissions contracts.

Promises lawyer Gerald Sauer said that when patients leave early, the balance of the month's payment is retained for their use if they check back in, or the money is sometimes transferred to other rehab centers where the patients seek treatment. "No one is losing any money," he said.

But former patients and their relatives who have taken Promises to court maintain that the company intended to unjustly enrich itself at their expense by refusing to refund any money, no matter how short the patients' stay.

"They get people at their most vulnerable point to turn over huge sums of money," said Michael Parks, a lawyer for a former patient identified only as John Doe, a 50-year-old lawyer and alcoholic who sued in July. "Promises has a double standard of caring for celebrities first, at the expense of regular people."

The suit accuses Promises of evicting the plaintiff after a week -- and keeping the balance of his $49,000 payment -- because of false claims that he had made a "sexually inappropriate remark" to an unnamed celebrity patient.

The Promises staff tolerated "racially insensitive comments" by a celebrity, the suit alleges. Promises denied the allegations. A hearing is set for November.

Tucky Masterson said she wasn't in her right mind when she paid about $35,000 for a month at Promises. "I was on heroin," she said.

Masterson left Promises after two stays that totaled about a week, according to a suit she filed in 2003. She said she eventually received $15,000 in a settlement, minus legal fees.

"I was treated at Hazelden -- I was there for three days -- and they charged me to the penny for those three days," said Masterson, 48, who runs a sobriety house for women in Huntington Beach. "With Promises, I had to fight tooth and nail to get any money back."

Her story mirrored those of other plaintiffs and their relatives.

Sauer said Promises did nothing wrong. "Just because someone files a lawsuit, does that mean anything?" he asked.

In 2004, the state cited Promises for providing medical services, administering TB tests and having doctors conduct physical exams at its Westside location, all of which it was not licensed to do, records show. Fisher, of the state agency, said Promises stopped the practice as a result.

Promises founder and Chief Executive Richard Rogg declined through a publicist to be interviewed for this article.

Among the other Malibu rehab centers with no-refund policies are Renaissance, whose website features a testimonial by actor Daniel Baldwin, and Passages, which counts fashion designer Marc Jacobs among its graduates.

"If you leave, your money stays," said Passages co-founder Chris Prentiss, who added that the center immediately resells the vacated bed -- the monthly cost is $67,550 -- and that returning patients must wait for the next opening. Their payment stays on account, he said.

In the last six years, Prentiss said, only seven patients have departed early and failed to complete treatment later.

In 2005, the state cited Passages for exceeding its patient capacity. The center complied with a corrective order, Fisher said.

Passages says on its website that it has the "highest cure rate in the country" and is "renowned as the most successful alcohol rehab and drug treatment center in the world for many reasons."

Addiction researchers have criticized Passages for saying that it cures patients. "A cure? That's pretty good," Scott Walters, a University of Texas School of Public Health professor, said facetiously. Walters co-wrote a landmark 2001 study on treatment success rates. "People have been making claims about successful treatment since the dawn of time, since the snake-oil salesmen," he said.

Prentiss says his center eliminates dependencies by treating their underlying causes -- depression and anxiety, for example -- through intensive one-on-one therapy. Passages also disdains Alcoholics Anonymous' 12-step program, which Promises and other Malibu centers have adopted or adapted.

"We have an 84.4% success rate since we opened our doors in 2001, the highest in the world," Prentiss said.

Not to be outdone, Promises declares on its website that it is designed for "anyone wanting the finest rehab program in the world."

Promises attorney Sauer did not respond to questions about the basis of those statements. The center also declined to put The Times in contact with former patients who could provide testimonials.

"Anybody can make any claim they want and get away with it," Walters said. "It's essentially an unregulated industry."

[email protected]

Times researcher John Tyrrell contributed to this report.


Copyright 2010 Los Angeles Times