How and When Outpatient Rehab Works Best

0:00:14 William Moyers
Hello and welcome to Let's Talk, a series of podcasts produced by the Hazelden Betty Ford Foundation on the issues that matter to us and the issues that we know matter to you. Substance use disorder, prevention, research, treatment and recovery support. I'm your host, William Moyers, and this week Let's Talk is on the road. We're here at the Betty Ford campus in Rancho Mirage, California. And we're joined by Matt Polacheck. Matt, welcome.

0:00:40 Matt Polacheck
Thanks for having me.

0:00:41 William Moyers
Thanks for being here today. You had a little bit of a drive. You're our Director of Outpatient Services in West L.A. Outpatient treatment was once upon a time we didn't talk about outpatient treatment. Why is outpatient now so important, Matt?

0:00:56 Matt Polacheck
Well to me I think it was the missing link. And I think the shift happened when we really with (stumbles) looking at science we looked at addiction as a chronic disease versus you know versus an acute disease. And so what happens is people go away and get treatment and families and loved ones think they come back cured. Well the bad news is we don't have a cure. But we've got good treatment. And the key really is think of it kinda like landing a plane and you want it to be smooth. And you go away for treatment a lot of times and you come home and your problems are still there, you still have all the issues that were there when you left, except for what you need really is support around you. Some people say the opposite of addiction is community. And what outpatient really is is building a recovery community around someone so they can really go basically from you know an inpatient setting to a more self-management way of living their life.

0:01:40 William Moyers
Now outpatient isn't for everybody, though.

0:01:43 Matt Polacheck
Well I think it really depends on the person and really how kind of acute the you know the disease has gotten. And so I think the real key really is to have a good assessment and figure out really where you're at in your level of addiction. But some people do step in at an outpatient level and some people need to detox first. You know the real key to that to me is really the medical model and understanding really medically are you at risk if you were to stop and not be in a medical setting. 

0:02:06 William Moyers
Why has outpatient become so important in the context of insurance coverage? 

0:02:11 Matt Polacheck
Well I think that what insurance, you know our managed care partners have learned really is they wanna limit re-occurrences, you know, of a substance use disorder. And the problem really like I said is when you come home and you don't have that support system, your chances of having a re-occurrence go up. And so by kind of putting an emphasis on longer care, more chronic care, versus acute care, we're gonna have much better outcomes. 

0:02:32 William Moyers
Hmm. But outpatient isn't for everybody, we know that there are some people—I was one of those—who needed residential trait—treatment. How do you decide what level of care is appropriate for the patient? 

0:02:44 Matt Polacheck
Well I think you really wanna gather not just the patient but stakeholders. Family members, psychologists, doctors, and get input from everyone. 'Cause as you know, there's a different side to every story. And so for me, I think you know gathering as much information as possible. And then we really gotta look at the substances. Certain medi—you know certain substances people use they can stop without any medical issues. And then you also have to realize whether we do need to separate that person from their dealer or from their drug of choice because some people and you know have success stepping right into outpatient. And some need to really separate before they can be successful. 

0:03:16 William Moyers
One of the advantages of outpatient is that they—is that the patient or the client can continue to work or continue to be a parent or continue to be active in the community, right?

0:03:26 Matt Polacheck
Yeah and the—the greatest kind of part of the reason I kind of got into this field is it's the only field I know in science where in one month, to two months, to three months, you can see those relationships you know really mend and get better. Addiction just shreds families as you know. And so, in outpatient the greatest thing is having the g—you know the patient come in their first day and 30 days later, seeing the love—you know them be present in their kids' life again, being able to go to their soccer games. And so I think that's the great part of outpatient is you can do the work, but you can also reintegrate into your community. And then hopefully build another one you know more supportive one.

0:03:59 William Moyers
I know one of your keen interests has been the stigma of addiction. And couldn't a case be made that outpatient treatment actually helps to de-stigmatize the illness because the patient is still present and accounted for and around town?

0:04:13 Matt Polacheck
I—I think so and I think you know people like you, William, who are going out in the community and doing work like this is the most important. Because we're still struggling with this. I mean we have the brain science now. You can see the brain scans and see how you know addiction plays its role in the brain. It's a chronic disease, yet people still think about addiction as a—a voluntary (stumbles) you know moral issue or your know someone volunteering to you know use substances, yet well you know well we were talking about breast—you know other chronic diseases. Whether it's cancer, you think about breast cancer, you think about the pink bracelet or someone running a 10k. When we think about addiction, we still think about someone with a needle in their arm. We've gotta kind of re-conceptualize this as a chronic brain disease and really start kind of getting people out there like yourself to really kind of educate the public.

0:04:56 William Moyers
Well you too, you've been very passionate about it. And you've got that clinical piece that is as valid and resonates as loudly as somebody like me who might have been on that personal journey as well. Tell me how did you get interested in this field? 

0:05:10 Matt Polacheck
Sometimes every story has a sad beginning obviously. [Moyers chuckles] You know and I was—my family business was in jewelry. And so I was gonna be a jewel—you know go into the jewelry business. And I had a couple instances in college where I had a friend who drank and he—he actually died from drinking from an alcohol-related car accident. And so it was that and then I had another friend commit suicide who was also fighting addiction. And I literally in my junior year of college turned a sharp left from you know business to psychology. And went up and I got into grad school in Berkeley and worked at the Salvation Army Rehab Center for a lot of years. And like I said earlier, just you know something resonates with the addiction—you know with addiction to me and the population and to me it just seems like you know having to be part of an organization like this you know our mission statement of hope and healing and we can—there's so much—there's 20 I think the kind of the misconception is you know everyone goes in relapses and all this stuff. There's over 20 million people in recovery in the United States. And it's a growing—growing community. And there's so many great people out there and so many great communities in West L.A. You know, we've got—we've got you know our patients started hiking groups. I had a patient come up to me and say you know I don't hike. I'm—so I said 'What do you do?' He says surf. I said start a surfing group. So now they have a sober surfing group. [Moyers chuckles] And so we've got all these great recovery communities and—and to—for me to get to see the change from Day One to Day 30, 60, and you know years and years later— 

0:06:34 William Moyers
Yeah. 

0:06:34 Matt Polacheck
There's not a more rewarding field.

0:06:37 William Moyers
So we've talked about this before—treatment is really only the beginning of the process and you touched on it with you know aftercare group or—or sober surfing groups, or running groups or so on. What is the dynamic of—tell us what recovery looks like down the road for people.

0:06:54 Matt Polacheck
I you know I think it's community-based. And I think that the—once we slowly de-stigmatize addiction and people—it becomes part of—you know and people understand it as a mainstream chronic disease, I see it shifting more towards you know other chronic diseases. Whether it's diabetes, you know, people—there's no judgment or stigma on diabetes. I think one of the things that people you know don't—when they look at other chronic diseases, you know, all stuff like that starts you know voluntary—having a high sugar diet or something along those lines. And then it becomes involuntary. And we have to accept the fact that that's part of you know part of the evolution of it. And so for me, I see community, you know becoming a big part of it, and I just see the lower the stigma goes down, and hopefully more you know I'm a huge AA fan I just see the work that it does. But the one issue is we don't get a lot of people publicly coming out you know and saying I've got an addiction. And so, I'm hopeful that more people will come out, express, tell their story. There's nothing more powerful than hearing someone else's story. And we de-stigmatize it; it becomes part of our community. In West L.A. we're seeing advantages and we're seeing that start to happen. But we've got a long way to go.

0:07:58 William Moyers
You talk about the stigma of addiction. There's also been a stigma for people in recovery who use medication as part of their regimen of recovery. I know it—West L.A. we use our COR-12® which is well describe how you use it.

0:08:14 Matt Polacheck
So I think that medication is an important component. And I think that that was a missing piece but really what we're looking at is comprehensive treatment. And I think the most important part is people understand that one size doesn't fit all. And so, when we individualize treatment and we use medication as an aid towards that, for everyone it's different. For some people it's gonna be a—a medication that's a blocker of opiates, you know. Such as Vivitrol. Some people it would be Suboxone. Which people are familiar with. But really it's individualizing treatment and then more importantly, the COR-12 program is more about comprehensive treatment. So it's using that as a piece of it but really surrounding [sic] person with you know coping skills, with good CBT, with good treatment, plus community. 

0:08:55 William Moyers
Yeah. Mmm-hmm. 

0:08:55 Matt Polacheck
So it's—it's one small piece to the puzzle. 

0:08:58 William Moyers
Is COR-12 applied differently in a residential setting than it would be say in the outpatient in L.A.? 

0:09:02 Matt Polacheck
So similar to in an inpatient in Hazelden Betty Ford, we have our specific COR-12 groups. But it's also very similar in the sense of kind of the key really again is taking a patient and pushing them towards self-management of a chronic disease. And so it's very similar in that way. And the treatment, the great part about having you know all the centers across the United States is we can step people down. They stay in the continuum, they stay with a lot of patients they are with, and also we can communicate you know really well with each other. And so, the treatment kind of has a like I said earlier about landing a plane— 

0:09:32 William Moyers
Right.

0:09:33 Matt Polacheck
A much smoother process. 

0:09:36 William Moyers
Not long ago, you had some really significant interactions with the United States Surgeon General. Tell us about that.

0:09:43 Matt Polacheck
Yeah I went up north to do a Town Hall in Seattle. And I got to sit down and chat with him for a few minutes. And you know I think that we had—the conversation we—we talked about MAT Treatment, we talked about opioids, and some of the interesting things we discussed is you know right now we've got a pretty significant fatality issue in the United States with Fentanyl.

0:10:00 William Moyers
Right. 

0:10:01 Matt Polacheck
But in 2016, four—forty percent of opioid-related overdoses were from prescription opioids. So I don't—I think the world some—you know, right now the news is all Fentanyl, Fentanyl, Fentanyl, which is a serious crisis and we need to get it under control. But we still have a prescription opioid use issue. And so I think—you know we talked about balancing that out. We talked about this idea of more comprehensive treatment. You know and again, stigma, and advocacy and all the work you do. 

0:10:28 William Moyers
We—we've seen so much attention paid to the opioid epidemic, rightly so. 70,000 people will die of overdoses in the United States this year. And the majority of them will be because of opioids. But you see it in West L.A. People come in with all kinds of addiction to lots of substances, right? 

0:10:45 Matt Polacheck
Yeah and you know most opioid users are actually polysubstance users. 

0:10:50 William Moyers
Oh, interesting.

0:10:51 Matt Polacheck
And so I think that you know unfortunately the difference with the opioids I feel like is with most substances, it goes this is kind of Psych 101 but it goes from a positive reinforcement to a negative reinforcement. Meaning most people start using drugs adding onto something you now positive in their life to enhance something.

0:11:05 William Moyers
Aha. 

0:11:08 Matt Polacheck
And then it becomes a negative reinforcement. They're doing it to avoid a withdrawal or they're doing it to avoid pain in their life. Opioids are different. Opioids normally start off as a negative reinforcement. 'Cause you have chronic pain, or you're prescribed it. And so they're a little different. But at West L.A. we see a lot of alcohol still, alcohol use disorder, opioid use disorder. But most, you know, a lot of patients we have are polysubstance, unfortunately. 

0:11:30 William Moyers
Where is marijuana in that con—in that universe of substances? I mean I can't remember I should know this, but I can't remember if marijuana is legal in California. It is? 

0:11:40 Matt Polacheck
It's—it's legal in California. We're seeing an increase. And the scariest part to me is we've got great new brain studies on how the brain is still developing. You know up until your mid-twenties to late-twenties. And we're seeing a lot of young adults coming in with marijuana addiction. And obviously you know—

0:11:56 William Moyers
You mean you can get addicted to marijuana? [teasing, laughing] 

0:11:59 Matt Polacheck
You know that's I mean that—and again that's—that's why you're here. You know, that's why and I'm thankful for the work you do is that you're out there spreading the word. Because you know I—I think let alone the THC levels are so much higher now, we're seeing families destroyed every day by marijuana. Destroyed. I mean this is not—this is not some—this is not your grandparents' marijuana to begin with. 

0:12:18 William Moyers
Right. And what about alcohol? Where's—where is it in the scheme of things? 

0:12:21 Matt Polacheck
Well I—I—alcohol is just the problem we just can't get over I feel like. And I still think, you know, or the percentage of people that we—that we treat are still alcohol use disorder unfortunately. You know I—you know being someone that you know thinks the access to drugs and alcohol can be you know—it becomes easier and easier with the Internet and all this stuff. Alcohol is the easiest drug to access, you know. And for us—for our patients in the outpatient the challenge and that's why community is so important is it's everywhere. And you know, I don't think—I don't have any studies to back up that you know alcohol use is increasing, but we are seeing, you know, increases in a lot of other substances.                                     

0:12:58 William Moyers
You talked about community being so important. And I think there's no doubt that our outpatient, wherever the—wherever it is and whomever's outpatient is outpatient is an integral part of the community—and it allows the patient and the patient's family to still be part of that community without having to go away for treatment. 

0:13:13 Matt Polacheck
Yeah. And—and support, you know. 

0:13:15 William Moyers
And support. 

0:13:17 Matt Polacheck
I think that's the biggest problem, you know. People you know it's—it's important to go away to treatment. But the support people can get at home. And really figuring out who is not supportive, you know. And weeding out the old people and bringing in people that are healthy in your life. But, we—we can't do this alone. We can't fight addiction alone. We need people around us. We need support. We've got a family group every Wednesday night that started in a small room. And then it went to a bigger room. You know. And now we have to do multiple times a week family group because they—they—you know these are families getting brought back together. They need support around 'em. They need loved ones. And this is not a disease you can fight alone. 

0:13:48 William Moyers
You're—you're propagating there in West L.A. you're propagating the antidote to addiction which is community. Which is the first word of the first step of those Twelve Steps that many people have taken. Matt Polacheck, thank you very much for giving us that sense of community that manifests itself there in the outpatient facility in West L.A. Thanks for joining us today. 

0:14:09 Matt Polacheck
Thanks for having me. 

0:14:10 William Moyers
And thanks to all of you, our loyal listeners and viewers to Let's Talk. On behalf of our Executive Producer, Lisa Stangl and that great crew at Blue Moon Productions, I'm your host William Moyers we'll see ya again.