Addiction Treatment: Evolving Care and Closing the Access Gap

0:00:23 William Moyers
Hello and welcome to Let's Talk, a series of award-winning podcasts produced and delivered by the Hazelden Betty Ford Foundation. Each podcast focuses on an issue related to addiction. From prevention and research to treatment and trends, current events, advocacy, and of course, recovery from a substance use disorder. I'm your host, William Moyers, and today I'm proud to introduce our guest, President and CEO Mark Mishek. Welcome, Mark.

0:00:51 Mark Mishek
Thank you, William. I'm glad to be here.

0:00:52 William Moyers
Glad you're here too. Hard to believe you've been the President and CEO now for 12 years.

0:00:56 Mark Mishek
It's amazing. Time flies when you're having a good time.

0:00:59 William Moyers
And of course [chuckles] we could look back well not retrospective but we wanna look forward here in the future of addiction treatment. And here we are at the Betty Ford Center in the winter of 2020. And this podcast will hopefully have a nice, long shelf life. So, we'll have to look out even further than just the next couple of weeks.

0:01:19 Mark Mishek
Right.

0:01:19 William Moyers
But what do you see in the years ahead and when it relates to what we at Hazelden Betty Ford will be delivering in terms of treatment? 

0:01:26 Mark Mishek
Well, it's a great question. There will be I think tremendous changes coming in the field, in the clinical model, in the way we deliver care. and I think where you're gonna see a lot of change has to do with virtual care and Telehealth. Now virtual care or Telehealth has been around for many, many years. And it's been delivered in a lot of different settings. What hasn't happened though is the treatment world, the treatment of substance use disorders, hasn't really grabbed onto it the way it's going to happen in the future. The population that's coming up, the young men and women who will be moving into work, who will be suffering from substance use disorders in the future, have a very different way of approaching the world than you and I do.

0:02:15 William Moyers
Mmm-hmm. [nods]

0:02:15 Mark Mishek
They use their phones. They use their devices. They are comfortable on them. And so, how we meet them—meet our patients where they're at in the future—part of that has to be that we are very good at it and understand what parts of the care that we deliver can be delivered virtually. What parts of the care that we deliver can be delivered over a telephone. How can our patients access content, access lectures, on demand. That's gonna be really critically important going forward. So that's one thing that's gonna happen. The second thing that's gonna happen is that I really do believe we're in a stage now where we're gonna have a real shaking out of the field. I think that because of the requirements to invest in electronics, electronic health record, to invest in virtual care, to upgrade your facilities, to participate in health insurance, a lot of the treatment centers out there won't be able to do that. They don't have the capital to do it, they don't have the expertise to be able to move into the insurance world, and so I think we're gonna see a lot of centers that are gonna close or merge. What that'll do for us is it's gonna put even a heavier demand for our services. We are gonna see, as we're seeing today, a continued escalation of people coming to us for care and service. So, this organization is gonna need to invest in, of all things, bricks and mortar. There's no question about it. And we've got a plan here for the Betty Ford Center. We've got plans throughout the organization for the next five years. But looking well into the future, people attending treatment in person is not going away. It's the preferred modality you know addiction is a disease of isolation—

0:04:01 William Moyers
Yes.

0:04:01 Mark Mishek
So people need whenever possible to come in person. And so there'll be a high demand on our—on our sites to be able to provide more and more care. No question about it.

0:04:12 William Moyers
One of the things that's happened in the evolution even of the way we deliver care is there has been a surge under your leadership in outpatient.

0:04:20 Mark Mishek
Right.

0:04:21 William Moyers
Can you talk more about the role outpatient will play in the future?

0:04:24 Mark Mishek
Sure. Our Chief Medical Officer, Dr. Marvin Seppala, told me when I first started here that 90 percent of the people who get care for a substance use disorder do it on an outpatient basis. And at that time, we really had no outpatient services. So I'm pleased to say today sitting here this morning about of four patients, three of 'em are getting services on an outpatient basis now in the organization, and one out of four are getting it on a residential basis. And that's the way that it should be. So, outpatient is critically important for access. For people to be able to get care in their neighborhoods, where they live, for an affordable price. And that's what outpatient allows us to do.

0:05:06 William Moyers
What about the use of medications and the use of perhaps other forms of therapy going forward? Do you see that there'll be more of a role for that in an organization like ours?

0:05:18 Mark Mishek
I hope so. And we have to continually evolve our clinical model. We can never rest on our laurels. There's huge, wonderful work going on on brain science right now to understand the biochemistry of addiction and hopefully this will result in new treatment modalities, it'll result in perhaps even more effective medications to help with craving for example. Right now there's really not a medication to help with methamphetamine.

0:05:44 William Moyers
Mmm-hmm. [nods]

0:05:44 Mark Mishek
That would be great if something came along to help with the intense cravings that methamphetamine users, addicts, substance—who are addicted to that substance use. And so I would hope as we go into the future we're gonna see more and more new therapies, advances, and continue to enhance our clinical model. We're never done. [Moyers chuckles] Hopefully we're always moving forward and always doing a better job of understanding what it takes to get sober.

0:06:11 William Moyers
And on that point, what about the role that the Twelve Steps play? I mean when we were born in 1949 in Center City, Minnesota, it was in a model that included the Twelve Steps. Those Twelve Steps hang on the wall of every one of our facilities. Whether it's outpatient, residential. We give Big Books to all of our patients. We recommend them to aftercare groups that are all about the Twelve Steps. What role will the Twelve Steps play going forward?

0:06:39 Mark Mishek
Well they're gonna be a pivotal, key role. Substance use disorders are diseases of the mind, body, and spirit. And absolutely the Twelve Steps of Alcoholics Anonymous, of Narcotics Anonymous, Marijuana Anonymous now, are absolutely critical to get well. To get into recovery. What we can provide here is that clinical stabilization that needs to occur. A kind of a coming out of the fog that needs to happen so that people can engage in a Twelve Step community and can start to understand the Steps and start to work 'em. That's what our role is to move them from that expert clinical care we have—

0:07:15 William Moyers
Yes. [nods]

0:07:16 Mark Mishek
—Into self-management and that's where the Twelve Steps, Twelve Step groups are critically important. And it's our job to introduce our patients to all that—that whole world. 'Cause that's how you're gonna get well over the long-term.

0:07:28 William Moyers
Talking about that clinical model and the role that clinicians will play—and of course our Graduate School is doing that, training that next generation—what is the role of education, you know, whether it's undergrad or Master's Degree programs, what's the role of education in the delivery of addiction treatment?

0:07:48 Mark Mishek
One of our founders, Doctor Dan Anderson, had a wonderful saying. And we quote it often around here and that is: 'We help more people by educating addiction counselors than in treatment.' The point being is that education is critical to our mission as an organization to be the leader that we are. So, we need to continue to grow our Graduate School, we need to continue to grow medical education to make sure prescribers understand the dangers of opioids for example and what appropriate prescribing should be. So it's gonna be critically important for our mission.

0:08:24 William Moyers
What about in terms of leadership on advocacy, on policy, going forward? Whether it's at the federal level in Washington or at the State level, what role does Hazelden Betty Ford play going forward in that?

0:08:36 Mark Mishek
Well what I'm—you know I look to the past and one thing I'm really proud of for the last 12 years here is how our team has really grown our advocacy efforts.

0:08:44 William Moyers
Yeah. [nods]

0:08:44 Mark Mishek
So, as we look into the future, continuing to build on that is gonna be really important for the organization. Because as we say in our strategic plan, if not us, who? And I—that is really important for us to understand. We're the largest nonprofit in the country that is focused on substance use disorders. We need to have a voice at the table. We need to be heard and we need to have a position on these issues like we have for example today on legalization of marijuana.

0:09:10 William Moyers
Yes.

0:09:11 Mark Mishek
—We need to have a position; we need to be heard.

0:09:13 William Moyers
By the way, what is our position on marijuana?

0:09:14 Mark Mishek
Our position on legalizing marijuana for recreational purposes is we're not in favor of it. The science of what marijuana is is really in its infancy. It's not clear exactly how it works, what it does. We do know that we treat people with marijuana use disorders. It is addictive and it's particularly dangerous for young people with developing brains. We know that through our experience. And so, we're opposed to it.

0:09:42 William Moyers
Mark, you have led us through some really remarkable times. We've had a couple of tough stretches during the course of the last 12 years. Here we are in 2020, still our President and CEO. But you mentioned in your previous response that we are the nation's largest nonprofit provider. We're a not-for-profit. What is it like as the CEO and having the leadership team that you have, what is it like to have to manage to the margin with a mission that is as vibrant as diverse and as important as ours?

0:10:16 Mark Mishek
Well it's always a challenge. It's a challenge for any health care organization 'cause so many health care organizations are tax exempt nonprofits. And you've gotta have the margin. Otherwise you cannot invest in your people. You cannot invest in making sure that you have a modern Electronic Health Record. You can't pay your physicians and nurses and other important medical personnel the kind of salaries that they need to stay with you. So, we really always need to be following that balance and making sure that we're providing enough of a surplus every year to reinvest back in the organization to treat more people, to have highly engaged employees, and to make sure the families and patients are getting what they need from us.

0:10:59 William Moyers
And going forward, what is the role that philanthropy will play in sustaining and growing the mission of Hazelden Betty Ford?

0:11:06 Mark Mishek
We won't be able to continue to be the leader without philanthropy. The great health care organizations in this country that are leading the way, Mayo Clinic, M.D. Anderson, pick your great health care organization, they all have just tremendous philanthropy. And we need to have that also so that we can do research, that we can fund education, we can provide scholarships for students who wanna be Substance Use Disorder Counselors. It's critical that we have the philanthropy. Because the margin from our health care services is not enough—

0:11:42 William Moyers
Mmm-hmm.

0:11:42 Mark Mishek
—To be able to afford to be able to do these other very important things.

0:11:47 William Moyers
We only have about a minute left, Mark, so I'm gonna give you the opportunity to look into the crystal ball going forward and knowing that we won't necessarily hold you to it—

0:11:57 Mark Mishek
Good. [Both laugh]

0:11:59 William Moyers
But, we've been around for 70 years now. This is our 71st year. You've been our President and CEO for the last 12 years since 2008. What do you see going forward as it relates to addiction in general and specifically Hazelden Betty Ford's role in addressing addiction?

0:12:16 Mark Mishek
Well, addiction's not going away, let's start with that. Substance use disorders are actually climbing right now. Alcoholism is climbing while the opioid—the use of prescription pain pills thankfully is starting to go down. Fentanyl is not going down. So, it's going to be with us. Sadly right now, because of some of the abuses in the field, I see a major shakeout coming—

0:12:40 William Moyers
Mmm-hmm.

0:12:40 Mark Mishek
—For the next three to five years of a lot of treatment centers closing their doors. A lot of organizations not being able to cut it. And that is not gonna be a good thing. Because we still don't have enough access to treatment in this country.

0:12:52 William Moyers
Mmm-hmm.

0:12:53 Mark Mishek
And a lot of the access that we have is underfunded, undercapitalized, and that's really unfortunate. So, our role here has to be to go back to our previous comments we made here, is to be that advocate out there. To make sure that as this turn of the wheel occurs as we have more treatment centers go out of existence that we're paving the way for others to open. That we're making sure that we can persuade these large academic health centers, some of these large health care organizations, to get into the business of providing substance use disorder services. Many of 'em aren't there today. They wanna go in there, we need to help 'em get there. Because access will be critical going forward.

0:13:33 William Moyers
Access always the key to let other people find that hope, help, and healing that is vital to the process.

0:13:41 Mark Mishek
Absolutely.

0:13:42 William Moyers
Mark Mishek past present and future, thanks so much for your leadership, for being with us today. [turns to camera] Thanks to all of you for joining us along with Mark Mishek, the President and CEO of Hazelden Betty Ford. We hope that you have found today's podcast to be insightful and if you have, please let your friends and family, your colleagues and your neighbors, your community, know about these Let's Talk podcasts. On behalf of our Executive Producer, Lisa Stangl, thank you all for tuning in today, we'll see you again.