The Big Casino: Defining Addiction Treatment Success

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©2014 Rick Macnamara, LCSW

At the heart of decision-making about any healthcare treatment is the success rate. Americans like to know their odds of survival. Readers may recall that Uncle Junior on the HBO series The Sopranos referred to his cancer as “The Big Casino” and in one sense that is very descriptive of how we view our disease survival rates. If one treatment has a 95% survival rate after five years and another treatment has only an 87% survival rate, we’ll put all our chips on the first treatment and spin the Wheel of Fortune in “The Big Casino”.

Studies of treatment effectiveness are common in the medical field and often enough, those studies are reported in the news media. It is encouraging to see that new surgical techniques based on technological advances can allow us and our loved ones to spend many more years together than their particular illness might have allowed even as recently as ten or fifteen years ago.

In the Addiction Treatment Industry, there are studies of the effectiveness of treatment but the results are unclear. Controlled studies of specific treatment centers are rare; any that were conducted by the facility and not by an independent research organization have a self-serving air about them so that even those using credible methodology may not inspire confidence in prospective clients. Over my career, I have heard wildly different success rates for addiction treatment ranging from about 50% to an astounding 95%. If the rate is 50%, you’re playing in The Big Casino at a rate only slightly better than the payoff on a typical Las Vegas Strip slot machine; that’s not encouraging. If the success rate was truly 95%, I would love to review their data because I have a hard time accepting that any treatment center anywhere can “cure” 95% of the people who walk through their doors.

It is dangerous for clients and families when a facility does its own success rate studies. Here in New Jersey, where I am based, Dr. Henry Cotton, a former director of the Trenton State Hospital, claimed 85% cure rates for such serious illnesses as schizophrenia by pulling all of the patient’s teeth and performing dangerous exploratory abdominal surgeries looking for “focal infections”. Sadly, many patients were mutilated and almost as many died before independent analysis indicated that Dr. Cotton’s statistical methodology may have been spurious, leading to his own subsequent breakdown and removal from the hospital staff.[1]

The value of independent review of disease outcomes cannot be overstated and anyone considering laying out tens of thousands of dollars to a rehab (Promises Malibu charges a reported $48,000 for 28 days, for instance) should question the source of any reported success rates.

During my time in a leadership role for a large behavioral health managed care company, we began compiling information on readmission rates for a number of high volume facilities over a 30-day and 60-day period. We were in a good position to conduct this research and publish it to the facilities as a value-added service because we knew when an insured member was discharged from one facility only to readmit to another. Facilities would only have access to readmission date for readmits to their own shop, which could give a misleading picture. When considering admission to a facility, ask if they have any such independent data.

Alcoholic Anonymous, by far the most pervasive influence in American addiction treatment, occasionally reports success rates, but some critics point out that most AA studies are based upon self-reports by their members, which is hardly a representative sample. A study conducted in 1996 called Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) seemed to indicate that most therapies for alcoholism, including participation in AA, had roughly equivalent results. [2] Follow up studies questioned the methodology and the results of what was at the time the largest and most expensive study of alcoholism ever done.[3]

St Jude Retreat is one of the few treatment centers that use an independent research company called Clearwater Research to study their effectiveness. In November 2005, they reported that the average success rate across the three St Jude Retreat was 68.24%. St Jude does not utilize the 12-step model; instead, they use Cognitive Behavior Education (CBE). I have not had the opportunity to review the complete report including data and methodology, but this figure is probably closer to the reality of addiction treatment outcomes. [4]

In my career, I have answered questions about success rates this way: “There is no magic program and no credible guarantees in addiction treatment. When you decide that having a steady job, a nice family, and a real future is more important to you than whatever you’ve been addicted to, your success rate will be 100%.” In the rooms, people talk about becoming “sick and tired of being sick and tired” and that is really where it’s at. And at that moment of clarity, finding effective treatment, whether it is to treat an underlying depressive disorder or a physical problem like diabetes, is the most important thing you can do.

[1] Madhouse: A Tragic Tale of Megalomania and Modern Medicine, Andrew Scull, Yale University Press, 2005. ISBN 0-300-10729-3
[2] Alcohol Clin Exp Res. 1998 Sep;22(6):1300-11. Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes.
[3] BMC Public Health 2005, 5:75 Are alcoholism treatments effective? The Project MATCH data by Robert B Cutler and David A Fishbain
[4] St Jude Retreat website:

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