Ep. 32 - Tom Longenecker
Jan 02, 2021
“Money,” as the saying goes, “makes the world go round,” right?
Can it also be useful in fighting substance abuse? Some people are trying just that, rewarding people with cold hard cash for their sobriety. Tom Longenecker, a clinical specialist with Synergy Health Programs, joins us on the Behavioral Corner this time with insights into this controversial treatment and a more in-depth look at the ongoing battle against substance abuse.
Synergy Health Programs is a leading provider of mental health care services in and around our community. Through Synergy, mental health clinic professionals help our patients understand and treat a variety of mental health disorders and overcome everyday challenges, while developing the tools for long-term success in the outside world.
This Addiction Treatment Works. Why Is It So Underused?
PHILADELPHIA — Steven Kelty had been addicted to crack cocaine for 32 years when he tried a different kind of treatment last year, one so basic in concept that he was skeptical.
He would come to a clinic twice a week to provide a urine sample, and if it was free of drugs, he would get to draw a slip of paper out of a fishbowl. Half contained encouraging messages — typically, “Good job!” — but the other half were vouchers for prizes worth between $1 and $100.
“I’ve been to a lot of rehabs, and there were no incentives except for the idea of being clean after you finished,” said Mr. Kelty, 61, of Winfield, Pa. “Some of us need something to motivate us — even if it’s a small thing — to live a better life.”
The treatment is called contingency management, because the rewards are contingent on staying abstinent. A number of clinical trials have found it highly effective in getting people addicted to stimulants like cocaine and methamphetamine to stay in treatment and to stop using the drugs. But outside the research arena and the Department of Veterans Affairs, where Mr. Kelty is a patient, it is nearly impossible to find programs that offer such treatment — even as overdose deaths involving meth, in particular, have soared. There were more than 16,500 such deaths last year, according to preliminary data, more than twice as many as in 2016.
Early data suggests that overdoses have increased even more during the coronavirus pandemic, which has forced most treatment programs to move online.
Researchers say that one of the biggest obstacles to contingency management is a moral objection to the idea of rewarding someone for staying off drugs. That is one reason publicly funded programs like Medicaid, which provides health coverage for the poor, do not cover the treatment.
Some treatment providers are also wary of giving prizes that they say patients could sell or trade for drugs. Greg Delaney, a pastor and the outreach coordinator at Woodhaven, a residential treatment center in Ohio, said, “Until you’re at the point where you can say, ‘I can make a good decision with this $50,’ it’s counterproductive.”
Two medications used to treat opioid addiction, methadone and buprenorphine, have often been viewed with similar suspicion because they are opioids themselves, even though there is abundant research showing they substantially reduce the risk of death and help people stay in treatment. But the federal government has started aggressively promoting such treatment for opioid addiction, and has heavily invested in expanding access to it.
As of yet, there are no medicines proven to suppress the intense cravings that come with addiction to meth and cocaine. Instead, there are a raft of behavioral interventions, some of which have very little evidence of effectiveness.
“The most common treatment is to do whatever the hell you feel like,” said Michael McDonell, an associate professor at Washington State University who has conducted a number of studies on contingency management. “We had two statewide meetings about meth recently, and at one, a colleague said, ‘Why aren’t we just doing contingency management? Why would we spend all this money on interventions that won’t work?’”
The fact that no public or private insurer will pay for contingency management, except in a few pilot programs, is a major challenge to expanding it; the biggest obstacle is that offering motivational rewards to patients has been interpreted as violating the federal anti-kickback statute. A group of treatment experts recently asked the Department of Health and Human Services to waive the statute for two years as it pertains to contingency management, but the agency refused, saying programs that provide rewards need to be evaluated on a case-by-case basis.
Congress recently told states that they could start spending federal “opioid response” grants on treatment for stimulant addiction, but the agency that distributes the grants allows only $75 per patient, per year to be spent on contingency management — far less than what research has found effective.
“The biggest question is how do we get the payers on board with this,” said Eric Gastfriend, the chief executive of DynamiCare Health, a technology company in Boston that has worked with BrightView and other treatment programs to provide contingency management through a phone app that patients can use to share saliva test results with providers in real time, via video. For rewards, patients can earn up to $600 over the course of a year through DynamiCare, on a debit card that blocks cash withdrawals and purchases at liquor stores and bars based on merchant category codes.
“I was hesitant to try it — like, hey, is this legal?” said Dr. Shawn Ryan, the chief medical officer and president of BrightView Health, an addiction treatment provider with locations throughout Ohio, which started using contingency management last year. But the results have been striking, he said, adding, “I’m talking about significant improvements in attendance to therapy sessions, significant reductions in drug and alcohol use.”
Rewarding people for changing a behavior or adopting a new habit is a familiar concept, used by everyone from parents who are trying to get their children to do chores to companies that are trying to get their employees to stop smoking. Research has found it also helps people who are addicted to opioids, but for them, there are other treatments that are equally or more effective. For addiction to stimulants like meth and cocaine, however, contingency management has the best outcomes — especially when combined with therapy that helps people find healthier ways to meet their social and emotional needs than using drugs.
A 2018 meta-analysis of 50 clinical studies of interventions for cocaine and amphetamine addiction, for example, found contingency management combined with an intervention called the community reinforcement approach was the most effective.
Federal officials say that they want to expand access to contingency management for stimulant addiction, but that finding an effective medication for it would be better.
“If we were paying for it, that would help,” Dr. Nora Volkow, the director of the National Institute on Drug Abuse, said of contingency management for meth addiction. “But we badly need medications to help strengthen the response to behavioral interventions. This is a highly, highly addictive drug.”
One patient at BrightView Health, Jodi Waxler-Malloy, 47, of Toledo, tried contingency management treatment after participating in more than a dozen treatment programs for cocaine, heroin and meth addiction since starting to use drugs in her early 20s.
BrightView restarted her on buprenorphine for her heroin addiction and set her up with the DynamiCare app and debit card as an incentive to stay off meth. DynamiCare would add between $1 and $25 to her debit card whenever she went to BrightView for a doctor appointment or therapy, though she never knew the amount ahead of time.
“Nothing’s for free, so at first I said, ‘Yeah, yeah,’” Ms. Waxler-Malloy said. “But the next day, I looked at the app on my phone and they’d given me $25 for detoxing. Wow, really? I went back the next day and I got $5 more.”
Ms. Waxler-Malloy said the monetary rewards helped her get through the first month of sobriety in particular, a period when her housing was precarious, her cravings were intense and she needed to save whatever money she earned waitressing for rent at a sober living house that she was waiting to move into.
“It was enough to buy cigarettes or grab something to eat,” she said. “Maybe I was going to the appointments and meetings for the wrong reason at that time, but it helped me in the long run — helped me meet people, have a support group.”
Contingency management has been used the most by the Department of Veterans Affairs, where 110 clinics and hospitals have employed it since 2011 to try to help more than 5,100 veterans stay off drugs.
Dominick DePhilippis, a licensed clinical psychologist who oversees the program at the department, said he had seen new interest in the approach outside the department as meth addiction has surged again over the past few years. He published a paper in 2018 that found that, on average, patients in the department’s contingency management program attended more than half of their scheduled sessions, and that the average percent of urine samples that tested negative for the target drug was 91.1.
“It’s not a panacea — not all patients respond to contingency management,” Dr. DePhilippis said. “But I think of it as a scaffolding. We can’t provide this reinforcement indefinitely, but for a sufficient amount of time that the patient will begin to experience the naturally occurring benefits of recovery.”
For rewards, the department’s treatment programs give vouchers for $1, $20 or $100 donated by the Veterans Canteen Service, which runs cafeterias, coffee shops and retail stores in many of the department’s medical centers. Patients receive an average $200 in coupons over 12 weeks, which they can spend only in those outlets. For now, these programs are suspended at most of the department’s centers because of the pandemic; at those that have resumed, Dr. DePhilippis said, a clinician can make prize draws from the fishbowl on the patients’ behalf.
“In the drawings, I did pretty good,” said Eric Alick, 63, of Philadelphia, who completed a contingency management program for cocaine addition at the Corporal Michael J. Crescenz V.A. Medical Center in Pennsylvania. “I might get three ‘good jobs’ in a row, but then, bingo.”
Among the things he bought with his rewards were a new drill set for his job as a handyman, perfume for his wife and coffee and meals for homeless veterans whom he had met in the hospital cafeteria.
One problem with contingency management, evidence suggests, is that people have less success staying abstinent after the treatment ends. For that reason, Richard Rawson, a researcher at the University of Vermont who has studied meth addiction for decades, believes it should be used indefinitely, just as medications for opioid addiction often are.
“Unfortunately, addiction is a chronic brain disease and treatments need to be designed to accommodate this reality,” he said.
For Ms. Waxler-Malloy, losing the debit card when her four months of contingency management ended in early January was hard, although her therapy sessions and 12-step meetings helped. Then, in May, she lost her waitressing job because of the pandemic and she relapsed, using meth and heroin “full force,” she said, for three weeks before stopping with help from Brightview.
Still, the eight months she went without using drugs was her longest stretch of abstinence in more than two decades. She believes she may not have relapsed if contingency management, with its promise of rewards, had still been part of her treatment regimen.
“That kept me real accountable,” she said recently. “Even just to stop at McDonald’s when you have that little bit of extra money, to get a hamburger and a fries when you’re hungry. That was really big to me.”
Ep. 32 - Tom Longenecker Podcast Transcript
The Behavioral Corner
Hi, and welcome. I'm Steve Martorano. And this is the Behavioral Corner; you're invited to hang with us, as we've discussed the ways we live today, the choices we make, the things we do, and how they affect our health and wellbeing. So you're on the corner, the Behavioral Corner, please hang around a while.
Steve Martorano
And let me welcome you guys to the Behavioral Corner. And happy new year if I haven't said that or not. There's never been a year more eagerly anticipated than 2021, for all the obvious reasons. And certainly, we're, you know, among that group bye bye 2020. And who knows, things gotta get better nothing. We're really grateful to have the time with our guests because it's a very, very busy time in the field of behavioral health. As you can imagine, Tom Longenecker has been a guest on the program, at least once before, he's a great resource to talk about his field he is now we love and I'll get you it'll explain to you is now I met him when he was primarily a when Retreat Behavioral Health, which is our underwriter was primarily and exclusively a substance abuse and treatment facility. And now it's expanded to include the wide range of things we refer to as behavioral health. The side that handles the mental health piece of that is under the umbrella of Synergy Health Programs, and Tom is one of the I guess the track leaders that handle that right time. Is that how it works?
Tom Longenecker
I'm I'm a clinical specialist. And then we have five primary therapists who are working in two different tracks. And so I'm a resource for all of them.
Steve Martorano
Yeah, let's talk a little bit about this because some people are a little confused when Retreat who as I said, as our partner were a renowned substance abuse treatment facility. And they expanded beyond that to include mental health issues, it was kind of a distinction, but not much of a change. Because in the field of substance abuse, you always dealt with mental health issues, which are commonly referred to as co-occurring disorders. Now, of course, it's possible under a behavioral health model to separate you don't have to go get mental health issues, singularly as a result of your substance abuse. So you're dealing with both kinds of patients?
Tom Longenecker
So some of our patients purely have a mental health diagnosis, with no substance abuse diagnosis, others of our patients will have co-occurring, and we're able to try to address both of those at the same time. Whereas in our other programs, some of our patients there have purely a substance abuse disorder, diagnosis, and some will have substance abuse alongside with maybe a secondary mental health concern.
Steve Martorano
you know, when the purely mental health diagnosis side so that people understand Retreats Behavioral Health programs, you are not a psych hospital. So what does that mean? And who do you see?
Tom Longenecker
Okay, so you know, the higher-level care would be an acute unit, which is going to be noted by lock words, oftentimes a short stay, we would be a stepper. So below that were our patients, once they're through initial three-day isolation, which is COVID related, it's not related to mental health or otherwise, they've grown the campus. Now they might have supervision, they might have a one on one aid, depending upon what their safety concerns are. But unlike a higher level of care, there are no lock words there. The doors to the rooms are not locked, they're able to again, go to the calf, walk up the hill, go to the clinical rooms...
Steve Martorano
So, clearly at the...
Tom Longenecker
...gym, play volleyball. So it's just like the rest of the camps, which is somewhat unique in that field. I think there are only two don't quote me on this. I think one of the only two programs in the Commonwealth that have that kind of care.
Steve Martorano
Everybody they're under a diagnosis of mental health diagnosis is a voluntary patient, they're there because they're looking to get help. So in that regard, you see lots of your garden variety stuff. I mean, you know, from anxiety and depression, what are some of the other things that we might deal with?
Tom Longenecker
Certainly, depression, and it's all many forms is something we see very, very regularly as well as anxiety and its different forms. We will also see some of what we in the past called access to dimensions which would be borderline personality for bipolar disorders. We also deal with some people who are coming in in the schizoaffective dimensions of schizophrenia and its whole family of a cluster of the dimensions like about that with hallucination, delusion, suicidality is a very significant piece in terms of, we are the next step for a good number of people who have been in dire straits not long before coming here. They might have had a brief stopover at an acute care location, and then becoming to us for more for a longer period of time for care and to be doing some therapeutic work. So that would be very significant.
Steve Martorano
All of that, as well as the substance abuse issues, have been, of course, monumentally impacted by this virus. Like every other aspect of our lives, it should come as no surprise that the number of overdoses has skyrocketed in the past year, and skyrocketed is the word here. As I say, it should not be surprising, but it is nonetheless shocking. The numbers I see from the latest CDC estimates, between June of 2019 and May of 2020, 1230 people have died from drug overdoses. That's a massacre far more than dying automobile accidents. And just to give you a finer example of this, in the city of San Francisco, more people have died of drug overdoses than from COVID. Some of this is a result of just a sort of unfortunate path, substance abusers are on particularly when they're dealing with something like fentanyl. But in what other ways have this pandemic exacerbated the problem of substance abuse?
Tom Longenecker
Well, first, it's played out in several ways. I mean, I'm quite aware of people that we've worked within the past, who actually was able to pull together recovery and time and sobriety. And then they find themselves in not so much in March, but April, May, June, very isolated, they might have been furloughed or lost their job. And one of the key things there is so many of the stories were that they were no longer in the face to face relationships with people in the rooms and the 12-step programs, other places in the recovery community. And so you get a combination of isolation, on its many different kinds of levels, particularly isolation, from the very resources that were a part of what provided me the strength to get through. Can you add to that loss of a job or a tremendous amount of time in my hands that I don't know what to do with, you know, some of our relationships are maintained, because we have certain kinds of connection and certain kinds of distance. And, you know, I think many people can recognize when people have been in quarantine together, sometimes we know each other too. Well, you know, and, but it raises those tensions and stressors there. And, and then you add to that, again, some of the other resources that I've relied upon simply are not available to me in the same ways they work. That's one piece of people who were actually making recovery work. They were doing what they needed to do, and suddenly, we're in a very different world, and the things I relied upon to swim against the current are not available to me in the ways that I've become accustomed to them.
Steve Martorano
Are you seeing your patients face to face? Are you still doing that? Are you doing everything?
Tom Longenecker
Yeah, yeah, well, here on the hill, this is inpatient. So our staff, including myself, have been here, for the most part since March. Time, so I've been here besides them in a standard kind of days off. I've been here throughout that time, outpatient programs have been primarily telehealth in via zoom
Steve Martorano
Tom is referring to the two facilities that anchor retreat here in the northeast Pennsylvania area, or in Ephrata. And down the road in Akron. One is the outpatient, as Tom said, in the hill, is the residential community was on the issue about the other side. I spoke to Jack Sodak, who heads up Synergy for you guys and has been running the outpatient plenty. Have you had a lot of any experience at all with telemedicine and is it helpful?
Tom Longenecker
I do have been doing some zoom work. I would say it's certainly better than nothing. That's one way to look at it. I think it's a challenge. Personally,, I'm not very technologically adept. So I think it's a challenge in terms of how I am accustomed to working with groups and working with individuals. So there's just a personal professional challenge for me in terms of having retooled, I think that actually, I would say that it's been surprisingly better than I thought it might have been. I just came out of having some decent group work across the last couple of weeks with groups that I was working with via zoom. And I think they actually developed beyond my initial expectations and some of my own hesitancies.
Steve Martorano
Because you know, because if you have great experience of being as they used to say, in the rooms and any You don't even have to have that kind of a background, you understand that in any setting when you're face to face with one or more people. There's a whole lot of communication that goes on, it's nonverbal. And you can only pick that up if you're in the room, people's postures, their hands, what they're doing with their bodies, they move, and that's all removed. How do you overcome that?
Tom Longenecker
Well, actually, you actually make an interesting point because now when I am face to face with patients, and people I'm working with that we're all masked, I'm missing a tremendous amount of just this subtle communications that are just hidden from me now. So when I'm actually on zoom, I've seen more of a person's person's face. So no matter. So it's an odd situation across the board, whether we're in face to face or whether we're on zoom, I think probably one of the things that is beneficial about-face to face is not just what happens face to face. But the things that happen afterward, after the group convene, after it departs, rather, you know, for people who go to the rooms, it's going out for coffee, it's, it's all the other things that happen around that. Even on the hill, where we're much more stylized and formalized. It's the conversations that occur after the group breaks. And the other kinds of ways that people who've been in it can go and they keep talking about or they keep working through some of what happened there. Now that can continue here on the hill. Whereas I think that can be more limited when people are living independently in their houses. And the only connection is virtually the only connection is via zoom.
Steve Martorano
Why is that carry over from out of the formal sessions into the more informal setting important? Why is that carry over important do you think?
Tom Longenecker
We are wired to be sociable to be connected. And we can make a distinction between being sociable and connected. One of the key understandings of what's going on with addiction and compulsion is its disconnection. So part of the healing is a deep connection. And so there are other very informal ways of simply being part of with depth in places where I know myself as somehow important to this thing that we're part of, and it's outside of the realm of condemnation, not necessarily outside the realm of judgment, outside the realm of my worth is, so I think there's a big piece of that. And again, you know, neurologically, somebody who's in early recovery, is going through a time period where their brain is starved for pleasure. Whatever substance they were using was provided to some degree, something that the body interpreted as pleasurable. And we take that away from somebody during abstinence. And so we're going to go through a time period where the body's natural reserves of endorphin, and serotonin are not up to production levels, they're there, they're still quite depleted. And so physical touch the skin to skin contact, that's what they teach new parents these days, lots of skin to skin contact with your baby, okay, that that's bonds, and provides a tremendous amount of contact and a tremendous amount of pleasure.
Steve Martorano
All of which is being cut off.
Tom Longenecker
You know, we talked about, you know, sex makes people happy. But really, the thing that actually really sponsored happiness is actual skin to skin contact, which doesn't necessarily need to be sexual, to provide some of that knowledge. And that's a key piece. But again, that sense of being connectable is something that provides pleasure so that it allows the brain starts to be less depleted. And let's really start.
Steve Martorano
And in terms of surfy, it's always occurred to me that this carry over from the formal structure of say, a group, to the social aspects of after the group is beneficial, because it seems to me anyway, that the person in treatment gets to appreciate as a process, not confined to Well, here's my therapist, and let's sit down and do this thing here. Now I've done that. But when it's outside, when you have the cigarette or the cup of coffee, or in the dorm at night, then it becomes not what you're doing but who you are. You're working on your sobriety.
Tom Longenecker
And again, it's into that kind of integration is just another kind of connection, right? It's kind of seniors together.
Steve Martorano
Right. Yeah. And again, you know, this virus has just disturbed the universe in so many ways. Do you worry that Lee and 81,000 people overdosing? There's a lot of reasons for that. One of which would occur to me is that people overdose, it's because they aren't getting to treatment fast enough or in time, you worry that people who ought to be seeking treatment, both for mental health issues and for substance abuse issues, are reluctant to do that set against the backdrop of a virus?
Tom Longenecker
I'm certain that that's partly the case. I mean, we start off with, and I'm not quite clear on this at the minute statistics on this, but relatively only about a quarter of the population that should or could be seeking. substance abuse treatment is actually seeking substance abuse trigger for a variety of reasons. So we've already got a really a minority of people seeking that, who really should or could be, add to that, you know, the stigma of seeking treatment. Add to that, concerns about being an institution where, rightly or wrongly, we suspect that we could be more susceptible to COVID add to that concerns about insurance, who's going to cover those costs, he's gonna help me with those costs. Add to that, also, I think the implications are, trauma tends to be the gateway drug for most much addiction. And look at some of the events that go on to this prolonged period that we've been going through as a country. And we have cultural trauma. People lose jobs, people are unable to maintain their rent or their mortgage, and family relationships become much tenser, economic concerns become heightened. And then you add to that, that 81,000 deaths of people think about that, in terms of who are the children who are left be cared for by grandparents are the spouses, significant others, the extension of the family, and that adds to that whole level of how we experience something we get stuck in, it leaves its mark deep in us, and we remain stuck there. There's something that does not get resolved.
Steve Martorano
81,000 deaths create, not a ripple, but a tsunami of effects. You know, emanating out from that it's just incredibly this year, in ongoing opioid and substance abuse epidemic, which got swept away of course, the in the wake of a COVID. Tom Longenecker with this. Tom is a clinical specialist with synergy health programs. They are a part of a retreat, behavioral health. And he's talking to us about what he does in the mental health field as well as substance abuse. And we're going to pick up on something brand new to me an article I read in the New York Times last week that Tom's going to try to enlighten us upon, we're on the Corner...The Behavioral Corner.
Synergy Health Programs
Studies show that 2020 has negatively affected the mental health of millions of Americans. That is my app retreat, we work to provide comprehensive mental health programming through our Synergy Health Programs. To learn more about Synergy and the comprehensive mental and behavioral health services we offer. Call us today at 855-802-6600.
Steve Martorano
Tom, so I sent you an article in anticipation of asking you about this, because I thought well, how about this idea? The article begins with a fellow that says that Stephen Kelly had been addicted to crack cocaine for 32 years, when he tried a different kind of treatment last year was so basically in the concept that he was skeptical, what would happen is he would go to a clinic twice a week provide a urine sample. And if he was clean, free of drugs, he would then draw a slip of paper -- it sounds like a game show doesn't it -- he would draw a slip of paper out of a fishbowl and it would contain half messages. You know sort of encouragement. "Good job." "Way to go." The other half were vouchers for -- ready for this -- money. Cold hard cash. Moolah. Yeah, that's right. They were paying people not to abuse, whatever substance they were abusing. The whole thing is controversial, to say the least very experimental, I think, and referred to as "contingency management." Tom, I'm always suspicious of really jargony names for things, it makes me feel like they're, you know, hide something. What was your impression of this?
Tom Longenecker
I think in some ways, what they're working out of is, is a form of operant conditioning. So operant conditioning is, it's an attempt to reinforce or punish up behavior. Okay, so if I have to go to my probation officer, and I provide clean urine, showing no sign of using, I don't really get a reward other than I don't go back to jail, I don't go I don't violate my probation. If I go and provide hot urine or, you know, the probation officer might violate, I might have to have more legal issues, okay. Or, for instance, our dog, I don't allow our dog to come on the carpet, in our front room. And, you know, her options are to be praised for not going on the carpet. But the other part is she desires to be on the carpet because she's closer to the people she wants to be close to his or her options are, am I going to get scolded and told to go off the carpet? Or do I get praised? And so what operant conditioning is, is trying to relate behavior to an outcome. And so at some level, what they're trying to do is really, on the coin, clean time, ongoing abstinence, gets a potential reward. And I think in some things, it's a, you don't know what the reward will be. I think in some other programs, I'm under the impression that the reward gets higher each time. So maybe the first reward is $5, then 10 and 15. I'm not really sure how they always work that, but either way, the potential is, I get rewarded for abstinence. And so relating the behavior abstinence, or at least being able to show absence with some kind of pleasurable reward.
Steve Martorano
If something like this is going to get a foothold in the treatment of substance abuse, the good old USA would be the place where, you know, money doesn't talk, it swears. I mean, that's how we keep score in this culture. Who has the most money, who has the most toys, so I guess it would make sense here, I'm confused about this sword, I understand it. Look, the techniques you just described, are pretty much the way most conscientious parents raise their kids. It's as simple as that. You know, you want to watch the movie, do your homework first, you want to go play, cut the lawn, I mean, stuff like that, and the denial that stuff we understand about that. But with regard to substance abuse, can the reward no matter what it is, be so powerful, that it cuts off the craving for a drug, like heroin? I mean, can it work like that?
Tom Longenecker
I don't know that I can answer that with authority.
Steve Martorano
What's your suspicion?
Tom Longenecker
My suspicion is that if we look at this as one piece of an array of different interventions, particularly an early recovery, and remember that in early recovery, the brain is starved. And so some kind of reward is almost necessary. So for some people that reward is I go to a meeting, and I'm surrounded by love and affirmation, and we go out and smoke cigarettes and go to friendlies and eat ice cream later on, or whatever, whatever they're doing. Hmm. And that for some people is a strong, strong reward. What I'm deeply craving some kind of pleasure. And it's even difficult to have some kind of pleasure. So I think we need to realize how that might function more acutely or, more significantly, particularly for people in early recovery. Just recognizing just how starved the neurology the neurological basis is. I think that you know, certainly, it can work in some ways, in terms of actually challenging actual craving. I know in the article you provided me they were highlighting this, particularly for methamphetamine, and cocaine dependence. As opposed to opiate or alcohol. tenancies, partly because we have medicines, we have pharmacological means to address some degree of craving with opiates, and alcohol, We have Naltrexone. We have Vivitrol, we have, you know, some of those means to address those. Whereas I'm not aware of an awful lot that we have that can really truly address, really, what is a parasympathetic craving for amphetamine, of some form.
Steve Martorano
And so people understand this, this is not your garden variety, treatment. And in fact, most insurance companies want more data, more research, before they're going to pick up the tab on this kind of contingency management. But interestingly enough, it's being done in our area at the VA hospital in Philadelphia, they are trying this out with the voucher program Look, like I think most of you professionals in it, if it works, good. Let's give it a try. I mean, M.A.T., which is medication-assisted treatment, as you just mentioned, was for the longest time thought to be something antithetical to treating this now it's not that's changed. Who knows if this could work? But there are legal considerations to consider. I guess, in some places, you're not supposed to pay people to not use drugs, right? That's illegal.
Tom Longenecker
Yeah. I'll play the kind of advocate for this for a second. No, but we also give bonuses for performance at work. Sure, people get paid to do surveys, in education, we have a certain kind of rewards. I mean, that's actually again, had to go back to parenting. There's some kind of rewards that we give. I know that for people with mental retardation or on the Asperger spectrum, that there is some kind of rewards that are built into the systems to behavior. homelessness and substance abuse are two areas that we, I suspect that we're very reluctant to reward for doing the things that we think you should do anyway.
Steve Martorano
It's it's fascinating. I mean, we use words like a reward. And then when you attach money to it is a very clear idea forms in your head and what we're really, really not talking about how much money you're giving people a sense of an affirmation, you've done something worthwhile. Here, this will remind you of that, and you'll keep doing it. I mean, I've always thought that one of the great reinforcers for people in sobriety is the accumulation of time, the longer you're sober, the more you want to make that a bigger number, how many deaths weigh the days and years count.
Tom Longenecker
And statistically, the longer period of time people have been absent, tends to predict the longer time people have accidents.
Steve Martorano
Yes, exactly, exactly.
Tom Longenecker
The same thing, the longer time people have in treatment exponentially per day, we see that it tends to be predictive of more time in essence,
Steve Martorano
I knew you'd shed light on this for us. It's it was fascinated by that. We're going to find out more about that. There's some unbelievable stuff out there about technology and I read about apps that now we'll do saliva tests on the phone somehow or another and, and be rewarded right through your phone. So It's an amazing read. Let me ask you, but I'm gonna let you back your very busy schedule, I'm sure. One day COVID will be gone, not would. And we will get back to whatever the normal is then now, at that point, I'm guessing, though that even if COVID were to be eradicated tomorrow, what you're about the work you're doing is not going to go diminish.
Tom Longenecker
I'm, I'm positive that. Yeah. Luckily, there are other jobs I can do if we've ever fallen into that world. Luckily, there are other things I can do.
Steve Martorano
I guess my question is, are we just on the cusp of a real sort of mental health crisis? Or are we in a mental health crisis?
Tom Longenecker
I think we've been in a mental health crisis. And in a substance abuse crisis for quite a long time, it was exacerbated in the last half-year or more. I'm curious, in terms of seeing what the after-effects are again, yeah, referring back to the 81,000 deaths is turned into a massacre, in terms of how that plays out in the lives of people who are the witnesses and standby. And I've seen this and it these people have been important in their lives, I'm expected to see the tsunami of that effect. And it's just because this is a tragedy, this is tragic.
Steve Martorano
And grief has been delayed.
Tom Longenecker
Grief has been delayed, just even the kind of the communal means of a funeral, which is a very simple way of marking that transition that change. Well, this has been removed from us in terms of viscerally, you know, so many funerals are now either not occurring, or they are occurring again, fortunately, there's a lot that can be done virtually, but we are still missing some of that basic, connecting with one another.
Steve Martorano
Tom, thanks so much out for people who might hear this and are, you know, cut off isolated, struggling? What should they do, they can't sit there and expect this to go away, they have to be a little they call the family to the what do they do?
Tom Longenecker
There are always interventions if people can always call upon interventionists and others if this is something that you're recognizing for yourself. So many people say I waited too long, I thought that depression would get go away, or one of the problems with depression is I just don't have the energy to make the move. And, or, or my anxiety gets in the way or I'm just waiting for the right time to make the move. Things are never the right time, I want to deal with my drinking, or I want to deal with this problem I've got, I recognize it's a problem. I just need to wait or I can do it without making the shift to leave my home, leave my apartment, leave my family takes off. However much time I needed to really become part of a bubble and address it. Those kinds of reasons are constant, no matter if we're in the middle of a pandemic or not. But one of the things I hear over and over again is I should have done this earlier. Because if people see the result, one of the great rewards I see over and over again, for people who really invest themselves is that quickly, they find this is like lifeblood. And so that's rewarding. In itself. I suspect that there's a lot of things we could do that would draw upon contingent management in certain different ways of being more overt about providing certain kinds of rewards. But one of those is simply the rewards of recovery, which is not without its trials, but not without the tribulations, not without difficulties.
Steve Martorano
Yeah, there's a great expression that's applicable. Living Well is the best revenge. It's also the best plan. Tom Longenecker clinical specialist, Synergy Health Programs. Thanks so much for the work you do and for the time you give to us. We really appreciate it, Tom.
Tom Longenecker
Thank you, Steve. Thank you for what you're doing.
Steve Martorano
Hey, guys, thank you for hanging on the Corner with us. Don't forget to follow us on Facebook, Instagram, follow us in a cab on a bike like us. Never in my life if I had to ask people to like me because it never did any good. But like us, you know that the whole thing and look for us here on the Behavioral Corner. Take care, everybody.
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