An Easy Fix for Addiction Hotlines

by Andrew Walsh

A few months ago I was invited to speak to a class of students at Rutgers in the addiction certificate training (ACT) program at the Graduate School of Social Work. I shared my experiences from graduate school and working in the field of substance abuse. While I was with the students, I was prompted to share some of the writing and undercover work I have done in the field of substance abuse treatment.

For a year and a half, I did full-time work and full-time graduate school. While my schedule was hectic, I was able to compare what I was learning in the classroom with what I was experiencing in the field. I was horrified.

Under the guidance of Professor Greenagel, I set out to start documenting and writing about the ever widening gap between best practices and what was actually occurring in the substance abuse field. One of the first subjects I tackled was addiction hotlines. My previous piece on addiction hotlines can be accessed here.

I found that the majority of the hotlines ranged from negligent at best to operating illegally. One of the main takeaways from my undercover work with the addiction hotlines was the lack of consideration that people with Medicare, Medicaid, or no insurance received. When I posed as a 27 year old with insurance seeking substance abuse treatment I could not get my phone to stop ringing. However, when I posed as a 26 year old with seeking substance abuse treatment with Medicaid, I could not get a phone call to last more than three minutes.

I was thoroughly convinced that the horrors of the substance abuse field would cause some of the students to reconsider their career paths.  A few months passed and unexpectedly one of the students from the class contacted me. She posed a simple question that stopped me in my tracks. She asked

With state treatment facilities in a state of stagnation due to lack of beds for Medicaid, Medicare, and the indignant, how can private centers work to meet this need for people with Medicaid, Medicare, or no insurance?

I recognized that I left my previous work half-complete. I did a mournful job of illustrating and summarizing the problem but I did not provide any solutions.

I set out to remedy the situation and decided that I first needed to quantify the demand for substance abuse treatment among Medicaid recipients, Medicare recipients, and those with no insurance. After quantifying the demand, I then sought out to quantify the services available; i.e. where can these people go to get help. My work on the Medicare population can be seen here and the piece on the Medicaid population can be accessed here. The main takeaway was that the demand for substance abuse services for these populations far exceeds the supply.

I spent one year working in the call center of a psychiatric hospital. Working as an addictions triage specialist, I took anywhere from 50-100 calls a day from potential clients or their family members looking for substance abuse services. I was fortunate that Medicare was accepted for treatment at that psychiatric hospital. However, I still received dozens of daily calls for patients with Medicaid or no insurance seeking services. After I did some research, I began to end those conversations by saying, “We can’t provide services to you here but if you get a pen and paper I am happy to give you the name of the facilities that can and their phone numbers.”

Inevitably, the callers would express sincere gratitude with some variation of: “Thank you so much. I have been calling around everywhere but I couldn’t figure out who could help me.”

I hold advanced degrees, have a few years of direct practice experience with substance abusers, and am familiar with the majority of substance abuse providers in the tri-state area. All of my experience and research has made it possible for me to know which facilities accept Medicaid, Medicare, and those with no insurance.

When I reflect back on my work, education and directed research, I come to two clear conclusions:

  1. The demand far exceeds the supply of services for Medicaid, Medicare, and those with no insurance
  2. Services exist but substance abusers and their families get worn down trying to find the programs that will accept them

I am a social worker, which means I am an idealist. But I am also a pragmatist. Ideally, I would like to see an expansion of offerings for the Medicare, Medicaid and uninsured populations. Pragmatically, I know this will take a long time. Additionally, it is unrealistic to hold private facilities responsible for expanding services to those populations.

That written, I believe private treatment providers can help clients access the services that do exist. The best practice would be for these private entities to call the appropriate facilities with the client and do a warm hand-off to the appropriate party. Pragmatically I realize that this causes a significant burden on the private entities and will be met with significant opposition. The practice that will encounter the least resistance from the private treatment providers but still produce a significant effect is providing the clients they cannot treat with the names of the facilities that can help them. As my previous work has shown, these lists are relatively small and should not take more than two minutes to share with these clients.

While I am troubled by the fact that there are waiting lists for Medicaid, Medicare and those with no insurance, I am horrified that people cannot even find these facilities to get on the waiting list. Private treatment provider hotlines are often the first point of contact for many substance misusers and their families. Even if they cannot provide services directly to these clients, ethically they should refer the clients to the facilities that can provide the services. With people dying because they can’t even get on the waitlist to keep the flame of hope alive, treatment providers that fail to refer clients are in essence saying a life may be worth less than two minutes.


Andrew Walsh a Master’s Degree in Social Work and a Master’s Degree in Human Resource Management from Rutgers. Prior to working in the behavioral health field, Andrew worked in the Gulf of Mexico oilfield as an internal business consultant focused on innovation and improving the efficiency of people, processes, and procedures. He eventually decided to return to NJ to practice innovation in the behavioral health field. In his free time, Andrew enjoys hiking, cooking, and reading.

The Five Ways You are Most Likely to Die

Every Thursday for many years, I’ve run a multi-family group in an addiction treatment center for young adults and their families. Last summer, I wrote this list on the board and asked them to guess its significance:

  • Car crash
  • Hiking
  • Shoveling snow
  • Heart Attack
  • Cancer

People were dumbfounded and mostly had no response. I told them that these were the mostly likely ways that I would die (in no particular order). We’ll come back to that group. A few days later, I offered up the same list to my friends, parents, and my ex-wife. Only two friends got it right. My ex-wife figured it out after hearing just the first three.

One family member in the group exclaimed that it was a morbid topic. Another played into my hands by asking me how I arrived at that list. I explained to the group that I often drove above the speed limit and that there is a high correlation between speed and accidents. I discussed how I am hiking higher and higher mountains and have recently started hiking in winter conditions including deep snow and on sheets of ice. My driveway is over 100 feet long and opens into a large parking area – I shovel it alone and it often can take three or four hours. While I exercise and neither drink alcohol nor smoke cigarettes, I do have a diet high in red meat and I avoid vegetables. I have a sweet tooth and also smoke cigars. There is no known history in my family of cancer, but there is one for heart attacks. After explaining my list, I stated that I could lessen the chances of dying those ways by engaging in the following behavioral changes:

  • Drive slower. Never text or eat while driving.
  • If I’m taking a dangerous hike or going in extreme conditions, always have a guide or a partner.
  • Take breaks every half hour while shoveling snow. Don’t make speed a point of pride.
  • Eat a bit healthier. Lose some weight.
  • Eat a bit healthier. Reduce sugar intake. Cut down on cigars.

I have fully committed to items 2 and 3. I am slowly addressing items 1, 4, and 5 (ironically, those are the most likely ways I’ll die). I had every group member silently write down their list of the five ways they are most likely to die. Then I had them break up into smaller groups and share their lists. They were instructed to discuss what behavior changes they could attempt in order to reduce. After a half hour, I brought everyone back into a big circle. Their most common answers: drug overdose, car crash, cancer, heart attack, respiratory disease, and suicide. These are six of the ten ways that most Americans die (a note on the four group members who mentioned suicide – none of them had active suicidal ideations but they all had a history). The talk surrounding how to reduce these outcomes was lively and suggestions included: quit smoking, see a therapist, keep going to 12-step meetings, stop texting while driving, eat more vegetables, and take medication as prescribed.

Three other answers stood out. An older father listed diabetes. It developed from drinking and he has to monitor his blood daily, take insulin shots, and get regular medical checkups. Most of the clients did not know that heavy drinking could cause diabetes. A 2016 Cato Institute Study reported that diabetes is actually a top-ten killer of Americans.

Three people listed either “getting shot” or “getting killed.” They were clients in their 20s with long drug histories. One woman expressed fear about an ex-boyfriend who was currently incarcerated. I suggested talking to her counselor and a lawyer and to consider a restraining order. The two men who said they might “get shot” did not have a particular person in mind but each had dozens of friends who had either overdosed or were killed as a result of their lifestyle. Both agreed that remaining drug free and avoiding their home town greatly increased their life expectancy.

Three others listed “terrorist attack.” I addressed this issue from the flank. I wrote down the lifetime odds of Americans that die via falling (1 in 133), motorcycles (1 in 949), poison (1 in 1,355), fire (1 in 1,454), heatwave (1 in 10,745), and animal attacks (1 in 30,167). I wrote down the number of Americans killed in America by foreign born terrorists between 1975 and 2015. The Cato Institute reports the number is 3,024 and the lifetime odds are 1 in 45,808.  I asked the group why some people would be more concerned about terrorism, shark attacks and lightning strikes over problems caused by speeding, alcohol use, prescription drug abuse, smoking, and lack of exercise. A 23 year-old male who was five months clean replied, “We don’t want to acknowledge the problems that are our fault and have to make changes. It is easier to be afraid of things beyond are control and that are on tv a lot, like terrorists and shark week.”

It was the kind of statement that group therapists strive for – I couldn’t have put it better and it was much more impactful coming from him. There are a number of lessons here, and I would like readers to jot down their own list and discuss it with their friends and/or family members. And figure out what you can change so that you can live a little bit longer.