Warren Musselman credits his post-alcohol life to two things: finally finding a program that offered counseling he could connect with, and deciding he just couldn’t suffer through withdrawal again.

He’d already cycled through detox centers 27 times.

“For me, what finally took is that I got sick to death of going through detox,” Musselman said.

Withdrawal from alcohol is an uncomfortable process at best and can be dangerous without the right medications. Musselman, of Estes Park, said it was only during his last stay that he received help to understand why he drank, and learned how to cope when he went home. Before that, he had only encountered 12-step programs, which he found overly rigid.

“You’ve spent years not having any other tool (than alcohol) to deal with that depression or anxiety, so you use that tool even though it makes things worse,” he said, adding that he learned other options in counseling. “Stopping drinking doesn’t fix the problems that drove the drinking.”

Colorado’s quiet killer

Alcohol-related deaths in Colorado spiked during the pandemic, and the state ranks as one of the worst for deaths due to drinking. In this four-part series, The Denver Post examines why so many Coloradans are dying, and ways to save lives that the state hasn’t pursued.

Click here to read more from this series.

There’s a pressing need for more people to find suitable treatment in Colorado, which has one of the highest rates of alcohol-related deaths in the country. The number of people dying in the state from causes related to drinking spiked more than 60% from 2018 to 2021, before falling slightly in 2022. When researchers count those who died of long-term conditions linked to alcohol — liver disease, certain cancers — drinking killed more Coloradans than opioid overdoses. While the state has made efforts to expand drug and alcohol treatment, it has done little to prevent excessive alcohol use in the first place.

This is the final story in The Denver Post’s four-part series examining what the state could do to curb Colorado’s high rate of alcohol-related deaths, which consistently rank in the top 10 among the states. Previous articles focused on how increasing taxes and limiting access to alcohol could reduce excessive drinking, while today’s story looks at how Coloradans have sought — and sometimes failed to find — treatment that could help them or their loved ones.

Alcohol treatment is relatively available in Colorado, with 503 treatment programs in the state, as well as 24 physicians and 38 psychiatrists board-certified in addiction treatment, according to the National Institute on Alcohol Abuse and Alcoholism.

Doctors and mental health providers who aren’t certified in addiction medicine also can treat patients with alcohol-use disorder, though they may not be as comfortable caring for people with more complex needs. (The term alcoholism has fallen out of favor because of accompanying moral judgments, and has been replaced by alcohol-use disorder. The general term for misusing any drug in a way that causes problems is substance-use disorder.)

Despite those resources, people who are concerned about their own drinking or a loved one’s don’t always know where to turn. Treatment options may not meet patients’ preferences, aren’t easily accessible in certain parts of the state, or don’t necessarily accept all forms of insurance, including Medicare and Medicaid.

Another factor is that many people simply aren’t aware of the variety of options for treating alcohol-use disorder, said Marc Condojani, director of adult treatment and recovery at the Colorado Behavioral Health Administration. Patients and even some doctors don’t know that approved medications can blunt cravings for alcohol, he said.

The Eastern Plains and Western Slope have significant bare spots with no local treatment programs. Providers that offer medication or have staff that speak Spanish are also thinner on the ground in the high country.

“I think the biggest challenge we face in a lot of places is not knowing where to look,” Condojani said. “Community to community, it’s certainly going to vary.”

Treatment has to fit the person

Many of the people who spoke to The Post about their experience seeking treatment for alcohol-use disorder didn’t want their full names published, saying they were worried about personal and professional consequences if more people knew about their history.

Renee, a Denver woman who spoke on the condition she be identified only by her first name to protect her family’s privacy, said she didn’t know where to turn when it became clear her brother Chris was struggling with alcohol. After he was hospitalized the first time, she encouraged him to attend Alcoholics Anonymous meetings, but he resumed heavy drinking at some point.

Chris had one unsuccessful stint in intensive outpatient treatment, but was willing to try a residential program after repeated hospitalizations. They couldn’t find a program with an open bed that would accept his insurance, though, and it wasn’t feasible to pay out of pocket, Renee said.

Out of options, she and other family members felt all they could do was urge Chris not to drink and stop by to make sure he wasn’t in imminent danger, she said.

By law, insurance companies have to offer an exceptions process for situations when needed care isn’t available at an in-network facility, said Kate Harris, chief deputy commissioner for life and health policy at the Colorado Division of Insurance. That process should allow the patient to pay no more than they would if they’d gotten care at a facility that had contracted with their insurance, though patients don’t always know they have the option, she said.

Chris was only in his 60s when he died in a nursing home in August, from heart and liver complications of alcohol use. It was even harder to bear the loss because he had said his head was finally starting to clear after a few months without alcohol, Renee said.

But the damage to his body was irreparable by that point.

“I just felt like, ‘God, couldn’t someone have done something before this?’” she said.

Across the country, people often don’t know where to turn if residential treatment and 12-step programs aren’t available or don’t meet their needs, said Tori Votaw, a clinical psychology doctoral candidate at the University of New Mexico who studies the addiction treatment landscape.

Other possible treatments for alcohol-use disorder include mindfulness-based strategies; cognitive behavioral therapy, which teaches people to challenge unhelpful thought patterns; motivational interviewing, which helps a person come up with their reasons for making a change; and community reinforcement, which helps a person find healthier sources of pleasure or satisfaction, Votaw said.

While those services aren’t as easy to set up as 12-step meetings, at least some of them should be available from most mental health providers, she said.

While they aren’t effective for everyone, some people do find 12-step programs helpful.

Tracy, of Denver, said she never drank habitually, but noticed when she did go out or drink at work events that she’d end up consuming more than she wanted to. She said Alcoholics Anonymous worked for her because the principles of the 12 steps were also good for her job and family life. She asked to be identified only by her first name, in keeping with the program’s emphasis on anonymity.

Tracy said she kept quiet about her reasons for quitting alcohol for a long time, because others didn’t understand how someone who was successful and had a happy family could be struggling with drinking. She often didn’t understand it herself.

“It was hard for me to fathom that there could be an ‘and,’” she said, meaning that a person could have a good life in many ways and still struggle with drinking.

Not every treatment method works equally well for every person, and the person seeking help needs to feel comfortable with their treatment plan, Votaw said. That said, some people do need inpatient or residential treatment, especially if they’re at risk of dangerous complications if they go into withdrawal, even if they’d rather not be away from home.

“An important factor is how much a patient buys into a treatment and believes it will help,” she said. “Generally, hope is predictive of a good outcome.”

Few get medication to help quit drinking

Sven Lehti thought entering a residential treatment program for at least a month would be the best way to kickstart a new stage of his life — one without alcohol. But the Denver resident’s insurance company didn’t agree.

The insurer denied Lehti’s claim as not medically necessary since he’d already gone through the detox process at home. So he instead tried a 12-week intensive outpatient program that involved about nine hours a week of group Zoom meetings. He said he found it useful to talk with the other participants about their experiences and learn new coping skills, but he had hoped to build deeper relationships living with other people in recovery.

“The detox is just a small part of rehab, in my opinion,” Lehti said.

Under laws requiring parity between coverage for addiction treatment and other medical care, insurance companies can’t require patients to pay more out-of-pocket for substance use disorder or take less-tangible steps to limit care, such as making it harder for addiction treatment providers to join the insurer’s network, the Division of Insurance’s Harris said. They can, however, refuse to pay for care they deem not medically necessary, so long as the limits aren’t stricter than those for comparable services, she said.

Not all insurers have followed the law, though. According to the state’s most recent report, six companies paid fines because their 2020 plans charged higher out-of-pocket costs for behavioral health care than for other services. The report noted that the state received only 46 complaints about mental health and addiction coverage in 2022 — far fewer than for other medical care — but attributed that to patients not realizing they have rights, rather than insurers consistently respecting those rights.

If Colorado residents feel their insurance refused to pay for care in violation of the law, they can file a complaint with the Division of Insurance’s consumer services team, Harris said. The team also can help if consumers aren’t sure what rights or recourse they might have in a situation, she said.

Lehti did get one proven therapy that’s underused, though: His primary care doctor prescribed naltrexone, which reduces cravings, and disulfiram, which reacts with alcohol to produce unpleasant symptoms.

He said the medication has helped get his mind off drinking, freeing up time and energy for other things, though he said he’s still working on breaking mental associations, like that he should pour a drink when sitting down with a book.

“I think about alcohol a lot less than I did four months ago,” he said.

A recent review of the research found that naltrexone and another drug called acamprosate cut the odds that patients who had reduced or quit drinking would resume drinking heavily.

Only about 265,000 of the estimated 29.5 million people who had an alcohol-use disorder in 2021 received medication to help them cut down or stop drinking, according to the national Substance Abuse and Mental Health Services Administration. People who had milder symptoms may have been able to reduce their drinking without medication.

Condojani, with the Behavioral Health Administration, said the state is urging providers to regularly screen patients for alcohol-use disorder, and to offer appropriate medications and other therapies. The last state data, from 2022, showed more than 80% of Colorado adults who saw a doctor in the previous year said their provider asked about their alcohol use, but the data doesn’t say how many received a treatment offer if they admitted heavy drinking.

“The same way they always take your blood pressure, they should do a brief screening for your substance use,” he said.

Addiction medicine groups now consider it the standard of care to screen for alcohol-use disorder, but not all providers do, and some don’t know what to do if a patient describes excessive alcohol use, said Dr. James Besante, chief medical officer at Santa Fe Recovery Center in New Mexico. Less than 10% of the estimated number of people nationwide who have an alcohol-use disorder get treatment any given year, he said. And some people may not have a clear idea of how much they consume, since one drink at a bar may contain multiple servings of liquor, or they may not tell the truth if they feel ashamed.

“It could be related to cost, it could be related to stigma, it could be that care just isn’t available,” he said.

Only 8% to 9% of people with an alcohol-use disorder who receive treatment get medication to help curb their cravings, Besante said. While medication isn’t right for everyone, it makes it easier for many people to either quit or reduce their drinking, depending on what their goal is, he said.

Naltrexone reduces cravings for alcohol and the pleasurable effects of drinking. Acamprosate may reduce the negative emotions that come with withdrawal, such as anxiety and irritability, according to the National Institute on Alcohol Abuse and Alcoholism. The third option, disulfiram, makes people feel sick if they drink.

Denver Health started offering the three medications approved by the U.S. Food and Drug Administration to all patients hospitalized due to alcohol, said Dr. Dale Terasaki, a physician who assists when patients in the hospital need addiction treatment. People with alcohol-use disorders tend to cycle in and out of hospitals, he said, and about one in seven hospitalizations at Denver Health from 2018 to 2022 was related to alcohol.

“They would be discharged after we would treat them for withdrawal, and before long they would be back,” he said.

Unlike opioid-use disorder, where the medical community agrees using medication indefinitely has large benefits, alcohol-use disorder doesn’t have a clear best practice for medication-assisted treatment, Terasaki said. If medication allows patients to function better and any side effects are tolerable, though, he said he generally doesn’t see a compelling reason for people to stop taking it.

“If it’s working, I’d say no shame in staying on it,” he said.

“You come out the same”

Some families have struggled for years to find help for their loved ones after the available treatment failed.

Denise, who lives in rural Colorado and spoke on the condition her last name not be used to protect her family’s privacy, said her son has been to rehab five or six times over 20 years of addiction, and while he doesn’t drink for the 30 days he’s in treatment, the cycle begins again shortly after he gets out.

“You come out the same as you go in,” she said.

Her son has been hospitalized about 16 times over the last three years, and each time, he leaves without much support, Denise said. In contrast, when her husband was hospitalized for heart trouble, he was offered home care to make sure he could safely make the transition, she said.

During her son’s most recent hospital stay for internal bleeding related to alcohol use, doctors told him that if he drank again, he risked dying, Denise said. When she spoke to The Post, he had been sober for about two months, but she’s not sure if that will last once he’s recovered enough from his hospital stay to resume normal life.

“He told us and the doctors he had a goal to stay alive until his kids finish high school,” which is two years away, she said. She’s not sure if he’ll make it.

Despite the perception that abstinence is the only option for people with an alcohol-use disorder, reducing the amount someone drinks could be a more realistic plan, said Votaw, who studies treatment. Little evidence exists one way or another about whether some people simply can’t drink moderately, or whether everyone could cut back with the right support, she said.

Not everyone is ready to quit or significantly reduce their heavy drinking, but doctors can take steps to try to reduce the odds of a bad outcome for their patients, Terasaki said. For example, people who drink heavily have a higher risk of severe pneumonia, so their doctors would want to emphasize the importance of getting vaccinated against respiratory diseases, he said.

“There’s other things we can do as far as disease management,” he said.

“People should really be encouraged”

More people need access to treatment that supports them from multiple directions, said a Denver resident, who spoke on the condition of anonymity because she was worried about consequences at work.

She said she had always been a social drinker until the pandemic, which hit right as she was getting divorced. By fall 2020, she realized she was drinking daily, sometimes having 12 or more servings in an evening.

“I would look forward to 5 o’clock. I would sit there and watch and wait,” she said.

She decided she needed help one day when she was traveling for work and started to feel withdrawal symptoms because she couldn’t have a drink when she normally would. She went to her primary care doctor at Kaiser Permanente Colorado, who referred her to the health care system’s “rapid intake” program. That involved meeting with a doctor, a substance-use counselor and a therapist to come up with a treatment plan together, she said.

It wasn’t feasible to take a week off her job, so the plan was to go through detoxification at home, with medication to prevent dangerous complications. She now takes a different medication to reduce alcohol cravings, and said getting quick treatment that took her situation into account helped her to move into recovery.

“Once someone has made the decision to seek treatment, they don’t want to spend weeks or months waiting,” she said.

Dr. Joseph Cannavo, regional chief of chemical dependency treatment services at Kaiser Permanente Colorado, said it can be difficult to find treatment for people who need something between a doctor’s visit and residential treatment. Kaiser’s program gets people started on medication to keep withdrawal from becoming dangerous or too uncomfortable, and then sets up a plan for follow-up care, he said.

In most cases, the program offers naltrexone, which works well for about half of patients, Cannavo said. But offering some sort of psycho-social help also is important, whether that’s meeting with an addiction counselor, therapy or a 12-step group, he said.

“With the medications we have now, alcohol-use disorder is extremely treatable,” he said. “People really should be encouraged.”

Though many people still don’t talk about excessive drinking as a treatable medical problem, some Colorado residents in recovery see a societal change taking place. Federal and state agencies run anti-stigma campaigns encouraging people with mental illnesses and substance-use disorders to share their stories, in the hope that others who need treatment will try to get it.

Many things could contribute to people not getting the care they need, but experts think shame is a significant factor.

People starting recovery often still feel shame about their inability to drink moderately, but more and more are opening up about their mental health and addiction struggles, said Tracy, the Denver Alcoholics Anonymous member.

“People are more accepting that everybody has something today,” she said.

Bobbi Kennedy, a volunteer at the fitness-focused recovery group The Phoenix in Denver, said she’s encouraged by how open younger generations are about substance use and recovery. Her father rarely drank, but didn’t want people to know he had liver failure, because he thought they would assume he was addicted to alcohol and judge him, she said.

Now, the stigma has lessened enough that young people who are “sober curious” or just supporting a friend don’t mind being seen in a recovery group.

“I think it just goes back to being less ashamed,” she said.

READ MORE FROM THIS PROJECT: Colorado’s quiet killer: Alcohol ends more lives than overdoses, but there’s been no intervention

The Denver Post is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity and newsrooms in select states across the country.