Acute withdrawal from drugs and alcohol can kill you in
the worst case scenario and at best can prevent you from initiating the
recovery process. So why are there no
detox units anymore or at least very few of them? You can still end up in a hospital going
through detoxification or in a county facility where the priority is more
containment of the acutely intoxicated than appropriate medical detoxification. There are probably a handful of detoxification facilities where you will
see physicians with an interest or a specialty in addiction medicine using the
best possible standards. Why is the government and why are the managed care
systems that run healthcare in the United States not interested in
"evidence-based" medical detoxification?
As a person who has seen the system devolve and who has successfully
treated a lot of people who needed detoxification this is another deficiency
in the system of medical care that is never addressed. Over the course of my
career I have seen patients admitted to internal medicine services for detox in the
1980s. When insurance companies and managed care companies started to refuse
payment for that level of treatment intensity patients requiring detoxification
were then admitted to mental health units.
When mental health units started operating according to the managed care
paradigm of no treatment for people with severe addictions, they were either
sent home from the emergency department or sent to county detox facilities. Those county detox facilities were often low in quality and one incident away from being shut down.
I currently teach physicians about the management
of opioids and chronic pain in outpatient settings. I am impressed with the number of addicted
patients who are taking opioids for chronic pain. This population frequently has problems
with benzodiazepines. There is a general
awareness that we are in the midst of an opioid epidemic and in many counties
across the United States the death rate from accidental drug overdoses exceeds
the death rate from traffic fatalities. The question I get in my lecture is frequently
how to deal with the addicted pain patient who is clearly not getting any pain
relief from chronic opioid therapy and has often escalated the dosage to potentially
life-threatening amounts. In many chronic pain treatment algorithms this is the "discontinue opioids" branch point. During my most
recent lecture I posed the question to these physicians: “Do you have access to a
functional detoxification facility?" Not surprisingly - nobody did.
I can still recall the denial letters from managed care
companies when I was taking care of patients with alcoholism and addiction in
an inpatient setting. They had been admitted to my inpatient mental health unit
and many were also suicidal. The typical managed care comment was "this
patient should be detoxified in a detox unit and not admitted to a mental
health unit.” This is an example of the
brilliant concept called "medical necessity" as defined by a managed
care company. In the majority of these cases, the patient's county of residence
did not have a functional detox unit and there were also clear-cut reasons for
them to be on a mental health unit. County detox facilities do not take people with suicidal thinking or associated medical problems. I
wonder how many letters it took like the ones I received to permanently disrupt
the system so that patients with alcoholism and addictions could no longer get
standard medical care.
The end result has been no standards for medical
detoxification at all. Some patients are sent out of the emergency department
with a supply of benzodiazepines or opioids and advised to taper off of these
medications on their own. That advice ignores one of the central features of
substance abuse disorders and that is uncontrolled use. Without supervision I
would speculate that the majority of people who are sent home with medications to do their own detoxification take all that medication in the first day or two
and remain at risk for complications.
Appropriate detoxification facilities staffed by physicians
who are trained and interested in addictive disorders would go a long way toward
restoring quality medical care to people who have a life threatening addictions. It would restore more humanity to medicine - something that business decisions have removed. As far as I can tell, people struggling with addictions and alcoholism continue to be
neglected by both federal and state governments and the managed care industry.
George Dawson, MD, DFAPA
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