Medicine to Psychiatry to Parking Lot: The Evolution Of Detox Over The Past 30 years

There is probably no better indicator of discriminatory rationing in the business run era of health care than the way substance users, alcoholics, and addicts are treated.  If you think about it - this is the ideal population to discriminate against.  In the severe situations where hospital detoxification is needed most of these folks are isolated and they have burned a lot of bridges.  They don't have a lot of friends and family members advocating for medical resources.  Most are unconcerned about their own health and many have significant medical morbidity associated with the addiction.  With any addiction, the tendency to continue the addicted states governs decision making so they enthusiastically leave medical facilities without addressing the problem as soon as a physician gives them clearance to go.  They are quite happy to keep bed occupancy and length of stay to the very minimum.  That is if they get admitted at all these days.

Back when I was in training as a medical student, I was fortunate to get most of my clinical training in large public facilities like county hospitals or VA hospitals.  In those days, patients with alcoholism or addictions who needed detoxification were admitted to Internal Medicine Services.  This was a great idea for several reasons.  Many people with addictions have significant medical comorbidity either independent of the addiction or due to it.  I saw many cases of acute pneumonia, pneumonia and meningitis, acute hepatitis, cirrhosis, pancreatitis, hepatic encephalopathy, delirium tremens, withdrawal seizures, and Wernicke's encephalopathy.  I don't think there is any better place in a hospital to address those problems than under the care of Internal Medicine specialists.  Until you have seen enough people critically ill and in withdrawal - it is difficult to appreciate the life-threatening aspects of intoxication or withdrawal from an addictive substance.  At some point in the mid to late 1980s, the detoxification landscape changed dramatically.  Suddenly a large number of those patients needing detox were sent to psychiatry services.  Only the obviously ill and delirious could get admitted to Medicine.  After the triage decision in the Emergency Department (ED) it was up to Psychiatry to sort out the problems and treat them as well as doing the detoxification.  There was also the development of county detox units, basically as a safer environment than the street, but offering little to no medical detoxification services.  If a patient went to a county detox unit and had a seizure there or became delirious - they could always be sent back to the ED.

A few years into my inpatient career. utilization reviewers started to deny the cost of care for anyone on my unit getting detox services.  That included people with the highest risk profile - depression, alcoholism, and suicidal ideation or behavior.  The primary rationale of these reviewers was that the patient did not require detoxification on an inpatient unit - even if they were in active withdrawal, taking high doses of detox medications, and had been discovered attempting suicide prior to admission.  The denial was based on an addiction or alcoholism and the fact that managed care companies had mandated that it was no longer an acceptable reason to treat somebody in a hospital.  The year was about 1990 and it was clear that this was a blanket denial of anyone with an addiction.  That had the predictable effect of inpatient psychiatry no longer being a resource for safe medical detoxification.  We are still dealing with the fallout from these business decisions 26 years later.  The fallout takes several forms including:

1.  A loss of infrastructure - there are no longer a significant number of Internists or Psychiatrists who routinely diagnose and treat withdrawal states and the associated addictions.  Most hospitals in any state do not have these services with the exception of the occasional person who is agitated or delirious in the ED and requires intubation and ICU support.  One of the frequent suggestions I hear about the current opioid epidemic is whether or not physicians are adequately trained in addictions.  With the loss of a detoxification infrastructure, I doubt that medical students and residents are seeing anywhere near the number of patients with addictions that they need to see relative to 30 years ago.

2.  A proliferation of inadequate detoxification facilities - a lot of the current facilities are run by counties and there is no medical aspect to treatment.  Decisions to get medical assistance may be made by someone with no medical background.  These facilities do not have environments that are managed to provide a calm and non-threatening atmosphere.  Many people admitted to them are fearful of the other patients and see the detoxification as a penalty.  They leave as soon as possible - even if they are still experiencing withdrawal symptoms.  Some of the facilities will only accept patients with a positive blood alcohol level by breathalyzer, and they discharge people when their estimated blood alcohol content reaches a certain level.  If you need detoxification from a sedative hypnotic or an opioid or several compounds -  you are out of luck.

City and county jails also double as detox facilities, in the same way that they double as psychiatric hospitals.  A common history is a patient on methadone or buprenorphine maintenance who is incarcerated, not given their usual maintenance medications and who is forced to go into acute withdrawal.  People who have been taking sedative hypnotics or using alcohol can also go into acute withdrawal that is potentially more serious.  Correctional facilities need systems in place to assure adequate and safe care for incarcerated individuals to prevent these acute withdrawal syndromes.  There are always a number of people with alcohol and drug use problems who die while they are incarcerated and as far as I can tell - these deaths are never investigated to determine if they received adequate medical and psychiatric care.

3.  A proliferation of "outpatient detox" - I can't really pinpoint when it became acceptable for patients with uncontrolled alcohol or drug use to suddenly manage their own detoxification using addictive drugs, but it is a common scenario these days.  Go into the ED with alcohol withdrawal and leave with a benzodiazepine to take on a scheduled basis.  Nobody should be too surprised if that medication is ingested at a higher than directed rate.  At times the entire bottle is taken on day 1.

4.  A disrupted spectrum of addiction care - apart from preventing life-threatening complications, the main reason for detoxification is to disrupt the cycle of addiction so that the affected person can get past all of the negative reinforcement (cravings, preoccupation, physical withdrawal symptoms) that keep the addiction going.  Without this modality, people are at home trying to cautiously taper off a drug or alcohol.  Many will go on for years without any success and they will be frustrated by the lack of abstinence or sobriety and give up.  Some with leave a clinic or ED with a supply of medication in order to try to detoxify themselves and realize that they are not able to take that medication on the suggested schedule to complete a safe detox.  Many will feel guilty or ashamed about going to AA or NA meetings while they are still using drugs or alcohol and give up.  Adequate detox avoids all of these problems with a rapid and safe approach to the initial stage of recovery from addiction.  

5.  The myth that business managers know what is best - the managerial class in America continues to run medicine without any knowledge of measurement, statistics, or quality.  In this case the logic seems obviously wrong.  Since the need for medical detoxification is an emergency it should be difficult to deny coverage for this condition.  That denial has been more or less routine and the cumulative denial has led to a serious degradation of services available for alcohol and drug use problems.

When I think about how medical treatment is supposed to work, every health plan should have adequate residential or hospital detox services for quality, safety and continuity of care.  Those facilities need to be more than holding tanks.  The environment has to be respectful, quiet, and comfortable where every patient feels safe and like they are being provided adequate care.  Active psychiatric consultation needs to occur because of the high comorbidity of psychiatric problems with addiction.  The current opioid epidemic has precipitated a discussion of improving the infrastructure to treat addiction.  That would not be too difficult since a large part of that infrastructure has been rationed out of existence in the last 20 years.

This sequence of events also has implications for all of the ideas about mandated physician education about opioid prescribing.  In some states the requirement is extensive and in many at this point it is mandated for licensure.  These mandates are shortsighted without the necessary infrastructure.  Addiction and detox services require administrative support and not administrative rationing.  Mandated education for physicians in not likely to do much good as long as they are sending addicted patients out with a bottle of medications and they end up detoxing in the parking lot.

It is time to drastically improve the treatment of all patients with alcohol and substance use disorders and stop the long-standing discrimination against them.      


George Dawson, MD, DFAPA

How Should APA Guidelines Work?

The guidelines of the American Psychiatric Association (APA) are an interesting story in how guidelines are important if used correctly by professional organizations.  The whole idea behind a profession is that the practitioners in that area have special expertise and that the expertise is standardized to some degree.  Standardization is useful in the case of physicians to assure the safety of the practitioners and so that people have some idea of what to expect in terms of safe and effective care.  Over a decade ago the APA began producing guidelines for practice in various areas of the field.  I thought it was an exciting development.  The guidelines were initially sent along with the monthly copy of the Journal of the American Psychiatric Association.  All of the guidelines are available publicly on this web site, but hardly anyone knows about them.  I make this statement because one of the many red herrings that the critics of psychiatry use is that psychiatry has no standards of care.  They seem quite shocked to find that these guidelines exist and address their complaints directly.  

I was asked to critique one of the existing guidelines and suggest how these guidelines could be used more effectively.   In looking at the guidelines web site, it is apparent that some of the guidelines have not been updated in quite a while.  Publication dates range from 2000 - 2010.  Given the pace of clinical research 5 years might be somewhat acceptable, but 10 - 15 is probably not.  Another issue that the APA needs to grapple with is the diagnostic manual versus treatment approaches.  There is widespread confusion about whether or not the DSM-5 is a guidebook for treatment as opposed to a guidebook for diagnoses.  The APA actually two approaches to treatment guidance - the guidelines themselves and a text entitled Treatment of Psychiatric Disorders (TPD).  TPD is currently in its 4th edition and it has gone from a series of two volume detailed text to a more basic single volume text.  That text was published in 2007.  Some of the chapters in the previous editions provide some of the most detailed information on the pathophysiology and treatment of certain disorders that could be found anywhere.  At that level of analysis, the APA has gone from providing outstanding information on the pathophysiology and treatment of psychiatric disorders to a relative vacuum over the past 10 years.

For the purpose of a more detailed analysis I will consider the Practice Guidelines on Substance Use Disorders and the associated Quick Reference Guide and Guideline Watch - a 2007 update of the original 2006 guideline.  I looked at the Guideline Watch first because it should reflect the latest literature reviews and treatment guidelines.  The document reviews medication assisted treatment of tobacco and alcohol use disorders with varenicline, naltrexone and acamprosate.  The document was a good summary of the literature at the time but it needs a serious update.  Since then there have been more extensive studies of the genetics, combination therapies, re-analysis of existing studies and side effects of naltrexone, acamprosate, and varenicline including use in specific psychiatric populations.  In at least one case, the current literature supports a course of action that is exactly the opposite of what is recommended in this document.  That course of action is: " Given its high potency and partial agonist activity at central nicotinic acetylcholine receptors, varenicline should not be combined with alternate nicotine replacement therapies."  An inspection of the references for varenicline notes that additional research has been done in this area and should be discussed.      

The Quick Reference Guide contains extensive tables from the original guideline so I will go directly to that document.  At first glance it looks like a significant document more than 200 pages long.  But about 177 of the 276 pages of the document are relevant text.   The rest are references and polls of various expert groups on what they consider necessary for a guideline.  Looking at the Table of Contents, the first thing that is apparent is that only a subset of substance use disorders is being considered.  Although it is likely that nicotine, alcohol, marijuana, cocaine and opioids represent the majority of abused substances psychiatrists treating addiction see a broader array of compounds being abused.  The full gamut of abused compounds should probably be addressed in the guideline whether or not there is a consensus about treatment methods or not.  The safety of users and treatment setting considerations will still need to be considered as well as the need for further assessments.  A good example would be Hallucinogen Persisting Perceptual Disorder and what might be the best assessment and treatment.  If the guidelines are supposed to apply to clinical practice then patterns encountered in clinical practice need to be addressed.  If the APA does not address them - governments and managed care companies will, most frequently to the detriment of patients.

The guideline uses the following conventions for the treatment recommendations.  They are conventions frequently see in professional guidelines:

[I] Recommended with substantial clinical confidence.
[II] Recommended with moderate clinical confidence.
[III] May be recommended on the basis of individual circumstances.

The introductory section does not suggest who the guidelines are written for.   This is a critical aspect of the document.  There is an implication that it is for psychiatrists based on the statement about a comprehensive psychiatric evaluation but I think that needs to be more explicit.  It is not uncommon for managed care companies to send letters that deny care to psychiatrists.  The letter often contains a list of guidelines that an insurance company reviewer used to deny the care.  The APA needs to be explicit that these guidelines are intended for use by the psychiatrist who has personally assessed and is treating the patient and not by an insurance company employee or contractor who is sitting in an office reading through paperwork.  Somewhere along the line professional organizations seem to have lost track of the concept that only direct assessment and treatment of the patient was considered the correct way to do things.  Putting it in all guidelines is a critical first step.

The next thing I would change in terms of guidelines is breaking out the treatment setting recommendations into separate sections in table form.  For example the Hospitalization guidelines are copied into the Supplementary section of this post.  They are all very appropriate and I doubt that there are any reasonable clinicians that would have a problem with them.   The problem is that these services are rationed to the point that it is difficult for any reasonable clinician to implement them.  By that I mean that a psychiatrist cannot get a patient meeting these criteria into an inpatient detox or treatment setting based on these criteria.  As an example, consider the patient who says they are drinking 1 liter to 1.75 liters of vodka per day for 6 months.  They describe uncomplicated symptoms of alcohol withdrawal (shakes, sweats, hangover symptoms and drinking in the morning to suppress these symptoms).  I think the person in this vignette meets criteria 2 for hospitalization and detox at least.  A significant number of patients presenting to emergency departments with this pattern of findings are not hospitalized.  Many are sent out with a supply of benzodiazepines to detoxify themselves.  Many are sent to county detox facilities where there is no medical coverage or so-called social detoxification settings.  None of these non-hospitalization options are realistic approaches to the problem.  Giving a person with an alcohol use disorder a bottle of benzodiazepines for home detox ignores the uncontrolled use and cross addiction aspects of the primary disorder.  It is highly likely that person will ingest the benzodiazepines all at once or use them to treat the morning withdrawal symptoms of the disorder.  Social detoxification is an equally suboptimal approach.  It depends on probabilities.  It is more likely that the person transferred to that setting will leave due to the adverse environment and go back to drinking or undergo withdrawal and not experience delirium tremens or withdrawal seizures.  Over the past 30 years, the managed care industry has refused to consider admissions in practically all of these situations often whether there was psychiatric comorbidity or not resulting in the rationing of care at the initial assessment in the Emergency Department.  There must be an awareness that clinical guidelines don't operate in a vacuum.  Having a guideline in place that nobody can use is not the best approach to providing quality care.   Managed care companies can deny inpatient care on practically any of the 7 inpatient criteria simply by saying that they do not exist.    

On the treatment side there are inconsistencies noted in the recommendations and editing problems.  For example, there are 49 references to "12-step" and 2 references to 12 steps.  One of the first statement one encounters is:  "The efficacy of treatment is related to the amount of psychosocial treatment received. The 12-step programs, hypnosis, and inpatient therapy have not been proven effective."  That characterization of 12-step recovery is inconsistent with just about every other reference in the document.  Where it is suggested it is footnoted with a "I" designation or "substantial clinical confidence."

Rather than critique other sections based on data that was not available at the time that this guideline was posted, I thought I would end with a comment on the process and general philosophy of professional guidelines.  Right at the top of this guideline is a section entitled "Statement of Intent".  The crux of that argument is contained in the paragraph (p. 5):

 "The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed
or to serve as a standard of medical care. Standards of medical care are determined on
the basis of all clinical data available for an individual patient and are subject to change as scientific
knowledge and technology advance and practice patterns evolve. These parameters of
practice should be considered guidelines only. Adherence to them will not ensure a successful
outcome for every individual, nor should they be interpreted as including all proper methods
of care or excluding other acceptable methods of care aimed at the same results........"

I don't really agree with that approach.  The concerns about saying that these are standards of care is a medico-legal one and I have rarely found that to be a sufficient basis to practice medicine.  An example would be litigation against a psychiatrist for not following the stated standards of care in a malpractice suit.  This may seem protective of psychiatrists for varying practice styles but it also has the more insidious effect of basically allowing any standard of care to apply.  A walk down the street to a different hospital results in an admission for medical detoxification when the first hospital discharges the patient with a prescription of lorazepam and a promise to follow up with their primary care MD.  The resulting business incentive practice creep results in a complete lack of detoxification and a lack of any standards of medical care.  The default standard is whatever businesses decide to pay for.  My observation is that results in an unacceptable level of medical care.  And further:

"The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment
options available....." 

I agree with the statement but let's face it,  the judgment of the psychiatrist frequently has very little to do with the judgment of the psychiatrist or what options are ultimately considered in the working alliance with the patient.  Practically all inpatient and residential care these days is dictated by managed care companies and insurance companies irrespective of what a psychiatrist would recommend or a patient would accept.  These are standards of care that are forced on psychiatrists and patients rather than the prospective quality based standards.

Stepping back from that fact medical standards play a peripheral role to what businesses want and that unacceptable standard has been present to one degree to another for the past 30 years, I don't think a new approach in guidelines is too much to ask for.  I don't think it is too much to ask that APA guidelines be up to date, internally consistent, inclusive, actually apply as a standard of care as opposed to using business standards as the default, and be used to advocate for the best possible treatment settings for psychiatrists and their patients.  There are a number of specific methods that can be used and I will discuss them when the draft version of the latest  Practice Guidelines for the Psychiatric Evaluation of Adults comes out this year.


George Dawson, MD, DFAPA


References:

Work Group On Substance Use Disorder.  Practice Guideline For TheTreatment of Patients WithSubstance Use Disorders,  Second Edition.  American Psychiatric Association.  This practice guideline was approved in December 2005 and published in August 2006.


Supplementary 1:   These are the hospitalization guidelines from the APA Substance Use Disorders Guideline.

"Hospitalization is appropriate for patients who 

1) have a substance overdose who cannot be safely treated in an outpatient or emergency department setting

2) are at risk for severe or medically complicated withdrawal syndromes (e.g., history of delirium tremens, documented history of very heavy alcohol use and high tolerance); 

3) have co-occurring general medical conditions that make ambulatory detoxification unsafe; 

4) have a documented history of not engaging in or benefiting from treatment in a less intensive setting (e.g., residential, outpatient); 

5) have a level of psychiatric comorbidity that would markedly impair their ability to participate in, adhere to, or benefit from treatment or have a co-occurring disorder that by itself would require hospital level care (e.g., depression with suicidal thoughts, acute psychosis); 

6) manifest substance use or other behaviors that constitute an acute danger to themselves or others; 

or 

7) have not responded to or were unable to adhere to less intensive treatment efforts and have a substance use disorder(s) that endangers others or poses an ongoing threat to their physical and mental health [I]."      (p.  11).

Clinical Care - The Hype Versus the Reality

As noted in recent posts, I was a participant in a conference that focused on the clinical care of patients with addictions.  The intended audience was primary care physicians.  One of the advantages of a course like this is that there is a lot of cross talk between the presenters and those attending the conference.  After a three hour segment about the treatment of opioid addiction and chronic pain, I was approached by a physician who updated me on the state of treatment of addictive disorders and psychiatric disorders in primary care.  One of the recommendations by our speakers was to suggest that drug and alcohol counselors in their own clinics might provide very useful approaches to treatment that could not be provided by the primary care physicians.  It is difficult to see how busy primary care physicians could suddenly take an hour or two to do group therapy for patients addicted to opioids or benzodiazepines.  Taking breaks from the productivity based schedule to do indicated psychotherapy for patients with histories of trauma is even less likely.  After all, isn't this the medical home model?

This physician was very aware of those constraints.  He had tried to implement these modalities in his clinic, but they were rejected outright by administrators.  We discussed some of my experiences in managed care settings as a consultant to internists in managed care settings.  I had an internist call me and say that he had a patient who was addicted to opioids and needed detox prior to surgery.  I called my boss about the resources available for that.  He told me that we did not have the time available to do detox from high dose opioids.  That problem has continued to worsen.  This physician was also not having any luck with getting detox for pre-op patients.  The opinion at the conference by speakers was that slow and gradual detoxification from opioids and benzodiazepines was the exception rather than the rule.  It is theoretically possible in highly motivated individuals with a relatively unlimited time frame.  The best approach seems to be fairly rapid detox with adequate protection (in the case of benzodiazepines and alcohol) against seizures.  Attempts at "outpatient detox" range from handing the patient a bottle of benzodiazepines in the emergency department to "social detox" in holding areas that monitor people and send them back to the emergency department if it looks like they are going into worsening withdrawal.  There are no acknowledged standards in the area.  Nobody complains about this inadequate care for addiction most likely due to the stigma of addiction and the general plan of many places to "get rid of" addicts rather than providing them with any kind of treatment that might be useful.

The evidence-based psychosocial treatments discussed at the conference highlight further deficiencies in the system of care.  The National Institute of Drug Abuse and their Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) was referenced.  Even a cursory look at these guidelines shows that there is probably no managed care system in the country that adheres to these guidelines.  A couple of examples:

"Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment."  (Principle number 5).

There are certainly plans that offer no coverage for addiction at the extreme end.  Many plans that do, follow utilization review protocols that frequently review the treatment being provided with an eye toward providing the least expensive care.  In some cases people with severe problems and no significant withdrawal or medical problems are discharged.  The default position is that the patient must fail, in many cases several times before treatment is funded.  In many cases there is a focus on whether the addiction or the psychiatric disorder is "primary" in order to shuffle the patient from one pool of money to another (addiction <-> psychiatry).  All of this financial gaming leaves the addicted patient out in the cold.  That starts with inadequate to nonexistent detox to treatment that lacks the necessary intensity to be successful.  It can also create a very negative and counterproductive attitude by the system of care to the patient with the problem.

"Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions." (Principle number 11).

When insured patients are incarcerated or committed for problems associated with an addiction there is usually a strong push to get the patient into public systems of care.  That includes state hospitals, public clinics, and public mental health problems.  The strategy is clear - shift the cost of treating addiction and mental health problems to government run systems.  Most states have taken a page out of managed care and responded by decreasing available treatment centers and hospitals.

All of these business manipulations do not bode well for people who need care for even moderately complex problems.  Certainly the detoxification and treatment of an otherwise healthy 25 year old is much different from a 60 year old with cirrhosis and diabetes.  But the system of care is currently not set up to provide necessary care for the least complex patient.  At a policy conference in Hawaii in 2011, I asked the policy wonks who were there to tell us how the "medical home" would revolutionize care for addictions: "What would keep a managed care company from doing a screening exam and leaving it at that."  His response was: "nothing".  It appears that I am able to predict the behavior of managed care systems much better than the policy wonks.

What would help?

The same thing that many professional organizations have failed to do over the past three decades.  Physician organizations like the American Society of Addiction Medicine (ASAM) need to promote adequate treatment guideline, make them publicly available, and embarrass these companies into using them.  ASAM currently has a complex matrix that is supposed to correspond with levels of care.  They are largely ignored by managed care companies.   ASAM should talk about the heavy drinker coming into the emergency department and walking out with a bottle of lorazepam.  It is rather ironic that NIDA does not step up and say what standards should apply, but any regulation needs to consider the Congressional sausage factory and their negative impact on quality care.

The negative impact of business on quality care is most obvious in the areas of psychiatric services and addiction.  Following the status quo and even going as far as endorsing managed care tactics is good for business, but not for people trying to recover from addiction.  From a policy standpoint, this is a much bigger problem than any issue with pharmaceutical companies, conflict of interest, or even perceived problems with psychiatry.  Denying that basic truth may be the result of three decades of ignoring this problem, but complaining about less important issues will not change the skewed health care landscape or get necessary treatment for people with psychiatric and addictive disorders.

George Dawson, MD, DFAPA

Why Are There No Detox Units Anymore?

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