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

Blaming Psychiatrists For Decreased Access - The Ultimate Political Manipulation?

I was trying to mind my own business this morning and focus on my usual PowerPoints but then I happened across the musings of 1BOM and and some of his associations to an article on the fact that psychiatrists accept insurance at lower rates than other physicians.  Interestingly, the authors look at some correlates of this phenomenon and then jump to the following conclusion:

"Nonetheless, our findings suggest that policies to improve access to timely care may be limited because many psychiatrists do not accept insurance."

The only way a sentence like this gets into a journal article is with the necessary qualifiers "suggest" and "may".  Certainly the press and the detractors of psychiatry won't pay much attention to the qualifiers.  I am sure that some managed care executives also see this as a reason for celebration.  At a time when they literally have psychiatry on the run because of poor reimbursement, rationing, and invasive management practices - what better "research" to back up more managed care practices?  It is not the onerous business practices after all, it is those pesky psychiatrists who refuse to accept whatever we want to pay them.

The authors of this article seem to ignore the historical context of 30 years of rationing psychiatric care to the point that inpatient care is generally of very limited value, psychotherapy-at least the research based kind is scarcely available, and psychiatrists trying to function in an outpatient settings are continuously harassed by insurance reviews or restrictions.  Many public systems of care previously under the oversight of psychiatrists are now being run by administrators with no mental health training who have no shortage of ideas about how systems based care should be implemented.  The authors provide an introduction to this research that contains the following paragraph:

"The Centers for Disease Control and Prevention estimates that a quarter of adults in the United States report having a mental illness at any given time and about half will experience mental illness during their lifetime.   In the wake of the Connecticut school shooting and other recent mass shootings, policy makers and the public have called for increased access to mental health services.  For example, President Obama’s “Now Is the Time” proposal, released in January 2013, called for better mental health services, including programs to identify diagnosable mental health problems early so that patients can be referred for treatment, and increased training of mental health professionals."

I really cannot think of a more politically naive statement about the state of mental health in this country or the likelihood that things are going to change.  It is certainly clear to me that we have a standard strategy for mass shootings in this country that does not involve addressing the widespread availability of firearms or lack of availability of a functional mental health system.  The public also seems quite content to accept the idea that violence and aggression are random acts and cannot be addressed from a psychiatric perspective.  The usual photo-op involves politicians showing up, suggesting some serious political work (that never comes to fruition), praising the heroes and then suggesting that we must all move on.  Occasionally there is the suggestion that people were just "in the wrong place at the wrong time".  It is really nothing more than political helplessness in the service of career politicians and special interests.  Torrey and Jaffe have taken a close look at what is wrong with the idea of a President's initiative on violence and aggression and there are many problems.  Transmuting all of these chronic problems into psychiatrists not wanting to accept inferior reimbursement or the additional free work required for insurance business is ridiculous.

In the next paragraph the authors resort to a familiar stereotype of psychiatrists:

"Psychiatrists play an important role in the diagnosis and treatment of patients with mental illnesses particularly because of their training and ability to prescribe medications."

It is well known that 80% of all medications for mental health indications are prescribed by primary care physicians.  Furthermore we are currently caught up in the latest managed care technology referred to as collaborative care that will greatly increase that percentage.  That will be true because of an expected rapid increase in access to antidepressant prescriptions and also because in some models - psychiatrists will not actually see patients or write prescriptions.  The real risk of eliminating psychiatrists is the diagnostic capability.  There are many interests who benefit by not considering the importance of eliminating that skillset.  Let me illustrate how that happens.  For many years, I worked in a Geriatric Psychiatry and Memory Disorders Clinic.  It was staffed by myself, by a neurologist, and an RN who  specialized in geriatrics.  We offered a service to primary care specialists and the community as a resource for diagnosing a full spectrum of cognitive disorders, dementias, and mental health disorders in geriatric populations.  We also offered some research protocols and treatment with what was then state of the art medications for Alzheimer's disease.  We also offered a full spectrum of referrals for psychosocial resources and residential care for patients that we saw and assessed.  We were told at one point that reimbursement for our services did not cover the cost of nursing services for out clinic.  Our nurse was an absolutely critical piece because she would gather information on the functional capacity, behavioral problems, and known medical problems of all patients coming in to the clinic.  She would often gather this information from more than one informant.  That would amount to about 8 hours of telephone work for one 4 hour clinic.  Most of the time was provided free gratis because she believed in what we were doing.  In order to possibly improve the financial status of the clinic, we started to travel out to nursing homes and see people there in person.  That model was not useful because we received dramatically less reimbursement consulting in a  nursing home setting.  We also had unreimbursed travel time with each visit and the cost of transportation.  Eventually administrators told us we had two choices - shut down the clinic or eliminate the nurse.  It was an easy decision for the neurologist and myself.  We barely had enough time to do all of the documentation associated with our services much less all of the collateral contacts.  So we shut down the clinic.

This is a classic example of how quality mental health services are rationed and put out of business.  Our clinic was well known for quality care.  Years later I was still being asked about why we shut our doors.  It is literally a function of how much information that you collect and analyze.  In order to make the necessary diagnoses the full spectrum of functional capacity, cognitive, psychiatric, medical imaging, and laboratory data needs to be reviewed or ordered for the first time and analyzed.  We would see people who were told by other physicians that "there is nothing else we can do for you" and they were wrong.  There can alway be a debate about how much comprehensive services that  utilize the full training and ongoing education of physicians is worth.  It is definitely worth more than a 5 or 10 minute visit, a prescription and a Mini-Mental State Exam score.

1BOM list some associated arguments about the issue of whether psychiatrists should accept whatever insurance companies decide to reimburse.  The most interesting of these is that the field can be parsed into basically psychotherapy and neurosciences.  Further analysis suggests that if psychiatrists want to provide psychotherapy they should accept whatever standard reimbursement a "non-medical" therapist should accept.  It is almost as if non-medical psychotherapy is an option in the training of psychiatrists.  That attitude is certainly counter to the fact that psychotherapy is an integral part of psychiatric training both as a treatment modality and as a necessary technique for studying the therapeutic alliance.   There are similar illogical arguments about transferring the neuroscience and neuropsychiatric aspects of psychiatry to neurologists.  Dr. Nardo in his wisdom points out that basically neurologists don't  want it.  That is why they went in to Neurology in the first place.  It seems that other specialists seem to know the demarcation of the speciality better than some psychiatrists do. 

The overall problem here is very familiar to me.  It is the reason I started writing this blog in the first place.  Everybody has been bombarded by business and managed care propaganda for decades.  One the the strategies contained in that propaganda is that medicine and psychiatry no longer define themselves.  Business defines medicine.  That is why all of my colleagues freaked out in the 1990s.  They heard that "things are different now" and did not know what to do about that.  Even today, the first reaction to the propaganda is to cannibalize your own specialty before thinking clearly about what this all means.  Managed care closed down my clinic because they said my valued nurse colleague was not "cost effective".  Closing that clinic eliminated the availability of two experts who were providing services that were not replaced.  Does that mean we have no need for geriatric psychiatrists, nurses, or neurologists?  The headlines today would suggest otherwise.

We will all remain in the limbo of politicians telling us we need increased access and insurance companies decreasing access in order to increase their profitability.  And that has nothing to do with the fact that psychiatrists need to be trained in neurology,  neuroscience, medicine, and psychotherapy.  Not accepting insurance is the ultimate affirmation that business does not define medicine or psychiatry.

George Dawson, MD, DFAPA

1: Bishop TF, Press MJ, Keyhani S, Pincus HA. Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry. 2014 Feb;71(2):176-81. doi: 10.1001/jamapsychiatry.2013.2862. PubMed PMID: 24337499.

Supplementary 1:    The issue of "financial viability" of my closed clinic came up on the 1BOM discussion.  In my experience financial viability is just more managed care rhetoric.  Like cost effectiveness it needs to be rejected outright.  The most obvious evidence is the collaborative care model.  Here we have a model that is strongly promoted by managed care and now the APA that is telling us that there are essentially unlimited resources to see what are called "med management" visits.  They are after all eliminating any actual diagnostic process and putting people on medications as soon as possible.  I am quite sure that some of the patients with complex problems that I assessed are now getting a PHQ-9 and placed on antidepressants.  I have already posted that (based on 2005-2010) data that antidepressants are already being overprescribed.  Collaborative care will result in a proliferation of additional "prescribers" to increase that number.  For that questionable low quality service, the patient will probably be charged around $50 for (at the maximum) a 10 or 15 minute visit.  In fact, in my health plan it can occur over the telephone with no actual patient visit.  If I was in private practice I would probably charge $300-350 for a 60-90 minute evaluation that look at all of the patients medical, psychiatric, and medical imaging data.  The final product is a diagnosis or list of diagnoses rather than a PHQ-9 score and there would be an intelligent discussion with the patient about what to do.  If medications were prescribed there would be a detailed discussion of the risk, benefit, and likelihood of success.  There would also be a detailed discussion of how to avoid rare but serious side effects and when the medication should be stopped and when I should be called if there were problems.

If you want to say that "financial viability" is a legitimate metric that exists outside of the mind of an managed care MBA, I would clearly disagree.  My plumber, electrician, and chimney sweep don't hesitate to charge me $200 to show up and then add charges on top of that.  The information content and technical skill they use to fix or install things does generally not reach the level that I would use in my 60-90 assessment.  Financial liability in a managed care system is basically anything outside of high volume low quality work that the company can profit from.  It is an artifact of cartel pricing that seriously discounts the skills of physicians.  The only reason my tradesmen are financially viable is that they don't have a cartel fixing their prices, forcing them to put out a high volume, low quality product and skimming their profits.

I hope that more and more physicians stop taking managed care insurance and put the financial viability theory to a test.  It certainly has not put tradespeople out of business and they are easily charging on par what physicians charge for reasonable medical care.  We can also learn a lot from our dental colleagues who are usually subject to severe insurance limitations.  I guess that by the managed care definition, dentists are also not financially viable?  

My dentist by the way charges way more than I would charge in private practice.    

Supplementary 2:  A reader suggested that I was erroneously saying that managed care hit mental health services harder than the rest of medicine.  The following excerpt from a report by Floyd Anderson, MD describes the results of the Hay Group report on this issue in the 1990s:

"More recently, the National Association Of Psychiatric Health Systems - Hay Group found that from 1988 to 1997 that a total value of health care benefits for over 1,000 large U.S. employers declined by 10%; general health care benefits declined by 7%, but behavioral health benefits declined by 54%. As a proportion of total health benefit costs, behavioral health benefits decreased from 6% to 3% during that period. This same study found that between 1993 and 1996, the use of outpatient behavioral health services dropped 25%, but use of outpatient general health services increased 27%. Inpatient psychiatric admissions between 1991 and 1996 declined by 36%, compared with a 13% decline for general health admissions during that same period. Mental Health Economics reported in September of 1999, “Despite the robust economy of the past five years, and the growing awareness of disparity between mental health care benefits and general health care coverage, the value of employer-provided mental health care benefits has declined by over 50% since 1988.”

That occurred in the context of overall health care expenses increasing. And do you really need a report? It may be hard to believe, but mental health services were delivered outside of jails at one point in time.