I’m feeling discouraged this week, due to a recent vivid display of my state’s broken mental health/substance abuse treatment system.
Details of this encounter have been changed to protect identities.
One of our former opioid treatment program patients returned to us, asking to be admitted again to methadone maintenance. In previous admissions, this patient struggled with repeated bouts of benzodiazepine addiction and had several near overdoses. He also had months at a time when he did relatively well, with little benzo use. I felt we were helping him – to some degree – until late last summer, when his condition worsened after his son died from an overdose. He was distraught and using all types of drugs in order to push away the pain of his loss. I became worried he would die of an overdose if we didn’t do something different. We really wanted him to go to inpatient care, because he’d become too sick for outpatient, medication-assisted treatment. He rejected this option and left treatment.
He was back last week, asking for help. He admitted to using a wide variety of drugs, including benzos, illicit methadone, cocaine, alcohol, and marijuana. He knew he was still grieving for his son, and he too had come to fear that he would die from his addiction. He was now ready to go to an inpatient residential treatment center. Even though we don’t offer that service, he came to us when he couldn’t find help anywhere else.
He’d already gone to our local hospital emergency department two days prior, asking for help, but he said he was turned away with no evaluation and no medication. Our patient told us the emergency department personnel told him he could be put on a waiting list for an inpatient program, and that it could take weeks for a bed to open up for him. Our patient left the emergency department feeling like personnel there didn’t care about what happened to him. He suspected they judged him as a bad person, not a sick person. He got no further referrals for treatment and wasn’t even offered clonidine, a blood pressure medication that can help with some of the opioid withdrawals.
Granted, our patient may be leaving out part of the story, or too sick to remember accurately. I know better than to take every patient report as completely accurate, but what this patient said had the ring of truth to it, and I tend to believe he gave an accurate account of his emergency department experience.
After this disappointment, he came to our program, saying he knew we did care about what happened to him. For the next five or more hours, our OTP counselor tried to get help for this patient.
First, she called our local management entity, or LME. This is a weird, non-descriptive term for local governmental agencies in North Carolina that contract with other mental organizations to provide care for any patient with substance abuse and/or mental health issues. LMEs are the safety net…but the net is broken.
The counselor called the LME and they offered to send a mobile crisis team. This is a grand term implying quick, on-site help for resolution of crises facing the service recipient. Service recipient is the new term for patient, by the way.
The mobile crisis management team consisted of a young woman with a bad attitude and little idea how to talk to patients who were sick and suffering. After an assessment of about forty-five minutes, which necessarily consisted of questions that we had already asked her, this mobile crisis management worker told our patient that he was in opioid withdrawal, and it was likely to get worse instead of better.
At this epiphany of the obvious, our patient thrust his face towards the worker and said sarcastically, “Ya think??” It was obvious our patient did not regard this revelation as particularly helpful. It was also obvious he had offended the worker, who angrily started to pack up her belongings. She said the only thing she had to recommend was going to the emergency room. When our patient informed her he had already gone there two days ago and no help had been forthcoming, the mobile crisis worker said that if he didn’t want to take her advice, she couldn’t make him. She said she could put on the list for a bed at an inpatient program, but it could take weeks for a bed to open. Then she left.
So…I was not at all impressed with the mobile crisis management team.
Our tenacious OTP counselor flew into action again, and called our favorite inpatient treatment program directly. This is a state-run program that’s also an opioid treatment program, named Walter B Jones ADATC (alcohol, drug addiction treatment center). It’s affectionately called “Walter B” by us. It’s the only inpatient program in the state that I know of that will admit patients with opioid addiction and keep them on their maintenance meds or start them on maintenance meds.
I felt that starting the patient on methadone as an inpatient, while benzodiazepine withdrawal was being managed, would be much safer. His mental health status could also be addressed, or at least begin to be addressed. A few weeks as an inpatient won’t fix everything, but it is a start, and the best option we could think of.
Walter B said they wouldn’t have a bed for at least a week, and that they needed an EKG and various labs prior to admission. This is because they don’t want to admit a medically unstable patient. Our patient would still have to go back to the hospital emergency department for the EKG and labs, since our OTP doesn’t have the capacity to do those. But our local emergency department sometimes refuses to do lab tests for inpatient admissions. I don’t know why, but I’m guessing it’s because most of these patients have no insurance, and the hospital assumes they’ll get stuck with the bill.
Next, our OTP counselor called a local detox facility. This facility does not “believe” in methadone maintenance and doesn’t even use buprenorphine to ease opioid withdrawal symptoms. But they do administer phenobarbital to help with benzodiazepine withdrawal, and they could perform the labs this patient needed for admission to Walter B. It wasn’t an ideal solution either, but an option.
No one answered the phone at this detox facility. The counselor left several voice mail messages, but didn’t get any calls back.
Frustrated but by no means willing to give up, our tenacious counselor called Project Lazarus. This is a program in Wilkes County that has received accolades for its work at preventing opioid addiction, overdose deaths, and promoting evidence-based treatments for opioid addicts. People who work at Project Lazarus have connections. They tend to know everybody in the treatment field, so they are often a valuable resource for us. One of their employees did know someone at the detox, and was able to call them through a back channel. That person finally called our counselor back.
Finally, a plan emerged. Our patient would go to this private detox that day or the next, where he could get the labs Walter B wanted. In a perfect world, our patient would leave the detox on the day a bed opens at Walter B. However, if that can’t be worked out, I will admit our patient to methadone as a stop-gap until the inpatient bed opens up. After treatment at Walter B., our OTP will accept him back into treatment and continue efforts to stabilize him.
This isn’t the best plan and it isn’t the safest plan. It’s piecemeal at best, and the plan could still fall through.
Ideally, our LME would contract with an agency that could do all of this for the patient. Ideally, detox beds could be offered on the same day the patient asks for help, with a seamless transition to inpatient treatment to continue patient stabilization. Inpatient treatment programs would offer patients medication-assisted treatment of opioid addiction or abstinence-based treatment and the patient could participate in the choice. Instead, most inpatient facilities don’t even mention the possibility of medication-assisted treatment, so there is no informed consent about which type of treatment is given.
If it took a dedicated and savvy counselor five hours and multiple phone calls to work out a plan for this patient, how would he have been able to access care on his own? Indeed, he did try to access care on his own, and failed to get timely help.
I wish all of the people who recommend inpatient abstinence-based treatment of patients with opioid addiction should be made to try to navigate our present labyrinth of care. This wasn’t even a non-insured person; he had Medicaid, and we still couldn’t find a bed for him.
I know our state has little money with which to treat mentally ill and addicted patients. Budgets for mental health and substance abuse treatments have been cut to the bone and then deeper. The public expects a safety net to appear without having to pay for it. The state-funded facilities do miraculous things with the little money that they have. But no one should have the misperception that our system of care is anything but broken.