Treatment Reform
The Problem
Patients diagnosed with an often-fatal co-occurring disorder and admitted to an inpatient treatment facility are routinely kicked out of treatment –often for extremely trivial infractions. Patients who are assessed as needing inpatient treatment in order to recover, and who fail to receive it, are at high risk of death as a result –a death that could have been prevented. Patients have been kicked out of treatment for sneaking a cigarette; walking into another person’s room; talking to, holding hands with, or kissing another patient; leaving treatment for a couple hours after notifying staff in order to say goodbye to a dying parent in a hospital; cursing at a staff member; making an inappropriate or offensive gesture to another patient; using a cell phone; and other behaviors that would not merit discharging a suicidal patient, or a cancer patient, or a kidney dialysis patient from necessary treatment. These actions would not even warrant expelling an adolescent from high school regardless of the fact that many of these infractions are disallowed in Maryland’s high schools; –regardless of students’ rule-breaking behavior, society still believes that these students are better off with a high school education than expulsion for “breaking the rules”.
Patients are discharged before their planned discharge date, often with very little notice (sometimes mere minutes), despite the fact that they have been diagnosed with an acute, chronic, often fatal disorder; and have been admitted to a healthcare facility or program on the basis that this level of care is necessary in order for them to recover from it. The sudden and unexpected dismissal –often to immediate homelessness, triggers feelings of extreme distress, crisis, depression, failure and hopelessness –the very feelings that caused or exacerbated their substance use in the first place. With a lowered tolerance to opiates, due to the time they have spent in detox, they are at extremely high risk of overdose. If they are involuntarily discharged from an outpatient Suboxone or methadone provider –often because they were late for, or unable to make an appointment, due to transportation issues or work conflicts, the onset of withdrawal is imminent. All gains that have been made while in treatment quickly unravel.
The Solution
Maryland must work to prevent involuntary and unnecessary discharges from treatment programs in order to prevent relapse and overdose deaths. Steps to mitigate the dangers of involuntary patient discharge must be considered and implemented immediately. Recent legislation has been proposed to collect and analyze treatment data regarding the frequency and circumstances of involuntary discharge from treatment.
It is unconscionable that providers continue to place patients’ lives in jeopardy by involuntarily discharging them –often for committing the very behaviors that they have been diagnosed as needing professional assistance to overcome.
THE PROBLEM
Many times, individuals who have been diagnosed with a chronic, potentially life-threatening, Substance-Use Disorder do not get the services they need in order to recover. Assessments for these patients often show that they need and qualify for long-term in-patient treatment, housing, on-going mental health or psychiatric services, Suboxone maintenance, family stabilization services and/or counseling, vocational training, educational services, legal services, and other wrap-around services –yet far too many are being discharged with no plan for how or where to access these services. Many patients are not even aware that this is exactly what their discharge plan from a regulated Maryland treatment provider is supposed to encompass. They often rely on a treatment provider to devise an appropriate discharge plan –only to discover they are being discharged to “nowhere” after it is too late for them to do anything about it. All too often they are simply left to figure out their “next level of care” plans on their own.
In 2017, the Recovery Residence Residential Rights Protection Act was passed, which mandated all regulated treatment providers operating in Maryland to match a patient’s discharge plan to their needs assessment, per nationally recognized criteria developed by the American Society of Addiction Medicine (ASAM). In addition, The Code of Maryland Regulations (COMAR), specifically spells out the ancillary services deemed necessary for recovery, that patients “shall be” provided in treatment, as well as linked to upon discharge from one level of care to the next. Unfortunately, unless the patient is knowledgeable that the assessment exists, that their discharge plan is based on it, that their assessed needs could be and should be matched to on-going services in Maryland’s ‘Continuum of Care’, and that their current treatment provider is responsible for ensuring this plan is in place prior to their discharge, than they are not likely to advocate for referrals to recovery services which meet all of their needs.
Inappropriate discharges jeopardize the lives of patients. Unless the patient receives the services that are necessary for their recovery –THEY ARE UNLIKELY TO RECOVER! Simply put,
EFFECTIVE DISCHARGE PLANNING IS A MATTER OF LIFE AND DEATH!
THE SOLUTION
Patients deserve to be empowered to advocate for what they need. It is not merely an OPTION to be referred to an appropriate and workable “next level of care”, it is a healthcare RIGHT! Maryland’s regulated treatment providers must be held accountable for assisting patients in accessing the services they need to get better once they are discharged from a higher level of care. Legislation must ensure that patients are provided an opportunity for that to happen.
THE PROBLEM
Behind the decaying walls of tumbling brick facades in some of our cities’ most blighted neighborhoods, lives a community of some of Maryland’s most marginalized and high-risk drug-users –abandoned by family and friends, and lost in a world of chronic drug use with no visible way out. Unable to navigate the often complex, fragmented, and broken treatment system, or else simply tired of trying, these individuals are stuck in a nightmare from which there is no escape, other than death. In their world, there is no one left who cares whether they live or die –young girls, whose bodies are sold by other drug users for brief sexual encounters when they are passed out from drug use, barely adult-age boys who were bussed in from other counties to “residential recovery” programs operated by for-profit thugs and investors, where they got kicked out with nowhere to go.
THE SOLUTION
The idea of a legally-sanctioned space for individuals to use drugs may be a new concept to many, but it’s a harm-reduction approach that works in more than 60 cities around the world to reduce the harms associated with drug use and increase uptake into addiction treatment. Numerous evidence-based, peer-reviewed studies have proven the positive impacts of such facilities, including: reduced opioid-related deaths, reduced public disorder and public injecting, increased public safety, reduced risk for viral and bacterial infections, and cost savings resulting from reduced disease, overdose deaths, and need for emergency medical services. Studies also indicate no increase in community drug use, initiation of drug use, or drug-related crime. This is an evidence-based approach supported by the American Medical Society, Dr. Sanjay Gupta –neurosurgeon and Chief Medical Correspondent for CNN, the Abell Foundation, and others.
Establishing a Supervised Safer Drug Consumption Facility Program where people can more safely use drugs under clinical supervision, and where these same individuals can find support, talk to counselors or peer-support specialists, obtain assistance with locating treatment services, and perhaps find a way to cross the bridge back to a life of hope and recovery is an idea worth trying.
AA/NA has become so infused in our society that it is practically synonymous with addiction recovery. Yet the evidence shows that it may be worse than no treatment at all for some. (academic misconceptionsofaaino
Advocates for treatment reform argue that AA/NA has remained static and at odds with continually developing understandings of addiction. They argue that forcing addicted people to attend ‘meetings’ compromises their understanding of their diagnoses and prognosis –limiting their perceived potential, ambition and motivation. Participants may resign themselves to being incurably “diseased” for life before they are given the opportunity to explore other perspectives and pathways that may better suit their personal needs and goals.
Legal precedents exist to protect patient rights –court rulings have declared that inmates, parolees and probationers cannot be ordered to attend. Though AA/NA itself was not deemed a religion, it was ruled that it contained enough religious components (spirituality, god, prayer and proselytism) to make coerced attendance at meetings a violation of the First Amendment. There have been a number of court cases, beginning in 1996, reflecting the fight to avoid being coerced by justice system officials to attend AA/NA. The 9th U.S. Circuit Court of Appeals in San Francisco noted “adherence to the AA fellowship entails engagement in religious activity and religious proselytism.” (academic misconceptionsofaaino
Despite these precedents, judges still order justice-involved clients to participate in 12-Step programs. Estimates of the percentage of meeting members who are forced to attend by the justice system are as low as 36% and as high as 80%. In addition, a significant percentage of meeting attendees are required to participate as part of a treatment protocol. According to data compiled by Alcoholics Anonymous World Services, Inc., nearly a third participate as a treatment program requirement, while 8% are referred by a counseling service and another 8% are referred by a social worker (Flora et al, 2010).
Forcing an individual to attend meetings, who receives no benefit from them, is not useful. Recovery is a very personal journey with many paths to achieving the desired goal. It cannot simply be imposed on people who are regarded as ‘having a problem’. People who do well in AA/NA might very well self-select because they find it meaningful for very personal reasons.
Given the potential outcomes for the 80% of individuals who leave the program within the first 30 days and the additional 10% who leave the program within the first 90 days, professionals should be wary about trying to push people into AA/NA. For those individuals who are less likely to find it meaningful, it is a mistake, which can have many harmful, if not tragic outcomes (academic misconceptionsofaaino