John Doe (name changed to protect privacy) had been living in an ‘abandominium’ (defined by Urban Dictionary as “an abandoned apartment, condo or row-house, now occupied by squatters”) in East Baltimore, eating at local soup kitchens, and panhandling for enough money to feed his opiate addiction. He knew he would die if he didn’t get out.
He reached out to a street outreach worker who helped him get into a High Intensity Residential Detox Facility, located in Dorchester County, Maryland. He told his friends and family that he was really going to succeed in winning his 8-year battle with heroin and prescription opiates this time. He felt positive and strong and determined. He told them he could never picture himself returning to the life he had lead –shooting whatever he could afford that day into his veins and ‘falling out’ on top of his filth-stained sleeping bag on the needle-strewn floor of the window-boarded rat-infested dwelling with the caved-in roof, that he had called ‘home’.
On the day before John’s discharge from treatment –one day before he was scheduled to enter a long-term halfway house, he sought out a girl he had met there, to say goodbye. He wanted to tell her that he would always be there for her, and make sure she had his phone number in case she ever needed to call. Someone said she was in her room.
Although they had both been warned when they first arrived that no one is allowed in anyone else’s bedroom –had even read the rules and signed an agreement to abide by them –in that moment, just like so many other moments in their lives, they were not thinking about “the rules”. Within 10 minutes, staff had shoved their belongings in two plastic bags and were escorting them to the side of the icy road. After 30 days of struggling to gain a tentative foothold in sobriety, the ‘treatment team’ was kicking John out of treatment with no place to go.
It was windy and freezing that day –single-digit temperatures, and they were miles from the nearest town. After walking for hours in freezing drizzle with one coat between them –frozen, stressed, exhausted, humiliated, defeated, hungry, and losing hope with every step –they were finally able to hitch a ride to the nearest town and find a phone. The girl called her parents. But like so many parents are advised to do by an outdated 12-Step paradigm, they hung up the phone. When John called his Mom, she agreed to pay for an Uber to drop the girl at her apartment and then drive John three hours back home to Montgomery County.
Eleven arduous hours after being kicked out of the treatment facility, they finally arrived at the girl’s apartment after midnight. The initial ‘high’ of recovery was gone, replaced by the old fears, anxieties, and insecurities. The vision of continuing treatment and living in a recovery residence was shattered, along with it, the hope of a GED, a good job, and re-connection with those he loved. John decided to stay at the girl’s apartment.
The girl had a small baggie of heroin hidden in her apartment from before treatment. As John pushed in the syringe, he felt the warm intoxicating relief wrap around him like a secure blanket, washing away the anxiety, insecurity and fear. Then he felt nothing at all.
A Common Occurrence
Patients diagnosed with an often-fatal substance-use or co-occurring disorder, and admitted to an inpatient treatment facility, are routinely kicked out of treatment –often for extremely trivial infractions. They are discharged before their planned discharge date, often with very little notice (sometimes mere minutes), despite the fact that they have an acute, chronic, often fatal disorder; and have been admitted to a healthcare facility on the basis that this level of care is NECESSARY in order for them to recover from it. Patients who are medically 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; briefly leaving treatment to say goodbye to a dying parent in a hospital; cursing at a staff member; making an “inappropriate gesture” to another patient; using a cell phone; and other behaviors that would not warrant 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 students’ rule-breaking behaviors, society still believes that students are better off with a high school education than expulsion for “breaking the rules”. Not so, in much of the addiction treatment world.
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 prematurely 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.
Health Department and Legislators Turn a Blind Eye
In 2018, F.A.C.E. Addiction Maryland asked Delegate Howard, A.A. County, to help end this treatment tragedy. The result was House Bill 852 –a bill that would have created a work-group to assess the frequency of and determine the harm caused by unplanned patient discharge, and propose changes that would either eliminate these practices or at least mitigate the harm to patients. Sadly, the bill did not pass in either 2018 or 2019.
During the summer of 2018, Maryland Department of Health (MDH) convened the Residential SUD Treatment Provider Quality Improvement/TA Work-group to study quality of care in treatment facilities and propose solutions. The work-group was comprised mainly of treatment providers –noticeably absent were consumers of treatment services. While the benefits of opioid maintenance therapies –methadone and buprenorphine were promoted ad nauseam, the topic of unplanned discharges was ignored, despite the fact that HB 852 had been tabled, as a result of a lobbyist for the treatment industry testifying that the work-group planned to address and resolve the issue over the summer. The work-group, initially slated to continue throughout the year, disbanded without explanation after only a few meetings.
In a 2020 pre-legislative session meeting with Delegate Pena-Melnyk, Vice Chair of the House and Government Operations (HGO) Committee –the Committee that initially hears the bill and votes to move it forward, the Delegate stated emphatically that H.B. 852 “will not pass”. When asked what to do to prevent the death of patients prematurely kicked out of treatment for trivial reasons, she suggested contacting the State’s Attorney’s Office or negotiating with lobbyists representing the treatment industry.
Patient Abandonment
However, F.A.C.E. Addiction had already attempted repeatedly to meet with the States Attorney’s Office regarding this problem after the Quality Improvement Work-group disbanded. In particular, we wanted to find out whether the Patient Abandonment Law could be used to sue treatment providers who prematurely discharge patients, particularly when the discharge could be directly linked to an overdose death. Patient Abandonment is a form of medical malpractice that occurs when a physician terminates the doctor-patient relationship without reasonable notice or a reasonable excuse, and fails to provide the patient with an opportunity to find a qualified replacement care provider (nolo.com). Despite repeated calls and follow-up emails with State’s Attorney Office staff, F.A.C.E. Addiction was unable to locate anyone in the Office who could answer our questions, and we were also unable to schedule a meeting with The State’s Attorney to discuss the matter.
The Next Policy Challenge
In a recent article posted on Variety.com, Inside the Fight for Regulation as Rehab Centers Cash in on Patients, Gene Maddaus, author, perceptively points out:
“The addiction-recovery industry has exploded in recent years, as upstart operators capitalize on the availability of insurance amid the deepening opioid crisis. Experts say a major concern is that market forces — rather than medical necessity — often dictate the course of treatment, because drug addicts have become bankable commodities.”
A decade ago, grassroots advocates were concerned with ‘awareness’ –no one was paying attention to the fact that our loved ones were dropping like flies in communities across Maryland. Today, there is not a media outlet that is not covering the ‘opioid epidemic’, and it would be difficult, if not impossible to find a policy maker who is unaware of the problem.
The challenge now is to figure out how to hold treatment providers and policy makers accountable for solving the problem, rather than simply building a mountain of wealth on the backs of those who are in a fight for their life. It is high time that policy makers stepped in to oversee and regulate Maryland’s treatment industry –but that would mean ending their pandering to pharmaceutical / medical community lobbyists –the folks making thousands of dollar contributions to their re-election campaigns.