American Association for the Treatment of Opioid Dependence
Washington, D.C. ~ April 13-16, 2003
Hot Topic: Administrative Detox
Facilitator: Joe Neuberger
Delaware NAMA
Bitch and Gripe.Com
Administrative Detox is our subject. It is a policy whereby methadone patients in treatment are banished from their programs for the umbrella term of “non-compliance.” Now we’re not talking here about a rightful detox that would occur to any patient committing acts of violence towards program staff or other patients. But patients discharged from treatment against their wills for issues of continued use of illicit drugs or like issues of this sort.
Today I am setting aside my personal moral outrage felt because of the loss of quality of life, and in some instances, life itself which is the result of any use of administrative detox, where theories of “another trip to the streets” as a beneficial behavioral tool are acted out, but concentrating here only on the social outrage felt as a tax-paying citizen concerned for a rational use of limited public resources. Let’s look at the scientifically substantiated results of any use of administrative detox where we take a patient in treatment, with a life which by ANY objective measure is magnitudes better in all analysis categories, and subject him or her to an accelerated dosage reduction schedule and once again unleash the demon of opiate addiction on the patient’s family, their community and themselves.
So let us look at some of the social consequences of this, what I term, aberration of medical treatment:
1st: Mortality
Before the introduction of MMT, annual death rates reported in four American studies of opiate dependence varied from 13 per 1,000 to 44 per 1,000, with a median of 21 per 1,000. Although it cannot be causally attributed, it is interesting to note that after the introduction of MMT, the death rates of opiate dependent persons in four American studies had a narrower range, from 11 per 1,000 to 15 per 1,000, for a median of 13 per 1,000. The most striking evidence of the positive impact of MMT on death rates are studies directly comparing these rates in opiate-dependent persons, on and off methadone. Every study showed that death rates were lower in opiate dependent persons maintained on methadone compared with those who were not. The median death rate for opiate dependent persons in MMT was 30 percent of the death rate of those not in treatment. A clear consequence of not treating opiate dependence, therefore, is a death rate that is more than three times greater than that experienced by those engaged in MMT. And a UCLA ongoing 30 year study has shown that in some age groupings, notably those over 50 years of age, have a 50% chance of death from an untreated opiate addiction.
2nd: Criminal Activity
Opiate dependence in the United States is unequivocally associated with high rates of criminal behavior. More than 95 percent of opiate-dependent persons report committing crimes during an 11-year at-risk interval. These crimes range in severity from homicides to other crimes against people and property. Stealing and prostitution in order to purchase drugs are the most common criminal offenses. Over the recent decades, clear and convincing evidence has been collected from multiple studies showing that effective treatment of opiate dependence markedly reduces these rates of criminal activity. Therefore, it is clear that significant amounts of crime perpetrated by opiate dependent persons are a direct consequence of untreated opiate dependence.
Our prisons are full to the bursting point and those who have been given the task of caring for opiate dependent populations are contributing to this crisis when they discharge an active addict, for the research on criminal activity in these populations is clear: Robbery related violent crimes for the males; Prostitution for the females. Activities brought under control under continued MMT treatment vs. activities again unleashed on our communities as a result of the use of administrative detox.
3rd The Costs of Health Care
Although the general health status of people with opiate addictions is substantially worse than that of their contemporaries, they do not routinely use medical services. Typically, they seek medical care in hospital emergency rooms, and only after their medical conditions are seriously advanced. The consequences of untreated opiate dependence include a much higher incidence of bacterial infections; tuberculosis; hepatitis B and C; AIDS and sexually transmitted diseases. Because those who are opiate-dependent present for medical care late in their diseases, medical care is generally much more expensive.
Anyone involved in methadone treatment knows of the miraculous change that occurs in the status of the health of those who present for this treatment. Administrative detox sentences these individuals back to the dismal levels of ill health that they were at when they first presented, taxing an already resource-starved system of health care to the detriment of these health care systems and our communities.
4th Joblessness
Opiate dependence prevents many users from maintaining steady employment. Much of their time each day is spent in the thrice daily ritual of drug-seeking and drug-taking behavior. Therefore, many seek public assistance because they are unable to generate the income needed to support themselves and their families. Long-term outcome data show that opiatedependent persons in MMT earn more than twice as much money annually as those not in treatment. A fact that affects the quality of life of not only the addict, but of the family units that are dependent on them for sustenance. Before detox a working contributor, yes, not perfect, yes, with issues needing attention, but still a contributor to the well-being of a family unit now rendered unrecognizable with REAL social and economic costs to the communities in which they reside.
So, to review, a result of administrative detox is an increased death rate among these fathers and mothers, employers and employees, with the resultant social costs related to these deaths; increases in criminal activity which burdens an already “bursting at the seams” criminal justice system with the concurrant decreases in quality of life for the communities in which they reside; the same can be said for the health care system and the impacts an active addiction has for stressing its limited resources; and joblessness that is a direct result of an active addiction that has it’s own time clock that runs counter to any 9 to 5 routine with the resultant destruction of the family unit, both economically, spiritually and socially, where fathers and mothers of children are changed into, not participating, wage-earning parents in a family unit, but active addicts where all else becomes subservient to the thrice daily ritual of felony crime in the pursuit of laying an active and intense sickness to rest. Not the result of any moral or physical weakness of the patient, but the direct result of the administrative detox actions of the provider. Family units now rendered unrecognizable with REAL social and economic costs to the communities in which these populations reside.
In Conclusion:
The impetus in methadone treatment over the last decade has been to apply the scientific lessons learned and move this life-saving modality firmly into the medical specialty in which it belongs. The science on this subject is voluminous. But there remains among the providers of this treatment resistance to this model. Talk is cheap, but actions speak volumes, and providers who still apply administrative detox as a behavioral modification tool are, through their actions, denying the medical model of opiate addiction and evidence an ignorance of the long substantiated research supporting it. For in what other medical specialty would such an outrageous practice be tolerated?? A heart specialist denying treatment to the patient non-compliant with dietary standards limiting cholesterol intake comes to mind. EVERY medical specialist to whom I have described this barbaric process has expressed outrage. Detoxing a patient for continued substance abuse is tantamount to sweeping one’s treatment failures under the rug, and blaming the sick for being so. A medical model would put plan “B” into place to correct any patient deficiency. And if plan “B” failed, then plan “C” and on and on. But many methadone programs will routinely discharge patients successful at opiate cessation for usage of cocaine, or benzos, or even marijuana. It is a blight on American medicine, and providers still employing this form of malpractice need to be brought to task. If not for the moral outrage that swells as a result, then for the economic costs to the communities in which they practice that Administrative detox lays on most every social system from mortality, criminal justice, health care, the economy and on and on. For what purpose does it serve? We have studies from 2000 showing that this Americans with Disabilities Act-protected population is being ill served by 35% of programs, i.e. underdosed. These are our treatment “failures” that end up administratively detoxed and back on the streets as active addicts.
I have just defined substantiable data in four categories that show that this policy of Administrative detox does damage to the addict, to his family, to his community’s criminal justice system, taxes its medical systems to the breaking point and stresses its economy both privately and publicly. And I now ask you “Where is the good that comes from this policy?? What treatment goals does it fulfill?? Where are our communities better off because of it?? Would funding agencies condone this use of their resources??? Would political powers congratulate providers for these results?? Would the citizenry applaud these effects?? What purpose does it serve other than promoting a relapse. And if that be a legitimate treatment “goal,” and not some aberration fraught with possible Ada mistreatment and malpractice, please provide me its justification. For program’s will need to produce these justifications in the days to come, for this issue is now near the top of the advocacy agenda.”
