Changing Models of Addictions Treatment

One of the Harvard-affiliated Boston teaching hospitals has announced that they are closing their inpatient detox unit to channel resources to treatment modalities more consistent with current best practices. Surprised, anyone? I was initially surprised and somewhat skeptical, but I can see both sides of this argument.

Inpatient detox units have been in existence for many, many years. These units provide medical detoxification for those who are physiologically addicted to a substance, in order to ease the symptoms of withdrawal. Since withdrawal from some substances can be fatal (alcohol and benzodiazapines are two such substances), medically-supervised detox is an important component of treatment.

Beyond the medical management of withdrawal, inpatient detox units typically follow the basic model of inpatient psychiatric units, with group therapy, psychiatry, and case management services. The content of groups is specific to addiction, and often incorporates 12-step meetings.

However, during the acute phase of medical detoxification, people often do not feel well enough to get out of bed to attend groups. In the past, when inpatient stays  were longer, patients would have time after the worst of the withdrawal was passed to attend and benefit from groups. However, hospital stays have gotten shorter and shorter across the board, and as soon as patients are medically stable, insurance companies push for a step down to a less-intensive level of care.

Therefore, according to the hospital that is closing its detox unit, offering inpatient group programming is no longer cost effective, because patients are not staying long enough to benefit from it. Instead, the hospital plans to offer a reduced number of inpatient medical beds for medical detox without additional treatment modalities, and expanded ambulatory treatment (Partial Hospitalization: day treatment) as a step down once inpatient medical monitoring is no longer necessary. Of course, this rapid step-down does not account for the fact that people have access to drugs as soon as they are back in the community, and so it seems important to prepare people with some skills to manage triggers and resist opportunities to use, prior to discharging them from inpatient care.

The hospital plans to channel some of the money saved by closing the inpatient unit into Suboxone treatment for opiate addiction, which, according to a hospital representative, is the current best practice in opiate addiction treatment. Opiate withdrawal is uncomfortable, but not life-threatening. Suboxone is a synthetic opiate available by prescription that is relatively long-acting, is less addictive (people who take it experience less physiological dependence), and has a "ceiling effect" where, after a certain point, increasing the dosage does not increase the effect.

These qualities make it less susceptible to abuse, and therefore more appealing to providers as an outpatient treatment. It is used both as for detox from opiates (including heroin and various pain medications) and as a long-term maintenance treatment for people who have been chronically addicted to opiates. As a longer-term treatment, it falls into the category of "harm reduction" treatment, because it maintains people on a constant dose of opiates without the risks of IV drug use (Hepatitis and HIV, among other things), and without the psychosocial costs of illicit drug use (various activities to get money for drugs, and to get the drugs themselves, as well as the toll this cycle takes on relationships and ability to function occupationally).

The hospital I've been discussing plans to offer Suboxone as part of a multidisciplinary treatment program, where patients will also receive group therapy and other treatment services to address the underlying addiction. This inclusion addresses my major concern with opiate replacement treatment, that underlying issues may not be addressed. It is unclear whether the hospital plans to continue maintenance Suboxone once patients complete the treatment program.

What do you think about this shift in addictions treatment? About the harm-reduction model and opiate-replacement? What is really crucial in addictions treatment, and where should it take place? What has been your experience with any of these modalities or forms of treatment?