The Beginning of the End of Residential Drug and Alcohol Treatment?

May 20, 2011— -- In my specialty as an addiction psychiatrist, I have often advocated for residential treatment when unremitting drug and alcohol problems persist because other, less intensive, services have failed. That may soon change.

Over the past two years, I've witnessed a worrisome trend: the medicalization of addictions. Some of this makes no sense to me. Let me explain.

There have always been drug treatments for acute detoxification of drug and alcohol problems. The drugs have changed over the years, but the concept of providing a brief period of drug stabilization to prevent seizures or delirium or to mitigate psychosis has gone one unabated.

For instance, barbiturates were once used to minimize alcoholic delirium, but the barbiturates were replaced by benzodiazepines and, although still commonly in use, the benzodiazepines have been more recently supplanted or co-administered with anti-seizure drugs, like valproex or gabapentin. The endpoint has largely been the same: we will stabilize the patient over an acute period of rapidly changing health conditions (sweating, diarrhea, pulse, blood pressure, temperature, pain) and, once the detoxification has been successfully completed and the patient is comfortable and alert, we will begin a process of education and behavioral health techniques to foster a hoped-for drug free recovery state.

That is changing, however, in certain facilities in ways that I believe are destructive and counter-productive.

Two cases serve as illustration: I'm asked to review the medical necessity and reimbursement for care provided in a high profile and nationally-acclaimed drug rehab. The case is of a 20-year-old male from the northeastern United States who is addicted to a drug, methadone (an opioid agonist replacement medicine) and alprazolam, a benzodiazepine anti-anxiety drug. He enters treatment and spends 29 days in rehab, where he is provided buprenorphine (a partial opioid agonist replacement drug for opioid dependence) in decremented detox and maintenance for the duration of his stay and clonazepam (used as a substitute for his alprazelom addiction). He is discharged with the recommendation and prescription to return home and continue methadone and clonazepam.

That's worth repeating. The patient is discharged to continue the same addictive drug for which he was admitted and a longer-acting (and still habit-forming) benzodiazepine drug to replace his other anti-anxiety medication. And with a price-tag of nearly $40,000.