Thursday, April 6, 2017

Chemical Dependency Treatment for the Uninsured

The second patient I ever saw at Promise Clinic was an initial evaluation. The person was new to both us and Elijah’s Promise-- from the beginning of our interview they (which I’ll use to maintain anonymity) admitted to chronic homelessness and presented as an intersection of many of the identities common to people experiencing housing instability. Throughout our conversation the patient was clear about their chief concern being finding a place to stay for the night. Our interaction was punctuated with phone calls to 211, the ciris housing line, in between palpations and intimate questions about psychiatric history.  

Just as they were not shy about what they wanted out of this appointment, they were not shy about their depression, heroin and benzodiazepine use. As our team unpacked the psychiatric history we uncovered an addiction severe enough to place this patient in rehab and inpatient hospitalization a few times over the past couple years.

As always, there were multiple teachable moments as part of this interaction. The most notable is us asking “So, how much is in one bag of heroin, would you say?” after the patient admitted to using 4-10 bags a day. They responded “None of y’all have seen a bag before?” which we met with uncomfortable silence.

Additionally, the patient had been to a rehab facility within the past month after which they had been referred to an outpatient program for chemical dependency and mental health treatment; he struggled with both. As the time of our appointment, they were no longer receiving services there. They started using again the day after after leaving.

So what happened?

It is common knowledge at this point the United States is in the middle of an opioid crisis. While heroin use and abuse has been increasing across demographic groups, research shows that it is most common among men, among people who have previously used substances, and people with low income.  So far, our patient fits all these criteria.

It goes without saying that maintaining sobriety from any addictive substance isn’t easy. I imagine the times when I tell myself I’m going to give up eating sugar (a substance with mounting evidence of its potentially addictive properties, while acknowledging that it does not have nearly as large a severity as illicit drugs). I can usually go one day, feel really good about my success, land on the next day and realize that I really, really want X-- be it a free cookie after a lunch lecture, or ice cream from Woody’s, and I succumb.

In substance abuse treatment, there is a loosely defined process for success in achieving and maintaining abstinence: Detox, Rehab, Ongoing Outpatient Support (12-Step Meetings, Chemical Dependency Counselors, or other integrative services.) The enormous importance of Outpatient Support cannot be understated, as it is a person’s best chance to maintain a functional life outside of inpatient rehabilitation. Despite the potential financial barriers to clinics and people, offering integrated programs and offering aftercare to people once they emerge from treatment is probably one of the better predictors of success.

What kept our patient from having access to evidence-based, supportive aftercare was their lack of insurance. Per them, after realizing that they wouldn’t be able to afford the Intensive Outpatient Program’s out-of-pocket cost (the program I used to work with cost approximately $800 a week) he had to drop out. As the data would suggest, soon after they used again.

This is not an uncommon story, especially when one considers who is using substance abuse treatment programs. As far as inpatient treatment goes,  about 6 in 10 admissions reported having no health insurance coverage at treatment entry… About half of admissions aged 22 or older expected to pay for their treatment using Medicaid, Medicare, or other government payment”. Given the hefty price tag of up to $25,000 (for the more upscale programs) it’s no wonder that people opt to not continue follow-up care without insurance to pay for it.

None of us as students at Promise Clinic are particularly adept at advising about substance abuse treatment, in general, let alone the nuance that comes with treating someone for chemical dependency. We coordinated a plan to meet weekly with our patient in order to provide positive pressure towards and reinforce the importance of sobriety. We suggested the free resource of Narcotics Anonymous, despite what some view as dubious success rates, and told them that we hoped they could continue their few days of sobriety until they met with us the next week.

I wasn’t there for this patient’s next appointment, but it was my understanding that the patient’s significant chemical dependency acutely presented in some way. At that point we realized that due to the extent of this patient’s illness and our lack of resources meant that he wasn’t appropriate for us; we referred him to a program who we believe could help him more, hoping that he would 1) follow-up (which he didn’t) and 2) could afford it.

But if we, the last line of defense in treatment for people who are underserved and uninsured couldn’t help him, I’m not sure who could.

Given the importance, there is a conspicuous lack of data on the availability of outpatient chemical dependency specific programming at Federally Qualified Health Centers or Free Clinics. Even more concerning is that research that has been done has looked at Obama-era emphasis on outpatient, community care available administered as part of the implementation of the affordable care act. While it is the rule of the land for now, Federally Qualified Health Centers are still unsure of what their future looks like under the current President. Free Clinics will continue to sit in the grey zone.

By no means am I saying that this is solely our-- Student Doctors, Promise Clinic, Free Clinics, Federally Qualified Health Centers-- responsibility. However, it pulls us into thinking about our place as serving others; if we can’t do it, then it is our job to work alongside with those who can.

What this looks like more broadly I can’t speak much to. Employing an assets-based framework allows us to see that there are some incredible resources at our disposal: three-hour appointment slots, a continuity of care model, weekly social work support, and psychiatry residents once a month. We may not have the capacity to meaningfully treat people who are actively using illicit drugs, but between all of those resources have successes helping patients cut back on their use of other addictive substances like tobacco or alcohol. If a patient isn’t actively using, we can provide the ongoing support and management of their more explicitly medical health conditions. In the future, perhaps psychiatry and social work can play a more active role in educating our student doctors on strengths-based, harm-reduction approaches to patients like the one we saw that day.

They slipped through the cracks later, but for a brief moment we held them and as well as insight into being able to help.   

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