Tagged Substance Abuse

Try This At Home: Program Brings Drug Addiction Treatment To Patients

https://kaiserhealthnews.files.wordpress.com/2017/04/20170417_atc_home-based_drug_treatment_program_costs_less_and_works.mp3Can’t see the audio player? Click here to download.

Hannah Berkowitz is 20 years old. When she was a senior in high school, her life flew off the rails.

She was abusing drugs. She was suicidal. She moved into a therapeutic boarding school to get sober, but she could stay sober only while she was on campus during the week.

“I’d come home and try to stay sober really hard — really, really hard,” said Berkowitz, who had trouble staying away from old friends and bad habits. “Sometimes I’d make it through the weekend, and sometimes I just couldn’t make it. It was white-knuckling it, just holding on.”

The transition back home always triggered a relapse for Berkowitz.

“I thought it was just my fault and there was no hope,” she said.

But Berkowitz did have luck. She had private health insurance and lived in Connecticut, where a startup company, Aware Recovery Care, had begun treating clients in the very environment where Hannah struggled to stay sober: her home.

A Chronic Disease Approach

Treating addiction is a growing business, and some treatments, especially inpatient care, can run tens of thousands of dollars. For many people, the help is only temporary. The National Institutes of Health estimates that 40 to 60 percent of people addicted to drugs relapse. But there is a way to help some people pay less for better results, said Matt Eacott, vice president of Aware Recovery Care.

“Ninety-nine percent of the industry really treats addiction as an acute problem — like a rash on your arm that you rub lotion on and you’re done,” he said.

Rather than a bad rash, Aware treats addiction as a chronic illness that doesn’t disappear just because symptoms are under control — a cost-effective way of treating addiction, Eacott said.

Aware comes into clients’ homes and connects them with a nurse, a primary care doctor, a therapist, peer support, 12-step meetings and a case manager. Clients hooked on opioids can get medication-assisted treatment. They can also submit to urine screening and GPS tracking, if that helps them stick with the program.

Hannah’s mother, Lois Berkowitz, said the program is intense at first. But as Hannah built coping skills, the supports faded into the background.

“It’s not like they’re doing the work for the addict,” said Lois Berkowitz. “They’re just basically taking them by the hand and saying, ‘Here are the places you need to go that will help you. And I’m going to go with you to start so it doesn’t feel that uncomfortable. And then we’re going to let you fly.’”

Before they fly, Aware clients have a pretty long runway. The treatment lasts a full year.

The Numbers

Aware has now expanded from its base in Connecticut into New Hampshire. The program is expensive: $38,000 a year. As of now, it’s available only to private-pay clients and people insured through Anthem health insurance in New Hampshire and Connecticut.

Anthem became the first insurer to pay Aware, because the treatment is based on hard science that’s yielding solid results for clients, said Dr. Steven Korn, Anthem’s behavioral health medical director. Science and results are rare in addiction treatment, he said.

“There are old, old notions that have hung pretty tough,” said Korn. “When I was young, when I was in training and as soon as substance abuse was mentioned, the response of physicians was, ‘Well, go to AA. That’s not our problem. We don’t treat that.’”

For a year of treatment, Anthem said, it’s paying Aware about the same as the cost of a month or two of inpatient treatment. Anthem also says 72 percent of Aware clients are either sober at the end of one year or still in active treatment.

That’s about twice the sobriety rate of people who check in to a facility for a month and then get no follow-up care, said Dr. Stuart Gitlow, past president of the American Society of Addiction Medicine.

Treating addiction at home makes sense because it’s the exact place where people learned their bad habits, Gitlow said.

“It’s all based on this concept that addiction is not about the substance use but is about what led to the substance use in the first place. And you can’t really get there without getting to know the patient,” he added.

Aware said it’s in negotiations with four more major insurers. It aims to have a couple of hundred clients in New Hampshire by the end of the year.

This story is part of a partnership that includes NHPR, NPR and Kaiser Health News.

Categories: Mental Health

Tags: ,

What Doesn’t Kill You Can Maim: Unexpected Injuries From Opioids

The trouble started for Lisa when she took a blood pressure pill and one to control seizures, along with methadone, a drug used to help wean patients off heroin.

“I inadvertently did the methadone cocktail and I went to sleep for like 48 hours,” Lisa said, rolling her eyes and coughing out a laugh. “It kicked my butt. It really kicked my butt.”

The last thing this 46-year-old Somerville, Mass., native remembers is starting to do laundry. That’s where Lisa’s daughter found her — passed out on the washing machine.

“My daughter brought me up and put me to bed. I hate the fact that she saw me like that,” said Lisa. We’re not using Lisa’s last name because she has used illegal drugs and fears going public about that could harm job prospects.

Lisa lay in the same position on the bed — one leg bent under her body, arms folded across her chest — for more than a day. Family members checked to make sure she was still breathing. Lisa’s daughter noticed that her mom’s right leg had gone white and looked shriveled.

“She came in and massaged it really, really vigorously,” Lisa said. “If she hadn’t done that, I don’t think I’d be walking on this leg. I think I would have killed it.”

As it is, almost five years after the injury, Lisa said she still limps in some weather, “or I have what I call flabberfoot. My foot, like, slaps the ground when I walk.”

Lisa never told a nurse or doctor about her injury.

“I was embarrassed. I didn’t want anybody to know I had a drug problem,” she said.

Lisa’s injury may reflect nerve damage, which doctors say is common in people who misuse opioids. Or it may have been the result of something called compartment syndrome, where muscles are damaged or die because blood can’t get in or out of part of an arm or a leg. In some such cases, the damaged muscles must be removed.

Dr. Ed Boyer remembers one such patient, a man who injected heroin while sitting and stayed in that position, leaning to one side, for hours on end.

“When he woke up, he had a compartment syndrome of his buttock and they had to remove half of it,” said Boyer, the director of academic development in the emergency medicine department at Brigham and Women’s Hospital, and a professor at the University of Massachusetts Medical School.

“So you can have very severe and disfiguring injuries,” he said. “Because now this individual has great difficulty even walking.”

Lingering Damage To Those Who Survive Overdose

The common understanding of patients addicted to heroin or other opioids is that they either survive a high or die, but that there’s no real damage to those who get up and walk away. Increasingly, emergency room doctors will tell you that’s not the case.

“I would say at least 75 percent — every three of four patients [brought] in after an overdose — has some sort of associated injury, whether it’s a minor injury or major injury from that overdose,” said Dr. Ali Raja, the vice chair of emergency medicine at Massachusetts General Hospital, the busiest emergency room in the Boston area.

The trauma ranges from frostbite or broken bones after a fall on the ice to serious brain damage. Raja said many injuries from drug use don’t get treated because patients who are revived never come to the hospital, and those who do are driven by their addiction to leave the hospital quickly and use again.

“They often believe that they’re just fine and they repeat the exact same circumstances that led to the overdose in the first place,” Raja said. “And they’re definitely prone to repeating the same injuries we just talked about.”

That prompts another question for the emerging science of drug and overdose injuries: What’s the effect of overdosing again and again? Dr. Alex Walley, an associate professor of medicine at Boston University School of Medicine, offers a theory about the impact on the brain.

“One way to think about this would be that an overdose is like a concussion, where you have a traumatic injury to the brain,” he said. “If the person doesn’t die, the brain recovers, but they may be, like with a concussion, more susceptible to a future event. And then there also may be cumulative damage that occurs.”

That damage, Walley said, might make these patients more difficult to treat.

Another injury that doctors see among some overdose patients is kidney failure. When a person spends hours in one position, blood stops circulating through muscles and that living tissue can break down, releasing chemicals into the bloodstream.

“They can clog up the filtration system in the kidneys,” said Dr. Melisa Lai Becker, chief of the Cambridge Health Alliance emergency department in Everett, Mass. “And when that happens, the kidneys can shut down completely.”

Patients coming out of an overdose often vomit, which can lead to aspiration into the lungs and pneumonia. And then there’s a condition called pulmonary edema, which hits some patients who are revived — their lungs fill suddenly with fluid.

“The lungs become so waterlogged that you can’t get any more oxygen into the body even though the patient is wide awake and they’re struggling to breathe,” Lai Becker said.

Doctors offer different theories about why this occurs. Lai Becker said it may be related to a sudden change in blood pressure when a patient is revived abruptly with naloxone. Other doctors think it’s a reaction to some part of the drug combination patients take.

Emergency doctors have many questions about why this is happening — it’s why researchers at the federal Centers for Disease Control and Prevention are now wading into this new field of opioid-use injuries, to gather data.

“We’re only beginning to scratch the surface and trying to understand what is going on, on this front,” said Mark Faul, a senior health scientist at the CDC.

Faul is studying the possible link between opioid overdoses and traumatic brain injury. He plans to collect data about how often an overdose leaves patients with permanent or temporary brain damage that that can leave them blind or deaf, or with amnesia or other cognitive problems.

Fentanyl Exacerbates The Problems

And there’s one more complicating factor: fentanyl. This very powerful opioid gives those who use it recreationally a high that is more intense than heroin’s but wears off more quickly. Traci Green, a senior scientist and deputy director of the injury prevention center at Boston Medical Center, said that means recreational drug users tend to use fentanyl more times a day than they would pure heroin.

“It also means more opportunity to overdose,” she said. “Simple math tells us that we’re going to have more visits to the emergency department and we’re going to potentially have more injury. And injury will beget injury.”

Fentanyl can also change the kind of injuries some emergency rooms see — more falls and head trauma because taking too much of the opioid cuts off breathing immediately and patients collapse. But Lai Becker has a different perspective. She said she has treated fewer of what she calls “in between” injuries in the past six months.

On one end of the spectrum, she said, “we’re seeing people who have fortunately had a good, full, complete reversal.” On the other extreme, she added, “patients have either arrived dead, or we’re able to resuscitate them, but unfortunately, they’ve already undergone brain death.”

To avoid fentanyl injuries and overdoses, people who are addicted to the drug at least should use it in pairs, Green urges, making sure one partner is stable before the other person injects. She said the state could help, too, by allowing patients who are addicted to opioids to use the drugs in a supervised setting like a hospital or clinic.

“Individuals who are able to spend time there don’t have to worry about hypothermia,” Green said. “They don’t have to worry about being hit or kicked or struck by a truck. This is something we should consider — this is a new era of prevention and intervention.”

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

Categories: Health Industry, Mental Health, Public Health

Tags: , ,