Nearly one third of California’s 1,800 + licensed rehabs provide non-medical detox. Somehow this has been allowed in California, while other states have barred other treatment centers from allowing non-medical detox due to the dangers from withdrawal. So how is this dangerous practice being allowed in one of the most progressive states in the nation?
Sadly due to the urgency of most rehab cases, families don’t always have time to do the due diligence to make sure the facility they are sending their loved one to has the appropriate type of care. Some cases are held to whatever their insurance will allow.
Lake Arrowhead’s Above It All treatment center sells the message of professional care, it says on its website that it provides “clinically supervised” and “around-the-clock medical supervision” for patients in detox and aftercare — are medical facilities. Not many know that detox typically happens in a tract home or that the most stringent medical requirement might be the full-time presence of someone who knows CPR. When it comes to the withdrawal symptoms and dangerous signs, the states low medical requirements don’t align with the risks of withdrawal.
Without the proper type of medical care during a withdrawal, sometimes the dangers can be more than fever sweats and shaky nerves. Sometimes without the correct care, a patient can die from their withdrawals. The state of California doesn’t keep track of the number of deaths that occur in detox centers. Officials with Health Care Services only will confirm the number of death investigations in the past 5 years, from 2012 to 2017. 84. But they also noted that the average number of deaths is about 24 a year, which could push the total to 140 by the end of 2017.
Most centers are just in the unfortunate position of just having an unhealthy patient walk into their doors. Drug addicts are not known for their stellar health, and some come with underlying medical problems. But when a new patient is admitted, it can be hard to predict who will have trouble and who will be fine.
Gary Benefield arrived at A Better Tomorrow, a non-medical rehab in Murrieta, CA, after he had recently come down with pneumonia and suffered continuously from emphysema and pulmonary disease, according to a state senate investigation in 2012. Gary died on his 53rd birthday while he was a patient at the rehab.
Brandon Jacques suffered a heart attack and later passed away while admitted to First House in Costa Mesa in 2011. Jacques was only 20 years old and come to the center to seek help for his alcoholism and bulimia. His death was one of the third at the facility, and First House later paid Jacques’ family $10.25 million after it was court ordered.
In 2012, 28-year-old Jason Redmer died of a drug overdose four days after entering West Coast Detox in Huntington Beach. His mother files a wrongful death suit after she learned that the staff didn’t seek medical help quickly enough after they had learned Redmer had ingested drugs. She later settled for an undisclosed amount.
Last year in 2016, Dillon DeRita was found dead of a heart attack on the patio of Pacific Coast Detox in Costa Mesa. He had only been at the center for two day after starting his detox regime. A video showed the rehab staff find DeRita unresponsive and walk away, without calling for help or administering CPR. When an investigation showed that staff had falsified records, the center was closed.
Since 2013, Three clients from Above It All in Lake Arrowhead have died. Terri Darling, 52, James Douglas, 25, and Matthew Maniace, 20. Donavan Doyle, 21, died in the woods near the Lake Arrowhead center after he had been kicked out of or he ran from the program, The San Bernardino corner said Doyle most likely died of hypothermia within hours of leaving.
But Above It All officials said the company is not responsible for any of the deaths, citing the autopsy reports concluded the deaths were natural or from undetermined causes.
Insurance companies claim risk is why part of detox is so expensive, whether doctors are present or not. Above It All charges patients nearly $40,000 a month after an initial $3,000 fee. This is a fairly common rate in the rehab industry.
The owner of Above It All Kory Avarell said that every client is required to see a doctor after arriving. But Matthew Maniace’s parents said the center never showed any record of Matthew being seen before or after his arrival at the detox center.
At 7am on February 26th, Matthew was found in the fetal position, curled up in his hospital bed. A check again at 9:20 am found him in the same position, but this time with yellow foam coming from his mouth. The nurse then started CPR, but it would be 30 more minutes before 911 was called. Emergency workers arrived 5 minutes after the call was placed and by 10:15am, Manice was pronounced dead.
Had Manice been checked every 30 minutes, would the nurse have noticed his disposition and gotten medical help? If they had called 911 right away, would Matthew have been revived?
Since their son’s death, Matthew Manice’s parents have learned a lot about California’s rules regarding addiction treatment. If California also followed other states that have forbid non-medical detoxes, might their son still be alive?
The practice of addicts weaning off drugs or alcohol without close oversight from a doctor or specially trained medical staff is dangerous enough that a growing number of states simply don’t allow it.
“Any program in the state that does detox is considered an acute care facility and is required to have medical oversight,” said Ann Scales, spokeswoman for the Massachusetts Department of Public Health.
North Carolina requires all detox be done under the supervision of a physician, whether it’s in a hospital or residential treatment setting. Indiana has the same law, where a patients detox requires the supervision of a physician or clinical nurse specialist licensed to practice in the state. Ohio, Tennessee, Vermont and many other states are aggressively pushing for a more medically centered approach to treatment.
California’s approach draws criticism from many in the industry. Mark G. Mishek, chief executive of the Minnesota-based Hazelden Betty Ford Foundation, was stunned by the lenient rules he encountered when his organization merged with the Rancho Mirage-based Betty Ford Center.
“I’m a hospital administrator. California is very, very cutting-edge and strong in hospital regulation, as you would expect it to be. It has a reputation for being tough,” said Mishek. “For addiction, I thought it would be the same way. But it’s just not.
“A friend was showing me a detox house in L.A. and I thought, ‘God forbid if my wife or daughter ever wound up here.’”
The state follows what is described, legally, as the “corporate practice of medicine doctrine,” which translates as physicians and other licensed health professionals could not work for unlicensed people, including most addiction treatment programs.
A new state law allows non-medical rehabs to partner more closely with physicians for “incidental medical services.”
But the new rule does not require patients to get a complete medical exam before entering treatment. And it does not require that a physician make the call on which level of treatment is best.
“If addiction is a brain disease,” asked Walter Ling, professor of psychiatry and founding director of the Integrated Substance Abuse Programs at UCLA, “where are all the doctors?”
Withdrawal symptoms such as heart attacks, organ failures, fluctuations in body temperature and seizures are all potentially lethal side effects, according to the National Institute on Drug Abuse.
“Detox is a really, really dangerous time for a patient,” said Hazelden’s Mishek. “The number of seizures during detox – particularly from alcohol or benzodiazepines (drugs such as Valium and Xanax) – means you have to have really good nurses and doctors to monitor withdrawal.”
Nurses and Doctor’s are not required in California. Though non-medical facilities must screen patients before admission and send higher-risk patients to more medically intensive care, the screening process often centers more on how an addict answers some questions than on any formal medical testing.
Questionnaires given incoming patients are very generic. Questions like:
“Are you feeling fearful?”
“Do you feel bugs crawling on or under your skin?”
“Are you hearing things you know are not there?”
But health histories provided by drug-addled clients are hardly complete, and intake workers don’t have to check with the client’s primary care physician to probe for underlying health risks.
Above It All used to have clients go to urgent care to be cleared as healthy enough for non-medical detox, but Avarell said only a fraction required hospitalization.
Poor medical oversight might have played a role in four deaths that took place from 2008 to 2010 at A Better Tomorrow, a now-shuttered rehab in Murrieta, according to a 2012 state Senate investigation.
The patients had complex medical histories, including problems such as asthma, hypertension, shakes, swelling, shortness of breath, diabetes, high blood pressure, liver disease and other maladies, the report found. But all four were deemed healthy enough to be admitted to the non-medical facility where they later died.
“The people who work in these places, for the most part, are recovering addicts themselves,” said Anthony Lanzone, an attorney who handled the Redmer family’s case against West Coast Detox. “They aren’t doctors. They aren’t nurses. They don’t know how to handle these problems.”
Some former workers at Above It All agreed.
In sworn testimony given in the wrongful death claims pending against the center, former employees expressed discomfort that patients were admitted to detox without seeing a doctor. The intake screening for one of the patients who died was done by a medical assistant earning $12 an hour, whose job included cooking and cleaning in addition to watching patients.
“Under-trained staff; nurses not adequately knowing how to handle a crisis emergency situation; simple things such as CPR; calling 911; not knowing the difference between contraindicated medications that were highly dangerous in a detox situation,” said Betty Jean Tarvin, a licensed vocational nurse, ticking off problems she believed were common at Above It All.
“I witnessed too much … medicine-related responsibilities put on house managers (who) are not medically trained,” Tarvin said during her deposition.
“When are they going to see there needs to be more medical staff on at the detox center?”
Above It All’s lawyer argued that the former workers had been terminated and were hostile to the company.
But Tarvin also offered kind words for Avarell.
“I just believe the company just got too big … Kory just wasn’t at that level yet. It was too much for him. I believe he has good intentions.”
Avarell declined to comment on specifics because of privacy laws and pending litigation but said his company’s intake protocol is thorough.
“Any good treatment center is going to screen for health issues before the potential client gets to the treatment center, and of course if they are in bad shape, they would go to a more appropriate place,” Avarell wrote by email. “Our assessment has lots and lots of questions, 34 main questions. … We have sent a lot of people to a higher level of care because they weren’t in good health when they got here.”
He estimates that about 5 percent of prospective clients were referred to higher levels of care.
Though the intake screening isn’t done by medical professionals, Avarell said it is prepared by a doctor. “(W)hen we hit a medical question that is out of the ordinary, we have either a nurse or doctor look at the assessment.”
Above It All’s policy was to have clients see a doctor in person within 24 hours of arrival, he said.
“Switching to an all-medical detox model is of course safer, can’t deny that,” said Avarell. “Is it doable? Yes, but not economically feasible. The insurance companies would never pay enough.”
It’s often hard to tell if a center offers medical or non-medical treatment. Critics say some non-medical centers use scientific-sounding jargon in their advertising to imply that they provide a higher level of care than they actually do.
Some argue that allowing non-medical detox without a doctor’s clearance translates into danger for patients.
“The notion of ignoring physiology, and not providing appropriate medical care for someone in a situation that can lead to a true medical emergency, or be a true medical emergency, is grossly inappropriate,” said Michael Miller, past president of the American Society of Addiction Medicine and medical director of the Herrington Recovery Center at Rogers Memorial Hospital in Wisconsin.
Miller suggested that the rehab model followed in California is financially driven and that actual hospitalization for detox is viewed as too expensive.
It’s difficult to know what type of care your loved one will receive when dealing with a non-medical detox center. It is important for the person to be checked out medically to insure the type of care provided matches the type of care needed. Don’t be afraid to ask questions, and if it’s hard to get answers, it may be best to find another facility.
The Recover has taken information formerly published in a Press Enterprise article. The Recover has no opinion on the fault of the treatment centers mentioned.
Also published on Medium.