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Would a three-day hold help or hinder treatment?

December 1, 2015
by Alison Knopf, Contributing Writer
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When Massachusetts Gov. Charlie Baker in October issued a broad set of proposals to address the opioid crisis, the addiction treatment community in Massachusetts, which supports them in general, was intently interested in one of the most controversial. Mirroring the state’s law allowing healthcare professionals to commit patients who are suicidal or homicidal to three days in a hospital, the governor's proposal would allow the same kind of treatment for people with substance use disorders (SUDs) who pose a danger to themselves or others.

There is support for the initiative, but the question is in the details. As the state legislature mulls over language for the proposal, treatment providers weighed in during interviews with Addiction Professional on the pros, cons and complexities of a 72-hour hold for people with SUDs.

What would happen during that 72 hours remains unclear. But even more worrisome to the field involves what would happen next. “Their conditions aren’t going to be cured in 72 hours,” says Vicker V. DiGravio III, president and CEO of the Association for Behavioral Healthcare (ABH), a state providers' association. “Assuming they can work out the details of what happens during the 72 hours, what happens in hour 73?”

For psychiatric problems, 72-hour holds are usually prioritized for a hospital bed, says DiGravio. It’s not at all clear that would happen on the substance use side, because there are not enough treatment beds—which is the main point of ABH's position. “There isn’t enough capacity in the system,” DiGravio says.

Massachusetts has a robust foundation for SUD treatment, comprising a full continuum of care. But at the residential end, there is a three-week waiting list for a bed at present.

But finding a bed isn’t necessarily the problem, says Raymond V. Tamasi, president and CEO of Gosnold on Cape Cod. “The context of this is the overdose deaths, and the need to interrupt this tragedy,” Tamasi says.

“What’s happening now is many individuals—I would say about half—who overdose and are revived sign a declination statement in the ER,” Tamasi says. “They never get to the point where they could be helped.” The emergency rooms offer to refer the overdose victims to treatment, but only a very small percentage agree to this, he says.

If non-fatal overdose victims are now getting little intervention, Gosnold is working to change that, in tandem with local police departments. By visiting overdose victims who were revived by the reversal drug naloxone, Gosnold has been able to persuade a majority of patients to enter treatment. It takes more than a referral to engage a person with a SUD in treatment, Tamasi notes.

“If we can reach out to people and engage them as quickly as possible after the event, we’re having some success in getting them to say ‘yes’ to treatment,” he says. So far, of the 60 victims Gosnold has visited in the police partnership program, 45 have entered treatment. “If we can retain a person, we can engage them,” Tamasi says.

It’s hoped that a similar arrangement could take place during the 72-hour hold, he says.

Hospital officials, however, aren’t so sure they know what to do with SUD patients for 72 hours if they don’t have a bed to discharge them to. But Tamasi and others in the treatment field say it’s more important to reduce overdose deaths, and that the issue of increasing capacity is a separate, though equally important, concern.

Treatment refusals

As of now, it’s the right of a patient with a substance use disorder to decline treatment in Massachusetts. Even patients who are suicidal often refuse treatment, says Stuart Gitlow, MD, past president of the American Society of Addiction Medicine (ASAM) and a strong supporter of medication-assisted treatment (MAT).

“We have always been able to commit to a 72-hour hold based on a mental health diagnosis,” says Gitlow, noting that a SUD is a mental health diagnosis. And in fact, many hospital beds are occupied by patients with alcohol use disorders. But managed care has made it difficult to admit patients for SUDs, he says.

“This all started 60 years ago, when ASAM was started because medical-surgical beds were not admitting patients with addictive disease,” says Gitlow. One of the main fights at the time was to get patients with addictions into medical beds. “We succeeded with that,” he says. “But when managed care came around, all that was lost, and now we’re fighting the same battle.”

And Gitlow is not sure that forced treatment is even possible. “When people use drugs and don’t want treatment, there’s no treatment you can give them,” he says.

MAT option

However, Gitlow says many individuals successfully rescued from overdose would be good candidates for treatment with buprenorphine, but that because of the 100-patient limit on medical practices, there aren’t enough physicians in the state to treat them. (Although Gitlow's practice is located in neighboring Rhode Island, most of his patients are from Massachusetts.)

We asked Gitlow if the 72-hour hold wasn’t a good opportunity to induct patients on buprenorphine. “Yes, but there would need to be someone to discharge them to,” he says. “Because we’re all at our cap, there is nobody to discharge them to.”

However, the three-day hold could be used to “educate someone about the options they do have, about rehab,” he says. “I’m honestly not worried about somebody losing their freedom for three days—these folks could use three days away from their drugs.”

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It really seems as though getting people with SUDs into treatment ASAP is a good idea. While there are legitimate concerns about what will happen during the 72 hour and what will happen next, but the benefits seem to outweigh the costs. It may be the first time an addict is experiencing treatment. A positive experience may change the addicts mind about what treatment is all about. It may also plant a seed.
If an addict is suicidal getting into care is the best thing that could happen. I've always found it odd that suicidal ideation is used as a reason to keep addicts out of treatment.

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