Detox: A day in the life

Opioid addicts have been flooding the treatment world in what has become an epidemic that has spread throughout the United States like a wildfire, the flames of which are being fanned by Big Pharma’s infinite supply of prescription pills. Occasionally, someone would admit to our rehab center with an alcohol or cocaine concern, but that was maybe one in ten or even twenty. We dealt mostly with hard core opioid addicts. Heroin and OxyContin were their preferred drugs of choice, used in conjunction with meth and benzos. That was the recipe for a high that we would most commonly see, the true definition of polysubstance abuse.

A common element of working with the addicted was that they would all claim they wanted to get clean, even when it was obviously not the case. Addicts would stand in front of us, saying exactly what they thought we wanted to hear, not realizing that everyone says the same thing when they're sitting in the intake chair. “I swear, I swear that this is my last time. I’m going to do whatever it takes.”

Hah, it was rarely the case. Such liars. Over 90 percent of heroin and opioid addicts in recovery relapse and we all knew it. From a treatment standpoint, it’s like the movie, Groundhog Day.  We’re watching the same fucking scenario unfold day after day, addict after addict, and we weren’t even provided the tools to offer an effective solution to help these poor bastards.

By 2015, a decade after I was working at this rehab center, The American Society of Addiction Medicine (ASAM) reported that there were 20.5 million Americans over the age of 12 suffering from a substance-abuse problem. Over 2.5 million Americans were addicted to opioids, and 2 million more were addicted to prescription pain medications. About 600,000 were addicted to heroin. These figures are lagging indicators and do not reflect the true number of people suffering from opioid and substance abuse today in 2017.

Drug overdose is now the leading cause of accidental death in the US, greater than car accidents or homicides attributable to firearms. In 2014, there were an average of eighty accidental opioid overdoses every day. In 2015, more than 50,000 Americans died from a drug overdose, an average of 137 people per day, over 33,000 of which were attributable to opioids.  And in 2016, the number of drug overdose fatalities was greater than the total number of U.S. military fatalities during the Vietnam War. Overdose deaths traceable to prescription opioids have quadrupled since 1999. OxyContin, Vicodin, and Methadone are the main culprits. In fact, overdoses involving painkillers are more common than those involving heroin and cocaine combined. Big Pharma is killing more people than El Chapo, but he is in custody.

Just Another Day

Not today, I thought to myself as I stared down at the screen of my ringing phone. The three hours of back and forth, the forms, the procedures, the bullshit. Odds were that this intake was just another heroin addict who would be calling back in thirty days, asking to readmit because he relapsed yet again. Shit, I just didn’t feel like dealing with all the intake paperwork.

Answering the phone in my perpetually burnt-out state, I barely mustered a “hello.”             “Call the dentist,” echoed back from the other end of the line. It was Jimmy, the head operations guy. If Jabba the Hut and Fred Flintstone were to procreate, they would produce Jimmy. He is bald, with huge bulging eyes that make him look like a goldfish suffering from pop eye, and the ends of his fingers are all flat and abnormally large, as if they’d been bashed to shit with a hammer. Jimmy oversees six different detox facilities, four of which are owned by the company I am working for. The dude spent TEN years in prison on drug charges, and now he’s responsible for overseeing six licensed detox facilities. What a joke. The owner of the company chose this guy, with his sterling prison yard qualifications, to oversee the company’s operations. This is who I have to report to.

This wasn’t supposed to be the case. When I first signed on with the company, the understanding was that I would be reporting to Dave, who was the company’s COO, and one of the owners of the company. It turned out, however, that Dave himself had been using again for quite some time – including, I might add, throughout the process of hiring me. During his relapse, he wrecked his car, ended up in the hospital, and then disappeared for a while. When he finally resurfaced at a treatment center in Nevada, he was told by the other owners not to come back. So now I reported to Jimmy. A sign of things to come.

 “Where’s this one from?” I asked Jimmy.

“I don’t know, Kentucky, Indiana, Ohio, some shit hole somewhere,” he replied. The inside joke was that almost every time we got a new client from one of these states, we needed to take them to the dentist. It was either for a legitimate oral health concern, due to poor oral hygiene or because they simply wanted drugs. I had one client, a rehab lifer who by his own admission had spent $2 million of his family’s money going in and out of more than 40 different rehab facilities, who went so far as to extract his own tooth while in rehab just so he could go to the dentist to get opioids.

“Let me guess. Another Nate Black special,” I said.

“You know it!” Jimmy replied. “You know the drill. Heads on beds. Doesn’t matter where they come from as long as they got that insurance.”

Nate Black was a body broker from the Mid-West, retained by the owners to provide a steady stream of clients who had insurance benefits to cover their treatment. Advertising free treatment on Craigslist, he would pay the addict’s monthly insurance premium and provide airfare to California if my employers did not want to pay for it. In exchange, he received a referral fee from my employers, so long as the client stayed in treatment for a predetermined minimum number of days. In certain cases, he would also collect on the insurance benefits that were above and beyond the cost of treatment, an additional source of income for himself. Meanwhile, my employers would get a new client and the insurance claim payments worth tens of thousands! This form of fraud and brokering is common in the treatment world.

Having worked in the high-end residential treatment industry on and off for ten years, this place was a wake-up call for me. For all of their endless neuroses and sense of entitlement, I much preferred dealing with celebrities, high-powered executives, and (worst of all) trust fund babies to dealing with the low-life clientele who were shipped to this facility. We had one poor guy from Indiana who was so badly off he made the inbred banjo player in the movie Deliverance look like Elon Musk.

I had started my career in residential treatment at one of the most expensive residential treatment centers in the country, the same treatment center where I had once been a client. I started out as a tech, a basic support staff position. Eventually, I became a life coach and a sober companion for the rich and occasionally famous. At that time, most clients were seeking treatment for alcohol and cocaine. A few liked their pharmaceuticals, mainly benzos, a little too much, and there was the occasional client trying to get off heroin or meth. Once, I even worked with an individual who sought treatment for an addiction to cough syrup. Today, ninety-eight percent of the clients I see are trying to get off heroin and/or OxyContin either used alone or in combination with meth.

 These opioid addicts are master manipulators. They lie, they cheat, they steal. In fact, these addicts would sell their grandma’s ass for a nickel bag of dope if it meant staying “well” for another day. Don’t get me wrong; I’m sympathetic to their suffering. I understand that their brains have been hijacked by one of the most powerful molecules in the world, the morphine molecule. It’s just that dealing with them daily while they are detoxing is about as pleasant as getting a rectal exam from a proctologist wearing barbed-wire gloves.

When they get to the point where they are sitting across from me for the intake interview, they’re at their worst. They’ve run out of money. They’ve manipulated a friend or a loved one into buying them a month’s worth of insurance so they won’t get dope-sick on the streets. Their loved ones have given them some sort of ultimatum to enter treatment. They’re facing incarceration or they’re court mandated. They have grown tired of the insanity that is their life on the streets, and they want a temporary reprieve to get clean just long enough to make it to their next run of morphine-driven insanity. Or worst of all, a body broker has sent them our way in hopes that they will stay long enough to earn him his referral fee. Most of the clients that come here do not want to be here, but it was my job to get them to stay.

The night before was brutal. I had already worked a twelve-hour day when I was called back into work just after midnight. We had a tatted-out, white supremacist skinhead who was refusing to give up his clippers during his intake. He was high on meth, and the staff on that particular shift possessed neither the temperament nor the ability to deal with the situation, so back to work I went. This was not what I signed up for when I took the job. Or maybe it was, and I just didn’t realize what I was getting myself into when I became Director of Operations of this sub-acute detox facility. I did know that I was not being paid nearly enough to deal with this bullshit.

Call waiting beeped on my phone, and I knew what was coming next: Amy. Amy was the company’s head of marketing, a commissioned assassin who was responsible for sourcing potential clients and making the necessary arrangements to have lost, addicted souls delivered to our doorstep. She had the scruples of Bernie Madoff and the personality of a rattlesnake. Everyone at the facility had issues with her, particularly me.

Amy was originally a heroin and meth addict from Kentucky. She had less than a year of sobriety under her belt when she was made head of marketing for the entire company. At first I couldn’t figure out why John, the principal owner of the company, would put someone who possessed neither the qualifications nor the personality to navigate such an important position in that role. Then it all became quite clear. I learned that John, a licensed marriage and family therapist who is part-owner of six licensed treatment facilities and who is married with three small children, was having an affair with Amy, who also happened to be one of his former clients.

 “Amy’s on the other line,” I said to Jimmy.

“Let me know how it goes,” he replied, laughing. I didn’t know whether he was referring to the intake or having to deal with Amy. Either one was going to be equally unpleasant.

“Hello,” I said in the fakest way possible.

“Ok, you have an intake arriving in three hours, a 27-year-old female. I’m going to text you the assessment and I will email you the VOB. Do you want me to call the doctor or do you want to do it?”

“I will handle it,” I replied, knowing that the doctor hated Amy as much as everyone else did. Why not shield her from having to interact with Amy, I thought. “How is she getting here?” I asked.

“I will email you her flight info,” she said, hanging up abruptly without the slightest hint of a goodbye.

“I always thought people from the South were supposed to be well-mannered,” I thought to myself.

It was 2:30 in the afternoon, which meant the client would be arriving at LAX sometime around 5:30 p.m. Anyone who has ever lived in Los Angeles knows that it can take nine hours to drive two miles during rush hour, which meant that I was going to have to send my driver soon to go and get her. With a little luck, the pickup would be timed just right. But if the new client were to arrive and start to get that junkie itch while waiting for my driver at the airport, there was a good chance she would bolt, and losing her would be on my ass.

My phone beeped again. This time it was a text from Amy with the basic assessment information. It read, “Mary R. 27-year-old female. For the past 18 months; Daily: 2 grams heroin IV, 1 gram meth IV, 4mg Xanax, drinks vodka occasionally.” Not the easiest detox case that I had ever seen, but certainly not the worst. Regardless, she was going to arrive in rough shape.

My phone alerted me that I had just received the email with the Verification of Benefits, (the VOB) and Mary R.’s travel itinerary. VOBs are processed by the medical billing company in advance of a new client’s arrival to confirm that the client’s insurance will pay for their treatment. If the billing company screws up and the new client lacks adequate insurance, neither the billing company nor the treatment facility will get paid. In this situation, the treatment facility can either keep the new client and eat the cost of her treatment or discharge her. But as this was a Nate Black referral, Mary R. was pretty much guaranteed to have adequate benefits.

I opened the VOB, and just as I suspected, she was from one of our big three, Kentucky. I thought to myself, “I wonder if Amy ever shot up with her?” I read the VOB and it didn’t surprise me that the billing and mailing addresses on the VOB did not match up, not even close. One address was in Kentucky, and the other was an address that I had seen on the VOBs of several other clients referred by Nate Black. It was a California address not too far from the facility –a telltale sign that insurance fraud was being committed.

I called the doctor to let her know that we had an intake coming in but I only got her voicemail, which was pretty inconvenient because she was going to need to call the meds in and email me the medication orders so I could enter them into KIPU, our EMR (electronic medical record) system. If I didn’t hear back from her within the hour, I would have to call the orders into the pharmacy myself to ensure that the meds were delivered before the client arrived. Legally, of course, I was not allowed to do this, being that I am not the doctor, but I had done it before on several occasions in similar situations. The last thing I needed was to have this chick show up in full-blown withdrawal and not have her detox meds ready to swallow. Most heroin and opioid addicts who travel across the country for treatment shoot up dope or snort their pills in the airport bathroom before take-off, and often also when they land. Given how much she was using each day, it was a guarantee that she would be high when she arrived at the facility, which would at least postpone the onset of any withdrawal symptoms, but I didn’t want to run the risk of her going into full-blown withdrawal and not having her meds on hand.

The worst case scenario was that I would have to give her one of our other client’s meds, and then simply replace the dispensed meds when hers arrived. Again, this was against the law and a violation of the State’s licensing regulations, but in times of crisis, we did what we had to in order to keep the clients safe and comfortable. Because we did not have set intake hours, and given Amy’s habit of sending new clients our way with little warning, such crises were all too common. Amy received a commission from the owners for each intake she arranged, and that monetary incentive was her sole concern. Whether we had the resources available to handle yet another client was of no matter to her. To Amy, an addict was just another head on a bed, and more money in her pocket.

Just as I was about to leave the office to find a driver for the airport run, Jamie, one of my techs, stormed in. Jamie was a 30-something former meth addict who desperately wanted to excel at her job, but the more she exerted herself, the more mistakes she made.

The facilities’ clinical director Lisa, a licensed MFT who had spent the previous summer in a residential eating disorder facility for anorexia, and who routinely abused her Klonopin prescription, diagnosed Jamie as having dependent personality disorder. Because of Lisa’s own personal afflictions, I tended to take her opinions with a healthy dose of skepticism. But I wholeheartedly agreed with her assessment that Jamie had some sort of mental health problem. Usually I just steered clear of Jamie in order to avoid having to respond to her constant need for validation, which drove everyone up the wall. Sometimes, however, I would have to intervene to, for example, ask her to pull up her sagging jeans. While such a wardrobe malfunction might amount to nothing more than a minor embarrassment in another work environment, it bordered on a criminal offense in the context of a houseful of detoxing male opioid addicts whose long-dormant sex drives were suddenly experiencing a reawakening at the sight of Jamie’s protruding g-string.

 Jamie’s most egregious mistakes involved the dispensing of medication. I had written her up twice in the previous month. I could not legally fire her outright, which meant that I had to go through the write-up process. In other words, I was stuck with her until her next fuck up, one that had the potential to put a client’s life at risk. My guess was that she was going to screw up either dispensing medication or entering medication orders into KIPU, tasks that she has been trained to do half a dozen times already and ones that were crucially important to be done correctly. But no matter how many times we trained her, she just couldn’t be relied on to get them right.

“It smells like shit in room 1, and I can’t figure out why. I sprayed Glade in there an hour ago and it’s still rank,” she exclaimed.

“Where’s Nate?” I asked. Nate was my go-to, a real workhorse. He was from South Central Los Angeles. He had never used drugs and he rarely drank. Most of his uncles either had been or still were heroin addicts, which meant he had witnessed firsthand the type of carnage the morphine molecule can cause. He was of a personality type that endeared him to the types of clientele that we served. I had recently promoted him to house manager, which meant that every unpleasant situation that I had previously had to deal with now fell on his shoulders. Thank God for Nate.

“He had to run to the store to grab cigarettes for everyone,” she responded. Cigarettes, the rehab staple. God forbid you run out of cigarettes.

“Alright let’s go look.” I got within three steps of the door to room 1 and I could already smell it. My first thought was to check the bathroom, which was next to the bedroom door. Clients in the past had clogged the toilet and not told anyone for days on end, resulting in similar incidents of aromatic unpleasantness. Room 1 had three beds in it, which meant three people detoxing at the same time and using the same clogged-up toilet. A common physical manifestation of opioid detox is diarrhea, so it’s not hard to imagine how wretched this type of situation can get.

I checked the toilet, but it wasn’t the source of the problem. I walked back into the bedroom, and once again the noxious fumes struck my olfactory senses like a runaway freight train. I quickly scanned the walls and the floor, unable to locate the source of the fetid odor. I walked around the beds, carefully examining the mattresses. I could tell that the offensive odor was emanating from one of them. I began flipping the mattresses over as if playing three card monty. I got to the third mattress. Jack pot!

I uncovered what looked like the aftermath of a murder scene, except that instead of a sea of blood, it was a sea of diarrhea that stretched out two feet in all directions. It had soaked through the mattress pad and into the mattress.

“Are you fucking kidding me? How did anyone not notice this?” I demanded, loudly. “Jamie, did no one notice that Kevin [the new intake assigned to that bed] had changed beds?”

“Um, I don’t think so,” she replied meekly.

“So you mean to tell me that Noc shift [the overnight shift] hasn’t been doing their 30-minute rounds, and day shift hasn’t been checking rooms, even though all the rounds have been signed off on?” I hissed. Auditing the rounds is one of my many daily responsibilities, and if they are not signed off on in KIPU they are flagged, but even if they were signed off on, it doesn’t mean that they had been performed.  

“Um, I guess not,” was her only reply.

Ultimately, as Director of Operations, this responsibility fell on my shoulders, but there was no way that I could micromanage every little task my unqualified support staff were expected to complete. I was overworked and under-resourced, which was standard company policy. I had no other option but to trust that my staff, who have all been trained to do their jobs, would take care of their basic responsibilities. But, alas, that was hardly ever the case as most of them were no very smart and extremely fucking lazy.

            At this point I felt my blood pressure beginning to skyrocket. And yet, what more could I expect when the company was only willing to pay $12 an hour for support staff? The principal owner’s yacht and brand new Escalade sure were sweet, though. Good thing he was saving money where it would really have counted by not hiring qualified support staff.

            “I don’t have time for this shit -- literally,” I exclaimed. “When Nate gets back please help him take the mattress out to the back dumpster, and have him bring Kevin into my office. Thank you.”

            I left the bedroom and headed to the other end of the house in search of Matt, the other tech on shift. I found him playing video games all by himself, not a single client in site. He could tell by the look on my face that I was ready to go Chernobyl.

            “Having fun?” I asked.

            “Sorry boss,” he replied, a sheepish grin on his face.

            “I need you to go to the airport to pick up a client who will be arriving in a couple of hours. I will email you her itinerary. Don’t be late!”

            My phone rang again. I was hoping it was the doctor, but no such luck. I looked down and saw that the CFO of the company, Steve, was calling. Steve was a nice enough guy, but he was completely clueless as to how the treatment world worked, which I came to find out in much greater detail later. I answered my phone.

            “What’s up Steve?”

            “Scott, we need to start collecting some form of payment from the clients when they come in.” The tone in his voice indicated that he was stressed out about something. “I don’t care if it’s a dollar, we need to collect something.”

            Turned out that HealthNet, one of the largest health insurers in California, had sent out letters to numerous treatment centers in Southern California. HealthNet was conducting an audit to identify treatment facilities that ignored their patients’ obligation to meet their deductibles and copays, a practice that the company I worked for engaged in routinely. The owners of my company had not yet received a letter from HealthNet, but the treatment world is closely knit in Southern California, and word had gotten out about the investigation. HealthNet was also investigating the illegal procurement of insurance policies for individuals residing out of state, the charging of inconsistent rates to different payers for drug treatment services, the payment of kickbacks in marketing to induce the referral of patients, and billing for services that were not deemed to be medically necessary -- all activities (plus a handful more along similar lines) that I had personally witnessed my employers engaging in.

            I told Steve that we would do what we could to start collecting copays from clients. I also mentioned that, because of the types of clients that were coming in, the chances of them having any money were slim to none. Most of our clients were destitute and penniless when they arrived, wearing clothes that had not been washed in days, sometimes weeks. (In fact, it was standard policy to wash all clothes brought by clients to prevent any bed bugs that might be traveling along in their luggage from infesting the house.) Steve replied that, if that were the case, the client would have to call a friend or family member to come up with some money. But for all of Steve's posturing, the truth was that -- investigation or no investigation -- even if a new client ultimately couldn’t come up with some form of payment, it really didn’t matter. As long as they had insurance that covered the cost of their treatment, they wouldn’t be turned away. We weren’t going to chase them for their deductibles or co-pays, as the insurance money was good enough for the owner.

            Just as I was hanging up the phone with Steve, Nate returned from his cigarette excursion.

            “Welcome back,” I said with a shit-eating grin on my face (pun intended). Immediately he knew something was up. “Check out bed C in room 1.”

            He locked the cigarettes in the office and we made our way back to room 1, where Kevin's bowels had laid waste to the mattress. In the meantime, Jamie had reapplied a healthy --or possibly lethal -- dose of Glade in the room, so Nate had no advance warning of what he was walking into. I flipped the mattress over, making sure to maintain visual contact with Nate’s face so I could see his initial impression of the atrocity that I had just revealed to him. He recoiled in horror.

            “Are you kidding me?” he cried.

            “Nope,” I replied. “We need to do a better job on rounds because nobody seemed to be aware that Kevin had switched beds, so nobody wondered why. We also need to go back through the med log and audit his medication to see if staff had offered him his Imodium,” I instructed. “After you and Jamie get done throwing this thing in the dumpster, I need you to bring him into the office. We need to have a little sit down.”

            I was sitting at my desk, auditing the rounds, when Nate entered with Kevin. Right off the bat, Kevin’s body language was symptomatic of someone in flight or fight.

            “Bro, why didn’t you tell anyone that you had an accident?” I asked.

            “What are you talking about?” he replied, his face becoming noticeably red.

            “You’re joking right? The giant pile of shit on the mattress,” I retorted.

            “It was like that before I got here. Somebody else did it,” he exclaimed.

            “You’re telling me that initially you slept there, on a shit-soaked stinking mattress, and it didn’t bother you?” I inquired skeptically. Nate, who was sitting next to Kevin, smiled and shook his head. Each time a client discharges, the bed they slept in gets turned over. Sheets and mattress pads get stripped and washed and the mattress is inspected. Nate and I knew full well that Kevin was the offender.

            “Why did you change beds?" Nate asked.

            “Well, I changed beds because the other one looked more comfortable.” Nate and I just looked at each other in disbelief. Seeing a prime opportunity for this young man to tap into his higher nature and maybe to gain a little wisdom from this experience, I switched gears.

            “Listen, Kevin. All three of us know what happened. It’s no big deal. Everybody shits the bed, sometimes figuratively, in this case literally. It’s not the event itself that matters, it’s how you choose to respond to it. I understand and recognize that you are embarrassed. I get it. But is this the person you ultimately want to be? A liar? We know that you shit the bed. Just own it.”

            No luck. This young man chose to allow his ego to dictate his response, fortifying himself in his opium-laced protective shell, denying everything to the very end. After The Shitter left the office, Nate and I in almost perfect unison said, “fucking junkies” -- our preferred response anytime we encounter poor behavior that is attributable to the junkie lifestyle, which for us was a daily occurrence.

Kevin's reaction when confronted was typical for an addict. The addicted state is one that revolves completely around the Self, with all thoughts originating from the lower nature (ego). The addict's lower nature is a mechanism that understands only one thing, MORE, and it can never be satisfied. In the addicted state, the only thing that matters to the addict is “ME,” at the expense of everyone else, including family, friends, acquaintances, etc. This modus operandi is understandable. The addict spends their life in a continuous manic state of fight or flight, obsessing over themselves and what they need to do to stay well. From the moment they first wake up to the moment their head hits the pillow at night, every thought revolves solely around satisfying the ego, the lowest and most primitive aspect of the Self.

The morphine molecule is a powerful driver of behavior. It doesn’t matter if you're homeless on the street with not a penny to your name or you're a billionaire. If you are an opioid addict, your entire existence revolves around your using schedule and trying to satisfy cravings driven relentlessly by the morphine molecule. All behavior is centered around whatever activity is needed to keep the addict well. The lying, cheating, and stealing are all behavioral manifestations of a mind that has been hijacked and overdeveloped by the most powerful molecule in the world. The addict's higher nature, the place where love, compassion, patience, and empathy reside in a healthy person, ceases to exist.

I admit that I was not “one” with my higher nature after The Shitter episode, because I was going to have to find time that did not exist to go out and buy a new mattress. I did learn one thing from this experience, however: $40 mattress bags are a great investment in a detox facility whose clientele are primarily opioid addicts.

I still hadn’t heard from the doctor, so I decided to take the bull by the horns and call the pharmacist, whom I affectionately called Big Nelson, myself. Big Nelson runs a pharmacy out of a local hospital. They’re an old-school mom and pop pharmacy that delivers, and they are very easy to work with. We gave them so much business that at Christmas, Big Nelson sent over a $500 box of chocolates as a thank you.

Our other pharmacy option was a local CVS, which I avoided like the plague whenever possible. Every time we placed an order with them they forgot at least one of the medications that were called in -- usually something critical-- and we had to go back and wait in their invariably long lines. The only advantage to CVS was that they were a 24-hour pharmacy, which came in handy when Amy decided that it was a good idea to send us a new client at 1:00 a.m. and the doctor needed to call in medication.

“Nelson, how are you my friend? I am calling in an order for a new client who is coming in shortly,” I said.

“Go ahead,” the familiar voice on the other end of the line replied.

I replied as if I had six years of med school and had been writing scripts for a decade. “We need our standard opiate detox protocol for a Mary R., DOB June 5, 1998. Suboxone, 2mg strips, 2-4mg SL q 12hrs NTE 8mg/24hrs, 30 count. Klonopin, 1mg, 1-2mg po q 4-6hrs prn anxiety, NTE 8mg/24hrs 60 count. Robaxin, 750mg po q 6hrs prn muscle cramps, 30 count. Seroquel, 50mg pg TID prn anxiety, and may have an additional 50-100mg po qhs prn insomnia, NTE 250mg/24hrs, 50 count. Phenergan, 25mg po q 6hrs prn severe nausea/vomiting, 30 count. Clonidine, .1mg po q 6-8hrs prn BP greater than 160/100, prn bone pain NTE .6mg/24hrs, 20 count. Imodium, 4mg po prn initial loose stool, then 2mg po prn each loose stool thereafter, NTE 16mg/24hrs, 1 box. Lastly, we need Melatonin, 3mg 3 to 6mg po qhs prn insomnia 60 count.”

In his hushed monotone voice, Big Nelson repeated the entire order back to me without error. He assured me that the meds would be delivered by 6:00 p.m., in time for Mary R.'s arrival. He didn’t question that I, not the real doctor, was calling it in.

To the layperson, this must sound like a boat load of medication, and it is. This is very much a MAT (medically-assisted treatment) facility, minus the behavioral therapy, that has adopted a Western approach to detoxing addicts. Withdrawal, nausea, bone pain, anxiety, insomnia, diarrhea, and vomiting are all symptoms that can arise, and we needed to have a medication to combat each symptom. Otherwise, clients would bolt and the owners wouldn’t get paid, which at this facility was priority number one.

Big Nelson then asked me for the client's insurance information and their Rx Bin number, which should have been on the VOB. With the VOB in hand, I relayed back to him the insurance information, but there was no Rx Bin number, which meant that the company would be picking up the tab for the medication, a $588 charge. This was a cost of doing business that the company was willing to absorb since we did not have the patient’s drug benefit plan information. The billing company, at the owner’s request, bills the insurance company $3,950 for each day a client is approved for medically-monitored inpatient detoxification. As long as the company was receiving its daily fee through the client's insurance, covering the $588 for the detox meds was no big deal.

I managed to get some administrative work done for about an hour or so -- a mind-numbing and time-sucking task that was also a necessary evil in our insurance-driven, managed-care world. The daily audit of client charts was one of those mundane tasks that made my eyeballs bleed. Staring at the computer screen, poring over each chart, making sure that each client was adhering to their medication schedule, confirming that rounds were completed on time, and ensuring that the necessary clinical hours required to capture insurance reimbursement had been documented was a daily burden.

I would often find mistakes. The owners refused to spend the money to hire nurses and, what was worse, they refused to hire any clinical staff, apart from our one benzo-addicted MFT. Instead of hiring qualified personnel to manage important tasks, such as making sure that clients self-administer the right dose of their prescribed medications according to the medication schedule, the owners simply delegated such responsibilities to the same $12-an-hour employees who were responsible for documenting clinical hours for things like “Mindful Walks” and “Movie Therapy." Like so much else in life, you get what you pay for. Mistakes were frequent, and clinical care was non-existent, all to the detriment of the clients, whose insurance benefits flowed into the company's coffers without them receiving any therapeutic services in return.