Alarmed by a worsening shortage of detox services across Minnesota, state officials are considering dramatic changes to the state's outdated system for treating chronic alcoholics and drug users.
Each month, hundreds of heavily intoxicated people cycle in and out of expensive hospital emergency rooms and jails, while others receive no treatment at all because of the state's dwindling number of detoxification facilities. Fourteen detox centers have closed across Minnesota in the past decade, leaving wide swaths of the state with limited or no treatment options for people suffering from potentially life-threatening symptoms.
Now, the state is exploring ways to expand treatment for addicts after more than a decade of cuts by county governments.
Last week, the Department of Human Services (DHS) sent a formal request to drug and alcohol treatment providers, seeking input on ways to expand detox and other treatment services.
"You know it's time to make changes when you have to send a sheriff 80 to 90 miles to the nearest detox" facility, said Gary Olson, executive director of the Center for Alcohol and Drug Treatment in Duluth, which receives patients from places as distant as Brainerd, two hours away.
Among the possibilities under consideration is the creation of lower-cost treatment sites for people who just need a place to sleep and sober up, and longer-term housing for homeless people whose dependence on drugs or alcohol helps keep them caught in a revolving door between the street and the ER.
'Nowhere else to go'
At the detox center at 1800 Chicago Av. in south Minneapolis, director Sharlee Benson pulls a bulky folder from a shelf. Nearly four inches thick, the folder is the treatment history of a homeless alcoholic named "Duane," who has checked in and out of the detox ward 1,296 times over the past two decades.
Benson pulls out another thick folder. This one is for "Joe," a chronic alcoholic who has been admitted more than 650 times.
Duane and Joe are such familiar faces that the nurses know how they like their morning coffee and eggs. The center declined to disclose their full names because of privacy concerns.
"This is proof that the system is not working," Benson said, holding up one of the patient files. "These patients have turned detox into a form of housing because they have nowhere else to go."
There are now 22 licensed detox facilities in Minnesota, down from 54 two decades ago, according to state data. The number of admissions to detox services has dropped 21 percent, from 38,837 in 2001 to 30,604 in 2012, while Minnesota's population increased 9 percent over the same period.
Though they represent a minority of patients, chronic inebriates such as Duane and Joe pose a special challenge: Most have been in and out of jail and multiple treatment programs, making it difficult for them to find permanent housing or stable work. They need detox services but are filling scarce beds that could be used by people who are more amenable to treatment.
Those who don't find beds in detox facilities often are sent to hospital emergency rooms, which cost up to 10 times more per patient. The ER at Hennepin County Medical Center in Minneapolis is treating 700 to 800 people a month who are chronic inebriates, according to county estimates.
Taxpayers often end up footing the bill because the patients have no insurance or the services are covered by Medicaid, which is funded by state and federal governments.
"This is an enormous cost to taxpayers and the outcomes are poorer," said Robert Muscala, director of a chemical health clinic in Edina, who said he sends about 90 percent of his heavily intoxicated patients to area emergency rooms — because the beds are usually full at local detox centers.
Behind the curve
There is now widespread agreement among doctors and groups that treat addiction that Minnesota is behind the curve in creating alternatives to expensive, inpatient medical care for chronic alcoholics and drug users.
In other states, addicts can get detox services on an outpatient basis, with withdrawal medication distributed over several days through clinics. Some states, such as California and Connecticut, have experimented with less-intensive forms of treatment, such as drop-in centers and "wet houses" for people who mostly need shelter and food while they sober up.
In August, a consultant issued a sharp critique of Minnesota's system of public detox services.
"The advances made in the field … have, to a large extent, now passed Minnesota's public addictions system by," wrote Peter Rockholz, a behavioral health consultant from Brookfield, Conn., who was hired at the request of DHS.
One major obstacle to the expansion of treatment services is a state licensing regulation (known as "DHS Rule 32") that requires detox services to be provided in hospitals or a supervised living facility licensed by the state — two of the most costly forms of detoxification. About 40 to 50 percent of detox patients "likely do not require those service intensities," according to the DHS memo issued last week.
In addition, since the 1980s county governments that are required by law to provide detoxification services have circumvented the mandate by contracting with detox centers in neighboring jurisdictions.
"With regulatory change, it would be possible to lower [detox] services costs by placing clients in appropriate levels of care," the DHS document says.
Many county and state officials will be watching an experiment in Hennepin County, which has proposed a 30-bed "sobering center" next to the Chicago Avenue detox facility. Patients would get a place to sleep and would be monitored regularly by staff, but they would not receive the sort of acute medical care available at detox centers or emergency rooms.
The county estimates it will cost just $150 on average to treat an intoxicated person at a sobering center, compared with $340 at a detox center and up to $2,500 at an emergency room. Stretched over a year, those savings would total $4 million to public and private payers. Hennepin County is expected to consider the proposal at a County Board hearing in February.
Benson, the director of the Chicago Avenue detox center, said the need is "becoming a life or death situation." On Dec. 19, she participated in a march and vigil in downtown Minneapolis for 147 homeless people who died last year across the state. Benson recognized 20 of the names because they were regular patients at the facility she oversees.
"There was a vast array of reasons for why they passed away," Benson said, "but many could have been saved had the right services been in place."