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Heroin addicts face barriers to treatment

Tuesday - 4/8/2014, 5:08am  ET

In this March 11, 2014 photo, Nora Milligan prepares to drive from her home in Patchogue, NY. Milligan, a single mom, is fighting healthcare providers in court for denial of care to her heroin-addicted son. Having exhausted her finances for his care, she continues to live in the home she raised him even as it is being foreclosed. As the number of heroin users in the U.S. rises, more addicts are seeking help but running into barriers that block them from treatment, including lack of beds in packed facilities, high costs for care and unwillingness on the part of insurance companies to pay for inpatient rehab. (AP Photo/Bebeto Matthews)

Associated Press

NEW YORK (AP) -- As the ranks of heroin users rise, increasing numbers of addicts are looking for help but are failing to find it -- because there are no beds in packed facilities, treatment is hugely expensive and insurance companies won't pay for inpatient rehab.

Some users overcome their addictions in spite of the obstacles. But many, like Salvatore Marchese, struggle and fail.

In the course of Marchese's five-year battle with heroin, the young man from Blackwood, N.J., was repeatedly denied admission to treatment facilities, often because his insurance company wouldn't cover the cost. After abusing marijuana and prescription painkillers as a teenager, Marchese had turned to heroin for a cheaper high.

Then one night in June 2010, a strung-out, 26-year-old Marchese went to the emergency room, frantically seeking help. The doctors shook their heads: Heroin withdrawal is not life-threatening, they said, and we can't admit you. Doctors gave him an IV flush to clean out his system, and sent him home.

Marchese and his sister stayed up all night calling inpatient treatment centers only to be told: We have no beds. We'll put him on a waiting list. Call back in two weeks.

As Marchese grew sicker with diarrhea, body aches and shakes, his sister tried a new tack. She called one more place and told them her brother was using heroin and also drinking alcohol. That did the trick, because alcohol withdrawal can cause life-threatening seizures.

He was admitted the next morning, and released 17 days later when his funding from the county ran out. Less than three months later, Marchese was found dead of an overdose in his mother's car, a needle and a bag of heroin on the center console.

"Insurance companies need to understand that this is a disease," said his mother, Patty DiRenzo. "Heroin is life-threatening, I don't care what they say. Because we're losing kids every day from it."

Of the 23.1 million Americans who needed treatment for drugs or alcohol in 2012, only 2.5 million people received aid at a specialty facility, according to the federal Substance Abuse and Mental Health Services Administration. Heroin addicts are a small slice of overall users, but their numbers nearly doubled from 2007 to 2012, to 669,000. At the same time, the number treated for heroin did increase sharply, from 277,000 to 450,000.

What is at issue is whether they are getting the treatment they need to successfully beat their habits. Advocates say they are not, partly because the insurance industry has not come to grips with the dangers of heroin withdrawal and its aftermath.

It is true that, unlike withdrawal from dependencies on alcohol or benzodiazepines like Xanax, heroin withdrawal does not kill. But it is so horrible -- users feel like their bones are breaking, they sweat and get the chills and shakes, and fluids leak from every orifice -- that many are drawn back to the drug, with fatal consequences.

Even if addicts make it through withdrawal, they often relapse if they fail to get into treatment. That's when many overdoses happen, because they try to use as much heroin as they did before, and their newly drug-free bodies can't handle it.

Because withdrawal is not directly deadly, most insurance companies won't pay for inpatient heroin detoxification or rehab, said Anthony Rizzuto, a provider relations representative at Seafield Center, a rehabilitation clinic on Long Island.

They either claim that the addict does not meet the "criteria for medical necessity" -- that inpatient care would be an inappropriate treatment -- or require that the user first try outpatient rehab and "fail" before he or she can be considered for inpatient.

"Ninety-nine-point-nine percent of the time, we hear 'denied,'" Rizzuto said. "And then we go to an appeal process. And we get denied again."

Susan Pisano, a spokeswoman for America's Health Insurance Plans, the national trade association that represents the health insurance industry, defended the industry's practices.

"Health insurers rely on evidence-based standards of care that look at: what is the right level of coverage, the right site of coverage, the right combination of treatments," she said.

There is a great deal of debate in the addiction world about what is the best way to get clean, but most authorities agree that inpatient care is often essential for full-blown addicts -- a first, crucial step in the process.

For the few who do get some insurance coverage, what they're getting falls short of what they need and often what their policies allow. While most insurance policies cover up to 30 days in a residential center, nobody actually gets those 30 days, said Tom McLellan, CEO of the nonprofit Treatment Research Institute in Philadelphia who served as deputy drug czar under President Barack Obama. The average duration is 11 to 14 days. After that, most insurance companies stop paying, and facilities discharge patients before their treatment is done.

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