Advocates say there’s a missing link in our detox system

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Every month, for almost a year, as part of a year-long effort to raise awareness of the issues and dispel the myths that lead to stigma, Dartmouth Health expert panelists and partners at the New Hampshire Union Leader and Seacoast Media Group have been focusing on different topics around mental health. This month, we explore substance use disorders and co-occurring mental illnesses, how they are treated, what programs are available and where there are still gaps in service.

One such gap is in New Hampshire’s detox system, according to Annette Escalante, senior vice president of the Manchester-based Farnum Center, a program of Easterseals New Hampshire.

“The treatment system in the state has changed; we do have more providers in the state, but one of the biggest issues remaining is we have not necessarily been addressing opioid withdrawal appropriately,” Escalante said.

Let’s talk about the monster in the room. For many dealing with substance use disorder, the thing they often fear most is the ever-present looming shadow of withdrawal. When people experience it, their body rebels with a wide range of symptoms, which, depending on the intensity of the case, can include flu-like symptoms, severe body aches, body temperature spikes, nausea, vomiting, anxiety, depression and intense mood swings. The brain craves the substance it has come to rely upon, and the adjustment can be violent and frightening. Even after acute withdrawal symptoms subside, issues that affect mood, sleep, memory and other things can linger.

So, it’s no wonder why so many people refuse to enter treatment when the door is opened for them. Behind that door is a gauntlet of grueling physical discomfort. And, in some cases, the very same emotional pain and traumas some people have sought to quash and bury with substances resurface.

Not all substance use disorders are born from trauma or mental illness, according to Escalante, but many cases are, and in other cases trauma and mental illness are born from an unhealthy relationship with substances.

“No one wants to go through withdrawal, with all honesty,” Escalante said. “Even if they don’t have a medical issue, they may feel like they’re going to die.”

The goal is to provide as much comfort as possible and a sense of safety for people who need to detox but are afraid to do so, Escalante said. The problem is the best level of comfort and safety is only available through something called “medical detox,” which is only available to people with specific qualifying medical conditions such as diabetes, high blood pressure or any condition that requires monitoring by medical professionals 24 hours a day.

“These individuals may feel more comfortable entering treatment if they know their withdrawal symptoms will be well-managed, such as with buprenorphine or methadone alongside other medications to help with symptoms during the acute withdrawal phase,” said Julie Frew, MD, a psychiatrist and addiction medicine physician at Dartmouth Health. “People with opioid use disorder need to know that treatment is available, that it works, and that it is possible to find meaningful recovery with the right supports.”

But treatment doesn’t truly start until after a patient goes through detox. Escalante thinks the criteria the state of New Hampshire uses to assess needs and assign treatment levels is good, but there needs to be something in between limited withdrawal at a residential program, which does not provide medical supervision, and acute medical detox.

“I feel strongly that a program is needed,” said Laurie Butz-Meyerrose, interim director of the Doorway program at Cheshire Medical Center in Keene, one of nine free intake programs for substance use disorder in the state.

Over the past eight years, Butz-Meyerrose has observed how things have changed in residential programs. Previously, patients would be admitted just after having used drugs or alcohol. Medical providers could prescribe “comfort” medications to help with the withdrawals. But lately, programs are far less comfortable accepting detox patients.

“This has created a serious problem for people trying to get into treatment,” Butz-Myerrose said. “They end up going to the Emergency Department or trying to detox themselves.”

Escalante, Frew and Butz-Meyerrose discuss the relationship between substance use disorder and mental illness, and how they are managed, as panelists in a new Heads Up webinar hosted by Dartmouth Health. It can be viewed on our Heads Up: A Year-long Mental Health Awareness Journey page.