Controversial opioid detox helps turn around Pontiac General Hospital
Correction: This story has been updated with the correct spelling of Dr. Julia Aharonov’s last name.
Pontiac — A controversial procedure that claims to help turn around opioid addicts' lives is helping turn around Pontiac General Hospital.
The independently run, for-profit hospital that has gone through at least four bankruptcies since its establishment in 1910 is under new ownership and has left the red since exiting its latest Chapter 11 bankruptcy in 2016.
It is due to the hospital's emphasis on the needs of the community, CEO Sanyam Sharma says, which includes drug rehabilitation — specifically, advanced rapid opioid detoxification, a fairly new procedure that has gone through little testing and has earned a bad reputation among some addiction experts.
Now the hospital, legally known as Oakland Physicians Medical Center LLC, is requesting a substance-use disorder license for residential detoxification from the state of Michigan, opening the way for stricter standards. It is the first opioid-reversal program to be licensed in this way in the state, Sharma said.
“The licensure," he said, "would allow us to affirm our belief in the way it is being done and add a sort of blessing from the state and regulators and show this is a safer, more clinically conservative way to implement and conduct this procedure to save these people.”
Advanced rapid detox seeks to accelerate the time it takes for opioid addicts to get through withdrawal. A doctor administers naltrexone, a medication that blocks the effects of opioids, as well as a sedative mixture with propofol to help patients with the pain, sickness and discomfort from the withdrawal that the medication induces.
Patients typically experience withdrawal symptoms for about six days after such procedures, compared to other detox treatments that take 20 days or more, according to the American Society of Addiction Medicine. In other treatments, patients taking naltrexone already are detoxed.
“It’s impossible to tell a drug addict or dependent person, ‘Come to me in 10 days, I’ll give you a shot, just don’t use anything.’ It’s not going to happen,” said Dr. Julia Aharonov, who leads the advanced rapid detox program at Pontiac General. “The only way you can give them a (naltrexone) shot is if they are going through a facilitated withdrawal. They literally wake up the next day, and they are blocked. Is it a stressful treatment? Yes, it is. Is anything in medicine completely risk-free? Absolutely not.”
Advanced rapid detox is a variation on a procedure developed in the 1980s that puts patients under general anesthesia instead of a lesser dose for sedation. It quickly fell out of favor due to serious adverse events, including at least two deaths, according to a warning the Centers for Disease Control and Prevention issued in 2013.
“What is going on there is what we consider to be inappropriate care,” Dr. Margaret Jarvis, a member of the American Society of Addiction Medicine's board of directors, said of Aharonov's procedure. “The risks to the patients are not by any means outweighed by the potential benefits. This is not something our society supports as being evidence-based and tested.”
Aharonov herself was skeptical when first introduced to the treatment 11 years ago. After consulting psychologists, neurologists and fellow anesthesiologists, however, she feels she has a method that is safer.
Under the original procedure, patients are knocked out under general anesthesia, are insensitive to stimuli and lose control of gag reflexes, Aharonov said. Addicts are more likely than nonaddicts to stop breathing or vomit from this, she said. Her procedure puts patients on sedatives that let them sleep, but still have control of these functions.
No patient has died on her watch, Aharonov and Sharma said, but some patients have had to use the hospital’s acute-care facilities for pneumonia and other complications following the procedure.
Aharonov has performed the procedure on thousands of patients, she said, including more than 300 at Pontiac General since moving there in 2017.
Little long-term research on the procedures exists. The CDC warns that available data suggests the treatment does not improve the one-year abstinence rates over standard detox methods.
“Patients often go through ultra-rapid detox and fall out of treatment,” Jarvis said. She said that is dangerous because they are likely to overdose if they relapse.
But Aharonov says follow-ups with her patients show a 64% success rate one year later. Studies report relapse rates after standard opioid detoxification methods are 72%-88% after one to three years.
The last official study on rapid detox in 2005 was before the Food and Drug Administration approved Vivitrol for opioid-dependent patients in 2010, Aharonov said. Vivitrol is the naltrexone shot she uses in her procedure. The injection blocks the effect of opioids for 28 days versus a pill that must be taken daily and can easily be forgotten.
“I can guarantee a person completely 100% sobriety if they stay on Vivitrol,” Aharonov said. Most relapses, she said, happen after 14 months. Aharonov has performed the procedure on some patients more than once.
How it works
The treatment attracts addicts from across the country; 90% of Aharonov's patients travel from outside Michigan. Pontiac General offers the treatment for about $10,000 — an amount not covered by insurance but is less than a similar facility in California.
David Lottes believes the expense is worth it. The 42-year-old store owner traveled from St. Louis last month for the procedure. After four surgeries in as many years got him addicted to painkillers, he tried several traditional treatments. He returned to a methadone clinic at a cost of $500 per month 12 years ago and has been dependent on the synthetic opioid ever since.
Eventually, Lottes decided he wanted off methadone. Over two years, he went from taking 190 milligrams per day to 25 milligrams. But three months later, his withdrawal symptoms still were present. Lottes had heard about rapid detox, so he researched it.
"This was a better and faster place for me to get my life back," he said.
He flew in on a Monday, when he had his last dose of methadone, and underwent a physical and psychological examination and some lab tests as well as a stress test because he is older than 40. He had the procedure, which typically takes less than an hour, on Tuesday morning and was sedated for the day while under observation.
The monitoring continued throughout Wednesday, when patients are encouraged to get up, walk, eat and do other activities. Typically, the hospital discharges them on Thursday.
“It’s a real roller-coaster ride,” Lottes said, describing how he experienced restless leg syndrome, flashes of hot and cold at the same time, creepy crawly feelings, pain like someone was pulling his hair from his scalp, vomiting, diarrhea and mood swings. “You feel like (explicit) the next day.”
But Lottes says he feels better with every passing day. Two weeks later, he still has withdrawal symptoms, but he is back at work, says he is not craving opioids and feels better than at other times he has tried to detox.
“Even though I don’t feel great, everybody keeps saying there is light in my eyes, my voice sounds different, I look a lot different,” Lottes said. “My old drive is back. This place here has been a miracle.”
It is a claim Aharonov dismisses: “We say this is not miracle. This is not magic. I am not Harry Potter. I don’t have a stick I wave over their heads, and they’re perfect by Thursday. This is a medical procedure — they will feel they have gone through a battle, which we have waged on their receptors.”
She added that she only addresses the physical problem of opioid addiction and counseling is not a part of the official procedure. But she encourages her patients to solve the psychological and spiritual complications that may drive them to the drugs through therapy, religion and community service. Many patients stay in contact.
It is unclear how many medical facilities perform rapid opioid detox. There are non-hospital locations in Royal Oak, Southfield and Wyandotte. Aharonov knows of only one other in the country that keeps patients overnight. Most are outpatient clinics and surgery centers, Aharonov said, that take patients to hotels following their procedure. It was a practice she did at her clinic prior to coming to Pontiac General.
“I don’t like that,” Aharonov said. “I think about the amount of times we have had to put in IVs on Wednesday or Thursdays to make sure they are hydrated because they are having diarrhea. You have to be on top of these patients.”
Advanced rapid detox is not the first practice that has caused controversy at Pontiac General. There were reports of maintenance problems, including roof damage, burst water pipes and heating and cooling system malfunctions, last year. A jury sided against the hospital in a civil lawsuit that accused it of requiring payment for a medical residency. In lieu of an appeal, Pontiac General settled and denies that it required payment, CEO Sharma said.
But Pontiac General is taking rapid opioid detox "out of the shadows," he said. "We said, ‘We have a higher level of care that we can provide.' If something goes wrong, we have an ICU, we have an acute-care floor, we have surgeons, we have everything to take care of somebody to provide a level of care that’s not really provided anywhere else in the country.”
Sharma, 27, and his parents, who own a medical school in the Caribbean and an ancillary medical business, acquired a majority share of the hospital and brought it out of bankruptcy in 2016, its second since 2008. It had several owners from 2009 to 2015 and lost $90 million. Under the Sharmas’ leadership, the hospital has turned a profit in 2016 and 2017 totaling $35 million, according to Medicare cost reports provided by the American Hospital Directory. Revenue was $185 million in 2017.
Sharma said the profits have allowed the hospital to pay back what its previous owners neglected, including employee wages, water bills and emergency medical services. The hospital has invested $5 million into deferred maintenance. It is hiring again.
Niche services such as rapid detox are where the hospital sees its opportunity when it sits in the same city as McLaren Oakland and St. Joseph Mercy Oakland hospitals. Pontiac General doesn’t have an emergency room, but it offers surgery, psychiatric and 24/7 urgent care services. To train young doctors, it has a family medicine residency program and announced this week a new psychiatry residency to begin in August.
“I thought that instead of trying to compete with those bigger players that are spending hundreds of millions of dollars on these acute care capabilities,” Sharma said, “why don’t we compete with psych hospitals and surgery centers to provide a higher level of care than anybody could find?”
The 336-bed hospital, however, still only uses about 70 of them. It received approval in February from the state of Michigan to add 30 psychiatric beds.
The Michigan Licensing and Regulatory Affairs Department is reviewing Pontiac General’s license application for its advanced rapid-detox program.
When asked if the safety and effectiveness surrounding such procedures would be taken into consideration, Pardeep Toor, a public information officer for the department, said in an email: “As a licensing agency, LARA determines whether the specific services being provided at a health facility require licensure. LARA’s jurisdiction is strictly focused on the license of the facility.”
Aharonov has performed the procedure under her professional medical license. A hospital license would open more opportunities for medical residents to learn.
"It’s currently more safe being done in hospitals," Sharma said. "We’re waiting for the state to catch up on the cutting-edge procedure that we are conducting that is saving many lives."