David Andreatta

@david_andreatta

The client, a man in his 20s, was addicted to heroin and wanted help.

Medical professionals who evaluated him recommended an inpatient program — 10 days of around-the-clock care in a safe setting that offered medication, hot meals, counseling and coping skills to help him stay sober upon his release.

Then Richard Caruso, who oversees the treatment programs at Unity Health Systems' Chemical Dependency, called the man's insurance company for approval.

Caruso recalled that the man had coverage, but the insurer declined to pay unless he had first failed to stay clean in a less expensive outpatient program, a nine-month regimen of voluntary therapy and medication.

"That's a typical response from an insurance company," Caruso said. "There are a lot of people who need inpatient services but because of denials from insurance companies are in outpatient."

As the region grapples with a sharp rise in heroin use, addicts and their loved ones who are searching for help are contending with a shortage of services and constraints placed on care by insurance companies, health care and addiction specialists say.

Demand for treatment is quickly outstripping supply, leaving addicts whose internal clocks revolve around their next fix to wait weeks in some cases for care ranging from scheduling counseling sessions to getting medicine to combat withdrawal.

The obstacles are perhaps felt more acutely by the heroin addicts of today, whom specialists characterize as younger, more affluent and more naïve than users of the past, who were generally of lesser means and more hard-bitten to bureaucracy.

For example, specialists say before insurance companies agree to cover inpatient services they want evidence that an addict has tried one or more outpatient programs, has little or no outside support network, and has a health condition that makes treatment a medical necessity.

"A lot of these heroin users now have families, and the insurers aren't looking at them the same way as someone who's homeless or living in a drug house," said Robert Lebman, president of Huther Doyle, an addiction treatment center in Rochester.

James Redmond, a spokesman for Excellus BlueCross BlueShield, a major insurer in the Rochester area, said the company examines a host of clinical evidence to determine whether inpatient services are necessary.

"These are very fact-sensitive determinations and, in some circumstances, the applicable evidence-based clinical criteria require outpatient treatment attempts before coverage is approved for inpatient services," Redmond said.

BARRIERS

Lisa Thompson, of North Chili, confronted the treatment barrier two years ago, when her son, then 26 and a longtime opiate abuser, threatened suicide and was admitted to the psychiatric ward at Strong Memorial Hospital.

She recalled spending the night with him there and being told the next morning that he would be released.

"I said, 'What do I do when he goes through withdrawal?' " Thompson recalled. "They said, 'This isn't the facility for him,' and they gave him some phone numbers."

While heroin withdrawal is an individual experience, it is almost universally described by addicts as excruciatingly painful. Even as addicts increasingly struggle to achieve a pleasurable feeling from the drug, they are often driven to take it to stave off the sickness that sets in hours after a dose.

But the symptoms of withdrawal, which author Edward St. Aubyn so harrowingly likened to "a litter of drowning kittens in the sack of (one's) stomach," do not qualify as a medical necessity for immediate treatment because they are almost never fatal.

"You don't die from heroin withdrawal, you just wish you did," Lebman said.

There are medications that make withdrawal more tolerable, but the most popular among them, buprenorphine, sold mostly in a compound called Suboxone, is increasingly difficult to come by legally in the Rochester area.

Unlike methadone, which has been used for decades to treat heroin addiction, Suboxone is available to addicts by prescription only from federally-certified doctors whose patient loads are restricted to 100 by law.

The restrictions have resulted in a shortage of authorized doctors here and elsewhere and fueled a thriving underground market whose dangers are not limited to economics. Like heroin, Suboxone is an opioid that can produce euphoria and become addictive.

A spokesman for Renckitt Benckiser, which manufactures Suboxone, said the company was unable to provide statistics on the number of doctors authorized to prescribe the drug locally, although addiction specialists cast the number as "a handful."

Nationally, there are about 24,000 such doctors, Benckiser spokesman Tim Baxter said in an email. He acknowledged the difficulty some have getting treatment, and said the company recommends doctor-created referral networks.

SCALING BACK

Specialists acknowledge there are limits to what rehab can do for an addict without the so-called wrap-around support from friends and relatives. They also concede that addicts' and their relatives' perceptions of what is needed to get clean are not always necessary or realistic.

The streets are littered with heroin junkies who have "graduated" from inpatient programs. There are also countless people who kicked their habit by religiously adhering to an outpatient regime.

"I've seen outpatient work and inpatient work," said Bill De Joy, the clinical director at Conifer Park Inc., a drug rehab center in Rochester that provides inpatient services out of its Albany branch. "From what I have learned from people fighting addiction, (inpatient) works better."

"Insurance companies don't see opiate addiction as life-threatening," De Joy said. "They feel like people can get sober in an outpatient setting, and they can. What they don't take into account are issues that people still have to deal with in their neighborhoods, in their homes, and the daily stresses that they learned to use opiates to cope with."

A generation ago, the typical inpatient program lasted a month and the average detox program, in which an addict purges his system of drugs, ran seven to 10 days. Nowadays, as a result of insurance companies scaling back their coverage and increasing their deductibles, inpatient services generally run 10 days and detoxes three to five days, according to specialists.

"Most insurances will only pay for up to 10 days," said Caruso, of Unity Chemical Dependency, which runs the larger of just two inpatient programs in the Rochester area. "You can apply for an extension, but you'd better expect a denial."

Earlier this month, dozens of people gathered in Albany to lobby on behalf of a state Senate bill that would give medical professionals decision-making authority for addiction treatment and direct insurance companies to pay for it.

One of them was Linda Ventura, of Kings Park, Suffolk County, who has been a vocal advocate for treatment reform since her 21-year-old son, Thomas, died of a heroin overdose in 2012. She recalled her insurance company denying to cover inpatient services for Thomas because he did not have enough of the drug in his system.

"They said he wasn't high enough," Ventura said. "Treatment should be deemed medically necessary by health care professionals, not an insurance company clerk."

Ann Hughes, a spokeswoman for Fidelis Care New York, which covers many families in the Rochester area, said addiction is treated through a variety of methods and that "denial of a specific level of care does not mean that no treatment is necessary."

"We are committed to helping all members receive the quality care or treatment they need in the most appropriate setting," Hughes said, adding that subscribers can appeal coverage denials through the state Department of Financial Services.

MVP Healthcare, another major insurer in the Rochester area, did not respond to requests for comment.

RECOVERY IS POSSIBLE

For most addicts and their loved ones, the treatment options and the commitment needed to stay with them are overwhelming. The result is often a seemingly never-ending cycle of remissions and relapses that wreaks havoc on families.

After her son was discharged from the psychiatric ward, Thompson recalled an inpatient program telling her that even if her son qualified for services, which was unlikely, it could be a couple of weeks before a bed opened up. Another treatment program wanted $3,000 up front — money she didn't have.

"As a mother, you're always there protecting your child," said Thompson, a beautician. "Helplessness is the most horrible feeling when you know your child could die."

She eventually turned to Syracuse Teen Challenge, a Christian-based drug and alcohol residential rehabilitation program for adolescents and adults. The program, which survives mostly on donations, charges $750 for a 14-month stay.

Thompson's son, Joshua VanDusen, now 28, graduated from the program in July 2013 and no longer uses heroin. He attends Valley Forge Christian College in Pennsylvania, where he is studying to be a pastor.

"I'm just so proud of him," Thompson said.

DANDREATTA@Gannett.com

Twitter.com/david_andreatta