Detox can end in death at some 'non-medical' Southern California rehabs
Dec. 17--Part of our ongoing investigation into the Southern California rehab industry.
"This is the beginning of your beautiful new life!"
So began a contract for Above It All Treatment Center, a drug rehabilitation facility in Lake Arrowhead where, in February, Matthew Maniace signed himself in for detox.
He was a red-headed, freckle-faced sweetheart-turned-tough guy. His Facebook page showed both sides; photos of puppies licking his face and of his new neck tattoo (part moth, part skull).
Maniace was also an inveterate drug user, with a preference for heroin and alcohol. At 20, he'd been to rehab in at least three states. He was hoping the trip to California -- to a licensed center described by a friend of Maniace's as the "best rehab in America" -- would help him seize his elusive prize: long-term sobriety.
What Maniace might not have known when he signed the admission form is that Above It All is what California regulators call a "non-medical" facility, which means it is not staffed by doctors.
About one-third of California's 1,800-plus licensed rehabs provide non-medical detox. Many wouldn't be allowed to open in other states because of the grave health dangers posed by withdrawal. Dozens of people have died in California addiction treatment centers since 2012, many of them during detox, according to state and local records.
But such facts can be lost on people checking themselves or their children into rehab, often when an addict urgently needs help.
Many believe centers like Above It All -- which says on its website that it provides "clinically supervised" and "around-the-clock medical supervision" for patients in detox and aftercare -- are medical facilities. Few know that detox typically happens in tract houses, or that the most stringent medical requirement might be the full-time presence of someone who knows CPR.
The state's low medical requirements don't align with the high medical risk often posed by withdrawal.
Death in detox
It's not clear exactly how many people die in detox in California. The state doesn't track that number.
Officials with the California Department of Health Care Services, which oversees non-medical rehabs, only would confirm the number of death investigations that have been completed over the past five years -- 84. But they also noted that the death rate averages about 24 a year, which could push the total to more than 140 from the start of 2012 to the end of 2017.
Often, people die in detox when they arrive in poor health or suffer from some underlying medical problem. But experts say it is hard to predict who will have trouble and who will not.
In 2010, Gary Benefield died on his 53rd birthday while battling alcoholism at A Better Tomorrow, a non-medical rehab in Murrieta. He was admitted even though he recently had been hospitalized with pneumonia and suffered from emphysema and pulmonary disease, a 2012 state Senate investigation said.
In 2011, Brandon Jacques, 20, suffered a heart attack and later died while undergoing treatment for bulimia and alcoholism at First House, a non-medical detox center in Costa Mesa. His was the third death at the facility, according to a state Senate investigation. First House later was ordered by a court to pay Jacques' family $10.25 million.
In 2012, Jason Redmer, 28, died of a drug overdose four days after he entered West Coast Detox in Huntington Beach. A wrongful death suit filed by his mother -- later settled for an undisclosed amount -- said staff didn't quickly seek medical help when they learned Redmer had found and ingested drugs.
In 2016, 21-year-old Dillon DeRita was found dead of a heart attack on the patio of Costa Mesa's Pacific Coast Detox, just two days into his detox regime. Video showed rehab workers checking on him, finding him unresponsive and walking away, without calling for medical help or performing CPR. The center later closed after an investigation found that staff had falsified documents.
And since 2013, at least three Above It All clients have died, including Terri Darling, 52, and James Dugas, 25. A fourth person, Donavan Doyle, 21, died in the woods near the Lake Arrowhead center, after he had been kicked out of -- or bolted from -- the program. The San Bernardino coroner said Doyle probably died of hypothermia within hours of leaving the center.
Above It All officials said the company is not responsible for any of the deaths and cited autopsy reports concluding all were from natural or undetermined causes.
Risk is part of why detox is the most expensive phase of rehab, whether physicians are on site or not. The admissions agreement at Above It All detailed charges of nearly $40,000 -- after an initial $3,000 fee -- for the first month of treatment. Those numbers aren't unusual in the industry.
For detox providers, the process appears highly profitable. A 2016 budget filed with the state by Above It All shows revenue of about $3.3 million and expenses of $453,618.
Owner Kory Avarell said those numbers include projected income from several different facilities, but expenses for only one, and bear no resemblance to the financial reality that ultimately unfolded. The detox side of the business is not profitable, he said.
Despite being a non-medical facility, Avarell said clients are required to see a doctor after arrival. Maniace's parents, who provided the insurance that paid for their son's rehabs, said they've seen no records indicating that he saw a doctor before or during detox at Above It All.
They are desperate to know what happened to their son, and a report from the San Bernardino County Sheriff's Department offers some detail about his last hours.
At 7 a.m. on Feb. 26, fewer than 72 hours after Maniace had been admitted, the licensed vocational nurse on duty checked on him and found him asleep in bed, curled up like a baby.
Though state regulations call for detox patients to be checked every 30 minutes for the first 72 hours, records show Maniace next was checked at about 9:20 a.m., when he still hadn't come out of his room.
This time, the nurse found him in the same fetal position, but with a yellow foam clinging to his mouth, according to the Sheriff's report. He was cold to the touch and didn't appear to be breathing, and a quick test could not find any pulse.
The nurse started CPR, but it was more than 30 minutes before 911 was called, according to the report. Emergency medical workers arrived within five minutes of that call but their efforts to revive him failed. At 10:15 a.m., Maniace was pronounced dead.
Friends rooting for Maniace to get clean mourned. "Any person that kind to pooches had to be a good guy," a commenter wrote on social media. "Such a shame that he couldn't overcome his addiction "
His parents don't believe it was that simple.
"This 20-year-old kid shouldn't have died"
If Maniace was checked every 30 minutes, might the nurse have noticed his distress and summoned medical help?
If someone had called 911 immediately, might that have made a difference?
Since Maniace's death, his parents have learned much about California's rules related to addiction treatment. And they've begun to wonder this, too: If California followed the lead of other states by forbidding non-medical detox entirely, might Maniace still be alive?
"This 20-year-old kid shouldn't have died," said his mother, Lynn.
Different rules elsewhere
The practice of addicts weaning off drugs or alcohol without close oversight from a doctor or specially trained medical staff is dangerous enough that a growing number of states simply don't allow it.
"Any program in the state that does detox is considered an acute care facility and is required to have medical oversight," said Ann Scales, spokeswoman for the Massachusetts Department of Public Health.
In North Carolina, all detox must be done under the supervision of a physician, whether it's in a hospital or residential treatment setting. The same is true in Indiana, where detox requires the supervision of a physician or clinical nurse specialist licensed to practice in the state. Ohio, Tennessee, Vermont and many other states are aggressively pushing for a more medically centered approach to treatment.
California's approach draws criticism from many in the industry. Mark G. Mishek, chief executive of the Minnesota-based Hazelden Betty Ford Foundation, was stunned by the lenient rules he encountered when his organization merged with the Rancho Mirage-based Betty Ford Center.
"I'm a hospital administrator. California is very, very cutting-edge and strong in hospital regulation, as you would expect it to be. It has a reputation for being tough," said Mishek. "For addiction, I thought it would be the same way. But it's just not.
"A friend was showing me a detox house in L.A. and I thought, 'God forbid if my wife or daughter ever wound up here.'"
The leniency is partly by design.
"If addiction is a brain disease, where are all the doctors?"
For decades, non-medical rehab facilities in California weren't allowed to have doctors on payroll. The state follows what is described, legally, as the "corporate practice of medicine doctrine," which means physicians and other licensed health professionals could not work for unlicensed people, including most addiction treatment programs.
A new state law allows non-medical rehabs to partner more closely with physicians for "incidental medical services."
But the new rule does not require patients to get a complete medical exam before entering treatment. And it does not require that a physician make the call on which level of treatment is best.
"If addiction is a brain disease," asked Walter Ling, professor of psychiatry and founding director of the Integrated Substance Abuse Programs at UCLA, "where are all the doctors?"
No testing required
Heart attacks, organ failure, seizures, fluctuations in body temperature; all are among the potentially lethal side effects of detox, according to the National Institute on Drug Abuse.
"Detox is a really, really dangerous time for a patient," said Hazelden's Mishek. "The number of seizures during detox -- particularly from alcohol or benzodiazepines (drugs such as Valium and Xanax) -- means you have to have really good nurses and doctors to monitor withdrawal."
That's not required in California. Though non-medical facilities must screen patients before admission and send higher-risk patients to more medically intensive care, the screening process often centers more on how an addict answers some questions than on any formal medical testing.
At most centers, rehab intake workers -- many with little or no medical training -- ask a series of questions to determine the severity of the patient's addiction. Many are drawn from Clinical Institute Withdrawal Assessment forms related to alcohol and other drug addictions, such as:
"Are you feeling fearful?"
"Do you feel bugs crawling on or under your skin?"
"Are you hearing things you know are not there?"
They also ask if the prospective patient has had a heart attack or cardiac problems, or is experiencing chest pains or other potentially serious health issues.
But health histories provided by drug-addled clients aren't always complete, and intake workers don't have to check with the client's primary care physician to probe for underlying health risks.
Above It All used to check with a client's doctor before checking them in for detox, but the company contends those contacts rarely yielded anything useful because the information was old. "The clients typically haven't been to the doctor, dentist, or any professional in years," Avarell said by email.
Requiring detox clients to get a full medical exam before starting treatment might give them time to change their minds, he added.
"When a client wants to come in, if a treatment center doesn't act immediately to get them ... they disappear too often, so having them see a doctor isn't really practical," he said.
Above It All used to have clients go to urgent care to be cleared as healthy enough for non-medical detox, but Avarell said only a fraction required hospitalization.
Poor medical oversight might have played a role in four deaths that took place from 2008 to 2010 at A Better Tomorrow, a now-shuttered rehab in Murrieta, according to a 2012 state Senate investigation.
The patients had complex medical histories, including problems such as asthma, hypertension, shakes, swelling, shortness of breath, diabetes, high blood pressure, liver disease and other maladies, the report found. But all four were deemed healthy enough to be admitted to the non-medical facility where they later died.
"The people who work in these places, for the most part, are recovering addicts themselves," said Anthony Lanzone, an attorney who handled the Redmer family's case against West Coast Detox. "They aren't doctors. They aren't nurses. They don't know how to handle these problems."
Some former workers at Above It All agreed.
In sworn testimony given in the wrongful death claims pending against the center, former employees expressed discomfort that patients were admitted to detox without seeing a doctor. The intake screening for one of the patients who died was done by a medical assistant earning $12 an hour, whose job included cooking and cleaning in addition to watching patients.
"Under-trained staff; nurses not adequately knowing how to handle a crisis emergency situation; simple things such as CPR; calling 911; not knowing the difference between contraindicated medications that were highly dangerous in a detox situation," said Betty Jean Tarvin, a licensed vocational nurse, ticking off problems she believed were common at Above It All.
"I witnessed too much ... medicine-related responsibilities put on house managers (who) are not medically trained," Tarvin said during her deposition.
"When are they going to see there needs to be more medical staff on at the detox center?"
Above It All's lawyer argued that the former workers had been terminated and were hostile to the company.
But Tarvin also offered kind words for Avarell.
"I just believe the company just got too big ... Kory just wasn't at that level yet. It was too much for him. I believe he has good intentions."
"Switching to an all-medical detox model is of course safer, can't deny that. Is it doable? Yes, but not economically feasible."
Avarell declined to comment on specifics because of privacy laws and pending litigation but said his company's intake protocol is thorough.
"Any good treatment center is going to screen for health issues before the potential client gets to the treatment center, and of course if they are in bad shape, they would go to a more appropriate place," Avarell wrote by email. "Our assessment has lots and lots of questions, 34 main questions. ... We have sent a lot of people to a higher level of care because they weren't in good health when they got here."
He estimates that about 5 percent of prospective clients were referred to higher levels of care.
Though the intake screening isn't done by medical professionals, Avarell said it is prepared by a doctor. "(W)hen we hit a medical question that is out of the ordinary, we have either a nurse or doctor look at the assessment."
Above It All's policy was to have clients see a doctor in person within 24 hours of arrival, he said.
"Switching to an all-medical detox model is of course safer, can't deny that," said Avarell. "Is it doable? Yes, but not economically feasible. The insurance companies would never pay enough."
It's often hard to tell if a center offers medical or non-medical treatment. Critics say some non-medical centers use scientific-sounding jargon in their advertising to imply that they provide a higher level of care than they actually do.
"What the hell is 'subacute non-medical detoxification?'" asked attorney Mick Meagher, who represents both rehab operators and rehab patients, referencing a phrase that's found on many detox websites.
"Either I'm sick or not. Either I need a doctor or I don't."
Cyndi Doyle said she believed Above It All offered medical care when she took her son there for help in 2013. When Donavan Doyle, 21, left the center after 19 days of treatment and later died in the wilderness, she didn't know that Above It All's owner, Avarell, spent most of his career as general contractor building homes.
"This place was supposed to be 'dual diagnostic.' They were supposed to have doctors and psychiatrists assess him (and) put him on the right kinds of medications. ... In my mind, they were supposed to know what they were doing.
"I would have never taken my son to someone who was a contractor," Cyndi Doyle said. "Are you kidding me?"
Some argue that allowing non-medical detox without a doctor's clearance translates into danger for patients.
"The notion of ignoring physiology, and not providing appropriate medical care for someone in a situation that can lead to a true medical emergency, or be a true medical emergency, is grossly inappropriate," said Michael Miller, past president of the American Society of Addiction Medicine and medical director of the Herrington Recovery Center at Rogers Memorial Hospital in Wisconsin.
Miller suggested that the rehab model followed in California is financially driven and that actual hospitalization for detox is viewed as too expensive.
"We can't afford to detox large numbers of people that way and, indeed, only a small number of people need that kind of care," Miller said.
"But no one should be admitted to a non-medical detox without an actual medical exam to determine which placement is appropriate for them."
'Manner of death: Natural'
Lynn and Bill Maniace heard from their 20-year-old son just three days before his death, as he was heading from treatment in Las Vegas to treatment at Above It All in California. He sounded optimistic and upbeat.
What they've learned in the 10 months since then raises more questions than answers.
They're confused why their son was in detox at all; the autopsy report showed no presence of illicit drugs in his system. They're baffled by the official cause of death -- "cardiomyopathy," or heart disease, "due to chronic drug and alcohol abuse," because the coroner also found that Maniace's heart and cardiovascular system appeared normal.
Maniace's death was natural, the coroner concluded.
The conclusion was the same for James Dugas, 25, of Massachusetts -- described by friends as a "bright and wonderful person" -- who died at Above It All two years ago.
Dugas was a heroin addict suffering from severe mental disorders, according to court filings. He also had a history of high blood pressure, seizures and childhood asthma, according to the Sheriff's report.
Dugas still had methamphetamine in his system when he was found unresponsive the morning of Dec. 13, 2015. He was was transported to Loma Linda University Medical Center and died of acute hypoxic encephalopathy -- where brain tissue is deprived of oxygen and there is global loss of brain function -- due to years of chronic drug abuse. Dugas' manner of death was natural, the coroner concluded.
His family sued, asserting that Above It All dispensed "incorrect contra-indicated medication without oversight," failed to monitor and evaluate Dugas, and failed to authorize and/or render medical attention for his "multiple chronic and acute medical conditions."
The coroner concluded that the manner of death was natural for Terri Darling, a 52-year-old guitar-playing grandmother from Iowa, as well.
Darling arrived at Above It All on June 27, 2014. She became addicted to hydrocodone and benzodiazepines following shoulder surgery. She had a history of hypertension, angina, diabetes, chronic obstructive pulmonary disease, fibromyalgia with chronic pain and was allergic to many medications. In the weeks leading up to her visit to Above It All, Darling suffered a string of seizures and had recently attempted suicide, according to court filings, autopsy and police reports.
"They take people they absolutely should not take, and are not equipped to take"
On June 28, after complaining that she was not feeling well, Darling was found unresponsive in her room, police records show. She was transported to Mountain Community Hospital in full cardiac arrest. Resuscitation failed.
Darling's family sued, charging Above It All with, among other things, failure to monitor and evaluate a detox patient and failing to render medical attention.
The wrongful death suits against Above It All are wending their way through San Bernardino Superior Court. Maniace's family has retained an attorney but has not filed suit.
"They take people they absolutely should not take, and are not equipped to take," said Karen Gold, the attorney representing the families.
"Could these deaths have been prevented if these people had been given medical care? Yes. Should facilities like this exist at all in this form? Hell no."
State officials who oversee the rehab industry -- while not commenting on any particular case -- urged caution in concluding who is at fault.
"Individuals with a substance use disorder (SUD) are often plagued with physical health conditions and suffer from higher rates of HIV, Hepatitis C and other life-threatening health issues," Carol Sloan, spokeswoman for the Department of Health Care Services, said via email.
"These individuals are also suffering from the SUD and can die from an opioid or other drug overdose. Not all deaths are the result of improper actions on the part of the provider."
The Maniaces are considering an independent autopsy on their son, which requires exhuming his remains. That would mean more agony, and Lynn Maniace isn't sure she can bear any more of that. Still, she said, she needs to know.
"The whole thing didn't sound right to me from the beginning. He was doing so well. He had no drugs in his system, no track marks on his arms.
"He was a sweetheart. Everyone was his friend," she said, her voice breaking.
"I really feel if Matt hadn't gone to California, he would still be alive today."
Staff writers Jordan Graham, Tony Saavedra and Scott Schwebke contributed to this article.
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