Addicted Medicaid clients cycling in and out of hospital-based detox programs cost New York more than $300 million last year, including $50 million spent on just 500 of the most troubled patients, the New York Times reported April 17.

The 500 most expensive Medicaid patients typically go into detox a dozen or more times per year, costing the state an average of $100,000 each annually. One patient was admitted 26 times to detox units in 17 hospitals in a single year; another spent 279 days in detox wards in one year.

"The dollars are being spent in the wrong settings," said Deborah S. Bachrach, the state's Medicaid director, who said reforms are "very high on our agenda."

Unlike in most states, most detox programs in New York are still inpatient, not outpatient programs. Critics from across a broad spectrum of interests agree that the state Medicaid law encourages use of "medically managed" detoxification, the most expensive type of hospital-based detox service. Medically managed detox costs about $1,300 per day, compared to about $100 per day for medically supervised outpatient detox services. Experts say most patients getting medically managed detox in New York should be in outpatient programs instead.

Moreover, 80 percent of patients discharged from detox are never referred to an outpatient addiction treatment program, so their underlying problems are never addressed and they soon end up in detox again.

Many of the detox "frequent flyers" see the programs less as a chance at recovery than as a place to get food and shelter. Some opiate users even use detox to reduce the amount of drugs they need to get high, in order to save money on drugs. Lack of housing for the homeless is seen as the biggest cause of overuse of detox programs, since homeless patients are less likely to stick to their treatment plans.

"For this small group of what are basically professional inpatient detoxification users, it's really a whole series of linked problems, and none of the parts of the system work very well," said Dr. Richard N. Rosenthal, an addiction specialist and chairman of psychiatry at St. Luke's-Roosevelt Hospital Center.