Why Is There Still No Basic Standard of Medical Care for Addiction?

Apr 06 2016

Why Is There Still No Basic Standard of Medical Care for Addiction?

April 7th, 2016

The patient is a 52-year-old male in the Emergency Department at an urban trauma center in the Northeast. His chief complaint is shortness of breath. He recently signed out against medical advice (AMA) from a hospital in the neighboring town, stating that he wanted to be closer to home. Then he signed out AMA from our sister hospital just three miles away.

And he’s going into heroin withdrawal.

“Will it kill you?” asks the doctor, the head of the team of residents and medical students responsible for this patient.  He’s responding to the senior resident’s question of whether we should treat the patient for withdrawal symptoms while we investigate the problem that brought him in.

“No,” we say in chorus.

“Right,” the doctor confirms authoritatively. “Benzodiazepine withdrawal can kill you. Alcohol withdrawal can kill you. But heroin withdrawal is just unpleasant.”

Unpleasant, it seems to me, is not the right word. I’ve sat with people as they were going through heroin withdrawal in detox wards and treatment centers. I’ve had teenage girls beg me never to try heroin because the withdrawal is worse than anything you can imagine. It is much worse than unpleasant.

But not all the physicians in the room agree.

“The problem is,” the young chief resident ventures cautiously, “that if we don’t give him something for the withdrawal, he’s going to sign out AMA again, and then he’ll be right back.”

“I’m hard-nosed about this,” says the doctor. “It won’t kill you, so I say tough it out.”

Sure enough, we go into the patient’s room in the Emergency Department, and he’s getting ready to go.  A tattooed white man, looking older than his age, pulling on his worn clothes unsteadily but determined to get out of there.

A 2015 article in the Journal of Addictive Behaviors, Therapy and Rehabilitation suggests that the standard in an acute care setting should be treatment with methadone for opioid withdrawal. A lack of care for the pain of withdrawal puts people with substance use disorders at high risk of leaving AMA, leading to poor health outcomes as chief complaints remain untreated. People who use drugs don’t trust medical providers because they know their pain may not be treated. While Patient-Centered Care, a buzzword of today’s healthcare system and a noble goal, promises that the patient’s views will be respected by their healthcare team, people who use drugs are excluded from decision-making. When the issues that brought them into the hospital are left untreated due to abstinence-only policies, healthcare costs increase in the long run when they come back in through the revolving door of the Emergency Room.

There needs to be a basic standard of care for addiction and withdrawal treatment.

In the 1980s and ’90s, the public viewed AIDS as a “gay disease,” and put the blame on patients. Suffering and death were seen by many as punishment for immoral behaviors. Activist groups such as ACT UP changed that, and through their risky, high-profile actions, they shifted the consensus. Now HIV/AIDS is treated as a disease, not a moral failing. Medication has been developed, and universal access to safe and effective medication is considered a human right.

Why is addiction any different? Medications that curb cravings and ease withdrawal symptoms, making abstinence more likely, have existed for decades. Medications for withdrawal (i.e., detox) are actually used on a somewhat regular basis—though not always, as the story above illustrates—but medications for ongoing treatment are almost never utilized. Private non-profit and for-profit rehab centers make up 87 percent of the treatment centers available according to a report by SAHMSA, but these centers rarely use medication-assisted treatment for addiction. For example, naltrexone is a medication that decreases cravings for alcohol. It has been found to be effective at reducing craving in people with alcohol-use disorders, but only around 17 percent of rehab centers utilize them. Surprisingly, even though over 40 percent of these centers provide smoking cessation counseling, highly effective smoking cessation medications just aren’t utilized enough (~15 percent).  

Historically, 12-step groups such as Alcoholics Anonymous, the primary model of treatment in most rehab centers, have frowned upon the use of medication-assisted treatment. Many Alcoholics Anonymous and Narcotics Anonymous members do not consider an individual “sober” if he or she is using medication. When most counselors at rehab facilities are participants in 12-step programs, with little or no training in other treatments, they perpetuate the philosophies they learned, which do not include medication.

People who suffer from addictions deserve a basic standard of care. Just like patients with HIV, they deserve access to effective medications.

Read more from The Influence:

How the Myth of the “Addicted” Baby Hurts Newborns and Moms

The Anatomy of a Heroin Relapse

…and follow us on Facebook and Twitter.

Dr. Paul Regier, a neuroscientist at the University of Pennsylvania, says that some of the physicians at the Center for Addiction Studies at the University of Pennsylvania have been fighting this battle for 40 years. A recent article in The New York Times quoted addiction expert Dr. Mark Willenbring, who said,We haven’t yet reached the Prozac moment.” The interviewer, journalist Gabrielle Glaser, whose critiques of Alcoholics Anonymous have won her fame in recovery circles, goes on to report that Willenbring “predicts that the day is not far off when giving a pill and five minutes of advice to an alcohol abuser will be all that is needed to keep drinking under control.”

As a neuroscientist, Dr. Regier studies the brain response to cues shown to elicit craving and subsequent relapse. He notes that in two separate studies from the research center where he works, both baclofen and verinacline were shown to reduce drug cue-induced activity in brain areas that process rewarding information. In another study, topiramate was found to reduce heavy drinking days and increase abstinence. He tells me that from extensive research, multiple medications have been approved by the FDA for nicotine (e.g., buproprion and varenicline), opioid (buprenorphine, naltrexone and methadone), and alcohol use disorder (e.g., naltrexone, acamprosate and disulfiram), and that medication, in combination with behavioral approaches, greatly improves one’s chances of dealing with a drug or alcohol problem.

Why is that man I witnessed in the hospital denied basic care, forcing him to check out AMA? How can it be up to the physician’s individual discretion whether or not to ease the symptoms of opioid withdrawal?

Now that I am on the inside of the white coat, I see the frustration of healthcare providers. We are trying to help this patient and he won’t accept our help. The attending tries to talk with him about his health as he pulls on his tattered jeans.  The patient seems angry. He isn’t listening or engaging with us. Once that biologically driven desire for drugs kicks in, he can’t hear anything else. After a dose of methadone this man might be able to have a conversation about his shortness of breath. Now he is just desperate to stop the pain.

The patient left and we went about our rounds. We saw patients whose diabetes was made worse by their diet or whose heart disease cannot be effectively treated while they continue to smoke. Yet somehow, they get the care they need. Their pain is treated.

I wonder about the man I met that day. I hope he came back quickly and got treated for his withdrawal. I hope that a healthcare professional was able to reach him with compassion and a lack of judgement, that maybe he even made the decision to seek treatment. I doubt it, but I hope he did. Most of all, I hope he didn’t go out in search of that next fix and overdose. I hope that mine was not among one of the last faces he ever saw.

Addiction treatment is not simple. I do not believe that there is one cause, or that one treatment will work for all. But I do believe that a basic standard of evidence-based care should be offered to all who seek help. Treating addiction as a moral problem has failed. Our medical system must stop withholding potentially lifesaving medication-assisted treatment from those who suffer.

April Wilson Smith will graduate with a Masters in Public Health this June. Before going back to school, she was a union organizer for 18 years.  

  • Mary Piepenbrink

    Beautiful accurate description addiction is a disease like all others except it holds a stigma like no other

    • Silver Damsen

      I’m not as sure that I believe that “addiction” is a disease in the true sense, as described by AA, for example. However, I do agree with Smith that treatment needs to move away from the AA model that argues against helpful medication and insists that prayer and meditating on the topic of “powerlessness” are ideal treatments.

  • Silver Damsen

    I agree that the way we, as in the US and its people and agencies, have treated addiction has been a huge, huge, huge failure and that failure is most manifest in the current opiate epidemic.

    I also like how the author/doctor points out that AA has unhelpful ideology that is hampering treatment. Indeed, I would argue that AA and its religious cult-like ideology is the biggest obstacle to effective addiction treatment.

    I like it that the author/doctor emphasizes all the useful medical choices now available and hints at the obstacles someone will face if they try to utilize these helpful medications and also attend AA and other 12 Step. The most logical next Step (and no it isn’t part of the 12 Step plan even though it should be) is to increase awareness as to these alternatives:

    11 Major Alternatives to AA
    (circa 2016)

    Free Self-Help




    womenforsobriety.org (includes men for sobriety)




    reddit.com (entirely online)

    Help involving paid professionals


    sinclairmethod.com (for alcohol)*

    ibogainealliance.org (for opiates)***

    *use medication to rewire the addiction pathways in the brain

    **aftercare is recommended, such as genesisiboganiecenter.com, holistichousevegas.com, and medicineheartrecovery.com

  • Kitty Mervine

    thank you so much. I see doctors wait for a patient to go out and smoke…. and indeed when my mother was in the hospital the nursing assistant took her and her bottles and bed out to a smoking area, saying “the stress from not smoking won’t let her focus on her recovery.” She did finally quit smoking, but by cutting down on them slowly with a doctors care and a nicotine patch. But addictions to drugs and alcohol, that’s “cold turkey”! The reason many people just can’t face handling withdraw. There is no safe place or relief. DO no harm is not “well he’s having a heart attack but he’s just an addict”. A lot of former addicts are wonderful members of society, and we don’t say “well he’s a smoker, so let’s not treat that heart attack…”

  • Kenneth Anderson

    Actually heroin withdrawal can kill people if they are in poor health. Although not as deadly as alcohol or benzo withdrawal, it is not safe either. These doctors are self righteous fools. They might as well say “diabetes won’t kill you, just get some exercise fatso.”

  • moonshadow42

    are you not familiar with he ASAM criteria? Those standards have been adopted, but I agree are not followed

  • Kudos Ms. Smith…hats off. Thank you for publishing such a poignant, insightful article that is so needed now. With patients that truly want to quit alcohol or opioids (heroin & pain medications), naltrexone not being offered/administered to them to help diminish cravings should almost be considered malpractice. They are definitely not getting the best care available if not presented such helpful, non-addicting medication…

  • Gary Thompson

    Live human study Ontario, Canada chest compressions only for overdose. Majority of harm is happening to non OD’s. Perpetuating a war on humanity on purpose. New program started Ontario, March 22 ‘Face the Fentanyl’ life threatening protocol.

    My response posted by Small World Labs

    Dr. Dailey and I were both published iin the 2015 CPR guidelines read comment box. Dailey mentions Naloxone can be ineffective. Omitted Naloxone can be ineffective poly drug OD, large ingestion, time release, body packers, Buprenophrine etc.

  • shelley

    Bless you, April Smith, and may your future career in Public Health be a boon for us all. You have said what all of us familiar with the drug world have known since Nixon declared war on us, that we are exempt from the rights usually afforded to citizens of this country, be they civil, constitutional or medical. It’s high time drug users stopped being this country’s scapegoat, that the DEA be reigned in, that our constitutional rights be respected. And it would be nice to be able to go to a hospital and not be subject to nurses and doctors that seem to enjoy denying us pain relief or basic medical care.

  • William

    I believe that this article tends to confuse care for a problem and a problem that doesn’t find itself being cared for in an emergency room.

    Care in an emergency room is what is called triage, investigate and support. No one comes into an emergency room to be treated for addiction so to declare that there has to be some sort of standard treatment for addiction is a non-sequitur.

    Folks do come in with Respiratory distress, Comatose, Found on floor, Found on Bench in Park, Found on Street, Seizing, Suffering from Heat or Cold Exposure and a myriad of other problems that can be related to addiction.

    As far as withdrawal from Heroin is concerned, it depends on who you talk to. If you read The Man with the Golden Arm, Naked Lunch and watch certain movies and television shows then I suppose the drama of withdrawal from Heroin is what it is however the reality is that the Vietnam experience and other documentation points to the withdrawal of heroin as being less of a problem than is pointed out here.

    I spent time in many emergency rooms in inner cities as well as on the wards of large and small hospitals. The reality is that I rarely if ever saw those suffering from Heroin Withdrawal. I would say that the vast majority of those treated for withdrawal were those that used alcohol and Barbs.

    On the other hand on the Pulmonary ICU I do recall seeing quite a few Overdose of Narcotics or combined overdose that were intubated for a time and my best recollection was a fellow that routinely made his way to the ICU only to wake up, remove his endotracheal tube, and leave AMA with his IV in his arm or central line if he had one so that he could have easy access to shoot up again and repeat the cycle of overdose and readmission to the Pulmonary ICU.

    So, there is not now or ever going to be a standard of card for emergency room treatment for addiction, since the reasons for coming to the ER are as a result of overdose, complications, and infections that are treated noting an underlying problem of addiction but not addiction as the cause of showing up in an emergency room.

  • BJ

    Amen! Yes! Preach on girl!

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  • I know

    Incorrect. Opiate withdrawal can kill and even just 12 hrs for me * been at 270mg now 169 day ( for legit real stuff… I mutual have or I won’t leave . I can’t walk. . Talking SEVERE SCOLIOSIS+, SPINAL FUSION . AND 1# U DUMB ASSES: THALIDOMIDE…….

  • I know

    I rushed this as per current severe pain and dangerous. Anger. . Docs I do remember need 20 mg benzoaapines or more. I was OK at 180 oxy… C R.,


  • I know

    The 200 mg morphs equivalent = wrong……… several pain clinic directors agreed. I agree. Over 180ng too much. Overkill. I agree.

    Toronto Yung docs are lost. Reading all be. Do. Bulldhit. Did urine test. Never did give. No weed. Dead wrong. False positive

  • I know