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:
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.