For too long we have waiting for drug addicts to hit rock bottom before intervening. But the costs to individuals, and to society, are simply too high. We must take firm, compassionate action, and it starts in the emergency department.
How many times have we reversed a heroin overdose only to have the patient leave the ED to OD again? Maybe it’s time to change that cycle. Here in Maryland, I am spearheading a subtle yet radical new approach, and a growing coalition of medical professionals, social workers and politicians are beginning to show their support. I’d like to share it with you, my colleagues, because it’s an approach that often begins in the emergency department.
Let’s consider a common scenario. A family brings in their grandfather who is depressed and suicidal. They found him sitting on the side of the bed with a shotgun in his mouth. With such evidence, you have the legal authority to commit the patient to a locked psychiatric ward – essentially incarcerate him – for up to three days or until such time that a judge can examine him to see if he is a “danger to himself.” If evidence of such is submitted to the judge, she can further commit/incarcerate him until such time that the “danger to self” has subsided.
Now let’s change the scenario slightly. Instead of a grandfather with a gun in the mouth, it’s a young adult with a needle in his arm. Both “weapons” are life threatening. The difference is that in the second scenario, the young adult is clearly not intending to commit intentional suicide. But it is reasonable, even obvious, to the rational person that the risk of death is so great that he is exhibiting a knowing and willful gross indifference to his own personal safety. And that is where we hope to change the law, to expand the definition of “danger to self” to include heroin addiction, to allow health care professionals, you and I, to involuntarily commit addicts to treatment. Before you start the push back let’s unpack this a little.
First and foremost, I’m not suggesting we mandate in-patient treatment. We don’t have enough psychiatric beds now. Patients can spend weeks in the ER waiting for such beds to open up. Furthermore, with people failing in-patient rehab multiple times, there simply will never be enough in the nations coffers to cover such a program. We could break the bank overnight.
But the cost of mandatory out-patient therapy is within reach, especially considering the savings over doing nothing. But how would mandatory out-patient therapy work? Maryland is already in the process of building its first “stabilization units” dedicated to substance abuse. After the catastrophes of the old drunk tanks, people picked up by ambulance and police with no other complaint but drunkeness could no longer be brought to jail, but had to go to the ER for clearance. Now we will have a place for such patients to be evaluated and stabilized before disposition. Such units could have an assigned judge that could hear emergency cases of “danger to self” resulting from drugs. A tracking ankle bracelet could be attached to the patient before being released to follow up the next day with an outpatient detox unit. If the patient failed to show up for medically assisted outpatient detox and therapy, a warrant for their arrest would be issued, and the standard punishment for this misdemeanor would be four days of incarceration. This just happens to be the standard time required for unassisted withdrawal. Cold turkey withdrawal is absolutely miserable, with its nausea, vomiting, muscle aches, and “goose flesh.” But it’s not life threatening. It’s a simple matter of “We can do this the easy way or the hard way.” After a few times of going through involuntary withdrawal, the patient will finally realize that outpatient therapy with medical assistance is not so bad.
For the patient with a tracking device and a mobile phone, telemedicine programs could help encourage follow up with therapy while letting them know when they are in dangerous areas of known drug dealing. Such tracking could also help alert law enforcement to areas where drugs are being sold.
I know what you’re thinking. Whoa, isn’t this a little over the top? A little big brother? Some civil libertarians might even argue in the abstract that “there is no law against stupid”. If there were, we might incarcerate smokers or extreme sport enthusiasts or even jaywalkers. But the heroin epidemic is a national disaster of historic proportions. It dwarfs the death toll of hurricanes, terrorist attacks, even recent wars. The Vietnam War cost America over 50,000 lives and untold injuries over the course of about 10 years. We will lose that many Americans to overdoses next year alone. And the body count continues to accelerate. Moreover, the secondary cost to society in health care, crime, cultural damage, and loss of productive lives in simply incalculable. A crisis of this proportion deserves a fundamental shift in culture and law. Our approach is to broaden the definition of “danger to self” with very narrow and specific language. The courts will always be leary of infringements on personal rights and will fight hard to uphold the right to due process. But I believe laws can be drafted narrowly that rise to the danger without introducing more risk to our personal constitutional right to be left alone.
Some argue that you can’t really help the addict until they want help. They say that you can’t see improvement until the patient “hits rock bottom.” But there is a lot of physical and social carnage that occurs as the patient free falls to the “bottom.” Besides the obvious risk of death, there is the risk of disease, HIV, heart disease, trauma, and many other expensive disorders. And society ends up picking up the tab for most of it. Further, all of us have seen the secondary fall out of the addict’s behavior, family destruction, spousal and childhood abuse, and violent crime. Society has an interest in preventing such damage and cannot stand by as though we have no dog in this fight. We do. And we have the right and responsibility to act, for the benefit of the patient and ourselves.
Yes, such a law would require an expansion of the courts along with a loss in some aspect of personal freedom. But I think these problems are not insurmountable. The larger question is whether we currently have the infrastructure to handle the influx of patients, even in an outpatient setting. And the answer is a resounding NO. After retiring from emergency medicine I have taken a position as the Chief Medical Officer of the largest methadone treatment facility in the nation, treating over 3,000 patients daily. (I know, that’s jumping from the frying pan to the fire! More on that another time.) But it is estimated that there are over ten times that many heroin addicts in Baltimore alone. Can we build the capacity to serve that many patients? Not overnight, for sure. But this is a pathway that is both rationale and eventually doable. As they say, Rome wasn’t built in a day. We can start laying a foundation for a better future.
I’d love to hear your thoughts, your criticisms, and your suggestions. As ER docs we have been living with this problem for decades. I think it’s time that emergency physicians lead the charge in 50 states to do something to change it. You can reach me at mplaster@epmonthly.online.
7 Comments
This article is an excellent argument for electing anybody who is NOT Dr Mark L Plaster, to Congress in the Third District of Maryland. It’s also an excellent argument for why Dr Plaster should not have a license to practice medicine. Sending patients to compulsory “cold-turkey” withdrawal because your opinion of them is that they were abusing drugs, is life threatening. The first time you send a 50-year-old with a chest pain to “cold-turkey” compulsory withdrawal and he comes back to the ER with ventricular fibrillation and at autopsy is shown to have needed a heart bypass operation instead of that trip to “cold-turkey” withdrawal, you’re going to need a new law passed, limiting your medical malpractice liability. Stop practicing medicine before you kill anybody else with your stupid suppositions, please.
I agree Dr. Plaster,
When these drug addicts put a needle in their own arm, leg or any other part of their body they are screaming self harm. How is that any different from someone who cuts themselves with a razor. Most of the time they deny they were trying to harm themselves. They say they are cutters and just wanted to calm themselves down.
Every time I try to 302 the heroin OD I’m told they’re just drug addicts. We all know that drug addiction and psychiatric pathology ride together. The sooner we realize that the drug addicts are self medicating the faster we can start helping them even if it’s against their will.
Liana Bittner MD
After 27 years of working in emergency medicine, I no longer believe that we have some obligation to save everyone, including people who are engaging in intentional self harm and who do not want our assistance.
If they put the gun in their mouth or the needle in their arm and then say “help me,” I am as compassionately committed to their survival as they are. Otherwise, it is their body, their choice. I recognize that my position is unpopular among the social justice warriors, but resources are finite, we try to fight every method that our species deploys to regulate itself, and new research shows that Americans now obtain almost half their medical care from the emergency department. We are overwhelmed, and it’s time to stop thinking we need to modify the system with possibly unconstitutional methods like this to address a problem that has high recidivism and who’s victims are among the least interested in resolving.
Larry Wilson
I am a little concerned about the inherent conflict of interest from a physician who works for the largest methadone facility in the nation recommending a plan that would likely increase their business substantially. Add to that the fact that we don’t have any examples or literature supporting enforced rehab, while we have a recent paper from the Lancet showing increased relapses after forced treatment. This approach is also likely to increase mortality once people are released, similar to the increase in mortality now known to occur after prison release.
A lot of this whole thing is our (physicians) fault. I see people receiving prescription s for literally hundreds of doses of Norco and other such opiate based medications. Couple this practice with the all too prevalent thought processes that “the patient is always right” and “the doctor made me feel…” add up to a prescription for the next wave of death and destruction which we’re now just beginning to see. Satisfaction scores are just one arm of a murderous multitentacled monster that is bent upon ravaging the already self destructive in our society by condoning their actions as acceptable on any level. Another arm is the idea that those who do not do our jobs are the arbiters of what is quality within our jobs. This is carried out by many who purport to be physicians but don’t really wotk in the trenches of medicine but actually hold white tower positions and don’t see the bloodshed at 2am on a Saturday night. Actually these people don’t get the idea that the hospital stays open after 5pm. This all has to change for any difference to be made. Thanks JCAHO for making pain the 5th vital sign!
Subject: I share your frustration
Really I do.
I also have been an Emergency Physician in practice for over 30 yrs and about 10 years ago transitioned full time as Medical Director of Primary Care and Addiction Medical Services in my native South Bronx. (My Methadone Maintenance Program has a capacity shy of 1000 and I provide consultation for 3 other programs in our Network). The human toll of lives claimed by this Opiate Epidemic is massive in New York City (particularly the Bronx) not to mention the collateral turmoil experienced by those who are close to those suffering from this disease.
I am a graduate of Harvard Medical School and continue to work part time in Emergency Medicine on the weekends at the VA(Got to preserve my skills).
I have been an avid fan of your articles for years and will continue to indulge whenever I see Mark Plaster listed but was a bit taken aback when you suggested though I am certain with nothing but the best of intentions and overwhelming frustration an approach to dealing with substance use disorder that if enforced would involve the authorities to incarcerate relapsers or recidivism if an arbitrary or collaborative standard was breached by the targeted individual.
First off, I am not certain if the target or better “Focus” is just the heroin abuser or does this pertain to all substance use dependent individuals? I am certain that you would agree that all fall under the category of “ danger to self”. Would it just include those who as you mention in your excellent article, ”Have a needle dangling from their arm” or all who come in with AMS suspected and confirmed to be opiate(heroin) related? Do prescription opiate users get a pass?
Does the same apply to those who are poly substance users, Opiate plus(Benzo’s, Etoh, Cocaine[crack or inhaled or IV], Crystal Meth, Molly’s, etc). Does the patient who I intubated for the 3rd time this month who test NEGATIVE for OPIATES but positive for cocaine, amphetamines, cannabis, with ethanol over 350 get an ankle trace as well?
Because if this happens to be the case, the burden to our legal system will most likely tax an overburden agency to point of madness. Most if not the majority of heroin/ patients who suffer from substance use disorders have long lost any semblance of impulse control and physically and psychologically unable to act rationally or responsibly and imposing penalties and deliberately causing a state of withdrawal is exceedingly counterproductive and places the chronically dependent individual at tremendous risk of overdose death once they have fulfilled their arbitrary penance at the hands of authorities. We have seen this played out over and over again and thus we as providers are obligated and have to move forward from the missteps of the past (whether well intentioned or not). I totally agree with you that ignoring the issue will not make it go away as history has brought us to the present state of substance induced overdoses claiming over 175 lives daily in the US and will exceed perhaps and sadly over 75K deaths (2/3 of these projected to be opiate related) this year(conservative).
Thinking reasonably, and in no way to impugn what you have suggested or laid out, may I suggest the following:
After stabilizing the patient in the ER or on the Unit, that the reasonably lucid patient have a consult with a certified Addiction Specialist before being discharged . Most if not all of the Academic Tertiary Center s would have the resources to afford a few and all others may be able to make use of Telemedicine.
It would be possible for that individual to formulate a plan or perhaps even start a treatment plan that would continue ideally as an out patient ie: Buprenorphine partial agonist for a selected few.
I cannot fathom any reason that if a patient arrived in extremis from suspected opiate overdose, that there would be a contraindication for that client(or family member) to leave without a naloxone rescue kit or an Rx for one. If we are to make a dent in this crisis we have to make full use of Harm Reduction and what better way to start than to save a life by supplying those most likely to come upon or be OD victims themselves. My experience is that many if not most opiate overdose deaths happen in full view of others who are also engaging but reticent or unwilling to make use of help for the risk of implicating themselves in felonious activity. Substance Use Disoder=Poor Decision Making Capacity=Brain Disease
A Social Worker in the ER would be tied to all those who suffer from this disease, to trace and follow those most at risk and again to make Optimal Use of Harm Reduction and Treatment paradigms that stand a better chance of sustained recovery that punitive measures could ever hope to attain.
I agree with you wholeheartedly that our current understanding and approach to dealing with this epidemic falls short on so many levels but the only approach that appears to stand any opportunity of providing a window of success with taming this plague is a multifaceted one guided by the expertise that you and I can provide starting in the trenches of the ER. We have to do better!!!! Hope to hear from you soon.(My email address: drosa@promesa.org)
Respectfully,
Daniel Rosa, MD
Medical Director
Acacia Health Care Networ
An interesting discussion regarding where we draw the line regarding compulsory treatment and individual liberty.
The “slippery slope” argument could easily be used here. If we come to a consensus that holding narcotic abusers against their will is ok, then why not the alcoholic, why not the tobacco abuser…
But I do see a difference in drug abuse that generally does not lead to immediate death (whether it’s alcohol, marijuana, or narcotic use that doesn’t lead to the need for advanced life support) and the near death experience that all emergency medicine physicians have had to treat: the acute narcotic overdose patient who would have died without Narcan.
I would not support forced treatment for drug users who have not crossed this line of near death overdose, but, for those that have, I could see the rational of at least a 24-72 hour hold for their safety and for further counseling and assessment. When someone has put a needle in their arm and has come close to death, then they may have crossed a line where it may be reasonable to intervene beyond a dose of Narcan. This could certainly be viewed in a similar manner as the suicidal patient who was found with a gun in their hand.
It’s frustrating to have a cyanotic, apneic patient awaken from Narcan, only to have them stand up and leave AMA 10 minutes later, despite a professional and diplomatic discussion about potential for relapse, risk of death, and offers of rehab. That person may lack capacity to make that AMA decision at that moment, but if they are alert, communicative, and walking, we are not able to hold them against their will, despite that it may be impaired status post overdose and hypoxia. Families are heartbroken as the patient leaves to continue their high risk behavior.
Allowing for a hold until the person is more clearly capable of making a decision is not out or bounds, but it is a delicate and dangerous game we would play with civil liberties.