ETHICS IN ACTION Treating–Not Judging– Substance Abusing Patients By Naomi Dreisinger, MD, MS, FAAP Emergency medicine (EM) is a complex field for which providers must have the ability to evaluate and treat many different types of patients and their illnesses. Inner-city emergency departments (EDs) are often swamped with patients who have drug- and alcohol-related addiction problems. Each night ED physicians are inundated with patients who are intoxicated. They are often undomiciled, unkempt, and a challenge to care for. Their complaints often seem meaningless. It is difficult for physicians to avoid falling into the trap of bias. It is your third overnight shift in a row working in the downtown city hospital. Glancing at the screen you note that the next patient assigned to you is one of the emergency department’s (ED’s) “frequent fliers.” The patient is a 56-year-old man with chronic alcoholism, complaining of foot pain. You roll your eyes—not again. Each night it feels as if the bulk of the patients you see in the ED are drunks. This is not
SAEM PULSE | MAY-JUNE 2017
what emergency medicine is meant to be.
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The Surgeon General recently released a report with a focus on alcohol, drugs, and health. In it, substance misuse is defined as use of any substance in a manner, situation, amount, or frequency that can cause harm to users or to those around them. Severe and chronic substance use disorders are commonly referred to as addictions. Addiction disorders have become rampant in many cities and small towns around the United States—so much so that as ED physicians we have become accustomed to treating patients afflicted with substance addiction disorders, yet few of us are able to view this condition as a medical condition; instead, we treat their medical complaints, perhaps provide them with a blanket, and usher them out of the ED as rapidly as possible. The Surgeon General has asked physicians to begin to change this viewpoint and view the patients seen in the ED who have substance addiction as having a medical illness, with the goal of helping these patients begin the process towards healing. Unfortunately, the tendency is for physicians to view substance addiction disorders as character deficits rather than true medical illnesses. Why is it so hard for doctors to accept addiction as a medical illness? Further exploration suggests that it may be because we are far from immune to substance addiction disorder ourselves. In fact, the rates of physician addiction are at an all time high with EM doctors being
at the forefront. As EM doctors, our world is one of high stress, many leave the ED at the end of a shift and turn to substance to relieve the stress of the day. This routine can quickly spiral out of control. Recognition of substances abuse as a medical illness allows physicians to admit their addictions and gain access to treatment without fear and with limited risk of stigma. There are few other medical conditions that are surrounded by as much shame and misunderstanding as substance use disorders. Our society treats addiction and misuse of alcohol and drugs as a symptom of moral weakness or as a willful rejection of societal norms. Our health care system has not given the same level of attention to substance use disorders as it has to other health concerns that affect similar numbers of people. Substance use disorder treatment in the United States remains separate from the rest of health care and serves only a fraction of those in need of treatment. As many as 18% of patients seen in the ED have substance abuse issues, yet these patients are often avoided and forgotten. Recent research on alcohol and drug use, including addiction, has led to an increase of knowledge and to one clear conclusion: addiction to alcohol or drugs is a chronic but treatable brain disease that requires medical intervention, not moral judgment. More than 40% of people with substance use disorder have a mental health comorbidity, yet fewer than half of them receive treatment. Effective prevention programs and policies exist. The ED is a hectic and busy place, yet it is the perfect place to begin to recognize these patients as in need of help and services. An extra referral or phone call is often all that is needed to help steer these patients in the right direction. ABOUT THE AUTHOR: Naomi Dreisinger, MD, MS, FAAP is the director of the Pediatric Emergency Department at Mount Sinai Beth Israel and Mount Sinai Hospital.