No right answers

I take care of my own patients in the hospital. I say that because it is not a given for internists. For a number of reasons, many having to do with time management and money, most internists utilize hospitalists, internal medicine docs who specialize in the care of hospitalized patients.

Taking care of patients in the hospital presents some unique challenges. First, they are very, very ill. You have to be pretty sick to get into a hospital these days. You must be willing to be available 24 hours a day, 7 days a week. And you have to be able to deal with some rather intractable problems.

My SciBling DrugMonkey had an interesting post about dealing with hospital patients who have addictions. This is a common, daily problem for me and other docs who see hospitalized patients.

The most common substance is tobacco, followed by alcohol, followed by “other” (pot, heroin, prescription opiates, methamphetamine, cocaine, etc.).

There’s a great deal of literature on how to treat substance abuse, but not much on how to deal with hospital patients who happen to have substance abuse. There is some literature showing that addicts and doctors have a profound mistrust of each other, which is a lousy place to start, but perhaps an inevitable one.

Residents and other inpatient docs work hard to save lives and get people better. When they encounter addicts, there may be an intensely negative reaction. Addicts often have behaviors that we interpret as not wanting to get better, and they often have unpleasant personality traits that make them difficult to care for. Some would like us to simply say that “addiction is a neurologic disease akin to Parkinson’s. Addicts are no different from anyone else with an illness.”

Bullshit.

Addicts are disproportionately affected by personality disorders that render them difficult to be around, much less care for.

Tobacco addicts are very common. Most hospitals have smoke-free campuses (don’t make me tell you the story of the cancer patient on oxygen who blew his face off lighting a cig). There is no safe way to allow people to smoke. We don’t have the personnel to escort them off campus, nor do we wish to take responsibility for allowing them to roam freely, perhaps to have “something very bad” happen to them.

Also, the most common problems we treat (pneumonia, heart disease, diabetes, peripheral artery disease, chronic lung disease) are made much worse by tobacco. If we allow a patient to smoke during treatment, we might as well not have admitted them in the first place. Tobacco withdrawal is unpleasant, and we need to acknowledge that and help the patient in any way we can so that they stay in the hospital to complete therapy. But no one dies of tobacco withdrawal.

The same can’t be said for alcohol. Alcohol withdrawal can lead to DT’s, which has a fairly high mortality rate. We have medications to deal with this, although dealing with the cravings is more difficult.

Heroin and other opiate addicts can be very difficult. Opiate withdrawal is not deadly, but feels absolutely horrible. Many addicts have found ways of gaming the system. Their personalities can be very difficult. Sometimes we avoid withdrawal by giving them some opiates, but in my experience, giving them enough to keep them from feeling sick is never enough. They want more.

This isn’t about judgment. This is about real medicine in the real world. We don’t know the neurobiology of addiction well enough to just give patients a pill and make it a non-issue. It is not “blaming the victim” to say that addicts must take responsibility for their behavior. Despite the cravings caused by their neurobiology, they must also make a conscious decision to remain in the hospital for treatment, to treat the staff with respect, and to honestly report their symptoms so that they can be properly treated.

In the real world, it sucks to be an addict. In the hospital, it’s even worse.

Comments

  1. #1 Joe
    July 14, 2008

    This is another fascinating post, about a world I hope never to see.

  2. #2 Radioactive afikomen
    July 14, 2008

    As with all of your good posts, I finish reading and want to cry “Moar! I want to read more!”

  3. #3 PalMD
    July 14, 2008

    Just a note for the nuclear matzah…

    My favorite hallucination:

    I had a patient who was having severe alcohol withdrawal. He appeared to be getting better. I asked him, “are you seeing anything that just might not really be there?”

    He said, “Not really. I mean besides those skeletons fighting with swords on the IV pole, I’m good.”

  4. #4 scicurious
    July 14, 2008

    Hoping a kitty paw on my keyboard won’t do me in before I’ve had my say here…

    Excellent post. My colleagues and I do a lot of basic research (and some clinical research) on drug addiction, and I always feel like it’s an eye-opener to see the practice side of the coin.

    I do agree that an addict does have to make the rational choice to remain in treatment. But I don’t know that any addict is really capable of making a rational choice when under the influence of powerful cravings. As you said, we have some drugs that can stop the withdrawal symptoms (methadone, nicotine patches, etc), but we really don’t have anything that can take care of the psychological cravings and leave the addict “clear” headed enough to make a rational choice.

    And it’s true that these people (even those as seemingly-mundane as tobacco smokers) can be horrendous to deal with, especially in the grips of withdrawal (and just TRY getting one of them to come back for a freakin’ MRI). But I do feel like their decision making not to stay in treatment and fight the addiction is sometimes influenced by the attitude of the people treating them. Many of the medical students that I know are being trained that, though drug addiction is a physical/psychological problem, it is in essence a problem of will (the first time you snort that cocaine is STILL your fault), and addicts deserve little sympathy. The influences of society at large (criminalizing drug addicts with little opportunity for treatment) probably do not help. Addicts that do stay in for treatment may have their cravings treated very grudgingly, if they are treated at all.

    I do understand that these people are no fun to deal with, but is there any movement to make hospital workers more sympathetic or tolerant to the problems that these people will face? Are there more efforts to diagnose and treat the often-comorbid psychiatric disorders that may underlie the condition?

  5. #5 PalMD
    July 14, 2008

    There is a tricky ethical issue in there. If a patient’s addiction is rendering them incapable of making rational choices, then they are incompetent and may not assent to or refuse medical treatment. To call someone incompetent is requires a profound level of cognitive debility.

  6. #6 greg
    July 15, 2008

    have you visited a japanese hospital? they go to great lengths to accommodate smokers. in the hospital where i work there are always patients with chemo bags, in wheel chairs, etc. wandering down to the second floor smoking area (which happens to be right across from the cafeteria. . . mmmm). nobody thinks this is strange.

  7. #7 speedwell
    July 15, 2008

    How do you treat sick doctors who have become addicted through occupational exposure (administering, being in the room with, etc.)?

  8. #8 PalMD
    July 15, 2008

    There are many programs for doctors who are addicts. Many states have diversion programs, and there are many specialists and inpatient programs.

    For example, one state will allow a doctor to voluntarily turn in their license and seek treatment, and because it was voluntary, they will give back the license as soon the doctor is deemed “clean”…they are then monitored for several years with random testing, etc.

    It’s a big problem.

  9. #9 PalMD
    July 15, 2008

    BTW, I’m not sure what you meant by “occupational exposure”. Docs become addicts the same way everyone else does, but they are at risk because they have easier access to rx’s.

  10. #10 Interrobang
    July 15, 2008

    It is not “blaming the victim” to say that addicts must take responsibility for their behavior.

    I’m not sure if you’re right there, since I’m not entirely sure an addict can. I’m not a health professional. I used to be engaged to someone who had a severe addiction to prescription opioids. In my admittedly limited experience, the only responsibility an addict ever feels is to feeding the monkey. That monkey is pretty high-maintenance. I’m almost certain that rational, responsible behaviour is mostly a thing of the pre-addiction past.

    That said, since my ex is male, affluent, white, well-insured, and not congenitally disabled, he’s not likely ever to have medical professionals in a hospital notice that he has a substance abuse problem, let alone have anyone denying him painkillers.

  11. #11 jba
    July 15, 2008

    This is something I am interested in having been on both sides of the issue. I personally dealt with addictions to a couple different drugs and have known more than a few addicts, mostly due to a mispent youth. I also worked in a hospital which of course, puts you in contact with addicts. I wasn’t a primary caretaker but did have lots of direct inpatient contact. One of the things that has bothered me was the attitude of treating addictions as a disease, not as a combination psychological/physical problem. I have never gotten a good answer as to why it should be classified as such and it always seemed to do more harm than good. Is this common? If so could you please explain to me why? I just don’t understand how someting that is ultimately a choice can be a disease and calling it one and trying to treat it as one always seemed more… touchy-feely than anything else. Like a way to force sympathy for the patient. Don’t misunderstand me, lots of addicts do deserve sympathy, but it always struck me as a trick, almost.

  12. #12 jba
    July 15, 2008

    interrobang, I think what was meant (and I could be wrong, of course) is that they need to take responibility for the initial choices and for the work to quit. I have known many addicts who want to stop, but only enough to admit it, not enough to actually do anything. The most common attitude I came across was “fix me, but I’m not going to help”. And they never got anywhere with that attitude. If your ex didn’t think he had a problem or just didn’t want to stop then feeding the need was his only concern.

    “I’m almost certain that rational, responsible behaviour is mostly a thing of the pre-addiction past.”

    Well, that’s true and not. Isn’t that helpful? :) It really depends on the drug and the depth of addiction. Opiates are one of the hardests things to *want* to quit, let alone actually stop doing. I’ve noticed cigarettes are the most common for people who really want to stop, but don’t feel able. And of course this is all anticdotal. I would be interested to know how accurate it is.

  13. #13 Adrienne
    July 15, 2008

    Wow, this is a very timely post for me. My neighbor was just taken off to the hospital in an ambulance early Sunday morning after suffering seizures in bed. He’s an alcoholic who also smokes. His SO has been letting us know of his progress…they are giving him tranquilizers to help him through the alcohol and nicotine withdrawal. So far, we know he is suffering from malnutrition (he had stopped eating), has a severe sinus infection that he can’t shake due to his other health problems, and emphysema. Today they are going to be checking out the state of his liver.

  14. #14 Adrienne
    July 15, 2008

    PalMD, these words of yours caught me:

    Addicts are disproportionately affected by personality disorders that render them difficult to be around, much less care for.

    What is the basis of this statement? I was not aware of this claim before, although it sounds reasonable. I had been under the impression, though, that it was mental illnesses like depression and anxiety that disproportionately affect addicts rather than personality disorders.

    What I’d like to know is exactly *which* personality disorders affect addicts.

  15. #15 Jim Baerg
    July 15, 2008

    Re: tobacco addiction

    How much of the harm comes from nicotine & how much from the tar, CO etc that comes with getting the nicotine by smoking.

    Would the addict getting the nicotine from patches or chewing gum or inhalers, reduce the health problems enough that ending the addiction can be left for after the addict is out of the hospital?

    I’ve wondered if a government policy of making the smoked form of the drug much more expensive than other forms would reduce the public health & public nuisance issues of certain addictions.

  16. #16 daedalus2u
    July 15, 2008

    One of the things that might be going on in the DTs is a lack of substrate the brain can metabolize. Normally the brain runs on lactate made from glucose, made in the liver via gluconeogenesis. Chronic alcohol use hijacks the liver to metabolize alcohol into acetate. The brain can do just fine on acetate. When alcohol consumption is stopped, that source of acetate is eliminated. It may take a while for physiology to recover sufficiently to be able to generate and use sufficient glucose. Some of the symptoms of the DTs are consistent with ATP depletion in the brain, such as white matter hyperintensities and acute psychosis.

    I am not sure what might be done to ease that transition. Maybe supply ketone bodies? Lactate? PalMD is correct; there are no right answers, only some that are less wrong.

  17. #17 PalMD
    July 15, 2008

    for example…

    PD’s and addictions tend to coexist, and PD patients are generally harder to care for, as, among other things, they elicit an unpleasant reaction in caregivers.

  18. #18 Ian
    July 15, 2008

    You seem to be blogging like nurses don’t exist! I hope it wasn’t intentional, because they definitely have a contribution to make, being the experts (we hope!) on how to care for the hospitalized, addictions or no.

  19. #19 PalMD
    July 15, 2008

    I didn’t really specify mds or rns, but “staff” sort of encompasses the whole megillah. The brunt of care of addicted patients falls on nurses. If you want to know how tough it is, just ask them.

  20. #20 MarkH
    July 15, 2008

    As usual I am unimpressed by DM’s analysis. Like we don’t know about addiction.

    As always it’s more complicated, we fight with these issues constantly, and there is no simple solution. You nailed it Pal.

  21. #21 Chris G
    July 15, 2008

    you know whats sad about the modern health care system. Profitering hospitals! when in history of the hospital system did it become ok to make hospitals profits over their paitents? I ain’t a doctor. because if i was i probely never get a job because i would tell the head of the hospital to F off during situations where the hospital’s profits take priority over patients.

    on another note:
    i was doing some research on ADD (or whatever they call it now adays). I don’t believe that it can be fully called a Diease, rather then a glitch in the evolution of the brain. I have A.D.D and i have seen many upsides to it. anyways sorry for taking this blog off topic. i was just wondering what other people thought

  22. #22 DrugMonkey
    July 18, 2008

    As usual, MarkH, you spout off without having done the slightest bit of homework. In this case, say, reading what I wrote. In which you will note that I expressed that these are very complex issues. Your solutions would be one hell of a lot simpler if you didn’t simply assume you already know everything.

    Furthermore, it was *very* clear that I was basing my post on a story. A vignette. Which may very well be limited to certain hospitals and not others. Certain care providers and not others. I suggest you read commentary from one DeWayne Brayton to see if I am talking about a highly unique situation. So Pal’s good at this..so what? Doesn’t mean others are not exceptionally bad at it. You, for example, with your overweening arrogance that you know it all are not setting up for being good at this particular aspect of medical care. just by way of example.

  23. #23 PalMD
    July 18, 2008

    geez, DM, did someone put crushed glass in your Cheerios?

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