A story I recently heard from an correspondent who works as a medical professional in a general surgery practice reminds me of the distance we have yet to travel in understanding even the seemingly obvious implications of drug abuse. My correspondent's practice sees a breadth of cases, including a diversity of acute trauma cases which are severe enough to require a surgery consult. Some cases will require immediate surgery and a lengthy hospitalization for recovery; several weeks may be required when someone has suffered severe trauma. Other cases might involve a little wait-and-see to determine if surgical intervention is going to be required; a several day observation window would not be uncommon. One of these latter cases resulted in an interesting story.
Agent: "We had a guy check himself out against medical advice while we were waiting to see if he was going to get better or require surgery. The patient was apparently really ticked off that they wouldn't let him out to smoke. He was found a couple of hours later lying in the street."
YHN: "So what happened, you mean he bled out or something?"
Agent: "Oh, no. In the Emergency Department they hit him with [the opiate antagonist] Narcan and he woke right up"
A lively conversation ensued. I learned a few things that surprised me.
return to huntFirst, it turns out that it is not uncommon for smokers to be refused the opportunity to continue with their normal smoking practices when hospitalized for, say, an acute trauma. Even if the person is reasonably able to move to the outside smoking area for the requisite drug taking. This arises in some part from essentially "tut, tut" sorts of attitudes in the caregivers. As my discussant put it "they offer them the patch". As in the transdermal nicotine delivery device which comes in three doses (7, 14, 21). In this discussant's hospital, the 14 mg patch is what is offered to smokers with no regard for their smoking history. This patient under discussion was a more than one pack a day smoker which at the least would have recommended the highest patch dose. "Hmmmm" said I.
The nicotine patch is intended to be used as a canonical agonist therapy for tobacco dependence. Recall that agonist therapy is well described as "a weenie version of the real thing". In other words, the primary pharmacological effects are similar, the therapeutic drug is just less effective. In the case of the nicotine patch, since it is the same active compound, the "less effective" nature is conveyed by the slower rate of dermal absorption and eventual transfer of the drug into the brain relative to the smoking and buccal (oral tobacco preparations deliver drug though the gums) administration. The point being that the patch is not an effective replacement for nicotine smoking in the non-treatment-seeking individual. When someone gets into the hospital because of acute trauma, they aren't necessarily looking to stop smoking. They are likely nicotine dependent and will be going into some degree of withdrawal and drug craving if they are denied their usual smoking rate.
I see a big problem for proper medical care. One presumably wishes the patient to accept recommended care and if not, to make an entirely unfettered and informed choice to reject care. A drug addict who is being denied their drug of choice and is craving drug is not very likely to make such decisions uninfluenced, now are they?
Getting back to my little case study story, it turned out that nicotine dependence was only the start of the patient's drug problems. Which the medical staff knew because his tox panels came back all lit up for various drugs including cannabinoids and opiates. At least in this situation, nobody did anything with this information. "Anything" meaning anything along the lines of trying to determine how addicted he was, to which substances and making some fair guesses about withdrawal and other effects if he were to remain hospitalized for the intended duration to follow his trauma concerns.
So the patient checked himself out against vociferous medical advice. No duh! He was placed in withdrawal from multiple drugs of abuse, apparently including some variety of opiate addiction. Of course he wanted out. The end of the story, in which the patient was found unresponsive and was recovered by an opiate antagonist tells us the rest of the story. Dude went out to shoot up some heroin. Suggests the opiates on the tox screen should have been followed by a little investigation because with evidence of an active heroin addiction in hand, one might anticipate exactly the observed outcome, no?
Let us not overlook the general point, however. It could have been nicotine or cannabis or alcohol or any other drug withdrawal that modulated the patient's decision making with respect to accepting or rejecting recommended health care advice. I mean, "against vociferous medical advice" generally means along the lines of "Patient Doe, if you leave and the thing we have you hospitalized to evaluate actually occurs, you will die". One would think the expectation here is that patient's would be extended the right to refuse medical advice only so long as they were making a judgment in their right mind, so to speak. And only after being fully informed of the risks they run.
Can the withdrawing drug addict really be expected to make a decision that comports with a right-minded, informed consent? Really?
I think not and I think that there might be some interesting questions regarding medical ethics and liability should evidence of recent drug abuse be in the hands of the medical practitioners who then proceed to put the individual into withdrawal because of hospital practices. Particularly if the patient checks out of the hospital against medical advice.
Culprits? Well, doctors who are trained in med schools in a mindset that doesn't really appreciate the lasting motivational consequences of drug dependence certainly don't help. There is also the problem of parity when it comes to health insurance. I need to explore this a little more but my agent suggested looking at the phone numbers on the medical insurance card in my wallet. Sure enough, there is a separate number to call for mental health / drug dependence issues. It seems that primary care physicians are hamstrung when it comes to requesting specialist consultation for something like drug abuse. Perhaps this was the problem in my discussed example- that a positive tox screen for drugs cannot automatically result in the right expert being called in. Unlike a weird cardiac indication, for example, or evidence of some unusual tumor. I don't fully understand the issues yet. I'm already in favor of parity for drug abuse-related health concerns, natch, but this question of drug craving modulating decision making on the part of the patient seems like a very strong additional argument.