A PATH TO RECOVERY: CONFRONTING THE ADDICTION AND MENTAL HEALTH CRISIS ONE PATIENT IN CRISIS AT A TIME

William Andereck, MD; David Smith, MD and Steve Heilig, MPH

The Problem:

They have too often been called “frequent flyers”—severely ill patients suffering serious medical conditions, from overwhelming infection and festering wounds to coma. We are not referring to patients with ongoing medical issues receiving emergency treatment from their regular physicians. Instead, these are patients who may not have come to the emergency room voluntarily, and if they did, they want to leave quickly. They are flooding our emergency rooms and acute hospitals. Frequently, there is no one else to represent them. Many have significant mental health issues, a substance use disorder, or both. They show up in our hospital emergency departments over and over, brought by ambulance, friends, or by themselves.

Sometimes they require a ventilator and admission to the ICU for a few days. They are helped as much as possible and, before much time has passed, hours or days, they feel a bit better and, despite ongoing medical needs, leave the hospital against medical advice—only to show up at the same emergency department, or another, with the same condition, only worse. This can continue for years while they keep suffering, healthcare staff get increasingly frustrated, and costs pile up, to no good end.

The current system of letting someone come to death’s door, then resuscitating them before turning them loose to repeat the process is, in our mind, an eerie form of medical waterboarding, with the patient’s disease as the tormenter and the medical team as the frustrated rescuer. We define this select group of patients as: those who suffer from medical conditions severe enough to require hospitalization, but, due to substance use or psychiatric disorders, repetitively demonstrate a lack of capacity to understand the nature of their disease, the recommended treatment, or the consequences of non-compliance. Their only hope is for a comprehensive path to recovery that provides a meaningful and effective benefit to those who qualify. That path requires a clearer understanding of addiction and mental illness.

Understanding Substance Use Disorder

Substance use disorder (SUD) affects millions of Americans and costs society billions of dollars1. It is a chronic, relapsing, and potentially fatal condition characterized by compulsion, loss of control, and continued use despite adverse consequences. Addiction, the earlier name, was recognized as a disease by the AMA in 1987. The current term, Substance Use Disorder even has its own ICD-10 diagnosis code, F19.10. Most people think of SUD as an episode of intoxication followed by a period of withdrawal. The withdrawal state has physical manifestations which are quite evident, and these symptoms become more intense after each exposure to the drug in question. What follows withdrawal, however, is more subtle and even more nefarious. Repeated episodes of withdrawal begin to change the very nature of the brain. The withdrawal response activates neural pathways in the brain at the most primitive levels of the subcortex (where the conscious brain never goes), inducing a profound sense of desire and craving for the previous substance. An individual’s capacity to make rational decisions can become overwhelmed by these cravings. This positive feedback loop of intoxication and withdrawal, followed by craving, is heightened in duration and intensity with continued use. It is the presence of the intense craving, not just the physical withdrawal, that uniquely characterizes what we call addiction.

It usually takes at least 90 days of sobriety for the brain to begin to stabilize and the cravings to begin to dissipate. 2 Although not as recognizable as withdrawal to the observer, craving is intense, and it diminishes slowly over months to years. It is the most common cause of relapse. The power of craving is well known to any former cigarette smoker who enters a room ten years after quitting and is triggered by a familiar old friend, situation, or place where they used to smoke. Now, added to our long-standing chronic epidemics of alcohol and heroin addiction, we have fentanyl and methamphetamine. Fentanyl is over 50 times more potent than heroin and the resultant withdrawal and craving are magnified proportionately. Methamphetamine, especially, results in hyperactive and dangerous behavior, including in the hospital. The standard 28 days in treatment is not nearly enough time to recover from drugs like these. It could, and often does, take years.

The Psychiatric Component

Our patient cohort is complicated by a high frequency of other psychiatric diseases. Schizophrenia is common, and its symptoms are compounded by substance use. Dementia of various causes also leads to non-compliance. There are powerful antipsychotic drugs at our disposal for some conditions such as acute psychosis, but it is a misconception to think that these agents treat the disease itself. They only help control some of the symptoms. Our treatments for dementia are even less helpful. The most effective treatment for all these conditions is trauma-informed and requires a safe, accepting, and comfortable environment without the triggers and distractions of the patient’s previous circumstances. Any significant healing will require time and rehabilitation in a supportive environment, in addition to any medications needed.

The Stigma

It is important to recognize that these fellow human beings are victims of a disease, not simply criminals. Many if not most have a history of severe early-life trauma. A disproportionate percentage are people of color and economically disadvantaged. Any successful approach to their treatment and healing must differ from the criminal justice system in its purpose, goals, and environment. Our purpose must be to provide compassionate, appropriate medical and psychiatric treatment to this subset of patients. One immediate goal is to keep them out of the criminal justice system, ensure their physical and emotional safety, and return them to a functional lifestyle, which includes food, shelter, clothing, and access to healthcare and employment opportunities where possible, offered in a supportive environment conducive to healing.

Our Ethical Obligations

Codes of medical ethics have emphasized respect for individual autonomy for over fifty years, and the principle is highly regarded in clinical medicine. However, Medicine’s initial obligation was to “do no harm”. As the profession matured, it proclaimed a distinct obligation to place the patient’s benefit above other concerns. We recognize our duty to help these patients. More pressing is our duty to prevent continued harm. When harm is imminent, autonomy to refuse aid becomes suspect. The concept of autonomy depends on a rational and “in-control” actor, free of compulsion. Our subset of patients, by definition, are suffering severely disordered control of their mental faculties as well as substance abuse.

The history of “deinstitutionalization” of the mentally ill, however well-intentioned (or not), has resulted in thousands of people chronically on the streets and in dangerous living situations.3,4 Civil rights are crucial, but there is no beneficence in continuing to allow, and even enable, countless people who cannot make rational decisions to live in misery. Paternalism has become a bad term in medicine and society but the current prevalence of homelessness, misery, and premature death among the mentally ill and addicted is worse. As was first noted a half century ago and is even more true today, we are letting people “die with their rights on”.5,6

Some argue that no one can stop substance use unless they want to. Clearly, recognition of the problem is necessary, but an essential characteristic of the disease of addiction is denial. Consequences are usually required to break through the denial and move to recovery. Those that succeed move into treatment when they recognize the source of the problem and are ready to begin a rehabilitation process. In a small percentage, brain function is so impaired that they are unable to make voluntary choices like this for quite some time. While numerous reports support the value of intervention7, It seems to us that requiring someone’s volition to enter rehab is another way of blaming the victim in denial for their lack of will. And it is important to note that SUD treatment has advanced considerably, especially with the development of much more effective medications, than decades ago when many residential treatment facilities were emptied due partly to some inhumane conditions and practices.

We recognize that “compulsory rehabilitation” could be abused and result in the inappropriate conservation of some people, but the possibility does not insure it will happen. Conflating the demographic that we are talking about to include people like Britney Spears, or the thousands of patients who can continue to function in an outpatient setting, is demeaning to the victims, and fallacious. As with much medical treatment for those too ill and impaired, we need to help those who cannot help themselves—until, hopefully, they can. This is in fact a crucial role of medicine as a profession.

A Path to Recovery

Medicine cannot solve this problem alone, but it does act as the portal of entry to a recovery program. Medication treatment for SUD and psychiatric disorders has improved markedly in recent decades but is still underutilized. Treatment also requires patient cooperation. But when such patients show up in distress at a hospital there is a chance to address their needs, even if they can’t recognize them clearly yet themselves. We can no longer waste the opportunity to begin appropriate treatment with a plan to supportive discharge. It is not enough to recognize the problem; we present the outline of a plan to offer some improvements.

Stabilization

Effective substance abuse disorder (SUD) addiction treatment should begin when the patient is encountered at hospital admission with appropriate agents such as buprenorphine, suboxone, or the necessary antipsychotic. The goal is to stabilize the patient’s psychiatric and/or substance use needs with the same dispatch afforded other medical conditions. Currently hospital staff complain that they do not have the training or the specialty support to address the addiction needs of their patients8. This is an explanation, not an excuse. What if they were not given the training to address diabetes? Failing to control the withdrawal symptoms of a critically ill patient is like neglecting to manage their blood sugar. The health care institucontinued on page 18 continued from page 17 tions of our city have the responsibility to manage substance abuse disorder with the same efficiency as any other disease. The Joint Commission, responsible for accrediting acute care hospitals, should assure standards for SUD equivalent to those for all other medical conditions. Public prodding may be necessary.

Conservatorship

Patients unable to cooperate with their recovery, as defined above, should also be unable to leave the hospital against medical advice, unless they obtain a legal release. Although it may seem like common sense, the idea of a medical hold to preserve a patient’s life would require changes in the 5150 statutes of the California Welfare and Institutions Code. The necessary changes would include provisions for expanding the criteria for what is now strictly a psychiatric hold to include medical conditions and treatment.

Enacting changes like this, unfortunately, could take years in today’s legislative climate. But there are allies in the legislature. California Senate Bill SB 43, sponsored by State Senator Susan Eggman, is currently in the legislature and offers a plan for more sensible and rapid conservatorship process. It represents an essential element of our plan. Even with passage, the public guardian’s office will need to be adequately staffed and funded to evaluate and conserve appropriate patients within the time constraints of an acute hospitalization. The aim is to get patients into appropriate longer-term care where they can truly begin, and stay in, the recovery process that will change their lives for the better. They of course must be provided with a workable appeals and representation process if they remain resistant to treatment in an institutionalized setting.

Too often, conservatorship is equated with criminalization This notion needs to be dispelled by assuring that the continuum of care is truly compassionate and supportive. To begin, administration of this program would be the responsibility of the Department of Public Health and related health authorities, not the Department of Corrections and other law enforcement entities—although collaboration by these sectors will be important.

Placement

For such efforts to be successful, the post-hospital management must be closely coordinated with the inpatient hospital plan. Conservatorship without placement in a facility that can expertly and compassionately meet the needs of those who are conserved is a waste of time and resources. Discharge would not be to the street, but to a closed residential facility for ongoing medical management and rehabilitation. Addiction medicine specialists as well as psychiatrists and psychologists should be integral to the program. The environment should be welcoming, free of judgement, and respectful of the patients for who they are.

The length of stay in the rehabilitation facility would be determined by the individual’s progress and, for our patients, last a minimum of several months, and must not be predetermined by rote or financially limited. Recognizing the role of triggers that induce cravings, the facility should ideally be geographically isolated, and visitors strictly limited. The facility would have programs from addiction medicine and counseling to job training, as well as tiered living arrangements based on progress.

Funding

These recommendations of course imply a significant increase in residential treatment capacity and quality. Programs that provide a path to recovery are expensive because they are necessarily human resource-intensive and can take considerable time. As with mental health treatment, successful requires trust and compassionate human connection in addition to whatever indicated medication and other interventions. However, over 15 years ago, studies showed that every dollar in treatment saved the society seven dollars in health and social costs.9

Treatment for substance use disorder is beneficial for a significant portion of the population, but those individuals who have deteriorated to the level of our defined subset of patients are a group whose prognosis for meaningful recovery is much more guarded. It is possible that many will not be able to return to a functional lifestyle even with a year or more of therapy. This means that a large portion of this population could become long-term wards of the state. The initial costs of this program could exceed the current costs of dealing with the problem. But the situation, fueled by fentanyl and methamphetamine, is clearly getting worse and the solutions will only become more expensive with further delay.

The “drug war” has failed on many counts and, while we support harm reduction strategies as well as the arrest and punishment of drug dealers, our plan is more focused on the most severely impacted victims. At this point we too often continue to “catch and release” addicted users to no useful end. We must recognize them as people with a treatable disease, and see them not as “frequent flyers”, but as people whom the system has failed. We can’t keep kicking the can down the road. Inaction is not just counterproductive and costly, but also immoral.

The authors thank the numerous colleagues who provided review and comments, including Drs. Robert Margolin, Keith Loring, Ruchika Mishra, Jack Chase, Lawrence Chyall and ethics committee representatives from various local hospitals and public health. The content remains solely the responsibility of the authors.

David Smith was the founder of the HaightAshbury Free Medical Clinics and President of the California and American Societies of Addiction Medicine, a specialty he co-founded, and founding editor of the Journal of Psychoactive Drugs.

Steve Heilig is Director of Public Health and Education for the SFMMS, Co-Editor of the Cambridge Quarter Of Healthcare Ethics, and a former Robert Wood Johnson drug policy fellow.