I wrote this article for the Hill in 2019. Do you think that we have made progress the last 5 years?
Addiction Treatment in American
By Brent Boyett DMD, DO, DFASAM
The Hill 2-24-19
It’s 10:32PM and is peak flu season in the hospital ED. The entire department is in a bustle with fever, cough, and wheezing. The wait time is 3 hours for stable patients and the doctors and nurses in the ED will scarcely have the opportunity for bathroom breaks, when an unresponsive patient covered in vomit rolls through the door from the ramp. The patient arrives by private care and the patient is blue. Quickly, a respiratory therapist suctions the airway, places a small tube through the nostril and into the throat. With a mask seal on the face, he begins to pump life-saving oxygen into the patient’s lungs, while a nurse starts an IV. As the patient’s skin begins to turn from blue back to pink, the nurse pushes a dose of naloxone into the newly started IV. Immediately, the patient sits straight up on the gurney and rips the mask from his face and the IV from his arm. He is agitated and confused but calms to a controllable state to soft but firm instructions of the nurse. Naloxone is a reversal agent for opioid overdose and every day this scenario and scenarios like it play out in hospital emergency department across the country.
Quickly, a doctor comes into the room where the now-alert patient is being placed on monitors. The doctor notes that the vital signs are normal. He quickly does a physical assessment and notes that the patient’s forearms are littered with needle tracks. He notes that the patient is emaciated and is poorly kept. He asks the patient about what he has been taking and how long he has been using. After the patient is registered into the hospital system, the doctor discovers that this is not the patient’s first overdose in this hospital. He received another dose of naloxone about 3 weeks earlier. At that visit, he was discharged after a strong recommendation to “find a rehab somewhere”. He did find a rehab, but with no medical care checked himself out early after only about 3 days when his cravings and withdrawals became unbearable.
Modern healthcare has developed amazing techniques, delivery systems, medical devices, and medications to cure acute diseases or control chronic diseases. The disease of addiction is characterized best by the latter description. Drug use is best characterized by periods of remission and periods of exacerbation but even after long periods of abstinence, the patient is never disease-free. Patients must be vigilant to avoid relapse and the triggers that increase the risk of relapse.
This is not unlike many other chronic diseases that our hospital and healthcare systems have become quite proficient at controlling. Asthma, emphysema, even hypertension and diabetes follow similar patterns of exacerbation and remission. Some can be controlled by lifestyle modification, but most require medication as well.
Medical specialties have emerged around long-term care and chronic disease of these chronic conditions. Pulmonology is the medical specialty that focuses on chronic disease of the lungs; endocrinologists are the expert authority in the chronic management of diabetes and other chronic hormonal disorders. Cardiologists manage chronic heart failure both in the hospital and outpatient settings.
Hospitals have evolved elaborate call groups to assure 24/7 coverage for patients who present with acute needs in the management of these chronic conditions. Hospital systems have cardiac units to address CHF and pulmonary units to stabilize acute exacerbations of chronic pulmonary disease.
Unfortunately, no such systems exist in the modern American hospital system to address the desperate needs of patients who suffer from addictive disorders. Lifesaving naloxone is administered in the emergency department and the patient is discharged only to go back home or to the street to repeat the process. Patients and their loved ones are given loose suggestions to “find a rehab” and when they do, they often end up in a facility that is neither regulated nor scientific in their approach.
The drug and alcohol rehab industry in the United States is wildly unregulated and inconsistent. Some employ the services of board certified-licensed physicians and others have no licensed healthcare professionals involved. Some call their customers “patients” and others call them “clients”. When it comes to choosing care for the disease of addiction, it is truly a “buyer beware market” in our country.
Sadly, American hospital and insurance companies have taken a hands-off approach to the treatment of addiction. As a result, patients and families have been forced to desperately search Google or copy down phone numbers from advertisements on billboards and park benches. Furthermore, the emergency room physician and the family doctor are in no better position to provide resources for care than the patient or family.
Evidence-based treatment for addictive disorders can be complex, involving the coordinated effort of physicians, social workers, and counselors just to name a few. The interdisciplinary approach can be compared to the complicated integration of care in cancer therapy. Cancer care is typically managed by the combined efforts of specialized trained and board-certified physicians who focus on the delivery of oncology care. Traditionally, this has not been the case for addiction treatment--but change may be on the horizon.
In 2016 the American Board of Medical Specialties, fully recognized addiction medicine as a medical subspecialty. Addiction Medicine falls under the authority of the American Board of Preventive Medicine and is the first newly recognized board in almost 30 years. Addiction medicine fellowships to provide specialty training are rapidly being established across the nation. The goal is to establish a workforce to deliver evidence-based therapies within the established hospital and healthcare system. In the future, patients will be able to go to their outpatient doctor and be referred to an addiction specialist or hospitalized patients may have an addictionologist consulted to the patient’s bedside.
Early intervention will become the standard of care. Just as we do not wait on a diabetic to have to go on dialysis or lose their vision to begin efforts of glycemic control, we will not wait on the alcoholic to develop cirrhosis to address harmful drinking. Smoking cessation therapy
will be employed before the emphysema patient becomes a pulmonary cripple and the patient dependent on pain pills will be treated before the pills to needles transition spreads HIV, hepatitis C or causes an overdose.
In the United States today, about 16% of the population (21million Americans), 12 and older, meets the criteria for a substance use disorder. About a quarter of all deaths are attributed to drug use. Each day, 10,000 people around the world die of substance abuse. Addiction affects one in five people over the age of 14. In terms of financial burden, substance use disorders cost society almost 5 times the cost of AIDS and twice as much as cancer.
The treatment of addiction should integrate alongside other medical specialties who manage chronic and acute diseases. Through early intervention and chronic long-term disease management of addiction, the healthcare system in the United States will save healthcare dollars.
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