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My Patient Mr. “J” — The Front Lines of America's Heroin Crisis

By Amado Alejandro Baez, MD, MSc, MPH
Alexander Bode

I was caring for a heroin patient a few months back.  This person was comatose and barely breathing.  His "usual" dose had resulted in an unanticipated overdose, since it was a bad batch of heroin laced with Fentanyl (we assume).  This was similar to dozens of patients we had seen in previous weeks.  Because of the Fentanyl, I had to administer three times the dose of the antidote Naloxone to "bring him back."

This is part of my life as an emergency physician in the midst of this nation’s opioid abuse and overdose epidemic.

I reiterated I was a friend and not his judge. “Addiction is a real disease,” I told him.  “I want to help you get better.” 

Mr. "J" , went on to tell me how I should stop trying to talk sense to him, as he had been a poli-drug addict for greater than thirty years and many others, including family and close friends had tried, and after years he had just given up and succumbed to his addictions. He left my emergency department that day alive. 

Opioid addiction is a chronic illness. Managing exacerbations of chronic illness is something emergency medicine physicians do on a daily basis. 

Typically, we stabilize these patients; inquire about inciting events and proper use of and access to, medications in order to prevent it from happening again. We manage these cases how we should manage chronic disease; with treatment and prevention. We would never tell the 75-year old COPD patient “Well you did it to yourself; take an inhaler and leave because we don’t have any space for you”.  However, there is a large subset of patients in the emergency department whom suffer from chronic illness that we do this to: modern day opioid addicts.

The National Institute of Drug Abuse defines drug addiction as a chronic disease, and like any chronic disease, drug addiction should be managed through medical intervention and prevention. Unfortunately, death due to overdose has risen more than 100% since the year 2000; and more frightening still is the 200% increase in deaths related to opioid overdose, according to a 2016 preliminary report by the CDC. These numbers indicate that we are not only doing a poor job managing drug addiction in general, but a terrible job when it comes to treating opioid addiction and preventing overdose. 

A contributing factor to this trend is how we treat opioid overdose as a one-time event – like a cut or a burn – instead of what it is; the manifestation of a chronic disease. Say an asthmatic with a dog allergy comes into the emergency department due to an asthma attack. You would never treat the patient’s symptoms and discharge them right back to a house full of golden retrievers without some form of counseling or continuity of care. But this is what we effectively do when we treat overdose in the emergency department and then discharge the patient right back to the environment they were using in. By not addressing the underlying cause of the overdose, we do not actually treat anything. Effectively, the treatment system is skewed against the opioid addict. 

Of course, the treatment of opioid addiction is complex and fixes are easier said than done when in reality, the resources are just not there. But, we can at least initiate that dialogue by ensuring addicts seek help in the first place. 

Unfortunately, we live in a society where opioid addicts are viewed through a negative stereotype, causing them to experience a certain level of societal ostracization. We often look at opioid addiction as a problem with self-control, instead of what it is; a chronic relapsing disease of the brain. By placing a stigma on opioid addiction, we effectively dis-incentivize addicts from getting the help they need in a system that is already skewed against them. 

This is a not a new phenomenon, studies in HIV positive patients have shown that societal stigmatization of a disease decreases the likelihood of treatment seeking, and adherence. To combat this, we need grassroots change not only in the hospital, but also in the community. This change should aim to shift the perception of opioid addicts to one that sees addicts as equivalent human beings who suffer from a chronic relapsing disease. Eliminating the stigma of opioid addiction will ensure more addicts seek help and treatment before they end up in the emergency department due to an overdose. 

One way this can be accomplished is by expressing empathy toward those close to you who may be suffering from opioid addiction. By letting them know you want to help them get better, you are acknowledging their addiction as a disease, not a character flaw. Overcoming any addiction - especially opioid addiction - is a team effort that requires just as much help from doctors as it does from family and friends. 

The opioid epidemic in this country is far from over. Opioid addiction continues to climb among most demographics and socioeconomic classes, making this a national problem that will touch all of us in some way or another. By adjusting our social lens to view opioid addiction as chronic disease, we can attempt to improve quality of care for opioid addicts, as well as promote an environment where people want to get help, instead of waiting until it is too late. 

Later that month I was walking with my family in a nearby park, and I noticed a familiar scratchy voice saying "hey doc!" "hey doc!" It was Mr.J.  He handed my 12 year-old daughter a small bouquet of hand-made leaf flowers, and told me "Thank you doc" leaving as if he felt embarrassed yet grateful. 

Ultimately, we should all make it a point to remind ourselves that the person addicted to opioids in the emergency department is not less of a person than you or I, but simply, a human being who needs help overcoming a chronic relapsing disease. 

About the Authors:  Amado Alejandro Baez, MD, MSc, MPH is Academic Affairs and Residency Program Director at Jackson Memorial Hospital in Miami, Florida.  He is also a member of the Dade Co. Opioid Task Force.

Alexander Diaz Bode is a medical student at the University of Miami Miller School of Medicine