My Patient Mr. “J” — The Front Lines of America's Heroin Crisis
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
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
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.
Diaz Bode is a medical student at the University of Miami Miller School of