How our health care system makes ER doctors addiction enablers
How the ER has become an expensive drunk tank
Amy Ho
October 8, 2015
I do a strange thing as a physician almost daily. I go to alcoholics and have them promise me they'll go home and continue drinking. Then I release them back into the wild to do just that.
I'm an emergency physician at an urban hospital, and I see alcoholics every single shift, brought in by the ambulance "found down"-- that is, found passed out in public places or belligerent on the streets.
When these patients get to the ER, it's a remarkably underwhelming work-up. We remove their urine-soaked clothes, put them on our monitors and for the most part let them "MTF"-- metabolize to freedom, which is to say they can leave when they can walk.
We'll survey for signs of trauma or injury and possibly do very basic lab tests to check for gross metabolic abnormalities, but more often we just give them some IV fluids and vitamins. When they're sober enough to make the bleary-eyed walk to the bathroom down the hall, I deem them stable for discharge and release them to whence they came.
It is undoubtedly one of the worst cases of "patchwork" health care that exists. Because while emergency medicine is by definition short-term care, we get to know our "frequent fliers" quite well -- our noncompliant heart failure patients, gang members who just can't stop getting shot, our end-stage COPD patients who still smoke a pack a day, our sickle cell patients and yes, our addicts.
So the question arises, why do I as an emergency physician not do more to stop their disease, the same way I do for organic chronic disease? I do ask every alcoholic if he or she is ready to quit, as one of the central tenets of recovery is that the alcoholic has to want to quit. But 9 times out of 10, they tell me, "Naw, doc, I'm cool," as they eye their water bottle at bedside that smells suspiciously like Everclear.
So what is an emergency physician to do, who still has the rest of the room full of patients to take care of? You do what you can and tell them they will die if they continue on, give them the stock printout of support resources that they inevitably leave behind with the dirty sheets and hope you don't see them again. If you want to go above and beyond, you can send the bright-eyed, bushy-tailed medical student or the bleeding-heart social worker in to give it their best shot also.
A strange thing happens, however, after I receive some variation of the "Naw, doc, I'm cool" response: I ask them when they plan to have their next drink. I ask which liquor store they're going to go to, how long it's going to take for them to get there and if they have money in their pocket for it. Because alcohol withdrawal is just as, if not more so, dangerous than alcohol overdose itself. There are few withdrawals from substances that can kill, but alcohol is the foremost of them. So they tell me they have their daily fifth of vodka still at home, they show me the bus pass they will use to get there, and I let them go and continue my complicity with their disease.
There are apparent issues with this form of "addiction medicine," but most of all a resource one: With the emergency room so often just the purgatory between drinks for alcoholics, few emergency departments are actually equipped to offer these addicts the help they need beyond their acute intoxication.
Mental health is notoriously underfunded, but addiction is an issue too expensive to continue ignoring. A study in the American Journal of Emergency Medicine cites $900 million annually in hospital charges from uncomplicated alcoholic intoxication (in lay terms, just drunk patients). The scarce psychiatric care in the emergency room is reserved for the already burgeoning group of patients who are a danger to themselves or society (with suicidal/homicidal thoughts or an inability to care for self). Rehab is inherently expensive and involves long waiting lists, so even if patients decide they would like to get help, they're still sent home for weeks or even months first. Inpatient admissions are already filled with "placement" barriers of chronically medically ill patients into facilities, and admission of medically uncomplicated alcoholics would be an inappropriate use of resources.
Given these limitations, the ER becomes a very expensive, often taxpayer-funded, drunk tank.
Pilot programs and innovations exist but are far from pervasive. "Brief Motivational Interventions" fancy speak for "lecture like your mother should have" have shown some gains in making headway with patients, although they require multiple encounters in the ER and the resources of overstretched case managers and social workers.
"Managed alcohol programs," which provide a controlled daily amount of alcohol to alcoholics in order to reduce harmful behavior, show limited success and get little political support. Limited resources have stymied intensive case-management programs.
Traditional 12-step programs like Alcoholics Anonymous prevail throughout the country, but they require the patient to actually attend meetings after discharge. Community-based programs attempting to partner with hospitals for direct contact with alcoholic patients face significant legal and privacy barriers. Some cities have punitive "serial inebriate" programs that allow police to arrest serial drunks and charge them with misdemeanors.
In an era of tight budgets, few legislators seem motivated to allocate resources for the difficult problems of alcoholism and mental health. Until that changes, it is the physicians who are stuck offering only short-term patches for addicts. We let them go on to their next drink, fully expecting to see them again.
This Dr. Ho seems to know the 'Alcoholic' quite well ... and, knowing the current 'recovery rates', just wants to help society to lessen the problem by getting us to our death beds quicker ... hey, it'd save the government a lot of moolah, huh??? ...
Seriously, I know the Drs hands are tied in most cases and they don't have the time nor resources necessary to effect a positive outcome ...
Thanks Pickle ...
__________________
'Those who leave everything in God's hand will eventually see God's hand in everything.'
This falls in the category of most frustrating outside issues. It is not just a matter of funding. There are polictical blocks too. In the US apparently some courts have decided AA is a religion. In many countries like my own, governmental organisations must be completely secular. You could have a guaranteed miracle cure for cancer, but if God was in it some where, it wouldn't be allowed.
A buddy of mine got a degree in D&A counselling. His course work consisted mostly of things he knew from experience would not work. He was told in no uncertain terms that if he suggested any non secular method (like AA which he knows works) he would be marked down. Treatment is not just about medical but also political outcomes. They will let you die before they will allow a power greater than the government to intervene! In his job in the corrections system, everyday he has to tell prisoners to do things that he knows will not work.
The other thing that the doc raised, community group cooperation with the medical profession. Our traditions say that we like to cooperate, but the practical outcomes depend very much on how the local AA group conducts its self. In my home town, in the rare event these days that we are asked to provide speakers for example, our GCs mostly believe in providence. Send along anyone who is willing to go, whether or not they are capable of carrying the message - who has the right to make that judgement -.
The result has been first complaints then a withdrawal of acces rights to AA members. Any AA interaction with institutions in my home town is closely controlled by the institutions concerned. There is no free access for AA members.
In another city, AA has absolutely free access to the detox wards, and runs several meetings in the hospitals. These are sponsored by one group who make sure the meetings stay on message, and also that appropriately selected speakers turn up. You couldn't ask for better cooperation, and the results are evident in the number of long term recoveries from people who made their first contact in the detox.
I guess what I am saying is that while political issues make life more difficult, medical professionals still seem to be primarily concerned with the welfare of their patients. If a local AA group can convince the docs that they have a viable solution and can be relied upon, most professionals will be only too pleased to have the help. In the two examples above, the law is the same for both areas, only the AA is different.
This falls in the category of most frustrating outside issues. It is not just a matter of funding. There are polictical blocks too. In the US apparently some courts have decided AA is a religion. In many countries like my own, governmental organisations must be completely secular. You could have a guaranteed miracle cure for cancer, but if God was in it some where, it wouldn't be allowed.
FS, it's not just "apparently." Three district U.S. Court of Appeals, 2nd, 7th and 9th) have ruled that AA is "religious" or "a religion" and that if the government forces an inmate or defendant to participate in AA, such is a violation of the Establishment Clause. I'm not sure these are political blocks as much as they are legal or constitutional bars.
This legal precedent affects AA greatly, though possibly not adversely. AA will simply have to adapt on a broad scale. Unfortunately, AA may not have the ability to change, if at all. Few AAers talk about the legal pecedent. The vast majority don't even know about it.
There is a level of cooperation in my country between the courts and AA which seems to be improving, and that is good news. I am not sure about our ordered AA attendance. We have some strong advocates of the practice, and some members who say that got sober through that process, so it has its good side. But on balance, I think AA would be better off without court ordered attendance. For one thing, many of those so ordered are not alcoholics.
We have a meeting at an institution where all patients are committed for 6 months under the mental health act, sometimes voluntarily, or as an option for serving the last part of a prison sentence. Of the alcoholics that find themselves in this place, the last stop on the road to oblivion, hardly any survive beyond 2 years. Part of the issue is the compulsory AA meeting each week which is attended by about 60 inmates, some of whom are not alcoholic, and most of whom have no intention of stopping drinking. The group dynamic has a devastating effect on the few voluntary patients who actually want to recover. They get a very hard time if they dare to share in the meeting.
Mixing compulsion with the AA principle of attraction just doesn't seem to work that well.
There is a level of cooperation in my country between the courts and AA which seems to be improving, and that is good news. I am not sure about our ordered AA attendance. We have some strong advocates of the practice, and some members who say that got sober through that process, so it has its good side. But on balance, I think AA would be better off without court ordered attendance. For one thing, many of those so ordered are not alcoholics.
I'm sure a small percentage of forced attendees in AA get sober. But not many. Just because someone gets a DUI doesn't make them an alcoholic. And AA is not for nonalcoholics, even those who might want to stop drinking with negative results,. AA's membership numbers are very probably pumped significantly up by people who don't want to be there. But to what good purpose? I can't think of one.
Fyne Spirit wrote:
We have a meeting at an institution where all patients are committed for 6 months under the mental health act, sometimes voluntarily, or as an option for serving the last part of a prison sentence. Of the alcoholics that find themselves in this place, the last stop on the road to oblivion, hardly any survive beyond 2 years. Part of the issue is the compulsory AA meeting each week which is attended by about 60 inmates, some of whom are not alcoholic, and most of whom have no intention of stopping drinking. The group dynamic has a devastating effect on the few voluntary patients who actually want to recover. They get a very hard time if they dare to share in the meeting.
This is clearly something for the AA group holding the meeting to address. Why is it complicit in this dysfunctional dynamic? Also, the mental health institutions who set these kind of situations up are an illustration of the Tragedy of the Commons concept. There's no guarantee that AA will be around forever. Already, it's in decline.
Fyne Spirit wrote:
Mixing compulsion with the AA principle of attraction just doesn't seem to work that well.
Agreed. It was never meant to. Unfortunately, AA doesn't have the ability to do anything about it. It is too weak. By design. An AA group has the power, but on too small a scale.
Great post. Cannot contribute too much other than to say that I never understood the court ordered forced attendance because AA is for people who have the desire to get and stay sober and I have heard angry shares from some of those who really didn't want to be. I have not felt safe at times. Was I sitting beside someone dangerous and someone who may take it out on one of us who are willingly attending meetings? I now leave it in God's hands and don't worry like I did and have been back there recently. Just early on I stopped attending meetings at one location because a large majority of people in that meeting were not there by choice and I allowed myself and my intimidation of them to keep me away. And I know of other members who stopped going there for that same reason.
This is clearly something for the AA group holding the meeting to address. Why is it complicit in this dysfunctional dynamic? Also, the mental health institutions who set these kind of situations up are an illustration of the Tragedy of the Commons concept. There's no guarantee that AA will be around forever. Already, it's in decline.
That is a very good point Tanin. In fact no group holds this meeting. It is listed in our meeting shedule as an institutional meeting. Attendance by AA members is completely random, just who ever turns up, but AA members are regarded as outsiders and hold no offices in the group, never get to chair a meeting. The chair alsways seems to have the objective of getting the meeting over as quckly as possible so they can all start their weekend. 20 minutes is not uncommon for a meeting of 60 people. The visiting AA.s share, and that's it.
You are right, it does beg the question of why is AA participating in this type of meeting. It doesn't seem to serve much useful purpose. Of the hndreds that have been through the place in the last five years, I know of only three sober in AA today.
Could you elaborate on the Tragedy of the Commons? Thats new to me.
