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Addiction, Homelessness, and Healthcare
I’m really tired today after coming off of working three days in a row. That may not seem like a lot to the regular work-a-day folks, but when you’re in healthcare, the hours are often long and arduous. I’ve worked about 40 hours in the past three days, and I work in a busy Emergency Department in Portland, OR. Every day that I worked, the ED was on divert — meaning ambulances were directed to not come to us because we were so busy.
When I left work last night, there were 30 patients in the waiting room. Many had been waiting three to five hours just to be put in a room; the wait time to see a physician after being roomed was even longer. Staff scurried about looking haggard, pulled in a million directions. At one point I counted 17 patients in the department that had been admitted to inpatient services waiting for a bed, but since the hospital was full they continued to board in the ED. Multiple patients were there with mental health crises that had landed them with psych holds.
Over the past week, many of the patients I cared for were in the hospital because of drug abuse — usually heroin and meth — or mental health or some combination thereof. Most of those patients were also homeless. Another nurse’s patient was put up for discharge back to the streets after she faked an illness in order to come in and sleep indoors, and as I walked by the open door of her room I saw her rummage through the cabinets, stuffing her patient belongings bags full of hospital supplies. She asked me for a fourth cup of coffee and a third boxed lunch when I pulled the hospital pillow out of her bag and told her that she can’t steal supplies from the hospital and she needed to leave. “I just need another cup of coffee, man! I spilled my last one. I need coffee with like four sugars and six creamers.” I told her it was time to leave.
Another homeless guy on heroin came in with some respiratory complaint and was kept overnight for observation. When the provider went to discharge him, he claimed he was going to go kill himself once he left. Social workers were called to talk to him about mental health resources in the community — it was pretty clear he did not actually have any suicidal ideation — but he threatened to jump off a bridge if we discharged him. He ended up staying four days in the ED between his stay for observation and the time it took to arrange his admission to the psych hospital.
Earlier last week, a patient came in for treatment of her abscesses due to daily heroin use. She said she really wanted to get clean, and she was worried that she couldn’t get into rehab if she had an infection. This was one of many admissions to our ED. Multiple times she tried to leave the department (IV in place) to “go to the cafeteria” and the “gift shop.” When she was told that wasn’t allowed, she started yelling and swearing at us, as though we were abusing her. Her son and his friend came to visit, bearing a Pop Tarts box. Another nurse noted some suspicious activity, and when she went in to investigate, the patient was drawing up heroin into a syringe her son had brought. She tried to say she had changed her mind and wasn’t going to shoot up after all, but when the nurse said that she would be calling public safety, the patient stuck the needle into her arm, making eye contact with the nurse the whole time. She then ripped out her IV and told her son they needed to get out of there now.
These are just a couple stories from all that I dealt with this weekend. I estimate about 33-40 percent of the patients I see are drug addicts, homeless, and have serious mental health problems. Injection is the most common way of using, which leads to all sorts of health problems that send people running to the ED for help. Many of these patients present to the ED over and over again with the same infections. IVs have to be placed using ultrasound because even the most experienced ED nurses can’t get a line because the patient’s veins are so sclerosed.
After about 24 hours since they last used, they go from cooperative and apathetic to antsy and abusive as they start jonesing for their substance of choice. I am constantly yelled at for not treating their pain, for letting them suffer, thinking that the hospital should be providing enough oxycodone to satisfy their two or three gram a day habit. Often these people have a “family emergency,” leave against medical advice, or just leave while no one is looking. Our social workers work tirelessly to help people get off the streets and into rehab. I cannot tell you how many times I have had patients decline placement in a shelter in favor of being on the streets. Much of transitional housing has high vacancy rates because of the no drugs and no drinking stipulation.
Walking in downtown Portland is not safe. I personally know two people that have been stabbed by homeless guys on the street with no provocation. A man was arrested for a stabbing after he said that his wife, Taylor Swift, told him to kill the guy that happened to walk by. Tent cities are everywhere, and one cannot drive through downtown without seeing shopping cart after shopping cart being pushed by someone mumbling to themselves.
There is a big call for legalization of drugs by the left and the libertarians. But how does that work? If we legalize drugs, making them easy to obtain and removing the stigma, how will that decrease the number of people coming to the ED with MRSA abscesses and endocarditis? While I agree that people have the right to make their own choices in life, how do we handle the stress placed on the country by these addicts? This patient population rarely has health insurance, or if they do it’s Medicaid, and they rack up tremendous hospital bills for their 48-hour stay in the ED to get treatment for their infections. The taxpayer pays for it any which way.
While decriminalizing drugs might save money from the prisons, courts, and police, it does up the cost of healthcare. We cannot turn patients away from treatment. There is no “three strikes and you’re out” policy in the hospital that allows us to tell a patient that we’ve already treated them three times before for injection-related infections so we can’t treat them again. Hospitals, nurses, and doctors would be sued six ways to Sunday if we did.
I’m all for individual freedoms, but I cannot see how legalizing drugs will do anything but hurt our society.
Published in General
That’s exactly what they say about Burlington, VT, too. People move there because of the safety nets. And then they never, ever leave.
A couple of comments talked about hospitals and jails, separately.
What about hospital jail?
It sounds stupid but I’m not joking, and maybe it already exists. But build a small wing in every large hospital, staff it with guards (not health care personnel), and when addicts come in and act as a danger to others or themselves, put ’em in hospital jail. For a week. No access to drugs. Just a room, food, water, etc, but that’s it.
In other words, create the incentive to keep them out of hospitals. And maybe the one week slot of sobriety starts to change things, for a few of them.
The two words just clanged in my head, and I haven’t thought it through much. But we’re already paying for them to stay at the ED, which is the most expensive part of the hospital. Build a wing to move them to, internally, so they don’t have to be transported anywhere else. Offer counseling and support, on site.
But get them out of the hospital.
Small, and has what @zafar omits (to be fair, Hari’s book omits it also) which is accountability in the social network. A friend’s kid is in rehab in a court mandated program after rehab in jail. Tough love and accountability are essential.
What looks to be good for my friend’s kid is that, within strict limits (which looks like it means you don’t jeopardize somebody else’s safety or recovery,) there’s room to fail safely pick yourself up, take the consequences, realize you lived through it, and start all over again.
So far, it looks like, to use Milton Erikson’s term, a “corrective emotional experience.”
It will hurt society, and Jeff Sessions is right to enforce Federal drug laws. The 50 states are supposed to be laboratories of democracy, but experimenting outside of Federal law isn’t allowed.
Or is it? Don’t ask a liberal. They flipflop back and forth between being staunch supporters of the 10th amendment when it suits their goals, such as drug legalization or sanctuary cities, to adamant supporters of the supremacy of Federal law when it comes to abortion rights.
Hang in there . . .
Yet, it might work.
I will disagree based in my quarter of a century watching the private sector only treat people with money. I will disagree based upon the community standing in the way of us building places of treatment at no cost to them, but too close to them for 25 years.
Libertarians live in a fantasy world. The private sector will not manage mental illness or substance abuse. And it is not the fault of government, it is the fault of our people. Americans do not want to face the realities of either.
I will take a lifetime of experience, in the trenches as my guide to reality over any theories.
Before we change the law to make sure that drug distribution is regulated and as safe as possible, let’s change the law that says we have to treat all such malefactors no matter what? I understand that this is the law today, but we can change it. And why not? Leaving aside that it would be politically difficult (or infeasible – but then so is legalizing and regulating drug distribution to make it safer). We can put limits on how much medical care we give people for free.
That is not immoral – in fact, it’s completely moral. People on a desperate search for rock bottom are entitled to find it.
Writing laws that flout the Constitution is also not allowed. Our masters in DC have decided that they can make anything they want into a federal crime.
The cost to society for not legalizing drugs is very high. My son was sold a mixture of heroin and fentanyl but was told it was only heroin. Fentanyl is much more potent than heroin. He did not survive the transaction. This was before the life-saving OD drugs were made readily available.
I do not blame society for my son’s death. I blame him. He injected the drugs. But society could make it much more difficult for people to get bad drugs.
Will it increase the problems encountered in the ER? So does saving the life of a man who overdoses. It permits him to overdose again. Nonetheless, it is the compassionate thing to do.
I don’t think there’d be an excessive increase in hospitalization with increased access to drugs. There’d probably be some, but there’s offsetting benefits in drug safety when it’s taken out of the black market.
The people who are the biggest potential problem are already using. Marginal users would mostly do so responsibly. There’d be some flashy tragic stories, but not in proportion to the amount of hand wringing over them.
And no, I don’t expect to convince anyone. It gets too exhausting and nobody’s budging.
We should realize that addicts are not in control. Where I have seen people really get better and stay better, is when they are forced, by the courts into treatment. The process takes two years, and involves the court and treatment working closely together. The staff to client ratio between both sides ends up being close to 1:2.
Keep drugs illegal, use that to let us force people into treatment, even if they don’t want it, because enforced treatment can work. It needs to include housing options, and a heavy stick to keep them there. It will cost a lot, but maybe we can have less deaths and destruction. Drugs destroy lives. Shrugging our shoulders and saying “it’s all on them” is beyond callous. Their ability to think is impaired. They are no longer people living lives of liberty; they are slaves to a substance.
Milkchaser, I am sorry for you loss. I have seen too much of that over the years.
I’m heartbroken and sorry for your loss.
I don’t see how as a practical matter society can make it much more difficult for people to get bad drugs other than legalization, so that sellers of bad drugs can be held liable.
I dunno. The ban/interdict thing is working out so well.
Oh, by the way: with cannabis legal under state law in some states and illegal elsewhere, the criminal who have been bringing drugs into the US are diversifying into smuggling from legal to illegal states, as already happens with cigarettes from low tax to high tax states.
Good. At least the product is relatively safe.
It also suggests that a federalist approach with the states as laboratories might be a problem.
On this subject, that’s probably true.
On the other hand, in a workshop we heard a comment, maybe not really a statistic. I cried when I heard it, because even if the numbers are skewed, it rings true:
I am simply vascillate between being angry with destructive children, and grieving for the life they experience that pushes them to become ever more defiant.
I don’t understand what you are saying.
Okay, fine, but I don’t see what that has to do with society making it much more difficult to get bad drugs. As long as cannabis is illegal in any state, there will be criminals in that state trafficking in cannabis. In every state, whether cannabis is legal or not, a user can get exactly as much weed as he wants. Criminalizing the free flow of commerce drives up societal costs and provides no benefits.
That said, there are unintended consequences to wholesale legalization, and those must be minimized to the extent possible. Education is the best defense against unintended consequences, but we’ve screwed that pooch by surrendering to government so much of the responsibility for education.
But the original point was to accomplish what milkchaser seeks: a society that makes it much more difficult for people to get bad drugs.
We have a jail program on Cape Cod that has been noticed around the country because of its success. I don’t know if it would work elsewhere, but Sheriff Cummings has turned around a lot of lives, and he gives talks to cities and towns around New England where they are interested in setting up this type of program:
We also have a special healthcare facility next door to Cape Cod Hospital that treats patients who are sick but not in need of emergency room life-saving services. The Duffy Health Center is geared to the homeless and other at-risk populations on Cape Cod.
A separate healthcare facility apart from a hospital’s main emergency room would help alleviate a lot of the problems in the hospitals in our major cities, and the people in the separate facility get to specialize in treating this particular patient population. It is a good idea. The Duffy Health Center patients have a good relationship with the staff.
The reason why I don’t think this would be the case is out here there’s a very lax attitude towards drugs. Drugs are pretty cheap and easy to come by, and the police don’t really crack down on IV drug use. I’ve never seen so many people with drug related problems in the ED as I have here. And I’ve been in EDs in the south as well- there was not nearly this amount of healthcare consumption. Where I think the difference between alcohol and drugs lays is in the fact that street drugs are highly addictive. Very few IV drug users use casually or socially or occasionally. They usually use daily. And those are the people that end up in my ED.
Only an addict can fix an addict. He can be helped – and indeed there may be best practices by way of metrics – but in the end he stands on his own or he falls.
Didn’t we used to have those? They were called insane asylums, and I think that was how our society deal with this problem for decades up until roughly the early 80’s. If someone is suffering from mental illness you lock them up, where under supervision they can be forced to take their meds and prevented from taking recreational drugs. This also means they are locked away out-of-sight instead of living on the streets where they will be a nuisance (if not a danger) to the rest of society.
I don’t disagree. However, circumstance can push the person way to the right way. We all respond to events. Forcing addicts into treatment works to get them on the “fix thyself” path.
Can you define “works” in this context?
As I recall from my research on the subject in the late 80s, the success rate for voluntary attendees of 30 day rehab programs was frustratingly low. As I recall, success was defined as clean and sober for one year following treatment, and few if any programs could claim a success rate as high as 50 percent. Most were under 20 percent.
In many ways, I equate the drug prohibition arguments with gun control arguments.
They both start from the assumption that ‘if only there were no (guns, drugs), the horrible things that stem from them would go away’.
Sure, in utopia. But we all know that making something illegal does very little to make that something go away.
If someone uses a gun to commit a crime, it is the crime, not the gun, that should be prosecuted.
If someone commits a crime because they are drugged or an addict, again, it is the crime, not the drug, that deserves prosecution.
If a user is racking up medical bills they can not pay, that should be used to force them in to treatment. If they refuse to address the cause of their medical issues, they should not be receiving treatment for the symptoms at others expense. But what possible benefit to society, or the user, is there in prosecution of occasional users? Or even functioning addicts? If they are using, but not committing other crimes nor indigent, prohibition just adds a further level of personal destruction to that use. As if meth or heroin isn’t destructive enough, so we want to add prosecution to the list, with some hope that it will be the final straw that pushes the user to clean up? Has that ever worked?
I understand, a little, the instinct to look at a user and think ‘I want something done’. But I don’t understand the resulting ‘something’ being ‘Send the police after users’. It just makes everything worse, for the user, for the police, for the jails, for society.
The program I outlined is over two years of wrap around services. That is far, far more than 30 day rehab. The clean and sober rate a year out (or no hospitalization) for the Drug Court and Mental Health Courts the place I used to work in, pushed 80%.
Guns are nothing like drugs. Drugs hijack the brain and the person loses control. The harder drugs have 100% rates of addiction. If drugs are legal, there will be more use. We already see that with drinking and pot. If we have more use, more people will become addicted.
I didn’t mean to equate them in that way. I’m just pointing out that prohibition of guns will do nothing to remove guns from the streets, just as prohibiting drugs has done nothing to remove them. And prosecuting drug possession is no more sensible than prosecuting gun possession. ( I’m aware of the second amendment issues that make this a flawed analogy, there are far more positive reasons, like self defense, for protecting gun rights than there are for drug decriminalization. )
And I ask, do you really believe the reason more people are not using drugs like heroin and meth is just because they are illegal? Or too hard to get?
It seems to be buying in to somewhat of a nanny state mindset to believe that. That we can not afford to leave people to their own devices, as they might, or will, make the wrong choices. I submit that those who are likely to make choices like those are going to do so without consideration of the legality of it.
Wait, so how is legalization going to make it worse? Sounds like everyone’s already doing drugs. Get rid of the black market and it’s not out of the question that things would get incrementally better. Less likely people will OD. It doesn’t sound like people are shy about going to the hospital now, but I imagine some people don’t get help when they should because it’s still illegal, but maybe Portland doesn’t have this problem because of the culture.
I’d put some caveats in this statement:
“Very few IV drug users [who show up in the ED] use casually or socially or occasionally [when drugs are illegal].
If something is legal, it gains some degree of moral-ness, while things that are illegal have some sense of immoral-ness. I do believe that is heroin and meth are sold in the corner store, that yes, more people will try them because they are easier to get. This seems to be so obvious, I don’t understand questioning it.
Further, if I can make having drugs on you a crime, then I have leverage to force you into treatment. Note, I am not saying that this happens now, but that it could.
The whole “The War on Drugs has failed, therefore all we can do it legalize it all” is a false statement. There are lots of things we can do differently instead of the current approach that are not “legalize crystal meth now!”