Posts Tagged Substance dependence
If you work in the North, you’re familiar with the scene: patients in gowns, riding wheelchairs and trailing IV pumps scrambling over snow banks and icy walkways and braving frostbite-inducing winds to get off hospital property to have a smoke. I suppose for most of my readers, the image will induce a great big “Meh.” But a new article in the Canadian Medical Association Journal suggests otherwise, and that smokers who need to exit the hospital to smoke face special risks and little support in managing their addiction. Money quote:
Study findings affirm evidence that tobacco dependence treatment is inconsistently offered in hospitals and heath providers were uninformed about tobacco dependence treatment, despite availability of nicotine-replacement therapy at study sites. This treatment gap is perplexing, especially as within Canada there exists an evidence-based hospital tobacco dependence treatment program. Unintended patient safety consequences of smoke-free property necessitate effective tobacco dependence treatment during a stay in hospital simply as a risk-management action. Moreover, a health-promoting policy that causes patients to face diverse safety concerns (treatment disruption, infectious disease contact, exposure to adverse weather and possible violence) projects a contradictory health message.
Not helping, of course, are the usual (and sometimes, let it be said, judgemental) opinions of heath care professionals who view smokers adversely and see them as the authors of their own problems.* They tend to take the somewhat cavalier position that if smokers want to go outside for a cigarette, well, that’s their lookout. Elderly woman who falls on ice and fractures a hip while out for a puff? Hell, she brought it on herself by smoking! But is it actually humane to send sick people to the curb in the winter to tend to their addiction? Is it consistent with good nursing practice? And what about the liability and duty-to-care?
*I will never forget the physician who told a young, pain-wracked lung cancer patient that she was responsible for her suffering, and that she should go home and “deal with it.” But some HCPs like to play the blame game in general and especially with patients with addictive behaviours.
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Health Care Policy That Matters to Nursing on Tuesday 17 May 2011
Advocates for the disease model of addiction say their arguments are evidence-based, and that their opponents are driven by ideology. But the closer you look, the shakier is the evidence for the disease model of addiction. The most cogent critique comes from Gene Heyman, a research psychologist and lecturer at Harvard Medical School. His book Addiction: A Disorder of Choice makes a convincing case that choice plays a much more important role in addiction than in other psychiatric disorders. And it demolishes the current “enlightened” picture of addiction as a chronic, relapsing illness with a bleak prognosis for recovery.
She concludes, against the general medical consensus (those elitists!) that
[d]rug addiction is a set of self-destructive impulses that are out of control – just like all the other impulses that lead us to choose short-term pleasure at the price of long-term pain.
The thing I always find remarkable about Wente is that under the guise of being contrarian, she almost always ends up confirming popular prejudices. Addiction is not a disease! Addicts deserve everything they get! Addiction is a moral choice! Conventional treatment enables addicts! Helping addicts by providing harm reduction strategies is wrong! Punish addicts for their addiction! And so on.
Wente nods (very) briefly to the benefits of the disease model of addiction, and the need to treat addicts with empathy and compassion. But how many people actually remember the real reasons we treat sick people, including substance abusers, in the rush to judgement?
“A disease is a condition,” Wente says, “that’s beyond your power to control.” Well, no. I would define disease, and I think I would get nods of agreement from my health professional colleagues, as any condition that prevents an individual from functioning with optimal social, mental or physical well-being. Unfortunately Wente thinks disease is always something entirely random, like bacterial meningitis or ALS. What I would like to ask Wente is this: if addiction is not a disease, and if addicts are entirely responsible for their condition, what about non-insulin dependent diabetics and those suffering from heart disease, which have strong links to lifestyle choices and, some would say, self-destructive impulses? Why should we treat them any differently than drug addicts?
The point is we all make choices, good or bad, for our health. Choice, however, often implies a moral value judgement and the assignment of blame: two things clinicians should avoid in treating patients. But choice — whether it’s your 80-year-old diabetic grandmother or the homeless substance abuser down the street — shouldn’t be confused with disease.
Kim McAllister over at Emergiblog is questioning her role as an emergency nurse. The source of her discomfiture? Patients seeking narcotics, or those we label as “DSIs”, drug-seeking individuals:
Getting patients out of pain [she writes] is one of the most rewarding aspects of emergency nursing. It’s as close as you can get to instant gratification – you medicate, the patient gets relief.
That isn’t what I’m talking about.
I’m talking obvious, blatant, in-your-face drug seeking that is becoming more obvious, more blatant and more in-your-face every day.
But the narcotics still flow.
And it’s getting harder and harder to be a part of that.
She places the blame for the increase in narcotic seeking patients squarely on the Joint Commission, which mandates U.S. hospitals to implement pain management measures when treating patients, and Press-Ganey, a survey company which rates hospitals according to patient perceptions.* Both of these institutions have created an atmosphere where emergency room physicians feel obligated to order or prescribe narcotics for anyone regardless of dependency, first to satisfy government regulation and in the second, to assuage patient perceptions of good care. (That the perception of good care is becoming more important than actual good care is a topic for another post.)
Kim McAllister’s frustration and sense of ethical distress is palpable. “I’m not helping anyone,” she writes. “I’m certainly not therapeutic in any way.” Emergency department nurses and physicians are not supposed to be an addict’s co-dependants, yet we’re often placed in the position of facilitating the addiction. We aren’t helping these patients by giving out more narcotics. How can I treat these patients ethically knowing that? It’s the moral equivilent of telling a Type II diabetic pound cake and Pepsi is an adequate breakfast.
As one old emergency nurse to another, I get it. But I have no words of wisdom for her. There aren’t any good answers, only judgement based on knowledge and experience. I can only humbly offer up for consideration what I’ve concluded. Your (and her) mileage my vary. For me, of course, it’s complicated. I have to ask myself, to start, who are the people who seek narcotics? If we eliminate those who want narcs to sell on the street, who need to be firmly escorted off the premises, and those who genuinely come to the ED in pain, we’re left with those with a drug dependency. Fine, you might say, send these loser addicts on their way. But notice how all three categories, and the last two especially, can overlap? What do you do with an acute bilary colic with an unwarranted fondness for Percocets? Tell her to suck it up, because she’s made her choices? More than a few times in my years as an emergency nurse I’ve seen physicians refusing to order pain control for large bone fractures because of a previous history of drug dependency. Is this ethical, or even wise? I’m not clear punishing drug addicts for their sins is part of the job description.
Only in the last few years I’ve to some sort of resolution, moving from where Kim is to a place of relatively less self-doubt. First, I recognize the truism that substance dependency is a disease, with its own etiology, pathology, and treatment. Very trite, yes, but something we all tend to forget in a culture that still views drug dependency as a moral failing, and a crime for the righteous to condemn and punish. Keeping this obvious fact firmly in mind allows the distance to see drug seeking as part of a medical condition, and focus on the patient, not the admittedly annoying behaviour. Secondly, I’ve come to realize we can’t fix addiction in the emergency department, during a two or three hour visit, in the same way we can suture a laceration or treat asthma. We never will, and beating ourselves up over this elementary fact is pointless. Addiction simply doesn’t work that way. It requires willingness on the part of the patient, and treatment modalities far beyond the capability of even the most experienced nurse or most sophisticated emergency department. Even getting the patient to recognize the need for treatment is a challenge in the ED: believe me, I’ve tried.
Hence, I am a pragmatist. Most drug seekers will come in with presenting complaints like lower back pain or migraine; these can be (willingly or no) given Toradol (and for those with a Toradol “allergy”, naproxen) and sent on their way. As for the rest, does it really matter? Giving the known drug addict IV morphine for renal colic (real or supposed) or sending her home with a script for ten Statex until she sees the urologist is not going to make a whit of difference in the course of her addiction. Of course she might sell them; at the very least, it encourages bad behaviour and multiple repeat visits. But again, so what? Is it our obligation to make that judgement? I’ve heard, “Oops, he really had pancreatitis! Maybe he wasn’t faking the pain!” too many times to count, I’m afraid. And do we want to be in a place where we actively discourage people already marginalized from seeking of health care?
I have no firm answers, and in the case of drug seekers, the answers tend to be coloured by experience and personal values. Admittedly, beneath the crusty exterior, I’m the prototypical bleeding heart. I prefer in the end, everything else being equal, to accept a patient’s description of pain at face value. It seems too risky and less ethical to act otherwise. But like I said, it’s complicated.
*In contrast, many emergency departments in Ontario, if not most, have sternly worded signs at traige that read, in effect, “Your narcotic prescription won’t be renewed here, so go ‘way.” We’re fortunate in Canada, as front-line nurses, not to have to deal with the Joint Commission, whose regulations often defy common sense and indeed occasionally border on insanity. Hospital survey companies like Press-Ganey do exist in Canada, but their influence on hospital policy and procedure are much less than in the U.S.