We Need to Consider Involuntary Treatment for Heroin Overdose

www.epmonthly.com/article/need-consider-involuntary-treatment-heroin-overdose/#comment-270064

For too long we have waiting for drug addicts to hit rock bottom before intervening. But the costs to individuals, and to society, are simply too high. We must take firm, compassionate action, and it starts in the emergency department.

How many times have we reversed a heroin overdose only to have the patient leave the ED to OD again? Maybe it’s time to change that cycle. Here in Maryland, I am spearheading a subtle yet radical new approach, and a growing coalition of medical professionals, social workers and politicians are beginning to show their support. I’d like to share it with you, my colleagues, because it’s an approach that often begins in the emergency department.   

Let’s consider a common scenario. A family brings in their grandfather who is depressed and suicidal. They found him sitting on the side of the bed with a shotgun in his mouth. With such evidence, you have the legal authority to commit the patient to a locked psychiatric ward – essentially incarcerate him – for up to three days or until such time that a judge can examine him to see if he is a “danger to himself.” If evidence of such is submitted to the judge, she can further commit/incarcerate him until such time that the “danger to self” has subsided.

Now let’s change the scenario slightly. Instead of a grandfather with a gun in the mouth, it’s a young adult with a needle in his arm. Both “weapons” are life threatening. The difference is that in the second scenario, the young adult is clearly not intending to commit intentional suicide. But it is reasonable, even obvious, to the rational person that the risk of death is so great that he is exhibiting a knowing and willful gross indifference to his own personal safety. And that is where we hope to change the law, to expand the definition of “danger to self” to include heroin addiction, to allow health care professionals, you and I, to involuntarily commit addicts to treatment. Before you start the push back let’s unpack this a little.

First and foremost, I’m not suggesting we mandate in-patient treatment. We don’t have enough psychiatric beds now. Patients can spend weeks in the ER waiting for such beds to open up. Furthermore, with people failing in-patient rehab multiple times, there simply will never be enough in the nations coffers to cover such a program. We could break the bank overnight.

But the cost of mandatory out-patient therapy is within reach, especially considering the savings over doing nothing. But how would mandatory out-patient therapy work? Maryland is already in the process of building its first “stabilization units” dedicated to substance abuse. After the catastrophes of the old drunk tanks, people picked up by ambulance and police with no other complaint but drunkeness could no longer be brought to jail, but had to go to the ER for clearance. Now we will have a place for such patients to be evaluated and stabilized before disposition. Such units could have an assigned judge that could hear emergency cases of “danger to self” resulting from drugs. A tracking ankle bracelet could be attached to the patient before being released to follow up the next day with an outpatient detox unit. If the patient failed to show up for medically assisted outpatient detox and therapy, a warrant for their arrest would be issued, and the standard punishment for this misdemeanor would be four days of incarceration. This just happens to be the standard time required for unassisted withdrawal. Cold turkey withdrawal is absolutely miserable, with its nausea, vomiting, muscle aches, and “goose flesh.” But it’s not life threatening. It’s a simple matter of “We can do this the easy way or the hard way.” After a few times of going through involuntary withdrawal, the patient will finally realize that outpatient therapy with medical assistance is not so bad.

For the patient with a tracking device and a mobile phone, telemedicine programs could help encourage follow up with therapy while letting them know when they are in dangerous areas of known drug dealing. Such tracking could also help alert law enforcement to areas where drugs are being sold.

I know what you’re thinking. Whoa, isn’t this a little over the top? A little big brother? Some civil libertarians might even argue in the abstract that “there is no law against stupid”. If there were, we might incarcerate smokers or extreme sport enthusiasts or even jaywalkers. But the heroin epidemic is a national disaster of historic proportions. It dwarfs the death toll of hurricanes, terrorist attacks, even recent wars. The Vietnam War cost America over 50,000 lives and untold injuries over the course of about 10 years. We will lose that many Americans to overdoses next year alone. And the body count continues to accelerate. Moreover, the secondary cost to society in health care, crime, cultural damage, and loss of productive lives in simply incalculable. A crisis of this proportion deserves a fundamental shift in culture and law. Our approach is to broaden the definition of “danger to self” with very narrow and specific language.  The courts will always be leary of infringements on personal rights and will fight hard to uphold the right to due process. But I believe laws can be drafted narrowly that rise to the danger without introducing more risk to our personal constitutional right to be left alone.

Some argue that you can’t really help the addict until they want help. They say that you can’t see improvement until the patient “hits rock bottom.” But there is a lot of physical and social carnage that occurs as the patient free falls to the “bottom.” Besides the obvious risk of death, there is the risk of disease, HIV, heart disease, trauma, and many other expensive disorders. And society ends up picking up the tab for most of it. Further, all of us have seen the secondary fall out of the addict’s behavior, family destruction, spousal and childhood abuse, and violent crime. Society has an interest in preventing such damage and cannot stand by as though we have no dog in this fight. We do. And we have the right and responsibility to act, for the benefit of the patient and ourselves.

Yes, such a law would require an expansion of the courts along with a loss in some aspect of personal freedom. But I think these problems are not insurmountable. The larger question is whether we currently have the infrastructure to handle the influx of patients, even in an outpatient setting. And the answer is a resounding NO. After retiring from emergency medicine I have taken a position as the Chief Medical Officer of the largest methadone treatment facility in the nation, treating over 3,000 patients daily. (I know, that’s jumping from the frying pan to the fire! More on that another time.) But it is estimated that there are over ten times that many heroin addicts in Baltimore alone. Can we build the capacity to serve that many patients? Not overnight, for sure. But this is a pathway that is both rationale and eventually doable. As they say, Rome wasn’t built in a day. We can start laying a foundation for a better future.

I’d love to hear your thoughts, your criticisms, and your suggestions. As ER docs we have been living with this problem for decades. I think it’s time that emergency physicians lead the charge in 50 states to do something to change it. You can reach me at mplaster@epmonthly.com.

Filed under: General Problems