Let Opioid Users Inject in Hospitals
HANOVER, N.H. — “How am I feeling, Doc?” my new patient answered. “I’m feeling like a caged dog.”
Hospitalized for a heart-valve infection resulting from injection drug use, my patient had purple hair and arms covered with hand-drawn tattoos. She smelled unwashed.
“I can’t go out to smoke. My boyfriend can’t visit,” she said. She gestured to the security guard in the doorway. “I can’t even pee without her watching me!” The guard rolled her eyes.
So, rather than building a therapeutic bond through small talk or discussion of her symptoms, we spoke of her confinement. The ban on visitors and the other unusually restrictive terms of her hospitalization were not a consequence of her drug addiction. They resulted from her behavior in the hospital.
Once a nurse found the patient in the bathroom shooting heroin into her I.V. line, the sink spotted with blood. A housekeeper changing bedclothes was almost spiked by a used needle hidden under the mattress. A constant influx of boisterous visitors came to her room day and night, some delivering heroin.
With quality of care, professional propriety and staff safety at risk, polite conversations escalated to rancorous confrontations. Finally, the patient got an ultimatum: She would receive care with a 24-hour guard in her room, with no exit and no visitors; or she could leave.
It is a new world in health care as America grapples with an epidemic of opioid drug abuse. The Centers for Disease Control and Prevention reported that opioid overdoses killed over 28,000 people nationwide in 2014, more than ever before.
From heart-valve infections to drug overdoses, the casualties of this epidemic wash up in our hospitals. It has changed my hospital service significantly. Almost every day, we try to save a young person dying from infectious complications of injection drug use.
Addicted patients usually bond with their providers over the shared goal of healing. Yet these interactions, which often bridge divides of class, culture and personal psychology, can break down. When addicted patients inject drugs in the hospital, doctors and nurses can find themselves cast in the role of disciplinarians, even jailers.
Confining patients to their rooms, restricting their activities and posting guards is expensive. It may also compromise a patient’s well-being: Ambivalent providers may visit less often, educate patients less avidly and spend less time devising the best treatments.
The worst effect of confining addicted patients in the hospital may be the damage to the patient-provider bond. I couldn’t blame my patient for feeling caged, even if she had brought those consequences on herself. Her nurses told me they felt conflicted, too. They wanted the simple bond of caregiving back — and they wanted the patient to stop getting high and jeopardizing staff safety.
The problems presented by injection drug use are legion, but creative solutions exist. One is the provision of safe drug-use rooms. Cities as far-flung as Vancouver, British Columbia, and Paris and Berlin have opened safe, well-lit rooms where addicts can get clean needles and other equipment without fear of incarceration. In New York State, Ithaca and Manhattan are considering similar initiatives. Such facilities can also connect addicts to needed services like preventive testing, acute care and treatment for addiction.
Safe drug-use rooms are typically designed to help keep addicts out of the hospital, but they could work for addicts within hospitals. A safe place to inject for addicted patients in the hospital could reduce conflict with staff, protect patients and providers from dirty needles and other drug hazards, and enable patients to receive respectful, high-quality care when back in their hospital beds. Safe drug-use rooms could also offer treatment for addiction, a step often neglected in hospitals.
The creation of these rooms for hospitalized addicts won’t be easy. There will be legal liability concerns, and hospitals must safeguard against the risk of overdose or unseemly behavior. It will be worthwhile to tackle these issues if it enables the provision of compassionate care for at-risk patients whose treatment would otherwise be endangered by conflict with providers.
As for my patient, I looked her in the eye and told her I was sorry she felt caged, and that I cared. In time, she relaxed, and trust grew. We discussed her symptoms, her life, and how we hoped to get her better.
We hadn’t cured her yet, not even close. Many challenges remained. I was glad we now had a chance to face them together.