The mayor of Ithaca, a town of just over 30,000 in upstate New York, has proposed supervised heroin injection sites to address a wave of opiate addiction. Such facilities — the likes of which already operate in Canada, Australia, and Europe — would allow drug users to shoot up under the supervision of a nurse who could deliver an antidote in the case of an overdose.
Meanwhile, an ER in Patterson, N.J., has banned the use of opiates — which sounds like a fast-track screening program for appropriate use of opiates in both acute and chronic pain. The pendulum appears to be swinging widely in both directions.
Clearly we have a problem.
Many people with drug problems engage the healthcare system at some point. It's at that point that we can get them treatment simultaneously for an acute medical problem and the disease of addiction.
Unfortunately, healthcare providers have little or no training in this realm. As a result, the addicts are dismissed as "drug seekers." They get a workup to rule out an acute problem (in order to avoid a lawsuit), and then they sent back on the street.
It’s what we call "Treat 'em and street 'em."
Don’t get me wrong: I get the personal choice argument. But most of these people are really sick, and do not understand the treatment available to them. They don't know where to get help. Many don't want help. Some are so high they don't know who they are or what they are doing. Some are being trafficked and don't even know it.
In our ER, we use opiates when necessary. When our only option is to administer intravenously, we drip the medication in over the course of an hour or start a PCA (patient controlled analgesia). This method avoids the euphoria associated with the rapid rise of blood level opiates that occur when an IV opiate is pushed quickly ("the rush").
Patients who need pain control are satisfied and appropriately treated, while patients in it for "the rush" will leave.
Meanwhile, patients who aren't having a pain crisis, but rather withdrawal or medical complications associated with IV drug use are started on medication assisted treatment (MAT) with buprenorphine, which also works very well for pain. They are typically maintained on buprenorphine during their hospital stay, and given a one-week prescription upon leaving the hospital. They are also referred for substance abuse treatment.
This method has been working incredibly well for us. We are having a huge impact on our community.
I don't think shooting galleries are the best solution. But I don’t think withholding opiates is any better.
Our approach bridges this gap, delivering excellent patient care and, most importantly, saving lives.
Posts by Melanie Rosenblatt, M.D.
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