I do a strange thing as a physician almost daily. I go to alcoholics and have them promise me they’ll go home and continue drinking. Then I release them back into the wild to do just that.
I’m an emergency physician at an urban hospital, and I see alcoholics every single shift, brought in by the ambulance “found down” — that is, found passed out in public places or belligerent on the streets.
When these patients get to the ER, it’s a remarkably underwhelming workup. We remove their urine-soaked clothes, put them on our monitors, and, for the most part, let them “MTF” — metabolize to freedom, which is to say they can leave when they can walk.
We’ll survey for signs of trauma or injury and possibly do very basic labs to check for gross metabolic abnormalities, but more often we just give them some IV fluids and vitamins. When they’re sober enough to make the bleary-eyed walk to the bathroom down the hall, I deem them stable for discharge and release them from whence they came.
It is undoubtedly one of the worst cases of “patchwork” health care that exist. Because while emergency medicine is by definition short-term care, we get to know our “frequent fliers” quite well — our noncompliant heart failure patients, gang members who just can’t stop getting shot, our end-stage COPD patients who still smoke a pack a day, our sickle cell patients, and yes, our addicts.
So the question begs, why do I as an emergency physician not do more to stop their disease, the same way I do for organic chronic disease? I do ask every alcoholic if they are ready to quit, as one of the central tenets of recovery is that the alcoholic has to want to quit. But nine times out of ten, they tell me, “Naw, doc, I’m cool,” as they eye their water bottle at bedside that smells suspiciously like Everclear.
So what is an emergency physician to do, who still has the rest of the room full of patients to take care of? You do what you can and tell them they will die if they continue on, give them the stock print-out of support resources that they inevitably leave behind with the dirty sheets, and hope you don’t see them again. If you want to go above and beyond, you can send the bright-eyed bushy-tailed medical student or the bleeding-heart social worker in to give it their best shot also.
A strange thing happens, however, after I receive some variation of the “Naw, doc, I’m cool” response: I ask them when they plan to have their next drink. I ask which liquor store they’re going to go to, how long it’s going to take for them to get there, and if they have money in their pocket for it. Because alcohol withdrawal is just as, if not more so, dangerous than alcohol overdose itself. There are few withdrawals from substances that can kill, but alcohol is the foremost of them. So they tell me they have their daily fifth of vodka still at home, they show me the bus pass they will use to get there, and I let them go and continue my complicity with their disease.
There are apparent issues with this form of addiction medicine, but most of all a resource one: with the emergency room so often just the purgatory between drinks for alcoholics, few emergency departments are actually equipped to offer these addicts the help they need beyond their acute intoxication.
Mental health is notoriously underfunded, but addiction is an issue too expensive to continue ignoring. A study in American Journal of Emergency Medicine cites $900 million annually in hospital charges from uncomplicated alcoholic intoxication (in lay terms, just drunk patients). The scarce psychiatric care in the emergency room is reserved for the already burgeoning group of patients that are a danger to themselves or society (with suicidal/homicidal thoughts or inability to care for self). Rehab is inherently expensive and have long waiting lists, so even if patients decide they’d like to get help, they’re still sent home for weeks or even months waiting to see the fruition of their decision. Inpatient admissions are already abused for social work placement (into nursing homes, long-term care facilities, etc.) for chronically medically ill patients, and admissions for medically uncomplicated alcoholics would be an inappropriate use of resources.
Given these limitations, emergency physicians are quite castrated in our ability to offer options — and the ER becomes a very expensive, often taxpayer-funded, drunk tank.
Pilot programs and innovations do exist, but they are far from pervasive. Brief motivational interventions — fancy speak for “lecture you like your mother should have” — have shown some gains in making headway with patients, although they require multiple encounters in the ER and resources by already over-stretched case managers and social workers.
“Managed alcohol programs,” programs that provide a managed daily amount of alcohol to alcoholics, have attempted to reduce societally-harmful behaviors of alcoholics, but their efficacy in helping to achieve sobriety is limited as is their political support. Intensive case management programs put the onus on case managers to coordinate and follow longitudinally with patients on their path to sobriety, but are severely limited by the resources necessary to have an army of case managers available 24/7. Traditional 12-step programs like Alcoholics Anonymous are one of the few resources that prevail throughout the country, but require the patient to actually attend meetings after discharge. More punitively and less compassionately, “serial inebriate” programs exist in some cities to just arrest serial drunks and charge them with a misdemeanor.
In an era of tight budgets, few legislators seem motivated to allocate resources for the difficult problems of alcoholism and mental health. Alcoholics are a particularly difficult bunch to command much compassion for from congressman, and mental health is terminally on the chopping block.
Until that changes, it is the physicians who are stuck offering only short-term patches for addicts. And we send them off to their next drink, fully expecting to see them again.
Amy Ho is an emergency physician. This article originally appeared in the Chicago Tribune.
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