christmas cheer?

Booze, hootch, brew, tea, aquavit, horse, smack, crack, crank, blow, Georgia Home Boy, special K, acid, meth, ice, X. Substance abuse is a never ending challenge and headache for ER docs. We have to deal with the chronic side effects of drug and alcohol use: liver disease, internal bleeding, dementia, and infections including HIV, hepatitis B and C and D, MRSA (a super bug), endocarditis (an invasive infection of the heart). Then there are the joys of withdrawal from drugs and alcohol, the vomiting, diarrhea, shaking, sweating, delirium and seizures. A user can die from chronic use, overdose and sudden cessation resulting in acute withdrawal. ER's also have to manage the collateral damage of drugs and alcohol, DUI's, child and spousal abuse and neglect.
The user rarely has health insurance, and often has been abandoned by the family that they lied to, stole from and abused. They arrive in the ER walking, by the police or by ambulance. Public intoxication is no longer treated by placement in the "drunk tank". The ER has become the repository for junkies, drunks and other users that society doesn't wish to acknowledge. Our local, state and national governments treat drug use criminally not as a disease. Billions are spent on ineffective attempts at stopping the manufacture, growing, distribution and sale of illegal substances. Little funding is left to treat the addict. Beds for alcohol and drug abuse are woefully inadequate for the number of people looking to get clean. Long term treatment programs and counseling are even less available. Volunteer groups on the AA or NA model are prolific but only effective after the acute withdrawal period has been completed.
The physiology of drug and alcohol dependency has been well studied and is well understood. There is good evidence that one's genetic make up may predispose someone to become addicted to alcohol or drugs. This is the basis of treating substance abuse as a disease, not a moral failing. The burden of care is enormous. Alcoholics and drug addicts are medical time bombs. The ER doc must diagnosis and treat the acute intoxication or withdrawal and find any underlying medical or surgical problem and treat those conditions. This must be accomplished on a patient who is often dirty, malodorous, physically and verbally assaultive to the people trying to care for them. Physical and chemical restrains are employed to help these patients despite themselves.
The mental health problems that frequently exist hand in hand with addiction will be the focus of a later blog. Suffice it to say that many alcohol and drug users are often self-medicating there depression, bipolar disorder or schizophrenia. Anyone out there think this is easy?
The drug seeker is a particularly nasty member of the substance abuse family. These patients usually start off as nice folks who are seriouly injured or have chronic pain conditions, such as arthritis, fibromyalgia or sickle cell disease. Their pain is treated with narcotic pain medications. The problem is that over time narcotics become less effective, requiring ever larger doses to maintain the same level of relief. The patient build tolerance to these drugs. They are less sedated by the medications. The patient finds that the more he or she demands the less their doctor returns his or her calls. The treating physician eventually "fires" the patient. Guess where they end up? Initially they are all sweetness and delight. They politely and tearfully relate their story of 10 over 10 pain in gory detail. When the doctor gets suspicious and hesitates or refuses the request for oxycontin 80 mg every 8 hours, Mr Hyde appears. You are insulted, threatened with both physical harm and legal actions. The drug seeker eventually realizes that his game is not working and makes a miraculous recovery from his chronic disability and storms out of the ER in a cloud of threats and obscenities.
For me the saddest part of abuse is the unintended victim. The drug addicted newborn is the most pitiable and innocent of the addicts' gifts to humankind. The thousands of people maimed and murdered by inpaired drivers often end up in the same ER as the drunk or addict who caused the accident. The families of the user haunt my psyche. They continue to love and care for the addict who makes their lives a nightmare. I am frustrated when the most I can offer is a list of detox facilities that have very long waiting lists.
So please, hark the heralds, enjoy Christmas, Kwanza, Hannukah, and the New Year. Drink slowly and in limited amounts. Have a designated driver or take a cab or public transportation. If you need alcohol or drugs to get through a family gathering, RSVP your regrets and spent the holiday volunteering in a shelter, soup kitchen, VA hospital, or nursing home. Christmas cheer is doing good by helping others not pounding down the eggnog.