William Haning, MD, DFASAM, DFAPA
Within medicine, those who practice in the emergency setting are those most often confronted with SUD as a crisis. Our training of physicians regarding patients with addiction is generally pretty aversive. The training process runs something like this:
We make an initial, tentative commitment to entering medicine, based usually on some positive experience during adolescence. The experience may be as simple as the sense of satisfaction following an act of altruism, or praise from someone in the field. Time passes, and we take the MCAT in the midst of a college curriculum saturated with difficult, even arcane topics – physical chemistry, organic chemistry, developmental anatomy, and the like. We matriculate on the tail end of collegiate debt, faced with an additional unsecured mortgage of 1/4 million dollars for medical school. Meanwhile, we watch our high school classmates go on to get an MBA, marry, and buy that first BMW. We do so without resentment, taking our meals from larcenous vending machines and our fitful sleep sprawled between upright chairs, content that we will be of use. All that we ask of the patient is that s/he 1) tell the truth; and 2) follow instructions. We are then confronted on our first emergency department clinical experience with the obstreperous, even rage full person with addiction, most commonly to alcohol, and are forced into a choice: this person, who 1) routinely lies and 2) will not follow instructions, must be a patient yet doesn’t behave as one. It is unsurprising that the young physician can only resolve this conflict with her projection by deciding that this is not really a patient, but just someone who is behaving badly. She will of course one day discover that these behaviors are not limited to those with addiction, but that invites a longer discussion.
Overcoming the pejorative viewpoint is difficult but possible if there are resources at hand, agencies and people, with whom to share the burden of meeting this patient’s needs. The problem, then, for the emergency medicine physician is not so much the complexity of the clinical issue as it is the awful loneliness of having to try and manage it at 1:00 AM. I believe that our response as addiction clinicians ought be one of availability, as well as of pursuing public policy initiatives that increase our numbers and properly distribute the burden of care.
Spoken as if he’d been there & done that! Then for the opposing situation, look at somebody with years of solid, good recovery under their belt and you’ll acquire a diametrically opposed view of what happens when substance abuse is overcome through a good recovery program!
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