A patient arrives at the hospital with a raging fever and chills radiating throughout his entire body. When doctors listen to his heart, they hear a whooshing sound that shouldn’t be there. They diagnose him with endocarditis (a heart valve infection), treat him with a high dose of antibiotics for several weeks, and send him home.
Although the medical team suspects that he contracted the heart infection from injecting heroin, they do not diagnose him with or start treatment for an addiction (medically known as substance use disorder) while he is in the hospital. After being discharged, the patient goes back to using heroin and, in a few weeks, returns to the hospital with the same infection or something much worse.
The patient described here, though fictional, represents a common scenario in hospitals today. Patients with substance use disorders often face a vicious cycle of receiving treatment for one problem without addressing the underlying issue. Studies show that 18 to 20 percent of hospital patients with an untreated underlying substance use disorder return to the hospital within 30 days.
Yale Medicine hopes to change that. As part of a new service, addiction medicine specialists will identify patients admitted to the hospital who show signs of having an underlying substance use disorder. They will offer these patients treatments to stabilize their condition, create a plan to address their substance use, and directly connect them to resources in the community they can use after discharge.
“Many people struggling with addiction may not ask for help while they are hospitalized because of the stigma related to their condition. And traditionally addiction has not been treated in the hospital,” says Melissa Weimer, DO, medical director of the new service, a collaboration between Yale Medicine and Yale New Haven Health System. “But studies have shown that a good time to reach patients—a “reachable moment”—is when they’re hospitalized for other medical conditions; they may be more receptive to getting help when it’s offered alongside their medical care.” This may be especially true when patients are hospitalized for conditions caused by substance use.
In 2015, Dr. Weimer worked with colleagues and community partners to help develop one of the first hospital-based addiction medicine consult programs in the country at Oregon Health & Science University. Earlier this year, she was recruited by Yale Medicine to develop a similar program. We sat down with her to learn more.
There’s confusion about what ‘addiction’ means. What is it?
Addiction is characterized by the uncontrolled use of a substance and a pathologic seeking of it at the cost of all other things. It should not be confused with substance withdrawal. Some people may experience withdrawal symptoms like nausea or sweating after coming off of a substance, like an opioid painkiller. But those symptoms alone do not mean that the person has an addiction. Those are just the body’s natural, physical responses to not getting a substance it's used to getting.
For someone with an addiction, craving and loss of control usually manifest as an intense obsession with obtaining and using the substance despite knowing that it's causing physical, emotional, or social harm. It can be caused by physiological changes to the chemicals in your brain that fuel the craving, and made worse by an underlying psychological condition like depression or social factors like homelessness.
One common misconception is that addiction is somehow a personal failure or caused by a lack of discipline. This is simply not true. Just like asthma or diabetes or other chronic diseases, addiction is caused by a host of genetic, biological, psychological, spiritual, and social factors. Nobody chooses to develop a substance use disorder.
Tell me about the program you’re starting at Yale Medicine.
This program is for patients admitted to our hospital. Our primary medical teams examine the patients. If they think that a patient may have an underlying substance use disorder, they will call us to do an evaluation. If we determine that the patient does have one, we'll offer to work with them to develop a treatment plan. This can include prescribing medications, counseling, and education. We also place a strong emphasis on connecting patients to treatment centers, therapists, and resources in the community after discharge.
For those who don’t want to use our services, we’ll try to give them tips for safer practices to reduce the risk of harm, overdose, or death. We will also encourage them to see us again if they change their mind and want to seek help.
Can you explain why connecting patients with community resources after discharge is important?
A lot of people who have substance use disorders have lost touch with family and friends. Instead, they may spend a lot of time alone or with others who use—their substance use becomes a large part of their social life. That’s why it’s important for us to help patients form relationships with people who are not using substances—we call these people “sober supports.” A great place to start building a network of social contacts is with mutual support groups like Alcoholics Anonymous, Narcotics Anonymous, or Smart Recovery. A formal substance use disorder treatment program can also be helpful.
Yale has a program called “Recovery Volunteers.” These are people who are far along in recovery themselves. They visit with patients and give them tips and strategies that have helped them with their own recovery.
In the end, navigating the substance use treatment system can be a major challenge for patients and families. It may be hard to find high-quality programs that provide evidence-based treatment and accept a specific insurance. We do our best to connect patients to the appropriate level of care for their condition and to programs that adhere to the best practices supported by science and major medical societies.
How do you recommend family and friends talk to a patient with a substance use disorder?
It’s important to broach the subject in a non-judgmental, non-confrontational way so that your loved one feels safe enough to talk about his or her condition. You don’t have to say, “Are you using drugs?” You can start by expressing concern and saying something gentler like, “What's going on? I've noticed that you're struggling. How can I help you?”
There are also lots of resources you can look up to learn more. Here are a few good websites and places to start looking for information:
- SAMHSA, the Substance Abuse and Mental Health Services Administration
- NIDA, the National Institute on Drug Abuse
- Connecticut Department of Mental Health and Addiction Services, which has a treatment center locator
- All of the Yale-New Haven Hospital Emergency Department sites have Project ASSERT [a team of health care professionals who are specially trained in substance abuse] with people who can offer help as well
- Talk to your primary care provider and ask them for suggestions for treatment centers
Is there anything friends and family can do if their loved one doesn’t want to get treatment?
Yes. If someone doesn’t want to get treatment, I would recommend offering support by making sure they are at least reducing the negative impact these substances have on their bodies. Under what’s called a “harm reduction” model, you may encourage someone struggling with alcohol use disorder to drink only in safe environments or to eat or drink non-alcoholic beverages in between drinks. For people struggling with opioid use disorder, family members could help by making sure they have a naloxone kit. (Naloxone kits contain the medication naloxone, which can reverse the effects of opioids and restore breathing during an overdose.) You can also make sure they are using clean needles by obtaining needles from a needle exchange like the one offered by Yale.
Lots of people think that the only way they can help a loved one get better is by issuing ultimatums. In reality, this type of “tough love” approach increases the risk of death because it forces people to use drugs more secretively. This puts them in a more dangerous situation where they can not readily receive the help that they might need.
How did you become interested in addiction medicine?
About 10 years ago, when I was doing my internal medicine internship, one of my patients was a middle-aged man paralyzed from the waist down, leaving him with chronic pain. He was taking opioids, prescribed by his previous doctor, but I soon realized that something was wrong. He was calling to refill his prescription weeks before he was due for one, and his life just seemed to be increasingly chaotic. I asked my supervising physicians what to do and no one seemed to know how to best help him—we didn’t have access to buprenorphine or methadone, which are the medications used to treat opioid addiction. No one even had suggestions for outside addiction treatment centers I could recommend. But most of all, I felt ill-equipped and unprepared to have a conversation with him about my concerns.
He eventually left my care. I found out a year later that he had died of an opioid overdose. I felt like a complete failure. That’s what inspired me to spend the last decade researching addiction and evidence-based treatment for it to help people like him lead healthier lives.
Only about 10 to 15 percent of people who have a substance use disorder receive treatment for it. The hope is that our hospital-based program will become the new standard of care and will change the way addiction is seen and approached by health care systems and medical providers.