Morning Rounds: Heroin
It has to be dealt with now or there may be no later—
Thursday, September 17, 2015 1:05 PM
One of the easiest diagnoses to make in emergency medicine is of a patient who has overdosed on heroin: they are the ones who have pinpoint pupils and aren’t breathing.
If there is no intervention, in most cases they will die. If emergency responders find them in time and can administer a drug to counteract the heroin or if a friend gets them to an ED in time for us to administer an antidote, they will survive.
As a medical condition, a heroin overdose is easy to treat. Trying to connect with addicts and convince them to get treatment is incredibly difficult.
Part of this may be a matter of desensitization. I completed my emergency medicine residency training in California and treated hundreds of heroin addicts. The vast majority came into the emergency department nearly dead and in almost all cases rejected offers of treatment and left as soon as they could in search of more heroin.
The addiction had swallowed up so much of their personality that there was very little left to connect to. Their responses to questions, how they connected to those around them, their plans for the future were all driven by their immediate need for the next high and to avoid the crash of withdrawal.
One woman I recently treated while working in an urban emergency department in Maine had taken such a large overdose that she needed two doses of a very powerful drug to counteract the poison in her system.
Still in her 20’s, she had dyed blond hair and multiple piercings and tattoos. She was an attractive young woman but her lifestyle and addiction had already taken a deep physical toll.
When she woke up, she completely denied using, despite the track marks on both her arms. We tried to encourage her to get treatment and to get away from her current boyfriend, who appeared to be a heroin user and, most likely, her dealer. Not surprisingly, she just wanted to get back to the streets, despite the fact that the drug had almost killed her only a few hours before.
When she left with her boyfriend, I felt no hope that she would break the cycle of addiction.
This young woman was not unkind or difficult to care for, but there was a profound hopelessness about her. I couldn’t see any sense of self-worth, or any thought for the future beyond that next dose of heroin. On a fundamental level, she just wasn’t there.
A young man I treated recently for an overdose had already been through several stints in rehabilitation. He had several medical complications as a result of his long-term addiction and after he was treated for his latest overdose, he was admitted to the hospital for those complications.
He was from a prominent family who was very supportive and his mother was desperate to help him, but none of that seemed to matter. He didn’t seem to care about anything; not his own near-death, not his lack of a future, not the agony his family was suffering.
As a parent, I could empathize deeply with his mother’s pain but the patient’s lack of concern for his own life, or the feelings of his family, made it hard for me to connect with him.
A third patient was a college student who had been found in the restroom at her job when a co-worker noticed she had been in the bathroom a long time and checked on her. She came within minutes of death.
She knew she was addicted and she wanted to stop, but despite the fact she had nearly died just a short time ago, she was more concerned about her finals.
She was different than the other two largely because she had not gone so far into the cycle of addiction. I could still talk to her and feel I was connecting with a real person.
We had a conversation about treatment and she said she was going to stop. She promised to call the telephone number I gave her but first she had to study for finals. She would take care of the heroin later.
I felt good about everything we talked about until we got to that last part. Heroin is not something you can put off until after finals. It is a monster that is eating you alive. It has to be dealt with now or there may be no later.
When she left the emergency room I didn’t feel terribly optimistic about her future, but there was at least a glimmer of hope. The fact that the addiction had not yet robbed her of her ambition or sense of self made me hope that perhaps someone somewhere could reach her before it was too late.
Mark Fourre, MD, is an emergency physician and Chief Medical Officer of LincolnHealth. He also serves on their Board of Trustees. Prior to joining LincolnHealth, Dr. Fourre was an attending faculty at Maine Medical Center where he developed the Emergency Medicine Residency Program and served as Residency Director.