By William Andereck, David Smith & Steve Heilig
Published in March 2024 Good Work News; Originally published in San Francisco Chronicle, July 2023
Sadly, they are called “frequent flyers” — severely ill patients with serious medical conditions who routinely cycle in and out of hospital emergency departments. On any given day, their affliction could be an overwhelming infection, festering wounds or even a coma. Sometimes they require a ventilator and ICU care.
These patients may not come to the hospital voluntarily, and if they do, they usually want to leave quickly. They are helped as much as possible but, despite ongoing medical needs, they leave the hospital against medical advice as soon as they begin to feel better — only to return soon after in even worse shape. The pattern continues while their suffering endures, health care staff get frustrated, and costs pile up. This sad dynamic has continued for decades in hospital emergency departments, but fentanyl and methamphetamine are making the suffering increasingly worse.
That’s because the disease underlying many of the problems these patients face is substance use disorder (SUD), more widely known as addiction. SUD is a chronic, relapsing and potentially fatal condition characterized by compulsion, loss of control, and continued use despite adverse consequences. The disease gradually overcomes our ability to control it — those of us who suffer from it cannot stop using drugs even though we know it is harming our health, work, family, social life and even our freedom.
One could characterize SUD as an ongoing cycle of a period of intoxication followed by a period of withdrawal. The withdrawal state has physical manifestations that are often quite evident — shaking, fever, nausea and vomiting, intense headaches, anxiety and, especially, a craving to do anything to feel better, including finding more of the drug one is addicted to. It’s often said that addicts don’t die from withdrawal but often wish they could.
These symptoms can become more intense after each exposure to the drug in question and each attempt at withdrawal. Repeated episodes of withdrawal begin to change the very nature of the brain and transform it in subtle and nefarious ways. The withdrawal response activates pathways in the most primitive levels of the brain’s subcortex (where the conscious brain never goes), inducing a profound sense of desire and craving for the addictive substance in question. An individual’s capacity to make rational decisions becomes overwhelmed by these cravings.
This positive feedback loop of intoxication and withdrawal, followed by craving, is heightened in duration and intensity with continued use. Intense craving uniquely characterizes what we call addiction.
Studies based on longstanding experience with heroin and alcohol show that it can take at least 90 days of sobriety for the brain to begin to stabilize and for cravings to begin to dissipate. Although not as recognizable as withdrawal to the observer, craving is intense, and diminishes slowly over months to years. It is the most common cause of relapse.
The power of craving is well known to any former cigarette smoker who enters a room 10 years after quitting and is triggered by a familiar old friend, situation or place where they used to smoke. Likewise an alcoholic who even walks by a bar can experience intense desire to drink.
Now we have fentanyl and methamphetamine. While the neuroscience of addiction and recovery is complex and still developing, fentanyl is over 50 times more potent than heroin, and it is safe to suggest that resultant withdrawal and craving is magnified proportionately. Methamphetamine withdrawal and craving, meanwhile, can result in hyperactive and dangerous behavior. This has disrupted care in hospitals, frustrating and endangering everyone.
SUD develops gradually. It also takes time to treat and recover from. Though there is variation among patients, vast clinical experience shows that in general, the longer one stays in treatment, the more likely that long-term success will result. Because our brains are essentially “reprogrammed” by addiction, they need to be “deprogrammed” by abstinence. That often requires medication, residential treatment, and prolonged participation in support programs.
Unfortunately, the standard 28-day residential SUD treatment program stay is not enough.
Treatment needs to be revamped to reflect current science. More rehabilitation programs are also needed. Likewise, we need more addiction medicine professionals embedded in hospitals and clinics.
Despite these obstacles, there is good news on three fronts:
There have been significant advances in understanding the neuroscience of addiction. Newer medications can help people resist and control their addictive behaviors. Finally, elected officials are recognizing that we need to confront addiction with newer approaches, rather than simplistic “drug war” failures.
Change will not be cheap, but studies show every dollar in treatment saves seven dollars in criminal justice costs.
What is needed now at all levels (of government in California) is heightened commitment to substance use treatment and recovery. This requires the recognition that those who are caught in an addiction cycle as not “frequent flyers” but human beings, disproportionately poor and suffering from a disease, that needs specialized supports.
Inaction isn’t just counterproductive and costly, it is immoral.
William Andereck is an internist and chairman of the ethics committee at Sutter Health/California Pacific Medical Center. David Smith was founder of the Haight-Ashbury Free Medical Clinics and is past president of California and American Societies of Addiction Medicine. Steve Heilig is director of public health and education for San Francisco Marin Medical Society and a former Robert Wood Johnson drug policy fellow.
The opinions stated in this piece are those of the authors.
www.sfchronicle.com/opinion/openforum/article/drug-addiction-science-fentanyl-meth-san-francisco-18211099.php
