Islands of the Lotus Eaters

 April 19, 2017 

“(Homer 9.90-101). “…the Lotus-eaters did not plan death for my comrades, but gave them of the lotus to taste/and whosoever of them ate of the honey-sweet fruit of the lotus, [95] had no longer any wish to bring back word or to return, but there they were fain to abide among the Lotus-eaters, feeding on the lotus, and forgetful of their homeward way. These men, therefore, I brought back perforce to the ships, weeping, and dragged them beneath the benches and bound them fast in the hollow ships; [100] and I bade the rest of my trusty comrades to embark with speed on the swift ships, lest perchance anyone should eat of the lotus and forget his homeward way.”

Appearing lately, albeit sotto voce, in the mainstream media, known more for superficial echoes of politicos  and self-appointed pundits, are some alarming truths about declining life expectancy in the United States as well as a frightful and meteoric  rise in  opiate deaths, suicides and mortality related to alcohol abuse, chiefly among whites.

A decline in life expectancy like the one we are seeing among whites has never been seen before.  Deaths related to opiate and alcohol abuse have never been higher in recorded history.

The pathology related to substance abuse has a prodrome and a trail of morbidity prior to mortality which has altered and is changing the diseases we treat in our hospitals.  Recently I arrived at one of our hospitals in the early morning to pick up the patients of one of the physicians going off for a break. My list of patients numbered sixteen.  The sickest was a fifty-four year old male dying of polysubstance abuse leading to sepsis, hepatitis C complicating shock, liver and respiratory failure.  His clinical state was that of a cachectic and chronically encephalopathic man on death’s doorstep.  A patient in the step-down unit nearby was a 41 year old female with staphylococcal septicemia, caused by intravenous heroin use, accompanied by septic bursitis of the hip, septic arthritis of the knee and pneumonia.  Two doors down was a man in his mid-forties admitted for vague chest pain whose real pathology was ethanol withdrawal.  On a regular medical floor was a thirty year old woman who had developed an arm abscess from IV heroin use.  Later in the day I was asked to do a medical consultation for a woman on the psychiatry service who had been taking oral opiates for years for “chronic pain” who had taken an overdose of ethanol and her opiates.

That morning, one of three or four of my patients was suffering from conditions related to substance abuse! In my patient experience, this prevalence is becoming the norm. Three of the four who had opiate habituations were being treated in the hospital with opiates, in spite of the fact that the drugs were foundational to the problems that had caused them to be so ill.

Substance abuse, particularly opioid, and its associated pathologies and rampant proportions, would appear to deserve a very high priority within the hospital with established protocols, treatment modalities and embedded structures for its recognition and treatment. This appears to be especially true given that it is part of an epidemic of death that is lowering the life expectancy of a large “demographic” of this country.  Treatment strategies and protocols for other medical problems are certainly in place within hospitals.  We are, after all, forced via our EHR systems to ponder anticoagulant prevention of deep venous thrombosis. We are asked electronically to identify and provide appropriate treatment for possible myocardial infarctions, stroke, transient ischemic attack, atrial fibrillation, pneumonia/COPD and adult vaccination.

Yet the substance abusers cycle through our system repeatedly as though their presence or absence was akin to a change of the weather and their treatment often includes supplying them with the poison that is already killing them.  We have no protocols for treating them acutely, no discharge protocols that steer them toward outpatient treatment. Their peccant pathology is something we avoid.  In fact, to me these patients seem to be the abandoned and the shunned. We try to avoid the correct diagnosis of opioid addiction by adding euphemisms such as “chronic pain” to patient problem lists.  Otherwise, we fear, our terms for addiction might be pejorative. We self-censor due to our own moral misgivings.  We would rather not recognize addiction as a disease because we harbor moral misgivings about the condition. We then leave these patients on drugs that are amnesic and suicidal. Almost by definition these patients are cognitively disabled.  They cannot create a constituency demanding addiction treatment.  They form a constituency of “drug seekers.”

And we admit people who are opioid dependent for other conditions and, even when their opiate intake threatens their health we simply continue or escalate their opiates.  How can a morbidly obese person with pneumonia and hypoventilation in respiratory failure benefit from opiates that will further depress the respiratory function and drive?

Beyond anecdote are the numbers of people known to die from prescription opiates or street heroine.   In 2015 someone in Ohio died of an opioid overdose every two hours and fifty-two minutes.  In 2014 Ohio had 2,106 deaths due to opioid overdose, exceeding the number for California, a vastly larger state in terms of population.  2015 saw a huge increase in the number of Ohio opiate deaths when it shot up to 3,050.  On average that is 8 deaths per day. The grim tally for 2016 promises to be higher but apparently is not yet official.  Regarding Cleveland and environs, Cuyahoga County suffered 500 opiate overdose deaths in 2016.  Roughly two thirds of these people were male and ninety percent were white and the largest cohort was in the age group between thirty and sixty.

Nearly all investigators of this epidemic agree that it began and was fueled principally by physicians inappropriately prescribing opiate medications.

These are the death statistics.  Numbers of substance abusers visiting emergency facilities and medical clinics seeking drugs, numbers visiting clinics and hospitals for treatment of substance abuse and numbers seeking treatment for overdose, associated infections or associated injury are harder or at times impossible to accurately define.

If, month in and month out, a person in Ohio died every two to three hours of a communicable disease—influenza or streptococcal rheumatic fever, the public outcry would not be hushed. 

I will argue that, although much is already being done on a state level to address this, little to nothing is happening within hospitals or systems of hospitals. Addiction is a well-studied disease.  Why have we no addiction specialists to consult?

Every change needs a starting point.  We need to correct our thinking.  We need to stop assessing pain as a vital sign.  It is not.  Pain as a vital sign is a charade, a fantasy and anti-science.  At the emergency department level we need to stop using opiates, particularly for opiate dependent people and reserve the drugs for acute or malignant pain according to rigid guidelines.  On the medical floors we need to disabuse ourselves.  Patients will not die from heroin withdrawal except in rare instances and do not require suboxone or morphine or other opiates. They may require intravenous fluid support and benefit from antiemetics or other non-opiate and non-benzodiazepine medication, but they do not benefit from our preservation of and enablement of their addictions.  Suboxone and methadone should be administered by teams of addiction specialists.

We must see the error of our ways.  Patients who chronically ingest opiates for “chronic abdominal pain” and “chronic idiopathic gastroparesis” have opiate gut syndromes, a fact pointed out over a hundred years ago, fashionably now ignored.  Patients who allegedly have “chronic pancreatitis” overwhelmingly do not have any radiological or biochemical evidence of pancreatic inflammation and they should not be treated with opiates. They usually present to the hospital when they have exhausted an outpatient supply of opiates.  I find them on our wards, absent any physical or laboratory evidence of hypovolemia in spite of their claims of intractable vomiting.  There are innumerable other patient improvisational theatrics that lead to unnecessary opiate administration; I will not dwell on fibromyalgia, migraine or low back pain, syndromes that demand alternative therapies to opiates.  And we must stop blithely dolling out opiates to hospitalized patients simply because they take them as outpatients.

We must reeducate ourselves. Nursing, physicians, hospitals and the pharmaceutical industry, the “we” that have control, must come back to an ancient recognition that opiates have an indication, acutely and chronically, for only a very small number of clinical situations.

We must disabuse ourselves.  No “patient satisfaction” evaluation should be requested of any patient regarding their pain management until our epidemic of opioid deaths has been ended.  No incentive should ever be given to an emergency department clinician to provide opiate management that is dubious.  Chronic opiate ingestion, not one to ten pain scores, should be flags and markers on patient charts indicating a potential life-threatening pathology.  If we are to count the cigarettes a patient smokes, let us count the milligrams of opiates they eat.

Our hospitals have become Islands of the Lotus eaters.  Look into any chart and it seems no matter what the condition treated, there is an opiate medication ordered.

We must do for our patients what Odysseus did for his men.  Their ship landed on the island of the lotus eaters and his men ate the plant they were offered.  They were drugged and forgot their duties, forgot their longing for home and refused to leave.  He dragged them back to their ship, binding them beneath their rowing benches and renewed their journey homeward.

-Peter S. Kibbe, MD FHM