No right answers

I take care of my own patients in the hospital. I say that because it is not a given for internists. For a number of reasons, many having to do with time management and money, most internists utilize hospitalists, internal medicine docs who specialize in the care of hospitalized patients.

Taking care of patients in the hospital presents some unique challenges. First, they are very, very ill. You have to be pretty sick to get into a hospital these days. You must be willing to be available 24 hours a day, 7 days a week. And you have to be able to deal with some rather intractable problems.

My SciBling DrugMonkey had an interesting post about dealing with hospital patients who have addictions. This is a common, daily problem for me and other docs who see hospitalized patients.

The most common substance is tobacco, followed by alcohol, followed by “other” (pot, heroin, prescription opiates, methamphetamine, cocaine, etc.).

There’s a great deal of literature on how to treat substance abuse, but not much on how to deal with hospital patients who happen to have substance abuse. There is some literature showing that addicts and doctors have a profound mistrust of each other, which is a lousy place to start, but perhaps an inevitable one.

Residents and other inpatient docs work hard to save lives and get people better. When they encounter addicts, there may be an intensely negative reaction. Addicts often have behaviors that we interpret as not wanting to get better, and they often have unpleasant personality traits that make them difficult to care for. Some would like us to simply say that “addiction is a neurologic disease akin to Parkinson’s. Addicts are no different from anyone else with an illness.”


Addicts are disproportionately affected by personality disorders that render them difficult to be around, much less care for.

Tobacco addicts are very common. Most hospitals have smoke-free campuses (don’t make me tell you the story of the cancer patient on oxygen who blew his face off lighting a cig). There is no safe way to allow people to smoke. We don’t have the personnel to escort them off campus, nor do we wish to take responsibility for allowing them to roam freely, perhaps to have “something very bad” happen to them.

Also, the most common problems we treat (pneumonia, heart disease, diabetes, peripheral artery disease, chronic lung disease) are made much worse by tobacco. If we allow a patient to smoke during treatment, we might as well not have admitted them in the first place. Tobacco withdrawal is unpleasant, and we need to acknowledge that and help the patient in any way we can so that they stay in the hospital to complete therapy. But no one dies of tobacco withdrawal.

The same can’t be said for alcohol. Alcohol withdrawal can lead to DT’s, which has a fairly high mortality rate. We have medications to deal with this, although dealing with the cravings is more difficult.

Heroin and other opiate addicts can be very difficult. Opiate withdrawal is not deadly, but feels absolutely horrible. Many addicts have found ways of gaming the system. Their personalities can be very difficult. Sometimes we avoid withdrawal by giving them some opiates, but in my experience, giving them enough to keep them from feeling sick is never enough. They want more.

This isn’t about judgment. This is about real medicine in the real world. We don’t know the neurobiology of addiction well enough to just give patients a pill and make it a non-issue. It is not “blaming the victim” to say that addicts must take responsibility for their behavior. Despite the cravings caused by their neurobiology, they must also make a conscious decision to remain in the hospital for treatment, to treat the staff with respect, and to honestly report their symptoms so that they can be properly treated.

In the real world, it sucks to be an addict. In the hospital, it’s even worse.