Pubdate: Sun, 15 Jan 2017
Source: Hartford Courant (CT)
Copyright: 2017 The Hartford Courant
Author: Kristin S. Budde


At four in the morning, the hospital's emergency department lights
fluoresce directly into your brain. Everyone, everything looks green,
especially the midnight heroin users. They are always shivering. Partly
the withdrawal, partly the cold, damp Connecticut weather. They tend not
to have proper jackets.

On a stretcher in the hallway, a 25-year-old "opioid withdrawal" is curled
up with three hospital blankets pulled over his head. I gently shake his
leg, but nothing is really gentle here. I introduce myself and whisper a
question about what brought him in. No response.

When I lift the blankets I'm surprised -- he looks almost 40. Glands poke
out from beneath his cheekbones. He shivers and snatches the blankets back
with dirty fingers, crescents of crud at the edge of each nail. Angry red
dots track the veins on his hands.

"Lemme sleep."

I can't. Everyone needs to see the doctor. Even though I know he's been
here many times before, that he needs a boxed sandwich and a safe place to
sleep. The hospital isn't a shelter, though. The addiction slowly but
surely destroying his life is not "imminent risk." He'll probably have to

I hear stories like his all the time.

The 2 million Americans who struggle with opioid addiction risk infectious
disease, broken relationships and financial ruin. Or worse: 2015, more
than 30,000 Americans died of opioid overdoses.

The risks are magnified in homeless patients, who have fewer supports to
begin with. (Homelessness itself can increase your risk of death by up to
9 times.) In Boston, overdoses are the leading cause of death in homeless

This isn't so surprising, since addiction treatment is nearly impossible
to get without insurance or money.

We can treat this patient's withdrawal in the emergency room for a while
and try to get him a detox (withdrawal under medical supervision)
referral, but that's about it. In a perfect world, he'd have housing, a
safe detox or medication-assisted-treatment (methadone or suboxone),
possibly a rehab stay (a longer inpatient stay for substance use
treatment), and consistent outpatient followup.

Those with insurance are sometimes better off, but not always. Medical
bills remain the leading cause of bankruptcy in the U.S., and insurance
companies don't always have up-to-date provider lists (meaning a list of
psychiatrists may include only a few who are actually accepting patients).
It's unclear how many millions stand to lose insurance coverage if the
Affordable Care Act is repealed.

The system is broken. But it's all we have to work with.

I try again to wake up the man in the stretcher.

"Just a few minutes. What brought you in tonight?" I talk differently in
the middle of the night. Short sentences. Less finesse.

"I don't have anywhere to go, OK? Let me sleep here."

"We can't just let you sleep here." Bad news shifts "I" to "we."

"How much are you using?"

"Ten bags a day."

"Detox is full till Tuesday." I steady myself on the side of his gurney,
hands wide on the rails like a barkeep. I'm shivering, too, despite my
white coat. When I was in medical school someone told me you shiver in the
middle of the night because your cortisol is low. I'm not so sure that's
the problem.

"What am I going to do for four days?" He's awake now. Eyes open and

"That's the first availability. The social workers can call around ."

"I went to detox and they say rehab but I don't have insurance and they
discharge me to the street and I use."

He needs somewhere to live. If he doesn't get sober he has a 50-50 shot of
making it to 50.

"Admit me to the hospital," he pleads. "Just a few weeks. I need help."

He's right. But that's not how it works. A few more questions, a quick
physical exam and we're done.

I ask again if he wants the detox bed. He doesn't. I can't force him to
take it. In a while he'll head back out to the street.

I wait a few hours before arranging his discharge paperwork. Maybe the
extra sleep will help. I've typed all the numbers for nearby rehabs and
detox facilities onto his paperwork even though he has no phone.

He's shoving the hospital blankets into his backpack when I come to give
him his paperwork.

"You're a bitch."

So it would seem.

Kristin S. Budde is a psychiatry resident at the Yale University School of
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