24 Hours

Nearly every day as a driver with Recovery Centers of America (RCA), I have the privilege of bringing in for detox and rehab a person who has decided enough is enough.  They want to be done with their substance use.  They want to heal and to reclaim life as they once knew it.

More often than not, this person will have consumed their substance just prior to getting in my company car so as to be comfortable for the trip.  Withdraw is nothing to smile at and they don't want to be going through it on the ride to RCA.

On rare occasion, I have brought in a person who had decided 24 hours earlier that they would no longer consume their substance.  For this discussion, I'm going to focus on patients with Substance Use Disorder who use heroin.  "Dope sickness" is the term for what patients experience when withdrawing from heroin use.  Here's some of what they go through…

The Symptoms of Withdrawal

Symptoms of dope sickness – and their intensity – can vary by person, the drug of choice, and the amount of drugs used on a regular basis. However, common signs of dope sickness include: 

Nausea, vomiting, diarrhea and/or constipation

Loss of appetite/huge return of appetite

Hot and cold flashes

Muscle aches and spasms

The sensation of bugs crawling on or under the skin

Hyper-awareness

Dry mouth

Headaches

Insomnia

Sweating

These physical effects are often accompanied by mental and emotional symptoms. Those who are dope sick may also experience: 

Agitation

Anxiety

Paranoia

Frustration

Depression

Despondency 

When a person I've just picked up tells me that they are dope sick, I call ahead and inform my coworkers in admissions that we will be arriving at a particular time and to please have nursing personnel at the door so as to alleviate our new patients' suffering as quickly and as much as possible upon arrival.  As with any illness or injury, total alleviation of suffering is not possible but much can be done to alleviate the worst of the pain and discomfort. 

These nurses are fulfilling their role as they declared to do when they took their Hippocratic Oath at the beginning of their careers.  Here's a modern version of that oath: (Red wording is most relevant to this discussion.)

Hippocratic Oath: Modern Version 

I swear to fulfill, to the best of my ability and judgment, this covenant: 

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. 

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. 

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. 

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. 

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. 

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems if I am to care adequately for the sick. 

I will prevent disease whenever I can, for prevention is preferable to cure. 

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. 

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. 

—Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

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Such is not the case for patients with 

Substance Use Disorder 

who live on the streets of Kensington.  

Nearly all of these people are reliant on Medicaid and the Medicaid based system of health care provision for their alleviation of pain and suffering and reclaiming life. 

It occasionally happens to the people on the streets that they don't have the money to buy their "medicine" and end up going 24 hours very unintentionally without it.  Sources of income vary and all have periods when they are not as lucrative.  Examples include: 

• Standing on a street corner with a cardboard sign…
• Hauling metal to the local junk yard for cash
• Trash picking and selling the items on the street
• Shoplifting and selling the items on the street
• Relying on your regulars with whom to do a "date"
• Standing on a street corner in hopes that some guy will want to do a "date" with you.
• Asking for money from family and non-street bound friends 

These people will not be picked up in a company car and brought to an awaiting nurse for their nearly immediate alleviation of pain and suffering. 

Here is a firsthand account of an all too familiar scenario at the intersection of Substance Use Disorder and Medicaid: 

I have personally been to several crisis centers in Philadelphia. A few months ago, I went to one and sat for about 13 hours in a waiting room so very sick shaking and sweating and vomiting everywhere and all for them to come out and tell me that there were no beds and said to come back the next day to try again. 

Mind you I was very very sick and when they told me that, I asked them what should I do as I was laying on their bathroom floor vomiting everywhere and it looked like someone had sprayed a hose on me because I was dripping wet. My clothes were soaked and I was flopping on the floor like a fish out of water. 

The doctor said to me "I don't know what to do." She said she cannot give me anything because I am not admitted and there are no beds. So they asked me where would I like to go to because they will call a cab for me. As I was waiting for the cab, security and a nurse came outside to me and asked me what I was doing and I said "You told me you are calling a cab." The nurse said, "We did not call one and you have to get off of the property!" 

Mind you I had no money and I was so sick so I ended up walking to the EL. The SEPTA personnel told me I cannot go through without money and I told them that I just came from the hospital. I showed them paperwork and they still said "No" so I ended up jumping the train and the SEPTA personnel hit the alarm! 

So thank God the train came before any cops got there so I was fine. As I was on the train I dropped to the floor and had a seizure. When I woke up people were standing around me and they were waiting for the ambulance but I jumped up and said no and got back on the next train and got off at Somerset station and had to find a way to get well... 

My experience that day with the crisis center made me so sick to my stomach thinking that I really wanted to get clean and I really wanted help and nobody helped. 

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RCA and similar private insurance facilities are modeling for all of us what health care providers to patients of Substance Use Disorder should be doing.  Patients in these places are treated with dignity and respect.  They are warmly greeted at the door upon arrival.  The process of healing begins right away. 

The person who decided 24 hours prior to getting into my company car that they would never use again and the street bound person who is unintentionally in that same 24 hour period unable to buy their "medicine" are equally human.  Neither is better than the other.  All or worthy of dignity and respect.  

24 Hours