Open Space
The Issue on Rabdomyolisis
A colleague at the Drug Addition Unit told me she had noticed a marked increase in the number of drug addicts coming to the Emergency Room, despite the limited response they found, as it is restricted to the intravenous administration of liquids. To my surprise, she explained that this procedure aims to prevent acute kidney failure by rabdomyolisis caused by the agitation arising from the deprivation state. My surprise increased even further, as I have never come across such a situation in the hundreds of heroine- dependents in a state of deprivation I have examined as part of my clinical relation with drug-related problems since the 1980s. I have never seen this procedure recommended in any current protocol at a hospital emergency room. I am not referring to the appropriateness of the procedure - I can understand the (remote) risk of a state of agitation causing decompensation in a shaky kidney and hepatic function.
Many drug-addicts reach hospital in extreme situations caused either by rupture in the drug supply economics, which leaves them very weak, or by complex medical and infectious occurrences that are normally ignored. In any case, generally these drug addicts are people who come from the most marginal and vulnerable part of society, from a physical, psychic, and socio-cultural viewpoint. Interventions should weight carefully the pros and the cons for patients, and they should be independent from the (good intentions) of health professionals. In this sense, a well-intentioned intervention, but inappropriate in a clinical context, may harm the patient. Even a well-intentioned and virtually adequate procedure may be disastrous if it does not take into consideration the implementation conditions and the bad uses it can lead to. It is a known fact, for instance, that interruption of drug consumption, which in itself is a necessary therapeutic step, may be associated to distinct situations, including serious risk of overdose and death.
Why do heroin-dependents in a state of deprivation resort to a hospital that offers them a particular urgent treatment, liquids taken through a drip, for a chronic condition that lacks a long treatment? Why do they resort to a procedure that is not part of an intervention strategy delineated in the context of the extremely long evolution of drug-addiction? Firstly, because, like many other patients, they do not chose the most appropriate treatments in a very rational manner. Their criteria when choosing is based on short-term benefits, announced in their social networks, and easily available. Secondly, resorting to an emergency room does not mean a wish to obtain treatment, rather, like with so many other patients, a need for relief of pain, which in this case is their deprivation symptoms. These are people who consume drugs by endovenous form and for whom the pleasure of drug taking is associated to the “addiction of the needle”; some will inject anything, or find pleasure in pumping out and re-injecting their own blood – “to pump”. The injection has become associated to pleasure and to the relief of deprivation, and at least this is what they find in the hospital solution.
However, when we examine the situation at the level of individual medical behaviour, at a hospital and institutional level of a public service, and at a system’s level, that is, socio-political level, what do we find? A doctor is confronted with a population he finds difficult to get near to, with patients who request an intervention and who are often in a very poor condition from a medical viewpoint. The doctor is trained to provide an answer, which he does, because it would be even more difficult not to do so. He provides an answer offering a somatic solution for a serious behaviour disorder. He will be aware of the frail health condition of these people, whose social marginality is evident: they come from underprivileged layers of the population, and were precociously affected by an illness (drug-addiction) that has interfered dramatically with their personal identity. They have a low educational level and, since adolescence, they have socialised at the fringe and, in some cases, even criminal edge of society, a result of which, already at the end of the line, brings them to this hospital’s emergency room. This contact with a health institution is a unique occasion for people who live at the margin, and a unique institutional occasion to transmit basic health messages or to screen trial risk situations caused by consumption. It is not possible to treat drug-addiction in this clinical context – the drug-addict confronts the doctor with therapeutic impotence and with the need to assume it. Rabdomyolisis is convenient for everyone.
Generally speaking, the doctor tries not to frustrate the patient’s expectations: what alternative to rabdomyolisis can the doctor have in an emergency room in the presence of a patient who asks him for help? For the sake of the patient, we may ponder the need for a quick diagnosis of his health conditions that are compatible with the demands of an emergency room, with a view to a referral for eventual treatment at a medical surgery. More than other patients who can have their health situation diagnosed as outpatients, these patients are normally out of the system and will never resort to it, except if they see it as an acute need. In the context of an underprivileged population at high risk, this approach is not only justified but can be more efficacious and rewarding than intervening at a later stage on morbid processes with a silent evolution. With regard to therapy involving deprivation of opiates, the logical clinical answer should be provided by a specialised service that offers a low-level replacement opiate, obviously open 24 hours per day. It is difficult to make the distribution of methadone to this population compatible with the context of an emergency room. Accordingly, pharmacological therapy is symptomatic: noradrenergic demonstrations resulting from locus coeruleus disinhibition by means of opiate deprivation can be controlled using clonidine, which is an alpha 2 – agonist, whereas anxiety associated to the experience of deprivation, which is common to any drug-addict, can be controlled with benzodiazepines or tranquillisers, which act reasonably fast when taken orally. Using a placebo by endovenous means reinforces behaviours that we want to stop, given that they add risks to the consumption. It is advisable to refer patients to a drug-addiction unit that is easy to access, and this should be the key point of the medical intervention.
Nuno Felix da Costa, FML
nunofelixdacosta@gmail.com