Nurses tell stories of patients who overdose on illegal drugs in their hospital beds. Doctors fret over patients who come out of surgery, go into withdrawal, and flee the hospital. Security guards stand watch while hospital staff search a patient for pills or bags of heroin.
"Every hospital in the state is dealing with this problem," said Dr. Deeb Salem, co-interim CEO at Tufts Medical Center. "It's more than difficult."
Hospitals say there's been little guidance for them about how to screen patients for an opioid addiction, how to manage a patient in detox while treating injuries from a car accident, for example, and where to make naloxone available. (The recommendation on that last one is everywhere, including hospital hallways, bathrooms and cafeterias.)
To remedy this gap, the Massachusetts Health and Hospital Association (MHA) is out with what it says is the first statewide "guide for patient management with regards to opioid misuse." It's a compilation of protocols collected from 13 hospitals in and outside of Massachusetts.
"Everyone seems to be doing it differently," said Salem, one of the guide's authors. "We wanted to produce a guideline that would help hospitals with understanding and using medications and procedures that would make it safer for the patient and safer for the clinicians taking care of these patients."
In addition to recommendations about screening and managing pain for patients addicted to opioids, the guidelines walk hospital staff who may not have worked with patients in withdrawal though the steps, using medications like methadone or buprenorphine to ease that process.
Patients addicted to opioids arrive at hospitals with many health problems that aren't directly related to drug use. MHA's vice president for clinical integration, Steven Defossez, another co-author of the guide, mentions a heart attack or a gallbladder infection.
"When someone comes into the hospital, if they are addicted to opioids, we know they will go into uncomfortable withdrawal symptoms within a matter of 12 hours or so," Defossez said. "What we wanted to do is develop a very compassionate program of medication-assisted therapy to keep people from going into withdrawal ... and this gives us the first step toward recovery for patients who chose to continue recovery on their discharge."
The guidelines also address some thorny issues.
Here's issue No. 5: Preventing patients from bringing opioids into a hospital.
"Searches," the guide says, "should not be more intrusive than necessary.... [They] should be performed with at least two staff present ... [and] except in an emergency circumstance, the patient must be informed as to the reason of the search."
Visitors known to be at risk for using opioids, the guide adds, should be asked to sign a zero tolerance for drug use agreement that gives hospital staff the right to search the visitor and any gifts they bring. Visitors and patients who violate the agreement may be asked to leave.
Salem, a cardiologist, says that's often a wrenching decision for doctors.
"The sicker a patient is, the harder or more impossible it is to say that 'you violated some of the rules, we're going to have to dismiss you,' " Salem said. "You're caught between a rock and a hard place in terms of trying to do the best you can."
The guidelines include treatment resources, tips about how to deescalate encounters with agitated patients and a recommendation to "closely monitor patients who are at high risk for misuse and harm with 24/7 supervision." Following that recommendation will be expensive.
The guidelines' other two co-authors sare Tufts medical student Ifeanyichukwu David Chinedozi and Megan Fernandez, who's just starting med school at UMass Medical.