Commitment to assessment and treatment: comprehensive care for patients gravely disabled by alcohol use disorders

Abstract

In January, 2009, a 32-year-old chronically homeless intoxicated man, found unresponsive in urine-soaked garments on a New York City street, was brought to the Bellevue Hospital Emergency Department (NY, USA) and pronounced dead from hypothermia. Our inability to prevent his tragic death—despite 428 previous emergency department visits and nine intensive care admissions, including one for hypothermia—prompted us to rethink our standard of care for such patients. Patients with severe alcohol use disorders who present frequently to the emergency department are too often dismissed as “chronic public inebriates”, “drunks”, or “frequent fl yers”. This pejorative terminology minimises the severity and complexity of alcohol use disorders; reinforces patient and clinician perceptions that recovery is unlikely; and fosters a defeatist, irresponsible “treat and street” model. Although these patients are regarded by many health-care providers as distractions from the real work of the emergency department, they are just as valid as every other attendee and should not be considered with learned helplessness or therapeutic pessimism. Comprehensive assessment and treatment that addresses medical, psychiatric, and social problems can improve health and social outcomes. For some patients, this approach might only be possible with involuntary commitment (ie, therapeutic detention). We argue that the present situation is unsustainable and that medical practice, social services, and the law should change to enable patients who are gravely disabled by alcohol use disorders to receive the care they need. More than 80% of countries have legislation for compulsory care for addicts. These laws—and societal attitudes—vary greatly, ranging from retributive to therapeutic. Many statutes are outdated, ambiguous, or defi cient in safeguards. In response to these concerns, legislative reform and innovative, promising models of care have emerged; a recent comprehensive assessment of policies, practices, and outcomes in New South Wales, Australia, led to substantive developments in involuntary commitment practices, which are generally viewed as successful. By contrast, in New York City, which is otherwise characterised by forward-thinking public health initiatives, the capacity to retain patients was recently constrained by a local court statement that alcoholism is not a committable mental illness. To better understand these vulnerable patients, we used administrative databases to identify frequent Bellevue Hospital emergency department users diag nosed with alcohol use disorders for a 2-year period starting in 2008. 51 extreme users visited the emergency department at least 10 times in each year, with an annual mean of 37 visits, 20 inpatient days, and US$75 723 in hospital costs. Since even more health-care services were provided by other hospitals, these fi gures greatly underestimate total costs. Usually, the patients are collected from the street, typically in an unresponsive and profoundly intoxicated state, and delivered to emergency departments (although occasionally they self-present, seeking care). Almost always, they are discharged quickly with documentation citing “non-adherence” and “against medical advice.” On average, they have six comorbidities (92% have psychiatric diagnoses and 41% focal brain injury) and an annual mortality rate of 8·6%—more than 20 times their expected age-adjusted rate. These people are gravely disabled by a confl uence of biopsychosocial factors that are often oversimplifi ed as severe alcoholism. They characteristically have physical and brain disorders, cognitive and psychiatric manifestations, and social dysfunction, which arise from or compound their alcoholism (panel). Although per sistent inebriety contributes to and can be reinforced by these comorbidities, in some patients, alcohol con sumption is no longer excessive. To address these appallingly poor health, economic, and social outcomes, the Bellevue Emergency Department collaborated with other hospital departments and community agencies. The focus was on comprehensive assessment, coordinated treatment, and discharge plan ning, and involuntary commitment when necessary. Extreme alcohol users with a grave alcohol use problem were added to an alert system and received enhanced multi-institutional services upon arrival at the emergency department. 14 people for whom previous measures had failed were involuntarily committed to inpatient care. The admission allowed the team to identify and address consequential coexisting conditions and to develop coordinated discharge plans. Seven of the 14 patients were connected to community services and discharged into supportive housing facilities (six progressed to permanent housing and attended outpatient care; one was struck and killed by a train). Of the other seven, fi ve were too impaired to function independently (two were transferred to state psychiatric institutes, one to a nursing home, and two refused placement and were released to the street after the local court statement precluded involuntary commitment for alcoholism). Of the fi nal two, one was discharged to residential addiction treatment and reconnected with her family, and one died from alcohol-related causes shortly after discharge. Complex, multidimensional illness—particularly when it encompasses impaired insight and self-care—needs Lancet 2013; 382: 995–97