Beds, beds, beds — We need more addictions beds

By Austin Lam.

With recent news of a major private donation to transform addictions care in Vancouver, British Columbia, I have reflected on my experiences as a resident physician taking care of patients with substance use disorders.

Drawing from her personal exposure to the devastating effects of addiction through the death of her brother, Jill Diamond reflected on the existing gaps in care and the importance of a seamless continuum of care. She rightly pointed out the need for inpatient recovery-focused beds. This has clicked with a reflection that I have held for this past year: where are our publicly-covered inpatient addiction beds in our hospitals?

Beyond opportunistic interventions, we need systematic interventions. There is a glaring incommensurability between opportunities for intervention and actual intervention needs in substance use disorders in inpatient hospital settings. In the current landscape of opportunistic addiction treatment, a patient is admitted under a Most Responsible Physician (MRP) service, e.g., Internal Medicine, Psychiatry, Surgery, etc. However, we do not have focused inpatient beds with the express purpose to optimize addiction treatment and to arrange appropriate community follow-up.

In the current landscape, addiction treatment teams ‘jump’ on the opportunity to help when requested by the aforementioned MRP services. The teams can then assist with managing substance withdrawal, offer medication therapies, engage in motivational interviewing, and provide connections to psychosocial services. But the addiction teams do not have beds themselves. The length of the patient’s hospital stay is contingent on their ‘primary’ reason(s) for admission or other medical/psychiatric/surgical issue(s) that necessitate continued inpatient treatment — and these may well be the consequence of addiction, such as cellulitis from intravenous drug use. However, substance use disorder is not by itself a reason for inpatient treatment optimization (though collegial work environments offer the opportunity for addiction teams to advocate for longer inpatient stay to optimize treatment, e.g., opioid agonist therapy).

Are substance use disorders not disorders that merit treatment in and of themselves in inpatient hospital settings?

Hence, we are left with a hodgepodge landscape of care, contingent on the collegiality amongst addiction and MRP teams as opposed to a systematic continuum of care that may allow patients who have been medically/psychiatrically/surgically stabilized to then benefit from longer inpatient stay under the care of a specialized addiction team who can focus on optimizing addiction treatment and to engage the patient and their support system (e.g. family/friends) in their recovery journey.

The task before us is not only to meet patients ‘where they are at’, but also to show patients ‘where they can be’ by discovering anew their self-understanding of life goals and larger sense of meaning/purpose. The risk of merely meeting people ‘where they are at’ is that it can objectify people as static entities. We are not static. We are dynamic beings, perpetually engaged in understanding ourselves and our world in the act of living. There is a risk of indulging in the bigotry of low expectations if we view patients as static at their ‘baseline’.

Beyond the laudable and crucial aim of reducing harms, we must encourage and promote flourishing in patients’ lives. Aristotle spoke of eudaimonia; Maslow wrote of self-actualization; and Frankl wrote of the importance of meaning. All these ideas tie to the fact that there are things that make life purposeful. We share common aims as human beings geared towards the discovery of meaning. John Finnis elaborated on the basic goods of human life: life, knowledge, play, aesthetic experience, sociability of friendship, practical reasonableness, spirituality/metaphysical orientation, and partnership. These are the goods that we must promote in conjunction with reducing harms.

Accordingly, the types of inpatient beds we need are not the ones we currently have accessible. Importantly, many patients with substance use disorders do not want addiction treatment or are ambivalent. For the latter, we can lower the barrier to recovery by offering longer inpatient stays with the aim of addiction treatment optimization, continued psychosocial engagement, and arrangement of appropriate follow-up care. We can not only meet the patient ‘where they are at’ but also actively foster recovery: we can identify and work towards the patients’ goals and importantly, support the patient in aligning their goals with what it means to flourish.

Rudolf Virchow, pioneer of social medicine, is quoted as having said: “Medicine is a social science and politics is nothing else but medicine on a large scale … the politician, the practical anthropologist, must find the means for their actual solution”. However, rather than just ‘the politician’, we — as citizens in the public realm — hold the influence to push for change. Our collective society must have the will to invest in inpatient addictions beds as part of a systematic continuum of care. We must strengthen participatory democracy. As John Ralston Saul pointed out, against the specialized nature of non-governmental organizations, “self-interest or business cannot lead in a decent society. Society must lead them”.

 

Author: Austin Lam

Affiliation: Department of Psychiatry, University of British Columbia

The views expressed in this publication are those of the author. They do not purport to reflect the opinions or views of the UBC Department of Psychiatry.

Competing interests: None declared

Social media account of post author: @austinaldenlam

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