You can lead a horse to water…

It has been a while! I have been on a very busy rotation, combined with Match Day (yay!) and getting ready to move (double yay!). I wrote this during my last rotation, on high-risk obstetrics, and it never made it up here, so here it is now. Enjoy!

The debate of the day in the residents’ room today has been whether to discharge a particular patient. This patient came in, pregnant, because she had been a heavy heroin user for the past year and she wanted to stop. She went cold turkey at home and was brought to us vomiting, shaking, and only somewhat coherent. She didn’t want to participate in an outpatient methadone program, which she saw as “just trading one addiction for the other” – she wanted to be completely drug-free.

So she completed a short methadone taper, and now she is getting ready to go home. The residents say that she is off methadone now (she received her last dose yesterday), so she can go home with medications to control her symptoms: clonidine for anxiety, zofran for nausea, indomethacin and tylenol for aches. We aren’t doing anything for her in the hospital that can’t be done at home, and this is the maternity ward of a county hospital, not a drug detox center.

The nurses, on the other hand, are afraid of what will happen when she walks out the front door. The patient is uncomfortable. Even with the medications, she is a bit anxious and feels a bit nauseated. She isn’t throwing up on the floor, she isn’t shaking, she isn’t unconsolable, but she is definitely uncomfortable. They argue that when the patient leaves the hospital, she will go right back to heroin.

We encouraged her to go to an outpatient methadone or suboxone program, but she refused. We encouraged Narcotics Anonymous, and she was skeptical. The county offered her a place in a residential home for pregnant women with addiction, but she would have to participate in the methadone program in order to stay there. Instead, the patient chose to stay with a friend and try to go it alone.

The question that this leaves me with is more of a societal issue than a strictly medical one. Relapse rates for heroin addicts run anywhere from 70-90% based on some sources. If this woman has a 90% chance of going back to using heroin when she leaves the hospital then can we, in good conscience, let her go home?

On the other hand, what right do we have to restrain a woman who appears rational and who wants to go home? As a society, are we willing to spend the money that it would cost to keep this woman in the hospital until she delivers? How much money will it cost us to take care of a child with in-utero heroin exposure? What if he is born addicted and has to stay in the hospital for supervised withdrawal? What if his mother goes back to heroin after delivery? How much money will we spend on the foster system, special education, and maybe eventually putting mom or baby in jail? Can we afford NOT to keep her in the hospital?

What do you think?

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