Message in a bottle
The science of modern medicine now has huge knowledge about the ill effects of sudden withdrawal of addictives but the world of modern hospitals has not been able to come to terms with the challenge of stopping them suddenly
Sanjay Nagral
Mar 27, 2023, Hindustan Times
Ravi was my patient for a long time . A young shopkeeper from Madhya Pradesh, he was suffering from a condition called chronic pancreatitis. The main feature of this disease is paroxysms of excruciating pain which travel from the front of the belly to the back. We operated on him eight years ago but his pain came back. We tried nerve blocks and all pain killers available. He needed several admissions just for pain killer injections as tablets wouldn’t work. Like many others with this disease, he was at the complete mercy of pain killers.
The last time he was in hospital there was a strange event. One night, I received an urgent call from the chief of security of the hospital. ‘Sir we have caught Ravi red-handed’. ‘Patient caught red handed’. Sounded bizarre. ‘With what?’ I asked. ‘With a bottle of whisky in the bathroom’ he said. “We will have to take action. We must immediately discharge him”. “Let me sort it out tomorrow’ I requested. The next day when I went to see him, a sheepish looking Ravi said ‘Sorry doctor, I made a mistake’. I have been consuming alcohol for years. It is the only substance that soothes my pain. I can’t sleep without it. If you want to punish me please discharge me ”. I met the superintendent to explain the situation and pleaded with her not to discharge him.
People with addictions are admitted to hospitals for a variety of reasons not necessarily related to substance abuse. This includes alcohol. This is suddenly stopped on hospitalisation. This results in an acute withdrawal state which presents a parallel challenge. Though it can be controlled, the delirium, tremor and rowdy behaviour is a big task to manage. It even interferes with treatment of the primary disease. Patients have pulled out tubes and ripped open their dressings after surgery. But it’s not just alcohol. Other regular addictions causing withdrawal get abruptly terminated in the sanitised regulated world of hospitals. Smoking, tobacco, sleeping tablets, pain killers and even caffeine. Withdrawal is an illness added to the illness.
If we take a broad view of addiction, most of us suffer from it in some form though we may not label it as such. I am used to a cup of tea as soon as I wake up. I get a headache if I miss it. The science of modern medicine now has huge knowledge about the ill effects of sudden withdrawal of addictives but the world of modern hospitals has not been able to come to terms with the challenge of stopping them suddenly. The forced cessation has major impact on sleep and mental peace both particularly important during an illness. Do hospitals have this mandate? Is it public service to stop habits during an acute illness or is it just a self image that cannot come to terms with patients continuing what gives them a kick that is in play here? Whilst practices differ in parts of the globe it would be sacrilege to think of Indian hospitals allowing a drink or a smoke to those who are regular users. Is it time to begin to ask the difficult question why not?
I remember the news of how a group of patients admitted to a Covid isolation facility were caught ‘smuggling’ alcohol into an isolation centre. Yes it was called smuggling. We know how patients during Covid in isolation suffered loneliness and even depression. For those who love their daily peg or smoke it must have been much worse. At least during normal times there is family to meet and talk to. The practice of Intensive Care Units to allow only momentary interaction with family has really no logic and is slowly changing in the Western world. But our ICUs are even more restrictive. Family members pleading with security at the entrance of ICUs is indeed a pathetic sight.
The other part of the healthcare ecosystem which has weaponised addictions to deadly effect is health insurance. It’s almost as if they first search for the word alcohol and smoking in the patients’ papers and mindlessly link it with all sorts of disease to reject the claim. As a result, agents, patients and even doctors have learnt not to mention these deadly words lest the claim be rejected. There needs to be a thoughtful debate about why addictions even with some connection to the disease should be grounds for total rejection? Isn’t addiction a disease? Is this some kind of punishment to add financial injury to the illness?
Addictions are a huge public health problem which demands urgent attention of health systems and strategies. They contribute a large part of a country’s disease burden. But that is different from punishing patients. More ominously, such practices have a whiff of captivity to them which is the last feeling an intimidating health facility should be giving. Henry Marsh, a well-known British neurosurgeon, in his latest book ‘And Finally’ has talked about his experience as a patient who has been diagnosed with advanced prostate cancer. In a scathingly candid part, he rues the fact that he was guilty in his career to be part of a system with lots of rules and regulations which has made hospitals resemble prisons.
The hospital industry in India has a new buzzword called ‘patient friendly’. Spas and restaurants are being added and everyone is welcomed with practised politeness. What patients may want though is very different. Feeling as normal as they can. This means meeting friends and family, eating good food and taking a walk in the hospital garden if there is one. And occasionally even a small glass of wine or a puff. So that they don’t do it in the bathroom. Because hospitals are neither schools nor prisons.