Providing care to people who use drugs
by Eva White (she/her) University of Maine Social Work student and Mabel Wadsworth Center intern
Take a moment to consider the following scenario…
A person calls a health clinic and tells the front desk associate they’d like to have an abortion. They estimate their gestation at around eight weeks, they were assigned female at birth, and when asked about prior health conditions, they share that addiction runs in their family. They disclose their insurance information, birthday, address, and any other information required to establish them as a patient at this health center. They tell the clinic they’d prefer a procedural abortion instead of a medication abortion, and they thank the front desk person for their time. On the day of their appointment, the clinical assistant calls them from the waiting room and engages in typical pleasantries before beginning the pre-abortion counseling routine.
During the portion of the counseling wherein the patient is expected to disclose any prior medication use, the patient reveals to the clinical assistant that they injected heroin an hour prior to their appointment. When asked further about their heroin use, it becomes understood that the patient is a regular, recreational user of heroin and other opioids. The clinical assistant asks a few more patient- and condition-specific questions and the counseling portion of the appointment is finished. The clinical assistant leaves the patient to wait for a few minutes while she consults with the doctor about the best course of action. During this discussion, the CA and doctor determine how to safely proceed with the appointment while considering the patient’s individual needs. Now, it is time to administer medications if necessary and continue with the procedure.
Some people may feel judgmental after considering the above scenario. Some may feel shocked that the clinical assistant didn’t abruptly show the patient the door when they revealed their drug use. Some may feel nervous, because if a health center is offering care to someone that uses drugs, they cannot be legitimate and safe…..right?
Now, please consider the following scenario….
A person calls a health clinic and tells the front desk associate they’d like to have an abortion. They estimate their gestation at around eight weeks, they were assigned female at birth, and when asked about prior health conditions, they tell the associate that dangerously high blood pressure runs in their family. They tell the clinic they’d prefer a procedural abortion instead of a medication abortion, and they thank the front desk person for their time.
During their pre-abortion counseling, the clinical assistant takes the patient’s blood pressure and finds it to be quite staggering. The CA asks the patient a few patient- and condition-specific questions, leaves them to wait for a couple minutes, and finds the doctor. She consults with the doctor about the client’s current condition and together, they develop a plan for how to safely continue the patient’s appointment. After a conclusion is reached, it is time to administer medications if necessary and continue with the procedure.
How are these two scenarios different? How are they the same? It is reasonable to assume that for many people, the latter scenario is quite normal. In fact, it would be considered malpractice for the clinical assistant to show this person the door after they disclosed a prior medical condition and still expected to receive care. In fact, it is any medical professional’s responsibility to cater to their patient’s needs. If a patient has an allergy, this is accounted for in their care. If a patient has staggeringly high blood pressure, this is accounted for in their care. If a patient has a pacemaker, this is accounted for in their care. If a person uses recreational drugs, this is accounted for in their care.
The point of this exercise in consideration is twofold. The first intention is to dig up the fact that many people are affronted and almost personally offended by the idea that someone who uses illicit substances has the exact same right to healthcare as someone who has never touched a pipe, needle, or pill. The second intention is to describe exactly why it is safe and legitimate for healthcare workers to serve patients that use substances. It is understandable for someone to wonder if it is safe for a patient to undergo an abortion procedure while on heroin. Are they truly able to consent to the procedure? Is the procedure impossible to carry out because of the drugs in their system?
When any patient is served by a medical facility, the implication is that their care will be catered to them as an individual. If they have high blood pressure, an allergy, a heart condition, depression, or any other medical condition, it is expected they disclose that information to their provider. This is not so that they may be shamed for a lack of exercise, family history of diabetes, or drinking too much coffee; it is because some medications, surgeries, or medical practices are contraindicated when certain conditions are present. For example, in a study on female military Veterans, it was found that 29% of the women presented with a medical contraindication to combined hormonal contraceptive use (Judge et. al, 2018). The contraindications listed were smoking, hypertension, and migraines. The point of this study was not to indicate that people who smoke should be turned away at the door of a sexual health clinic. The point was to illustrate the myriad options these people have other than CHC and how to use these other options safely. Just as with any other contraindication, it is possible to work with and around a person’s drug use to offer them services safely.
Are people that use drugs able to give consent to their healthcare providers? There are forms to sign, medications to take, and pokes and prods that must all be understood and consented to when someone visits any doctor. Sometimes, being high on some kind of substance prevents someone from giving informed consent; their cognition may be impaired, their physical ability to sign something might be hindered, or their emotional state is so heightened that they are unable to listen to and absorb important information. This is not always the case when someone is on substances. Peoples’ capacity to make informed decisions may not actually be affected by their substance use. In fact, if people regularly use or misuse substances, they may not be impaired by those substances and find that they become impaired when sober from that substance. For example, it has been found that regular THC (marijuana) users do not experience acute neurocognitive impairment when given a set of tasks to complete while high on the substance. (MacCallum et. al, 2021). In another study that researched assessments designed to test someone’s decision-making capacity, it was found that in most cases of substance misuse, it is entirely unnecessary to assess their capacity and actually violates ethical principles (Kumar et. al, 2022).
People that use drugs are humans. Humans deserve healthcare and kindness. At any healthcare facility, doctors; practitioners; nurses; and social workers should be trained to serve all populations, including people that use drugs. Doctors are expected and able to work with patients with diabetes, liver failure, blindness, deafness, borderline personality disorder, eczema, coronary heart disease, and PTSD. They spend hours deliberating with nurses about the best course of treatment for patients with contraindications and ask question after question to patients about their needs. They try new medications, use hypoallergenic supplies, and implement trauma-informed practice with patients. Why is substance use any different from another medical need? Substance use is stigmatized to an extent that prevents people from seeking healthcare services because they are afraid of being turned away, they are abused by providers, or their needs are not otherwise met. This is unacceptable, inhumane, and something that must shift in the healthcare field.
Judge, C. P., Zhao, X., Sileanu, F. E., Mor, M. K., & Borrero, S. (2018). Medical contraindications to estrogen and contraceptive use among women veterans. American Journal of Obstetrics and Gynecology, 218(2), 234.e1-234.e9. https://doi.org/10.1016/j.ajog.2017.10.020
MacCallum, C. A., Lo, L. A., & Boivin, M. (2021). “Is medical cannabis safe for my patients?” A practical review of cannabis safety considerations. European Journal of Internal Medicine, 89, 10-18. https://doi.org/10.1016/j.ejim.2021.05.002
Kumar, R., Berry, J., Koning, A., Rossell, S., Jain, H., Elkington, S., Nagaraj, S., & Batchelor, J. (2022). Psychometric properties of a new decision-making capacity assessment tool for people with substance use disorder: The CAT-CAT. Archives of Clinical Neuropsychology, 37(5), 994-1034. https://doi.org/10.1093/arclin/acac010