panel of discussants, Dr. Pinals, Dr. Prout, Dr. Wise, Dr. John Renner is our moderator. Today we'll be discussing a case of in-hospital substance use and the use of civil commitment for substance use disorders, which will be presented by Dr. Connie Schauer. She is a fellow in addiction psychiatry at Yale New Haven Health. Her professional interests include medical education, health equity, integrated care, health policy, and advocacy. I'll turn it over to them, thank you. Great. Great, thank you so much. Yeah, before I get started, I wanted to ask the panelists to all introduce themselves as well, starting from Dr. Pinals. Hello. Good afternoon, everybody. My name is Deb Pinals, and I am a forensic psychiatrist. I am the Senior Medical and Forensic Advisor for the National Association of State Mental Health Program Directors, and also hold the role at University of Michigan, where I'm the Medical Director for Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services, and the Director of the Program in Psychiatry, Law, and Ethics, and Adjunct Clinical Professor. Good afternoon, everyone. I'm John Renner. I think I know a lot of people in the audience. I'm at Boston University. The Boston VA, I've been helping with the Addiction Psychiatry Fellowship there for many years, former president of AAAP, and I'm delighted to be here, and I'll be a moderator today. Hi, I'm Dr. Tiffany Prout. I am a Consultation Liaison Psychiatrist at Henry Ford Hospital in Detroit, Michigan, where I work with Michigan State University and Wayne State University. My primary role is 100% consultation, where I do psychiatry and addiction consults. I'm Carol Weiss, Clinical Associate Professor of Psychiatry and Psychiatry and Medicine at Weill Cornell Medical College in New York. I'm also the Associate Medical Director of the Weill Cornell Medicine Center for Trauma and Addiction. Great. Thank you all so much for being a part of this case conference. So today, I'm going to talk about a case from my residency, and I really look forward to y'all's thoughts and good discussion. So in-hospital substance use and the use of civil commitment for substance use disorders. I have no disclosures. Learning objectives, we're going to describe the significance of in-hospital substance use and examine whether current practices are effective in promoting patient safety and reducing harm. We're going to discuss the utilization, evidence, and ethics of civil commitment for substance use disorders. And we're also going to discuss considerations for treatment, including involuntary treatment of patients with trauma history and substance use disorders. So this case, Anna, her chief complaint, I want to finish my antibiotics. So Anna is a 37-year-old woman. She has a history of opioid and cocaine use disorders, injection drug use, incompletely treated MRSA, MSSA, endocarditis, with severe tricuspid valve regurgitation, L4, L5, chronic osteo with discitis, untreated hep C, who presents to the hospital to complete her course of IV antibiotics one day after eloping from another hospital. And she also has the midline in place from the other hospital. Psychiatry was consulted for management of opioid and cocaine use disorders and whether to execute a physician's emergency certificate, or PEC, due to concerning behaviors on previous admissions. And just sort of a timeline of Anna, it appears that about 18 months prior to when I met her, she first presented to an outside hospital, was diagnosed with MSSA, infected endocarditis. She left that admission with her PICC line in place. And then shortly after that, she went to another hospital to complete her IV antibiotics. They did start buprenorphine for her, that admission. There was concerns for PICC tampering. She would take long smoke breaks, miss IV antibiotic dosing. They banned her husband. She was smoking marijuana in the hospital room. So there were a lot of concerning behaviors there. But ultimately, it looks like she was discharged to LTAC. Following that admission, she had a lot of ED presentations for overdose, and other sequelae of substance use. And then about three months prior to this admission, she represented to another hospital, this time with both MRSA, MSSA, endocarditis with septic pulmonary emboli. And she had a number of admissions during the past three months, usually leaving the hospital with a PICC line in place prior to treatment completion. And this current admission, you know, again, she had just left the other hospital the day prior, also with a midline in place. So I was on a CL at the time, and when I met with Anna, she said that she last used heroin and cocaine through her midline yesterday prior to arrival. This was about 20 hours ago. She says that she left the other hospital because that location of that hospital triggers her to use. She said that she goes outside for her smoke breaks, she, you know, in that areas where she does sex work and also purchases her drugs. She nonetheless says that, you know, I really want to complete my antibiotics. She declines buprenorphine, but she has some interest in methadone. She denied any cravings or withdrawal symptoms, and she also denied any psychiatric symptoms. And really, you know, she was like, you know, I'd really like to be left alone. In review of systems, she was complaining of back pain from the disguise, otherwise didn't have any bladder bowel incontinence, numbness, tingling, focal weakness, and the rest of her review of systems was negative. For her substance use history, she says cocaine is actually my drug of choice. Spending about $500 a day, injection only, and she says that because of, you know, the supply being laced with heroin, she also uses heroin mostly to avoid withdrawals every two to three hours, probably about $200 to $300 a day, also injection only. She smokes a pack a day, and she denied significant, you know, other substance use. Treatment history, she said that about 15 years prior, she did, you know, go to an opioid treatment program and was on methadone for about a year, maintained eight years of sobriety while attending NA meetings. She said that she's tried Suboxone in the past, but she really prefers methadone. Her psych history was really unremarkable. Her social history, so she is a white woman from New Orleans, grew up kind of in the Shreveport area, really traumatic childhood. She said that her father and aunt sold her body. She described having like a pimp when she was 13. She dropped out of school, started injecting drugs, and just a lot of intimate partner violence during that time, and she currently, she says that her main support system is her current common-law husband of about 20 years almost, and they live in, you know, I guess a nice abandoned house, just a lot of housing insecurity, and she does earn about $1,000 a day from sex work. So vitals were, yeah, and mental status exam, pretty unremarkable, you know, she said that she was pretty comfortable, and the cows that I measured was four, and so again, this is a patient who says that she has to use every two to three hours to avoid withdrawal, so the concern was, you know, she's probably using in the hospital, but my recommendations to the team, I didn't think she met PEC criteria. She's not suicidal, homicidal, nor gravely disabled, so this hospital, we didn't have addiction consultation services at the time. We weren't using buprenorphine or methadone, and so we were really managing opioid withdrawal and opioid use disorder with non-opioid comfort medications. No psychiatric medications needed as she denied all symptoms, and I said, you know, I told primary, you know, you can manage her pain with, you know, she was lacking opioids, you know, as needed. And then over the weekend, I was not there, but Anna was found somnolent with decreased responsiveness. She responded to IV Narcan, and a PEC was issued for danger to self and grave disability, and so the PEC process in the state of Louisiana, you know, you have to be either dangerous to yourself, to others, or gravely disabled, and you have to be either unwilling or unable to seek voluntary admission, and so with the PEC process, there's no visitors. She can't leave her room. She can't go outside to smoke, and she also has a one-to-one sitter at bedside. And then, you know, a week later, you know, we decided to extend, you know, file a petition for judicial commitment for danger to self, and I told her that day that we were doing this, and this was a very controversial decision at the time, and later that day, the primary team notified me and let me know, like, hey, she tried to run overnight, and at this point, Infectious Disease is recommending eight weeks of IV antibiotics, and when I had talked to her, she kept saying, you know, I came here voluntarily. She was crying. She said, I just wanna smoke. I just wanna see my husband, and in the affidavit for the petition for judicial commitment, we said that she met criteria for danger to her self, her failure to complete a course of treatment and repeated episodes of relapse on drug use despite life-threatening complications demonstrate evidence of her clear danger to her self as a consequence of her addiction, and, you know, even though she said that she wants to be here to complete her IV antibiotics, we said that she's unable to seek voluntary admission as a direct consequence of her addiction. And so, the judge agreed, and the judicial commitment was approved for eight weeks for her to complete treatment of her infection. Interestingly, so, and this is important, the petition for commitment was not for the treatment of her substance use disorder. It was for the treatment of her infection, but she met criteria for judicial commitment because of her substance use disorder, and again, we don't have the best, I mean, we didn't have addiction consultation services, and really, we just treated her with oral naltrexone. She was allied with the oral naltrexone. We also didn't have Vivitrol, and for those eight weeks, it was really difficult. You know, she was, every day, we tried to engage her in her substance use treatment, but she cried every day, said that she really just wanted to see her husband. She really wanted to smoke. She would promise us, I promise I'm gonna come back. I promise I'm not going to leave again. Psychiatry reduced visits to one to two times a week. CT surgery was consulted. They did not want to pursue tricuspid valve replacement for her severe TB regurgitation, and IDU recommended outpatient referral for the treatment of her hepatitis C, and so after completion of eight weeks IV antibiotics, she was discharged with oral naltrexone and referrals for outpatient substance use treatment. So what happened after discharge? So two weeks after completing her eight weeks of IV antibiotics, she was brought to the ED by police after being found injecting drugs in a grocery store, and she continued to have acute care presentations. Interestingly, the acute care presentations had decreased during COVID, and during this time, New Orleans was providing housing to a number of people and providing housing to unhoused individuals, which I think just says a lot about how housing can really prevent folks from seeking acute care services, and then about 20 months after the submission, she came back again with infective endocarditis, and at this time, it's not the recommended treatment, but she was discharged with weekly IV dalbevansin and oral doxycycline and flagyl, even though that's really not first-line treatment, and she did not follow up in the ED to get the IV dalbevansin, and then after that, she continued to present with sepsis and bacteremia, and I know that before I graduated from residency, I saw that she also started to present to the hospital again for her infection. Okay, yeah, so this was in 2018. At the time of Anna's commitment, we did not have any providers prescribing buprenorphine. We didn't have anyone specialize in addiction. Really, PsychCL, we were frequently consulted for folks with substance use disorders, and even though we couldn't provide evidence-based treatment, I think it was, I think this is a difficult patient population, and so that's why a lot of primary teams wanted us involved, and we did end up getting an addiction medicine fellowship the 2018 to 2019 year, and while we do offer buprenorphine induction in the hospital, we still don't initiate methadone in the hospital. There's only one OTP in New Orleans. It's across the river, and at the time, too, we didn't really have places to refer outpatient for folks who didn't have private insurance for buprenorphine, and Louisiana continues to lack resources for treating patients with substance use disorders today, and so now, we're gonna shift gears to our panel discussion, and I'll invite Dr. Pinell to talk about civil commitment for substance use disorders. How does involuntary treatment of substance use disorders versus general psychiatric disorders vary across states? What are some forms of compulsory treatment, and has mandated treatment been shown to be effective? Great, thank you so much. Well, first of all, let me just ask, how many people are here not from the United States? Raise your hand if you're not from the United States. Okay, so actually, I'm gonna give you some exercises. Can you stand up? It will be easy. You won't have to do jumping jacks. Okay, can you stay standing if your country has a civil commitment provision for people solely due to substance use disorders, not mental illness? Stay standing if you do. Okay, now, everyone from the United States, stand up. And stay standing if you are in a state that has a civil commitment law for substance use disorders, not just mental illness. Stay standing if you have such a law, for example, Massachusetts, Florida, Louisiana. Okay, so about 50% of the people, probably more like 63% of the people, last I counted, would have sat down. We have statutes like this in about 37% of states. Now, stay, don't, don't, don't, don't. Stay, for those of you that are standing and you have such a law, please stay standing if that law is widely used. Okay, so here you have the landscape. Okay, thank you very much, you can all sit down again. This is, you know, triple AP, they like to move around. This doesn't happen in forensic conferences, we sit still. So what you saw in this exercise was the variability of how civil commitment for substance use disorders is used really around the world, and frankly, around the United States. There's about, I don't have the latest count because laws come and laws go, but about 37% of the states have a law. Many of the states that have such laws do not actively use them. So I actually now am living in two states. If I had a substance use disorder like this woman, in one state I would be civilly committed to a place where there would be a rigorous treatment. I'll talk about the co-morbid medical condition, which creates another problem or challenge for policy makers and for providers in these states. But in another state, in Michigan, although we have such a law, if my family were able to pay for the treatment, I might be able to be committed, but the law's not really used because there isn't really a mechanism or a place to commit people to, which is the case in most states where it's not utilized. It's sort of one of these laws that's on the books, but because there isn't really a place, it's not, or a mechanism or a protocol, it's not really utilized. So it's sort of an interesting thing, how do we have laws that we don't even follow? It happens. And so I also wanna just point out something that, hold on, I just was, to prepare for this, wanted to read to you. In 2019, the American Psychiatric, oh, let me ask another, I won't make you stand up. Raise your hand if you think that these laws should be available. Okay, put your hands down. Raise your hand if you think these laws should not be available. Okay, so the majority of people who raised their hand said they should be available. That's consistent with other studies of physicians that are in favor of these laws until you start to unpack what these laws actually mean. In 2019, we raised this issue at the American Psychiatric Association Council on Psychiatry and the Law, and we passed a position statement. So if any of you are members of the APA, you should know that there's official policy on this, and the official policy is that, essentially, all states should assure that persons with SUDs have adequate access to high-quality treatment services across a continuum, and services should include consensual medication for addiction treatment in conjunction with psychosocial interventions for all persons with opioid use disorders and for persons with other SUDs for which medication is an effective component of treatment. And the next part of the position, which is official APA policy, says, although voluntary SUD treatment delivered in accord with evidence-based practice is known to be effective, the effectiveness of civil commitment for SUDs has not yet been demonstrated by generalizable research. Additionally, jurisdictional differences in implementation of such statutes and the type of treatment provided in the program to which people with SUDs are committed make comparisons difficult. And then finally, the last part of our position at the APA is that in the absence of more substantial evidence of effectiveness, the APA neither endorses nor opposes SUD commitment statutes. However, states that operate SUD commitment programs have a responsibility to assure that they satisfy four important conditions. First, that they should conform to applicable medical standards, provide high-quality evidence-based treatment for persons subject to such commitment, and otherwise protect such person's legal rights. Seamless linkages to care during and after the commitment period should be an integral part of the program. Second, they should monitor quality and specific outcomes, including reducing the likelihood of relapse, preventing overdose, and improving functional status. And third, these programs should be administered through health systems rather than correctional systems. And fourth, these programs should receive dedicated funding and not divert funds or resources from other mental health services. So that is the official APA position. So what do we do in a case like this? Here you have a woman with a very complex history, now with complex medical conditions. Very often, where there is civil commitment for substance use disorders, where people go are not going to be level 4.0 type facilities, where you can provide very IV antibiotics and that sort of treatment. So then you get into the logistical problem of what is really the commitment anyway. Now here you had a person who it seems like the judge committed her and she stayed for the first course of IV antibiotics. Frankly, she didn't have to stay probably. She could have, I mean, what would have happened had she not stayed? I don't know what would have happened in Louisiana had she not stayed. I mean, she would have potentially been held in jail for contempt, but then not gotten her IV antibiotics or maybe gotten her IV antibiotics in jail. I mean, it's really hard to imagine what would have happened with those logistics. So for about eight years, I ran the forensic services in the state of Massachusetts for the Department of Mental Health and was overseeing our court clinic services. And court clinics are a bit of a misnomer. We didn't provide actual treatment in those clinics. We provided evaluation, consultation and evaluation to judges. And Massachusetts is one of the states that most heavily relies upon its civil commitment statute. And in those days, that's in fact part of the reason why I ended up becoming a member of AAAP and became addiction medicine certified was because the opioid crisis was hitting. And my clinicians, who were non-physicians largely, were getting inundated with more and more and more of these evaluations. The statute in Massachusetts had been constructed probably to deal with chronic alcohol use disorder, but now we had an opioid crisis where the risk of death was much higher. And the concordance rate between filing a petition and having somebody committed was nearly 100%. You almost didn't need clinicians. Because even when the clinicians said they weren't committable, the judges were so worried that they got committed anyway. In those days when I started, the people were being committed to the prison system for their treatment. And where the men were getting some treatment, but the women, because of a different litigation where there was a class action suit that said the prison system isn't the appropriate place for substance use treatment. For the women, they would be warehoused because there was a settlement agreement that said there wouldn't be treatment provided. So when I worked at the women's prison, we had women that were committed, again, no crime. So substance use disorder, housewife, let's just say, husband worried that she's drinking, not taking care of the children, putting herself at risk. Pregnant woman with intellectual disability, just thinking of a couple of cases that we dealt with with severe alcohol use disorder, and also pretty significant intellectual impairments committed because they were afraid she wasn't taking care of her unborn child. These are the kind of people that would show up in the women's prison for, quote, treatment where they weren't allowed to be treated. Now, fast forward to what I would say is probably my career highlight still to this day, where there was litigation, a new governor, and legislators who really wanted to change this equation, and we were able to create, it's a long story. If anyone wants to hear it, I can certainly share it over a drink of water. Long story short, through funding, legislation, and frankly, having somebody who had then become addiction qualified and knew a little bit about treatment, built a program that I still don't think is a totally evidence-based program, but at least what we were able to support was having people committed to a non-prison setting where there would be full access to medications for opioid use disorder, a full array of treatments, family supports, visitation, counseling, as well as, and this was another thing that got debated in the budget, we insisted, because of some other work I had done with prison reentry and some of the data that showed people that got civilly committed, also were at risk of overdose when they left because they weren't connected to care, we put in these transitional supports of case managers and peers that would follow people upon discharge out into the community for up to six months to help make sure that they were connected to care. Now, I left the state of Massachusetts. I haven't tracked the data on how that program has progressed, although I do know that money has now been funded for men to be in the same type of setting, and they're using a similar treatment model. You go to another state where commitment will occur, you hear about what happened in Louisiana, and somebody would just tell me when my time is up, I'm happy to stop, but another state where there's a statute that allows for the commitment of pregnant women for the duration of their pregnancy, but offers no treatment. So part of the impetus for the APA statement was to say, look, if we're gonna think that this is the solution to the opioid crisis, and more states are gonna be passing these laws, which more states have passed these laws, we better make sure that there's treatment that becomes available for people when they get committed. We don't know that these commitment laws work. One could argue that they actually make things worse, especially if treatment is not provided during the commitment period and after the commitment period. I mean, we know just from how we know about addictions that continuity of care is critical. So I would just say that there's many statutory differences. We also have to think about different substances. When you look at the data, there's studies on people's thoughts about should you have commitment for marijuana, should you have commitment for cocaine use disorder, opioid, are these the same conditions, and would civil commitment be the same remedy? So there's many policy questions out there. There's many variations in practice, and we actually, I mean, the most important thing I can tell you to think about is if you are using these statutes, which when you're in the state, you worry you're gonna be negligent if you don't use the statutes, but the job I think we have is advocating to make sure that whatever we're using, that the patients are getting the right care in the settings and under these constraints of civil commitment if they're gonna be utilized. And I'll stop there. Thank you so much, Dr. Pinells. Next, we'll talk about the problem of in-hospital substance use. I will say, when I presented this case at a few different places, and some folks didn't really understand how somebody could leave the hospital with a PICC line in place, and then I realized that many hospitals, people can't even leave the floor to smoke or anything like that. You would have to sign out AMA. The hospitals that I'm used to working at, people can go out and smoke whenever, and sometimes they just don't come back. And yeah, so next we're gonna have Dr. Prout talk to us about consultation liaison psychiatry. How should primary teams in the hospital be advised regarding management of in-hospital substance use? What are the range of policies regarding in-hospital substance use and treatment of opioid use disorder? And how can treatment policies for substance use disorders, including harm reduction, be promoted in the hospitals? Thank you. Is it on? Yeah, okay. So, consultation's a funny role because I always say that as a consultation psychiatrist, I really have two patients, the patient and the primary team, and often they each need an equal amount of my time. And when we get a consult for a patient that's used substances in the hospital, primary teams are upset, they're angry, they're frustrated, they feel like they're not being cared for and they're frustrated. They feel like they're trying to save someone's life and the patient's doing everything they can to sabotage that. So, usually when we get this sort of consult, I will meet with the primary team, sometimes even before meeting with the patient, and just normalize the reaction that they're feeling, the distress they're feeling. The nurses are usually in a tizzy, documenting all over the chart, all of the things that the patient's doing that everyone's mad at. And just normalize, like, it's normal that you're frustrated, it's normal that you guys feel that this patient's not doing their part, even though you guys are doing your part. And also just reminding them of how common this is. It depends what study you look at, but up to 50% of patients that have substance use disorders admitted to using in the hospital at some point during an acute care stay. So, I tell them, you know, the fact that you guys actually identify this is a good thing because there's way more people in this hospital that are using substances that we don't even know about. So this gives us an opportunity to kind of intervene. The use of substances in a hospital relapses. They're an expected outcome of a substance use disorder, just like DKA and type 1 diabetes. It's normal, this is what we deal with, and to start in that way, I think, helps calm the emotions at times and allows us to be a little bit more productive. It's important to acknowledge that using drugs in the hospital, obviously, it has a lot of risks and a lot of liability for your hospital. So overdose, infections, death. That's what the teams are worried about. That's why we're angry at the patient for using. But that said, the reason that patients often use in the hospital is because of stigma. And that's what they'll say, you know, I really wanted to come to the hospital to get these antibiotics, but I'm not gonna tell anyone that I have a substance use problem or that I'm using because in the past, I've been called a junkie. I've been ignored by my doctors. I've been treated not as good as other patients. And that's really where the behavior comes from. I think if we start to approach them in a more empathetic way and be proactive early on in the hospitalization, and just talk to people, you know, we want to help you, what can we do to not have this happen? It can really change the sort of course of things. The patients themselves often feel like ashamed, hopeless, guilty, and I'll remind the teams of that as well. Like as bad as you are feeling, as mad as you are, often the patient is five times more mad at themselves. This is embarrassing for them. And ultimately, it really affects like their health. So when we get this sort of thing, the other thing we do is really try to figure out like what, why, why are we using the hospital? And this can be a variety of reasons. They may have pain that's not treated or it can be undertreated. They may be in withdrawal and nobody treated it. They may just want to get high and they're not ready to quit. We have to figure out first what that reason is and then try to address it with a consultation. It's not a perfect science, obviously, but if we can figure out what's motivating the behavior, sometimes we're at least able to intervene to get the person through the hospitalization and ultimately, hopefully, get their medical problem treated which is why they're there. I will go on to the second question about policies. So my own hospital does not have a policy for in-hospital substance use. We have some policies regarding opiate use treatment. We're allowed to do buprenorphine, sounds like similar to your hospital. We're not allowed to start methadone. These are both much more restrictive than the laws in my state. And I don't know how many of you spend time in your hospital's policies, but I feel like I spend a lot of time in there trying to figure out where it comes from and try to understand it. And both of our opiate use disorder treatment policies were created by a member of our legal team and two pharmacists. There's no physician on the committee. There's nobody that's treating addiction. There's no patients, there's no families. It's these three people that got together and decided we're not going to offer methadone. It's frustrating, it makes me angry and I think the policies in a hospital are often to reduce a hospital's liability. They're not really for patients. So I think that's the first thing that I think we can all really try to advocate for is to let's make our policies more patient-centered, let's get their experience, let's talk to families about their experience and let's have an addiction medicine doctor also here to try to make these policies. Because there's not policies, I feel that the reaction to in-hospital substance use can range from all over the place. I've had a patient that was there admitted for a bone marrow transplant. She was a donor for her brother, had known stimulant use disorder, alcohol use disorder and the team had basically a plan with her where she'd leave six hours a day, do whatever she wanted to do, come back because they really wanted this bone marrow transplant. Everyone was just kind of okay with it. We kind of turned the other way and ultimately the brother was able to get the transplant. I've also seen the other end of the spectrum where I had a patient that used heroin in the hospital and they restrained her, gave her a sitter, allowed no visitors. They took away a coloring book because the nurse said, well, what if her drug dealer's phone number is written in the coloring book? So just, I mean, this is just one single hospital, like the range of things that people can do to react. So it is important to have these policies but we do want them to be patient-centered, not punitive. Those measures are never gonna work and we wanna involve the patient when we can. If I have somebody that is ready to start treatment, ready to start the recovery process, they may be okay with a unit-based restriction but I would want them to be in on that decision with me, not just, you know, chastising them for doing the wrong thing and then putting them on unit-based restrictions because that doesn't really help anybody. So the patients have to be involved in the conversation. And then I guess that kind of leads way into the harm reduction question. So harm reduction is really important. It's, I think of harm reduction as practical strategies that can reduce the negative consequences associated with substance use but don't mean recovery or abstinence because as many of us know, our patients are not always ready for that. And being able to take a more harm-based approach can actually allow us to feel successful because instead of us saying, well, this is what we want you to do and this is what we think is best, we're able to say, where are you at in your recovery process, what are your goals? And then when they meet those goals, like, okay, I'm gonna take buprenorphine in the hospital so I can take my antibiotics. I may discharge and I may wanna go back to what I was using before but my goal is just to get through these antibiotics. And then we can both feel good about that even if they decide that they wanna still use when they leave. Harm reduction policies are things like having sterile needles, having sharps containers available throughout your hospital, information given to patients about alternative routes or safer routes of use, having a safe room for using if we're really being more liberal about our approach. So anything that we can do to reduce the negative consequences but maybe doesn't mean recovery. I feel like substance use disorders are one of the only disorders that we treat where we become so punitive and expect perfection from our patients, whereas we would never turn away somebody that came in for a COPD exacerbation that continues to smoke. And I think talking to your hospital and primary teams about that issue can sometimes help them conceptualize why we think this is so important. So I think that's all I have. Thank you so much, Dr. Prout. And then finally, we're going to get to our last discussion before opening it to the floor, trauma-informed care, with Dr. Carol Weiss. What are the implications of involuntary treatment for patients with a history of trauma? And are there any guidelines or best practices of trauma-informed care in substance use disorder treatment? Is the mic on? Okay, great. Okay, well, this is a very overwhelming case on so many levels. And before I get into talking about trauma-informed care, I first want to delineate how the goals of this case, or the goals of treatment in this case. Well, the patient's goals are clear. She says she endorses a strong desire to complete her antibiotic treatment. What are the goals of the treatment team? Primarily, their goal, like hers, should be to complete her course of IV antibiotics. This is a CL case, after all. In my opinion, a secondary prevention goal might be to facilitate or provide a bridge to ongoing addiction treatment or follow-up. But first and foremost, we need to get her through this medical situation in any way possible, and ideally without involuntary commitment. So, what is trauma-informed care? This is a phrase that's used very widely, very broadly, and it needs to be differentiated from trauma-specific services, which we won't be talking about. The trauma-informed approach consists of two fundamental principles. Number one, the primary goal of the trauma-informed approach is to avoid re-traumatizing a person, which in this case is exceedingly difficult. The second fundamental principle is implementing the trauma-informed approach requires change at all levels of an organization, which in this case is also very relevant. There are various more detailed explanations of what is the trauma-informed approach, and I'll briefly read them, but because this is a discussion and not a PowerPoint, please don't get too hung up on them. Some refer to the four assumptions of trauma-informed care, or the four R's, and the six principles of trauma-informed care. The four R's are realization about trauma and how it can affect people in groups, two, recognizing the signs of trauma, three, having a system which can respond to trauma, and four, resisting re-traumatization. The six principles are safety, trustworthiness, transparency, peer support, collaboration and mutuality, empowerment, voice and choice, and cultural issues. But again, for purposes of our discussion, let's just remember the two fundamental principles, avoid re-traumatization, and implementation requires change at all levels of an organization. So now let's turn to our case. What do we know about Anna's trauma? She has at least four areas of trauma. One, she has significant childhood trauma. She witnessed domestic violence between her parents, who also abused her. Her father and aunt sold her body when she was 13 and got her involved with a pimp, who she later married. When she was around 17, this was a three to four year relationship during which there was significant intimate partner violence. Sex work trauma. She reported sexual assault with this work, people not paying her, being incarcerated after performing sexual acts with law enforcement. On the other hand, she also felt aligned with the sex work is real work movement. Medical trauma, very well described already in this case. And then a category we can call other trauma, which I assume is full of things that we're not even aware of. Dr. Sau informed me that she had two children in her mother's custody with whom she had no contact. One of them died from an overdose. What signs of trauma do we see in Anna? Of course, the signs of trauma are commingled with the signs of substance abuse disorder in this case. Many of the signs look the same. Autonomic arousal, restlessness, irritability, hypervigilance, impulsivity, heightened startle. But the most prominent manifestation of trauma in this case is her inability to complete medical treatment. She does not feel safe in the hospital. In the presentation we learned that she reports leaving the prior hospital because the location of that hospital triggers her to use. And feeling trapped and powerless were primary experiences of her early trauma and are now re-experienced by losing agency and autonomy, which is characteristic of any confined hospital environment. However, in this instance that re-experiencing is further heightened by the involuntary commitment. Her current partner of 17 years is the only person with whom she feels safe, but he's not allowed to be with her in the hospital because he's usually intoxicated in the hospital and antagonistic toward the staff. Although he does advocate for her needs when she's hospitalized, he doesn't like her to be hospitalized because among other reasons she's the primary breadwinner of the relationship. But most familiar to us as addiction practitioners and already stated is we understand that she leaves the hospital or uses while she's in the hospital because due to numerous reasons outside of our control, including the regulations of her state, she's unable to receive appropriate management of opioid dependence during her medical hospitalization. More about that in a moment. Right now let's give a moment to also consider the trauma of those caring for her. Trauma-informed care also recognizes treating the treater. Dr. Hsiao wrote me in an email as she read to you during her eight-week admission she became even less engaged after her commitment, cried almost every day, begged us to let her husband visit and to let her smoke, promising she wouldn't leave. It was difficult for everyone involved. I lost a ton of sleep over this case. This brings us to the second fundamentals of trauma-informed care. Remember the first is thou shalt not re-traumatize. Number two, implementing the trauma-informed approach requires change at all levels of an organization. Dr. Hsiao explained that no, at the time of this case, no one in the hospital could prescribe buprenorphine. At a later date when they could, they had to connect with an OT program that was very far away on the other side of town across the river on the West Bank. Methadone, she was told it was not legal to prescribe it and if she could, they had to be connected to an OTP, which didn't exist. Catch 22. Here we see the moral injury of the caregivers. Unable to provide appropriate care, being placed in a circumstance where involuntary commitment is the only option, having no alternative but to re-traumatize someone with PTSD. Because the institutions where the caregivers are bound do not have systems in place for reasonable care. Dr. Hsiao wrote in her email to me, I can't tell you how glad I am to have pursued fellowship training. I'm learning and unlearning a lot. I realize now that the Northeast is the exception, not the norm. Lastly, what are some examples of utilizing trauma-informed principles in this case? A few suggestions. One, body before brain. That is trauma, like panic, is experienced physiologically more so than cognitively. Many of you are familiar with the popular PTSD guidebook, Bessel van der Kolk's, The Body Keeps the Score. So number one, minimize autonomic arousal. Primarily, we do this by managing withdrawal and physical pain, which we couldn't do in this case. There are also other somatic interventions. If possible, introduce Anna to engaging with her body in grounding, soothing ways. Perhaps start the session with a brief breathing exercise. Introduce her to other somatic awareness exercises or the concept of imagery. Two, wherever possible, engage and problem-solve collaboratively. For example, what do you need to stay one more day? Focus on short-term achievable goals like physical comfort. Ask her what went right today, what went wrong. Provide reassurance and encouragement. Three, if possible, during interactions, set aside the medical agenda. Instead, engage and reinforce in positive ways. Learn about the strengths or resilience of the patient. Communicate empathy and, if possible, admiration. Finally, recognize the trauma of the caregivers, especially in this case, Dr. Hsiao. Help her cope with the moral injury of working within a system wherein causing harm is embedded in providing care. Okay, thank you very much, Carol. Very provocative. I think we'll all agree that this is a really complicated case. Very difficult to manage, yet I see two things here. There was a combination of skilled medical care and state powers used to adequately treat her medical condition. I mean, she stayed for the time she was in the hospital, and then she got sick, and then she got sick again, and then she got sick again, I mean, she stayed for the time that they had her, she got that treated, but what they didn't do was deal with the trauma or deal with the addiction. And I think there were a couple of problems, one of which was, from my understanding, they could have prescribed buprenorphine or methadone if they wanted to, if they'd gotten the training or the right people, and I think we have a responsibility as clinicians to deal with both our hospitals and our states that are not really permitting us to provide the care that we want to provide and that we could provide. I mean, there is nothing in the law, for instance, that would have prevented them from prescribing methadone to her as a secondary treatment while she's in the hospital being treated for a primary condition. That is perfectly legal, yet somehow they were told that wasn't legal and couldn't be done. Well, that was not correct. So I think that raises some real questions about the system and the addiction part of her treatment. I mean, I would look on an event like this as an opportunity. We have two months to work with a patient, we could provide therapy, we could have worked to get her on medication, we could have worked to get her eventually in long-term treatment so that by the time she leaves the hospital, she can begin more extensive treatment for addiction, but that didn't happen. I think we really dropped the ball in terms of the addiction treatment. So those are my comments on this, but I would now like to open things up to the audience. If anyone has any questions or any comments, please go to the microphone. We'd be glad to hear. Hi. A great presentation. I'm Jen Creeden. I'm addiction and child and adolescent psychiatry at LSU in New Orleans. So familiar with kind of the landscape and its changes over the last few years. I was wondering, kind of off that point, knowing that different hospitals in the city have different ranges of willingness and ability to prescribe, particularly buprenorphine. Do you know, in that timeline, which was really great, do you know if she was ever willing to be prescribed buprenorphine and if there were any differences in like, if she was in a hospital where she could obtain it, if she was able to complete treatment versus leaving AMA? Dr. Cheryl? Yeah. So there were some hospitals that were offering buprenorphine at the time. I think, yeah, UMC was the first, and that was maybe a couple of years prior to this. So a lot of the residents were a little confused when they switched between UMC and Tulane. And so there were times that she really refused buprenorphine. And my suspicion is that she wanted to continue to use her own supply in the hospital. And just looking, doing a deep dive through her chart, it looks like there were times that she would hide the buprenorphine and continue to use her own supply. Yeah. And a lot of times, whenever there was interventions in place, for example, a behavioral contract or placing a hat in the toilet to start collecting urine, drug screens, she's out of there. Thanks. But was she using the buprenorphine to supplement the fact that she wasn't being treated adequately? I think she had, on some occasions, used buprenorphine. But there were also some times that she declined buprenorphine or she accepted it, and it would be found hidden somewhere else. Over here. Hi, Ken Rosenberg from New York City. I wasn't sure whether I should sit down or stand up when you asked if we had outpatient treatment. Now, it's interesting because I'm an addiction psychiatrist, and I know a lot about what's called assisted outpatient treatment. In fact, there was a big to-do in New York City, and just today, there's a demonstration against it, sponsored by the National Alliance on Mental Illness. And I have visited and spent many hours in AOT, Assisted Outpatient Treatment Court, but that's only for mental illness. And I understand that for mental illness, people are diverted from the criminal system or into a therapeutic system. But I have no idea if that exists for my specialty, so I'm wondering if you could tell us. And I know one of the reasons it works, AOT and mental health courts work, is because you have ACT teams. Some of you may be familiar with this. Teams are going to swoop in and provide housing first, provide good treatment, they get people to the top of the list for treatment. But I have no idea if that exists in what we all treat, you know, primary disease. Yeah, thank you for that question. Each state is so different. And some of the laws, like it looked like in the Louisiana statute, which I've not read, but it looked like from the slide that was presented from Dr. Hsiao, that it's embedded in the same statute, but you could use the rationale, the nexus of the dangerousness, the danger to self or others, was either substance use or mental illness. In some states, substance use is excluded as a basis for civil commitment for mental illness. And in some states, there's a totally separate statute. Some of them are in public health codes, some of them are in mental health codes. And so sometimes clinicians don't even know. If you don't know it, it probably means it's not utilized all that much. And it is true that AOT and civil commitment to inpatient units for mental illness is, you know, that's pretty much bread and butter of psychiatry that we do in every state. There's a long history of ambivalence about what to do with substance use disorders going back to very early times. And again, it goes back to the idea of, is this volitional, that, you know, the state's authority can control behavior, or is it medical, you know, is it something that needs treatment or punishment? I mean, we have been all over, we have inchoate policies, but that goes back to the 1800s. If you're interested after this, I can provide you with some references. Or Thompson Hall and Applebaum wrote a great history of the civil commitment of substance use disorder, and there's a paper that I wrote with some colleagues looking at the landscape as of 2014. So if I may follow up just very quickly. So is there a civil commitment in the New York metropolitan area? I can't speak to New York statute. Specifically, I haven't practiced in New York. So I don't know. Every state is so different. I wouldn't want to cite one state statute that I'm not familiar with. Thank you. Over here, please. Hi, I'm Lily Bajocki. I'm an addiction medicine physician, actually, and I did my training at the University of Florida. The PHP program that's associated with it provides housing and is known to treat physicians, lawyers and professionals, and they actually have a pretty good model. So anytime they have a suspicion that one of their patients in PHP would have any sort of craving, or they hinted that they were going to leave the facility, they were seen by an addiction psychiatrist, and they were seen by an addiction psychiatrist, and they were seen by an addiction psychiatrist, and they were seen by an addiction psychiatrist, and it's variable, and I think it goes to what happens with that commitment and trauma-informed practices, and a lot of the commitment practices across the board say the more people are thought to be treated fairly, explained, given choice within the non-choice, then they may find it less coercive in general. Thank you. Over here, please. Hi. My name's Eric Bartman. I'm one of the fellows at Columbia. So in your presentation of this patient, it seems to me that it wasn't ever conceptualized as an issue of capacity, and I'm curious why or why not, and what may make you consider it as a capacity issue. Yeah, that's a great question. Yeah, so we were saying as far as like voluntariness, because she's saying, you know, voluntarily, like, I definitely, you know, want to be here. I guess it was conceptualized too as, you know, she lacked the capacity to voluntarily stay there, and because of her addiction. If I could just jump in on that, I'd like to challenge that a little bit, Dr. Hsiao, because I think what the civil commitment is separate from somebody's capacity to make a decision, and the civil commitment is only, as you said in the law, it's only related to whether the person, due to their substance use disorder, is a danger to themselves or others or presents a risk of harm. The capacity assessment, it sounds like this patient was not viewed as somebody who needed a guardian to make decisions for her, that she was able to understand the risks and benefits of the IV treatment and wanted the IV treatment, and so that would be a separate issue. One thing I would say is that's another tricky area where you have people who, you know, may have those faculties and be able to make decisions and not have decision-making impairment. If you have somebody that does have decision-making impairment, say they're, you know, having, of course, a cough, dementia, you know, whatever the issue is that's causing that, even if a guardian authorizes the treatment, you still have the logistics of keeping a person who is ambivalent about care at best and traumatized at worst, you have the logistics that you have to manage. So I really appreciated Dr. Weiss's holistic framework. Thank you. Question, please. I'm Douglas Alexander, addiction psychiatry fellow in New Orleans. Peer support is a really big, important part of recovery from substance use. You know, the 12 steps are an important part of AA and NA, but so is walking into a room and feeling understood by the other people in the room. We're seeing more and more ACT teams around the country integrate peer support specialists and peer support liaisons as a way to gain the trust of patients and build rapport with patients. It seems like it would be an easy thing to do. Why don't we see more of that in hospitals? Is there any evidence for use of that in an acute care setting? We actually just started a peer support team in our hospital about two years ago, first in the emergency room, and it's been extremely successful in terms of getting people, especially like residential treatment. They really mobilize their supports. They'll provide transportation to the patients. It's been so successful that we've tried to steal them for the floors to come see our patients, and we just have way too much business. So that's actually one of the things that we're trying to lobby at our hospital, is getting more peer supports. Like I would rather have eight peer supports and one of me than another addiction psychiatrist at times. For us, it's been really wildly successful so far. Thank you. Over here. Hi. Matthew Rotnick. I'm a faculty at NYU School of Medicine and private practice in the city. For 14 years, I worked on the CL service at Bellevue. This was a fantastic case. Thank you, everyone, for presenting it. Certainly complicated. It reminded me a lot of some of the cases we had over the years. I have a few thoughts. One is, for purposes of the conversation, I wonder if it wouldn't be useful to speak in terms of substance-related disorders rather than substance-use disorders. For example, substance-induced cognitive disorder, substance-induced psychotic disorder. And I think if you do that, sometimes at least, in some cases, it makes things clearer. That the reason that we're considering civil commitment is not the substance-use itself, not the behavior, but the consequence. That is, when somebody is sufficiently cognitively impaired, that we can demonstrate that. And also, that hopefully, with some time, there would be resolution or at least improvement. Same with psychosis. That is, if we focus on the psychosis, focus on the cognition, we can bypass some of the complexity about freedom of choice and free will and all that. One of the things that we would do oftentimes on the CL service, again, a lot of interstate variability here in terms of what is permitted. We might deem someone not to have capacity to sign out AMA. From what I understand, that operates within a gray zone of the law. And I think that probably, had we not been working at Bellevue, with that Bellevue City Hospital patient population, had we been at a private hospital, we may not have been able to get away with that. I think that's a big part of this conversation as well, the socioeconomic piece. There are some patients, despite the complexity, who also have access to attorneys who might not act in their best interest but be able to get paid. I think that's a piece of the complexity here. That's it. Thanks. Thank you. Hi, yes. My name is Jennifer Malone. I'm a psychiatrist practicing here in Florida. I work exclusively with firefighters and their families. Substance abuse and trauma are things that I take care of all day long. I really appreciated your presentation, and I found it so validating as a provider. Thank you. The reason I braved this very anxiety-provoking microphone is your presentation reminded me of something Ellen Sachs, the psychoanalyst and civil rights attorney and patient with schizophrenia, she had said once, talking about commitment, that someone should only be committed once. After that, there should be sort of an advance directive made once the person is mentally well, saying, what would you like me to do in the future if this happens? I wondered if that could apply in cases like this patient, or in general for patients who are being civilly committed from substance abuse. Thank you. I'll just do a quick answer on that. There is something called psychiatric advance directives. It's usually thought about for people with serious mental illness, but many states have separate laws that include something that's called a Ulysses contract, which means when they're being committed, they can't undo what they said. It's a little clause so that it helps you when they're in that psychotic or mental state where they're changing their mind and you're trying to implement the treatment. But you can look and see if your state has that. It's an interesting thought to use it for people with substance use disorders. Carol, did you want to? Yes. I do love that Ulysses contract notion. I use it a lot in my treatment with substance abuse disorders. But as far as the Ellen Sachs book, she also spoke at Grand Rounds at my institution years ago. I was very much affected by that. It was really profound in terms of the impact that civil commitment has on somebody throughout their life. I see this so much also with patients where, as young adults, their parents have had them forcibly sent into treatment. And God knows I understand how and why that occurred and that it may have needed to occur, but we don't really fully appreciate the lifelong negative implications of having done that. Yes, there is the thank you principle, and I am involved in mandated care. In child custody cases, for example, and other forensic matters where there often is a thank you at the end. But there are many circumstances where it's not really clear that we have achieved much. Again, let's remember in this case we wanted to get her the IV antibiotic treatment. She did get that. That was a success. She may have said thank you for having, she did. So we got the thank you there. So, you know, in some cases it's worth it, in some cases it's not. We have time for about two or three more questions. Thank you, Rick Reese from Seattle. A couple of things that are absolutely crazy about how we do things. There are about 50,000 suicides a year. There's well over 100,000 opioid and other related overdoses a year. There's also hundreds and hundreds of millions of dollars spent in substance-related sequelae in trauma hospitals. I work in a level one trauma center, and about two-thirds of the people that are admitted to level one trauma centers, and that's studies from Harborview as well as several other level one trauma centers around the nation, show that somewhere between half and two-thirds of people admitted to trauma centers and burn units are admitted directly related to substance things that range from auto accidents to gunshots to falling off ladders while drunk, et cetera. So we spend, we have many, many thousands of acute care psychiatric units with civil commitment laws. We have almost no civil commitment centers for substance use. However, it's much more costly economically, and it's more deadly. So how we adjust, it's 1,000 to 1 in terms of spending on substance-related, shall we say involuntary treatment units to psychiatric treatment units, but the data has nothing related to that. That's just absolutely crazy. Yeah, I mean, I think that is a really interesting comment. It also presupposes that the civil commitment for substance use disorders works. And if it works, then we should have more. Well, nobody's doing it, so you can't measure it. Well, there are studies that look at outcomes related to inpatient for psychiatric conditions, but we don't have studies for substance use disorders. If it works, then, yeah, we should be funding it, and we should be passing statutes, and we should be implementing it. Well, we don't actually know what the structure of an involuntary substance use disorder situation would look like. Well, that's the problem. Rhode Island has something that looks pretty good, which is if you're committed around an illegal kind of act, you actually go to an involuntary unit, i.e. prison, with integrated addiction treatment and case-managed follow-up afterwards. So there are some models. No, there's definitely models. I don't think we want to have the prison be the place to do the actual treatment. Well, if it's an illegal activity, it makes sense. Yeah. But the idea that we're going to make a lot of— by the way, I don't know, how many of you have worked on an inpatient psych unit in the last little while? And most people I talk to around the country, about half, somewhere between a third and a half of the admissions over the last year or two or three are methamphetamine-related psychoses that either happen independently over time, because meth is ten times more available, ten times cheaper, and so we've got a lot more substance-related, as somebody well put, psychoses that are eating up psychiatric units. No, this is—and that's why in the APA statement we said we need more resources. I think we need more research. We need more research on inpatient psychiatric care that's— I mean, there's no question that you're bringing up excellent points. I can tell you, sitting at state policy tables, these are exactly the conversations we have. And then you have a limited budget, and you have to decide what you want to spend it on, and we don't have the data, so go do—we need more research. Another question over here, please. Yeah, John. Jim Halicus. I'm frankly shocked that they didn't start her on methadone by day three. I mean, these are internists trying to treat the cardiac status, and she needed the maintenance treatment. You wouldn't withhold insulin with a blood sugar of 500 just because you haven't really addressed that. And then the second thing is, during her eight weeks of IV treatment, it doesn't sound like she got any pharmacologic supportive care, antidepressants, mood stabilizers, things to calm her down, non-addicting anti-anxiety drugs. Something as simple as gabapentin might have done a lot. And then, before you start, it looked like from your history, and it went pretty quickly, she had a long period of abstinence. You described eight years, whether it was close to that. Unless she spent that in jail, that is a really useful bit of information. Finding why and how she maintained her abstinence then would be useful down the road, but not in the treatment. Yeah, these are all really great comments. Yeah, first about the eight months of sobriety. I did do a deep dive in the chart. She reported that. It wasn't true, but she did go to outpatient clinics, and she did have a lot of follow-up. And probably by the time we saw her, she's only been in acute care settings for several years. It was eight months or eight years. So I looked through that time. There were still a lot of ED presentations for overdose. So she wasn't clean. Right, right. So I don't think it was true that she reported eight years of sobriety, but it wasn't true. But she was engaged in outpatient care for some time. And then for the methadone, I mean, I've never seen methadone started in the hospital. I was told it wasn't legal. I believed this up until recently. How could it not be legal for a doctor to prescribe an appropriate medication? One more question, then I think we're done for the day. Hi. Jared Weiss, fourth-year resident in Queens, New York. The harm reduction discussion during inpatient care, the idea of providing clean needles, safe injection space, I mean, to me it's a radical idea, but it makes a lot of sense, right? We'd rather these patients come and get there. Even if they're not ready to stop using, we want them to get their antibiotic treatment so they're not dying out there. Is this something that's actually been implemented anywhere? I mean, I can certainly imagine a buy-in administratively, legally, in terms of liability for hospitals. Even though the clinical rationale is sound, I'm wondering if there's been any framework for that established. There are. They have it in Vancouver. They have almost like heroin clinics where you can go and get government-made heroin, that you know exactly what you're getting, you get a clean needle. And I think in some European countries as well that are much more liberal in terms of policies. It brings up a good question because even if we're keeping people alive, I think is that a way that someone wants to live? And I think that's why we have to involve the patient. What are they willing to do? What's the kind of life you want to live? Would you rather have it this way, or do you want to take your chances? And so, Brian, if you think you can't maintain it. I think we'll have to stop at this point. We've run through our time. I want to thank the audience. I think this has been a really provocative presentation. Raised lots of questions. I'm not sure we answered all the questions, but I think the point is that we have our work cut out for us. There's lots to do. And I want to thank the panel for some really wonderful presentations. Thank you. It was very nice to be here. Thank you.

substance use

hospital setting

civil commitment

harm reduction strategies

trauma-informed care

patient-centered approaches

evidence-based treatment

sterile needles

comprehensive approaches

treatment decisions

trauma implications