All of us who work in behavioral health know that the opioid epidemic is possibly the greatest challenge in healthcare today. However, the usual response to opioid overdoses—immediate treatment with Narcan and release—has proven to do little to reduce subsequent drug use or overdose. Recent proposals have suggested that treating drug overdoses like suicides may be one way to help prevent future overdoses and save drug users’ lives.
Drug overdoses kill more people each year than gun homicides and car crashes combined—a staggering 142 people per day die of overdose, two-thirds of them from opioids. From a population health perspective, this crisis has hit vulnerable populations particularly hard. Poverty, unemployment and the helplessness that go with them are closely tied to higher incidence of drug use. The National Bureau of Economic Research found that for every one point that a county’s unemployment rate increases the opioid overdose emergency department (ED) visit rate increases by 7.0% and the opioid overdose death rate rises by 3.6%.
In line with this, Princeton economists Anne Case and Sir Angus Deaton have called drug overdose deaths among people experiencing measurable economic and social deterioration “deaths of despair” alongside suicide and alcohol overdose. While the healthcare system doesn’t traditionally see drug overdose as a suicide attempt, arguably anyone who willfully uses a substance known to cause death does not have great regard for his or her own survival.
This begs the question: Why don’t we routinely treat drug overdoses as suicide attempts? When a person is determined to be an imminent danger to themselves or others—for example after an unsuccessful suicide attempt—they can be held as an inpatient without consent under a civil or involuntary commitment. Laws vary by state. The Treatment Advocacy Center has a helpful chart outlining each state’s standards.
Some states include drug overdoses in their involuntary commitment statutes, meaning that if a person arrives in the ED after overdosing on heroin, the hospital can admit them to a psych unit for treatment whether they want it or not. However, many others either explicitly exclude substance use from their involuntary commitment standards or don’t mention them at all.
While discussion of involuntary commitment can bring up uncomfortable issues regarding civil liberties and autonomy of individuals, one National Public Radio article stated that some drug users might want to be civilly committed because they fear for their own lives, and treatment is otherwise inaccessible. Some areas have begun developing crisis stabilization facilities—non-hospital safe places where individuals who are medically stable can safely wait out a civil commitment while being evaluated and matched up with appropriate long-term services.
What to do
With the caveat that we know that not all civil commitments are created equal, if we could take the best parts of successful civil commitment—immediate treatment, coordinated care and discharge planning—perhaps this may be another way to reach, treat and prevent future drug overdoses among opioid users. Here are some things you can do to help make this happen.
1. Talk about it. Have a conversation with your team and your leadership about bringing a model of care for suicide response into your approach to opioid overdoses. Does this fit with your organizational and/or personal philosophy? How could you put the idea into practice?
2. Advocate for it. If this is approach that you want to try, advocate for it, from your supervisor on up to your state legislators. The opioid crisis is a priority nationwide, so now is the time to take action and spread the message of approaches that you think will work. While Medicaid’s long-term future may be at risk, most states have current grant money to spend from the State Targeted Response to the Opioid Crisis Grants.
3. Take action. If you live a state that includes overdose in civil commitment statutes, work with your local hospital to build an effective, evidence-based emergency assessment that includes mental health and substance use disorder assessment. This approach can dovetail with a hospital diversion, crisis stabilization unit. Ultimately, help the hospital develop a treatment plan, save money, make the most of a civil commitment and save lives. If you live in a state where individuals are not held after a drug overdose, position yourself to become a resource (such as a non-hospital crisis stabilization unit) and a navigator for ED staff and the patients that need treatment after a drug overdose but don’t know how to get it.