Dealing with the dealer

[Tangerine123]

PGY2 at an addictions ward (21 acute "detox" patients + day clinic with 15 patients)

One of our patients tipped us off, that a patient sold him heroin while inside the ward, and that another patient is selling cannabis. We are "aware" of the cannabis situation, because a hall next to our ward has smelled of cannabis for a few days now. However, we have no other evidence to support any of his claims.

The patient being accused for selling heroin was not present today when we found out. He had permission to sleep at home for the night and will comeback tomorrow (Saturday) in the evening.

Since we can't search his belongings in his absence, and since the regular staff comes back until Monday, we won't actively do anything until then. We will then go through the patients' belongings, in a way that doesn't seem like we are targeting the suspect(s).

One of the main reasons to do it discretely, is that the whistleblower fears that he would be in danger if the suspect finds out (the accused patient has a history of violence)

Acute "detox" patients are allowed to leave the ward and roam the hospital grounds the first 3 days. Starting the 4th day they can leave the hospital in the afternoon and must be back by 21:00. After the 2nd week, they are allowed to sleep at home a few times before they are discharged.

We are aware that some of our patients (sadly) sell/buy drugs inside the hospital or in a nearby park. When we have concrete evidence, we discharge them. For example with a positive drug tests, or if we see them doing this.

I'm concerned however, that come Monday we won't find anything while searching the belongings. We will therefore have no evidence to discharge him, so it would boil down to a "he said, she said".

How would a situation like this be handled In your hospitals?

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[TheRightMedication]

I don't have a good suggestion but I want to pipe up to say that either that policy of letting patients leave and return is crazy, or I'm crazy.

I've lost more than one patient to smuggled-in drug overdoses on a general adult unit.

 

[ObsequiousAplomb]

I mean, it is he said she said if there's no other evidence than what one person said. Right?

 

[TexasPhysician]

Policies at this place are stupid.

 

[Stagg737]

Agree the policies are bad, way to lax. Just asking for stuff like OP mentioned to happen and not a place I'd ever work at without significant change in policies.

 

[clausewitz2]

Pretty sure OP is a resident in Germany, which has rather stronger laws limiting the ability to detain people and invade their privacy.

 

[Sushirolls]

If this is a German country/resident, then best to consult with attending and those in Germany for navigating patient rights, civil rights, hospital policies, laws, etc and how they are all intersecting.

The bulk of American diaspora here on SDN will be low yield for solutions.

 

[Celexa]

If this is a German country/resident, then best to consult with attending and those in Germany for navigating patient rights, civil rights, hospital policies, laws, etc and how they are all intersecting.

The bulk of American diaspora here on SDN will be low yield for solutions.

Sushi has the right of it. My reaction after I read this post was that I had nothing useful to say because no where I worked would have a situation anything like this because that degree of patient freedom while on a technically inpatient level of care would be nonexistent.

 

[smalltownpsych]

In the US this situation would not come up in a hospital setting as others stated. Would see it more in residential treatment settings here. I have been very involved in making decisions about these types of issues in residential. I have some general rules that guide me. First, as a clinician, I’m not a cop and my job is not to investigate. Second, just because you can’t act on it today, doesn’t mean that it is ok or allowed and steps can’t be taken to mitigate and protect others until such a time as sufficient evidence does accrue. Third, document the steps that can be taken and are taken and why. I usually had someone in a leadership role that was not a clinician conduct an investigation. Taking the steps, even if they aren’t likely to pay off in the short term is part of the process and will lead to desired result soon enough. Control dynamics get into treatment settings in a big way and then the only solution becomes only do things that will lead to desired outcomes and when that isn’t feasible then they end up doing nothing or just making more and more regulations to try and control the uncontrollable.

 

[birchswing]

In Norway you can even leave prison and report back.

I've long wished I could live in a Norwegian prison—it looks like the ideal rehabilitative place for everything under the sun.

 

[Liquid8]

Leaving the weirdness about letting patients freely come and go from a detox ward aside, If one of my patients admitted to buying (or using) drugs on a ward I’d be discharging that patient ASAP.

Then you deal with the supplier when you have the evidence. That takes away any risk to the whistleblower who has already left unless they’ve done something stupid like swap contact details with the dealer, but if that is the case that is really on them.

 

[calvnandhobbs68]

It’s an inpatient detox unit, why aren’t you guys doing UDS daily or at least every other day to try to catch this? I assume if the person you talked about actually used the heroin you would have caught it on UDS unless the drug screens aren’t being adequately supervised.

I mean this scenario is why you do that, someone continues to do heroin (or likely fentanyl at this point) while you’re actively trying to detox them and other patients, they need to get discharged. Multiple people pop positive and all say it’s the same guy who sold it to them, you probably have enough to d/c him. It’s not a punishment but unfortunately someone who is still using drugs on unit (and obviously selling drugs on unit) is a danger to other patients who are committed or trying to commit to sobriety. They’re also a danger of overdosing on the unit which would be a huge issue for the team and the hospital.

 

[comp1]

Definitely second daily observed UDS for everybody, but if your unit is letting patients wander off, buy drugs and then return to sell them...I'm guessing some administrator there would likely view this as violating the patient's autonomy and privacy. Hopefully you have naloxone all over because I'm sure you're going to be having a lot of ODs. This is just not how US acute detox programs work. If you leave...you've left. It's hard to wrap my head around just the liability that would be involved if they did.

 

[Tangerine123]

Thanks for the responses. Yes, so this isn't in the USA.

More context:

In 9 of our 11 wards, most patients can freely roam within the hospital grounds (garden), or go out of the Hospital and must be back by 21:00. This applies also to the addictions ward. The other 2 wards are acute wards, but not all of the patients in the acute ward are restricted to the ward only. Their "level of freedom(?)" depends on their clinical state. One of the "goals" of most of our wards is to progress patients. From being restricted to the ward (rare, acute wards only) to restricted to the hospital grounds, to being allowed to go out during the day, then being able to sleep at home, and finally discharged.

People's belongings are respected even in acute wards. Patients use their own clothes, have their own bags and a closet, can have their computers etc. Their belongings are checked at their admission, but rarely controlled. Patients have to consent to being searched (unless it's a life threatening scenario) and must be present during the search. In the addictions ward, if a patient objects to being searched, we take that as a relapse and proceed accordingly.

At the addictions ward. We do UDS when we admit a patient, and then in specific circumstances, but we don't do it on a regular basis. We would, for example, do them if the staff has the clinical impression that the patient has consumed more/something additional; of the patient admitted that they consumed something. If the patient wants to stay overnight with their family (we would test the next day) etc. If the patient objects to having a test, we assume a relapse occurred and proceed accordingly.

(Usually) Patients that have a first relapse have to discuss the event with the ward's physicians and psychologist, to identify why it happened and ways to avoid this again. After a second relapse we discharge the patient. This however varies on the severity of the event and the specific patient. We've done discharges after 1 relapse, or kept people after 2-ish etc.

As far as I'm aware of, the ward's attending has been there for 20 or so years. There's only been 1 case of an OD so far, and the patient survived.

To follow up on the events today. We searched the rooms, found alcohol, Benzos, Pregabalin, cannabis but no heroin. We proceeded to discharge the people that had these in their possession.

 

[calvnandhobbs68]

To follow up on the events today. We searched the rooms, found alcohol, Benzos, Pregabalin, cannabis but no heroin. We proceeded to discharge the people that had these in their possession.

lol wonder what else you'd find if you did more investigating of what comes in and out of the unit and did UDS regularly.

The fact that you guys found that much stuff and had to discharge "people" (implying more than one person) seems to be itself a problem and seems to indicate you're tolerating people actively continuing to use various substances on an acute detox unit. It doesn't seem that this would have even been found out if this patient hadn't "tipped you off".

 

[comp1]

This whole thing is so trippy. What is the point of these units? Just do a PHP and have the person sleep at home. The whole point of a residential program is to seclude the person from the world, their triggers and DRUGS for a limited period of time. This whole step up and down program where you're mixing different levels all together is just the recipe for chaos that you're seeing develop.

 

[Stagg737]

Pretty sure OP is a resident in Germany, which has rather stronger laws limiting the ability to detain people and invade their privacy.

If it's not a voluntary program or is court mandated, then sure. If this is a voluntary treatment program then it shouldn't matter. Either the patients agree to the rules in place (ability to leave, drug tests, searching possessions, curfew, etc) or they get discharged. Period.

To follow up on the events today. We searched the rooms, found alcohol, Benzos, Pregabalin, cannabis but no heroin. We proceeded to discharge the people that had these in their possession.

Imo that's completely unacceptable. Doesn't matter if the attending has "only had one overdose in 20 years". How many patients has he "treated" who were just using while staying there? Crazy.

This whole thing is so trippy. What is the point of these units? Just do a PHP and have the person sleep at home. The whole point of a residential program is to seclude the person from the world, their triggers and DRUGS for a limited period of time. This whole step up and down program where you're mixing different levels all together is just the recipe for chaos that you're seeing develop.

What OP described sounds like the old school institutions my dad used to work at in the 70's. Sounds like a great place for patients with SMI without an SUD to gradually gain functioning while getting treatment and reintegrating into society for long-term success. Sounds like an absolutely awful method for treating SUDs and a great way to destroy the therapeutic environment that residential/inpatient substance treatment is supposed to provide, which is obviously happening if staff found that much contraband from a single day's search.

 

[Tangerine123]

I agree with many of the post above. Honestly I've become really jaded, dislike the ward/patient population. I wasn't allowed to switch wards and had to do an extra 6 months here. If I'm not allowed to switch soon, I might just quit and continue my training in another hospital.

 

[Ceke2002]

PGY2 at an addictions ward (21 acute "detox" patients + day clinic with 15 patients)

One of our patients tipped us off, that a patient sold him heroin while inside the ward, and that another patient is selling cannabis. We are "aware" of the cannabis situation, because a hall next to our ward has smelled of cannabis for a few days now. However, we have no other evidence to support any of his claims.

The patient being accused for selling heroin was not present today when we found out. He had permission to sleep at home for the night and will comeback tomorrow (Saturday) in the evening.

Since we can't search his belongings in his absence, and since the regular staff comes back until Monday, we won't actively do anything until then. We will then go through the patients' belongings, in a way that doesn't seem like we are targeting the suspect(s).

One of the main reasons to do it discretely, is that the whistleblower fears that he would be in danger if the suspect finds out (the accused patient has a history of violence)

Acute "detox" patients are allowed to leave the ward and roam the hospital grounds the first 3 days. Starting the 4th day they can leave the hospital in the afternoon and must be back by 21:00. After the 2nd week, they are allowed to sleep at home a few times before they are discharged.

We are aware that some of our patients (sadly) sell/buy drugs inside the hospital or in a nearby park. When we have concrete evidence, we discharge them. For example with a positive drug tests, or if we see them doing this.

I'm concerned however, that come Monday we won't find anything while searching the belongings. We will therefore have no evidence to discharge him, so it would boil down to a "he said, she said".

How would a situation like this be handled In your hospitals?

How do the other patients feel about situations like this? Is there any chance of perhaps getting patients on board to confront these sorts of situations themselves? The reason I ask is when I was going through treatment for addiction in South Australia (methadone, outpatient, but knew some people who did inpatient treatment as well) treatment centre staff didn't really have to do anything in regards to dealers, because the patients took care of that themselves. We did have some patients, and dealers, trying to sell heroin outside one of the methadone clinic I attended, and every single one of them were run off by other patients, without the Pharmacist on duty having to life a finger. When someone was in treatment, and genuinely trying to get clean, it was considered absolutely unacceptable for someone to try to deal to that person within the confines of, or vicinity of a treatment centre. Obviously it still happened, but if you got caught then you were lucky to get off with a warning.

 

[Candidate2017]

Arguably, OP's issues are better answered by their institution and their society. Western Europe is rather permissive, and for all we know, everyone gets a couple ounces of weed and free needles upon checking into a facility.

OP should speak with their attending. But perhaps OP posts these questions because they feel the current norm of their societal practice environment is flawed. In which case, there's nothing to do. Just follow the norm, collect your 55k euro salary and take a couple months' of vacation like most western Euro doctors. I hear the Alpine skiing season is approaching?

It seems across different countries, the issues with practicing psychiatry have nothing to do with psychiatry but rather the issues within that particular society and the burdens it imposes upon psychiatrists.

 

[ObsequiousAplomb]

I'm curious, was the patient who had been accused of being a dealer one of the ones with contraband? How about the one who did the accusing?

In my (admittedly limited) experience, when patients accuse other patients of being their drug dealer, it's more likely an interpersonal dispute and/or the accusing person is the one found to have been selling the drugs than it is for the person accused to be the dealer (so long as only one person is accusing).

 

[PsyDr]

Simple solution:

Assign staff to a 1:1 observation at all times.

Probably not great for the heroin business.

 

[comp1]

I do like the idea of the OP being frustrated by society more than their particular institution. I do disagree that there's nothing to do. There's always SOMETHING to do...

 

[PsyDr]

 

[Tangerine123]

Personal Update:

I will rotate to the closed/acute ward on Thursday. Probably for the next 5 months. I'm really glad about this, because I fell like I need the experience. However, we will be (sadly, but non surprisingly) understaffed for now. I have 25 vacation days left this year. Let's see how that pans out.

The reason I was kept "hostage" in the addictions ward was because according to a few attendings, my German language skills aren't "optimal..". Progress and discharge notes here have a lot of copy-paste and psychotherapy isn't really a thing when compared to other wards. For context, I'm a non-native German speaker, that started learning German back in 2019. So I re-enrolled in an evening course for now.

it's really interesting to see how different countries have different views, rules and expectations on such subjects. I'll try and inform myself better regarding the situation here. Thanks!