The Consumer Product Safety Commission maintains the National Electronic Injury Surveillance System, a massive, anonymous database that tracks why Americans show up to the ER. That includes cases where someone arrives sheepish, uncomfortable, and very aware that gravity is not a valid explanation. Every year, doctors log what they find. Every year, the list gets longer.

Medical journals have been documenting the trend for decades. A study in the American Journal of Emergency Medicine estimated nearly 39,000 hospital visits per year related to rectal foreign bodies, with most patients middle-aged and male. More than half involved sex toys. The rest fall into a category best described as “how did this even occur?”

Researchers note that many cases escalate because people try to fix the situation themselves first. Pliers, tweezers, coat hangers, and other tools frequently appear in follow-up imaging, which explains why doctors beg patients to stop improvising.

So what exactly made it into the official records last year? Here’s a rearranged selection of items doctors reported removing, pulled from government data and emergency medicine case studies.

Some of the worst items found in People’s butts

• A full shampoo bottle, listed twice, once blamed on boredom
• A baseball, documented with the explanation “to see what it felt like”
• A corn cob holder
• A turkey baster
• A wine stopper
• A plastic cleanser bottle filled with liquid
• Eyeglasses
• A rock
• Two pencils
• A vape pen
• A flashlight
• A battery-powered light
• A film canister
• A rectangular travel toothbrush
• A dog chew toy
• Uncooked pasta
• An egg
• Marbles
• A sandal
• A doorknob
• Beard clippers wrapped in plastic, cited as constipation relief
• A light bulb, inserted glass-side first
• A plastic coat hanger, altered so the person could drive to the ER
• A corn-cob style pipe
• A thermos, discovered during a police body scan

Emergency physician Kenji Oyasu, who works in Chicago, summed up the situation in a viral TikTok when asked about the strangest object he’d ever removed. It was a full-size Yankee Candle. “The desktop jar,” he said. “The whole thing.” He explained that suction turns removal into a medical problem, not a pulling contest.

Doctors stress that these cases aren’t common, but they’re common enough to keep appearing in peer-reviewed journals. They also tend to get worse the longer someone waits.

This isn’t about shaming people. It’s a heads-up that, if you decide to stick something questionable where the “sun don’t shine,” the government will write it down for the world to see. 

The post The 25 Worst Items Pulled From People’s Butts in 2025, According to the US Government appeared first on VICE.

It should be noted, though, that we are nowhere near epidemic levels, as it remains quite rare and only affects cannabis power users.

CHS is an unpleasant side effect of a person’s plan to chill out with their favorite cannabis product of choice. After years of heavy cannabis use, a small but growing number of people will suddenly find themselves experiencing waves of nausea, abdominal pain, and vomiting so violently that it’s accompanied by a terrifying scream, hence the nickname “Scromiting” — a screaming vomit.

Episodes can last up to two days. Hot showers seem to be the only reliable form of short-term relief, and a lot of them. The only reliable long-term fix anyone has stumbled upon so far is the most obvious one: stop using all forms of cannabis, immediately.

Publishing their research in JAMA Network Open, researchers reviewed a national database of emergency department visits between 2016 and 2022, using cases that included both cannabis use and cyclical vomiting syndrome as a proxy for CHS, since it only recently became its own official diagnosis. They counted around 100,000 suspected cases in that period.

Rates were steady and low…and then 2020 hit, and suddenly CHS visits spiked across the country. Not sure what could’ve happened in 2020 that would’ve made everyone want to get out of their own heads for a couple of hours or maybe two straight years, but whatever it was, cases started dipping back down in 2022, though not quite back to the old levels.

The good news is that CHS is treatable once it’s recognized. Unfortunately, it’s often not recognized at all, and its symptoms can be easily misconstrued as something else entirely, leading to a battery of unnecessary tests.

Hopefully, that era is now over, as CHS is officially included in the International Classification of Diseases. Let’s just hope medical professionals brush up on all the latest diseases.

The post Cannabis Users Are Scromiting Uncontrollably, and It’s as Gross as It Sounds appeared first on VICE.

Dr. Darren Lebl of New York’s Hospital for Special Surgery told The New York Post that “a lot of patients come in and challenge their doctors with something they got from AI.” About a quarter of those “recommendations,” he added, are made up.

Research published in Nature Digital Medicine this year found that most major chatbots no longer display medical disclaimers when giving health answers. That’s a big problem.

Here are a few real-life cases where AI’s bedside manner went south fast.

1. The hemorrhoid from hell

A Moroccan man asked ChatGPT about a cauliflower-like lesion near his anus. The bot mentioned hemorrhoids and suggested elastic ligation—a procedure that uses a rubber band to cut off blood flow to swollen veins. He attempted it himself with a thread.

Doctors later removed it after he arrived at the hospital in agony. As it turned out, the growth wasn’t a hemorrhoid but a 3-centimeter genital wart.

2. The sodium swap

A 60-year-old man wanted to reduce salt in his diet. ChatGPT told him to replace table salt with sodium bromide, a chemical used to clean swimming pools. He did, for three months. He was hospitalized with bromide poisoning, suffering hallucinations and confusion, and his case was documented in the Annals of Internal Medicine: Clinical Cases.

3. The ignored mini-stroke

After heart surgery, a Swiss man developed double vision. When it returned, he asked ChatGPT, which told him such side effects “usually improve on their own.” He waited a day too long and suffered a transient ischemic attack—a mini-stroke that could have been prevented with immediate care.

Researchers wrote about his unfortunate case in Wien Klin Wochenschr.

4. The suicide “coach”

In California, parents sued OpenAI after claiming ChatGPT validated their teenage son’s self-harm plans and failed to flag his suicidal ideations. The case has renewed calls for guardrails on mental health responses and crisis escalation.

AI can explain symptoms, summarize studies, and prep you for doctor visits. But it can’t feel urgency, spot panic, or call an ambulance. And that gap, as these stories show, can be lethal.

The post 4 ER Horror Stories From People Who Asked AI for Medical Advice appeared first on VICE.

According to a study in JAMA Ophthalmology, eye injuries from pickleball are spiking harder than the pickleball that your soon-to-be ex-friend just spiked into your orbital socket. Researchers analyzed emergency room data and found a 405-per-year increase in pickleball-related eye injuries since 2021, topping out at an estimated 1,262 in 2024 alone.

The injuries are being caused by the two components that make up Pickleball: flying paddles and the pickleballs themselves.

The data, pulled from the National Electronic Injury Surveillance System, looked at injuries between 2005 and 2024. Out of an estimated 137,000 total pickleball injuries nationally, about 3,112 were eye-related, and all of those occurred post-2014, with 88 percent happening just in the past two years. The most common victims were players aged 50 and older whose reflexes are perhaps not as keen as they once were.

Some of the more common injuries sound pretty gnarly, too. People are getting their retinas detached and their eyesockets broken. Pickleball is even responsible for an uptick in something called hyphema, the medical term for when your eyeball starts bleeding internally.

The researchers say this is all happening because of the sudden flood of new, casual players who may lack the hand-eye coordination or physical stamina of a seasoned athlete who would be better equipped to fend off a ball being paddled at them. This would be fine if only people were wearing eye protection, which the researchers say people aren’t doing nearly as much as they should.

Pickleball has been around since the 1960s but it took a global pandemic making people go stir crazy for it to gain any traction before booming in popularity. Now that it’s at its apex, people are realizing that there actually is just a tiny bit of danger involved in the sport we all know as Big Ping Pong.

The post Pickleball Is Exploding in Popularity—and Wrecking Players’ Faces appeared first on VICE.

But what if you didn’t even get to see the emergency room doctor? Should you still be charged thousands of dollars?

That’s what Nathan Jachimiec did for his 11-year-old son, Ian, back in May. They pulled into the Good Samaritan Hospital ER in San Jose, hoping a doctor could explain their son’s mysterious rash, but I never got the chance to do so.

They just sat there, in the waiting room, constantly being told by a nurse to keep doing what they were doing.

U.S. Man Charged $5,000 for Sitting in the ER Waiting Room

The wait was interminable. At some point, Nathan and Ian decided the rash wasn’t as bad as waiting in this emergency room, so they left. They never saw a doctor, and they never got prescribed medication. Nathan collected his son and his son’s rash, and they went back home.

Then came the real emergency: a $5,000 bill from the hospital for an ER visit that never happened.

Jachimiec tried to contest the charge, but the hospital didn’t want to hear it. So, he called in the big guns: 7 On Your Side, one of those local news consumer advocate reporters who hounds and harasses businesses that screw people over and threatens to blast all the drama on the local news.

Suddenly, like magic, the $5,000 emergency room bill vanished. It’s as if it had never happened in the first place: Behold, the power of airing your dirty laundry in public.

In an email, Good Samaritan Hospital stated that it acted swiftly once it became aware of the situation. It also assured the public that it values transparency, compassion, and fairness, but apparently only after getting called out on local TV.

It’s disgusting that the family had to pay $5,000 for not eating and get to see a doctor, but it’s even more offensive that they had to pay that out of pocket. I’m sure there’s somewhere out there a Canadian or a Frenchman or someone from nearly any other developed nation on Earth, and even some that aren’t, who, rightfully, think $5,000 out-of-pocket for an emergency room visit is a crime against humanity.

This is like watching Breaking Bad and realizing all of that could’ve been avoided if Walter White had been covered under a universal healthcare system.

The post U.S. Man Charged $5,000 for Sitting in the ER Waiting Room—and Never Saw a Doctor appeared first on VICE.

Angerer, now 36 and in recovery, had been battling substance use disorder since she started drinking alcohol at age 16. She moved onto prescription pain medication after she broke her ankle and then eventually to street opiates like heroin and fentanyl.

Just two months before that 2016 overdose, doctors replaced an infected heart valve, the byproduct of her drug use. She was discharged from the hospital and began using again the next day, leading to a reinfection that ultimately cost her all 10 toes and eight fingers.

“[The hospital] didn’t have any programs or anything to go to,” Angerer says. “It’s nobody’s fault but my own, but it definitely would have been helpful if I didn’t get brushed off.”

This scenario plays out in emergency departments across the country where the next step—a means to divert addicted patients into treatment—remains elusive, creating a missed opportunity in the health system.

A recent study of Medicaid claims in West Virginia, which has an opioid overdose rate more than three times the national average and the highest death rate from drug overdoses in the country, documented this disconnect.

Researchers analyzed claims for 301 people who had nonfatal overdoses in 2014 and 2015. By examining hospital codes for opioid poisoning, researchers followed the patients’ treatment, seeing if they were billed in the following months for mental health visits, opioid counseling visits, or prescriptions for psychiatric and substance abuse medications.

They found that fewer than 10 percent of people in the study received, per month, medications like naltrexone or buprenorphine to treat their substance use disorder. (Methadone is another option to treat substance use, but it isn’t covered by West Virginia’s Medicaid program and wasn’t included in the study.) In the month of the overdose, about 15 percent received mental health counseling. However, on average, in the year after the overdose, that number fell to fewer than 10 percent per month.

“We expected more…especially given the national news about opioid abuse,” says Neel Koyawala, a second-year medical student at Johns Hopkins School of Medicine in Baltimore, Maryland, and the lead author on the study, which was published last month in the Journal of General Internal Medicine.

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It’s an opportunity that’s being missed in emergency rooms everywhere, says Andrew Kolodny, the co-director of Opioid Policy Research at the Heller School for Social Policy and Management at Brandeis University outside Boston.

“There’s a lot of evidence that we’re failing to take advantage of this low-hanging fruit with individuals who have experienced a nonfatal overdose,” Kolodny says. “We should be focusing resources on that population. We should be doing everything we can to get them plugged into treatment.”

He compared it to someone who comes into the emergency room with a heart attack. It’s taken for granted that the patient would leave with heart medication and a referral to a cardiac specialist. Similarly, he wants patients who come in with an overdose to start buprenorphine in the hospital and leave with a referral to other forms of treatment.

Kolodny and Koyawala both noted that a lack of training and understanding among health professionals continues to undermine what happens after the overdose patient is stabilized.

“Our colleagues in emergency rooms are not particularly well-trained to be able to help people in a situation like this,” says Margaret Jarvis, the medical director of a residential addiction treatment center in Pennsylvania.

It was clear, Angerer says, that her doctors were not equipped to deal with her addiction. They didn’t know, for instance, what she was talking about when she said she was “dope sick,” feeling ill while she was going through withdrawal.

“They were completely unaware of so much and it completely blew my mind,” she says.

When she left the hospital after her toe and finger amputations, Angerer recalls her next stop seemed to be a tent city somewhere in Midland, where she feared she would end up dead. Instead, she persuaded her mother to drive her about 300 miles to a treatment facility in Dallas. She found it on her own.

“There were a lot of times I could have gone down a better path, and I fell through the cracks,” Angerer says.

The bottom line, Jarvis says, is that when a patient comes into the emergency room with an overdose, they’re feeling sick, uncomfortable, and “miserable.” But surviving that episode, she emphasized, doesn’t necessarily change their perilous condition.

“Risk for overdose is just as high the day after as the day before an overdose,” says Matt Christiansen, an assistant professor in the Department of Family & Community Health at the Marshall University Joan C. Edwards School of Medicine in West Virginia.

Kaiser Health News (KHN) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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The post Emergency Rooms Often Don’t Do Enough for People Who Survive an Overdose appeared first on VICE.

“This is fucking bullshit,” she said, and then got up, and started pacing around the room.

She was young and white and heavy. She had light brown hair and blue eyes and she looked straight at you for too long.

“I have rights,” she said.

“It’s OK,” I said, like someone might soothe a child.

“It’s not OK!” she said, her voice rising.

“Where are you from?” I asked.

“I’m from Oklahoma!” she shrieked, startling me.

“I’ll come back,” I said, and retreated through the glass door. The security guards watched.

“She needs more Ativan,” her nurse said.

“Do you want us to restrain her again?” the guard asked.

“Let me think,” I said, as she sat down on the bed again and began to rock.

They shook their heads.

She had been in the emergency room for thirty hours.

A day earlier, when she was screaming and wild in the bus station, someone had called an ambulance. The paramedics had restrained her, and brought her in. She’d been sedated with Ativan, and Haldol—old drugs, with decades of history behind them, and so many stories to tell.

She’d slept. When she woke again, she was calmer, and asked to leave. She’d made promises. But she’d also complained that her chest was hurting.

Someone had ordered a chest X-ray.

“Medicine has admitted her to the floor,” the resident had said, on rounds, a few minutes before I walked into her room.

“Medicine?” I asked. “The floor?”

He shrugged.

“No one else would take her,” he said.

There was a long silence.

She’d stuck a needle into her heart.

People like her are unreachable, and beyond us. The language of reason might as well be birdsong in the trees.

So I sat there, looking at the X-rays on the computer screen, and the subsequent CT scan and the echocardiogram, reading the notes of different medical specialties—cardiology, cardiothoracic surgery, psychiatry, and internal medicine. Each was a tribal document, arguing that responsibility rested with another of the tribes.

We had not ever seen her before. She was a visitor, passing through. We didn’t know where she’d come from, or where she was going, and she wouldn’t tell us.

But the needle in her heart was not alone. Her abdomen was full of needles also, lit up on the X-ray like shrapnel from a forgotten war.

They were all the same, bright white among the shadows on the screen. They were three-inch sewing needles, exactly like those my grandmother had used, with a thimble. Looking at the screen, it seemed as if they’d been chosen with care, in their identical natures, as if she were following a form of order, repeating a ritual over and over again. They must have been there for a long time, because her belly was pale and unmarked.

The body can endure sewing needles in the abdomen. The odds favor you; the chance of damaging the bowel, or a major blood vessel, are low. If enough time passes, and the needle is not too deep, the body will even force it slowly and mysteriously to the surface, with mechanisms no one understands.

But this time, in the recent past—no one knew exactly when—she’d finally found the perfect place, just below her left breast, between her ribs.

She’d buried the needle into her chest until it disappeared, through the tough fibrous tissue of the pericardium, and deep into the cardiac muscle itself. It takes force to do this. The point of the needle extended into the chamber of the ventricle, and remained there.

If you looked closely, you could see a tiny, bloodless pinprick. But that was all.

The body can’t endure a sewing needle in the heart for very long. Already clots were forming around it inside the ventricle, and they could break away at any time, showering her brain and other organs. Or she might start bleeding for real, as her beating heart whipped the needle back and forth like a conductor’s baton.

A big and bloody operation awaited her: a sternotomy, where the chest is opened, and the heart is stopped for a while as a machine briefly does its work. But as the hours passed, she refused to let the surgeons touch her.

“We need to take the needle out,” I said, back in the room a few minutes later, trying to reason with her yet again, as if we were speaking about the ordinary world. “It’s why your chest is hurting.”

Again, the long clear stare.

“I put the needle in because my chest was hurting,” she said, patiently. “You can’t take it out. I need it.”

“Do you want to kill yourself?”

“Of course not,” she said.

She was calm then. And she looked perfectly well.

In the past, we had endings. We had mental institutions. Some were enormous, and I rotated through one of them as a medical student. From the outside, it looked like the campus of a liberal arts college, with red brick buildings and oaks and sheets of mown green grass.

Mental institutions were not indecent places. Depravity existed within them, but so did social responsibility and kindness. In the 1980s, funding was cut, and vast numbers of patients were either cast out into the street or placed in poorly-regulated group homes. It’s a story that has been told many times, to a collective shrug.

No one likes the mentally ill. They repel us, because they are so close to us.

Acts like hers reveal us. We feel the horror, and the vicarious thrill of deep and inscrutable transgression, and we are fascinated, but the pity we muster is abstract.

Funding for innocence is one thing. Funding for the unreachable and the frightening is another.

I called the surgeon.

“I spent 45 minutes with that woman this afternoon,” he said. “What do you want me to do? Tie her up and operate on her without her consent?”

“That’s what psychiatry is recommending,” I replied. “They wrote it in the chart.”

“I can’t do that. She has to cooperate afterwards. What is she going to do to the wound?”

I thought about it. He had a point—an open wound on her chest, with her heart beating an inch or two beneath it, with the drains and all the rest. The opportunities were grotesque.

“What would you do,” I said, “if she came into the trauma room with the needle sticking out of her chest?”

We both knew the answer. She would be taken to the operating room despite any protests she might make. The trauma room is a place where decisions are made, and action is taken. But context is everything.

“I won’t admit her,” he said, “if she won’t consent.”

So I made a dozen more calls that night. I spoke to the hospital administrator, to other surgeons, and psychiatrists, and internal medicine doctors, and the ICU. For a little while I enjoyed the absurdity of it. It felt surreal, and compelling, and pleasantly, seductively righteous. But after a while, I got of tired of my righteousness, tired of the same heavy obvious arguments and the quicksand of pages going unanswered. I got nowhere, because no one wanted her, and I understood this, because I didn’t want her either. I wanted her gone.

Somewhere between phone calls it occurred to me that no one in this story was rational. The needle was invisible to the naked eye, and therefore abstract. Abstract knowledge is as powerless as abstract pity. It so rarely moves us to act. We know better, and yet we follow our instincts anyway. The needle in her heart seemed like a statistic, like a graph of rising temperatures instead of heat.

Finally she was wheeled upstairs to the medicine floor, tied to the gurney with leather straps, my responsibility no longer.

Usually, when I go home, I don’t look back. I don’t think about those I’ve seen, I don’t have dreams. I leave them behind.

But for the next few days I followed her anyway, on the computer, from a distance. Partly, I followed her from curiosity, and partly I followed her from frustration, but mostly I followed her because she revealed so much about us. She spoke so clearly to our judgments, to our values and decisions and choice of responsibilities, to our primal natures, to how often the rational intellect simply launders our animal selves, offering desires as arguments.

The days passed. Still no one wanted her. The debates went on, the meetings were held, the ethicists appeared, moving without urgency toward the inevitable, as her heart began to show increasing signs of damage. Then, finally, on the third day, the needle began to move.

It was the movement that did it. This was knowledge that could be felt, ominous and urgent.

When the needle started moving, they took her to the operating room.

I read the surgeon’s note with fascination from my perch on my couch at home, many miles away.

They wheeled her into the room. They put IVs in her arms. They anesthetized her, intubated her, and put her on the ventilator.

They prepped her chest, scrubbing it with brown Betadine, in their gowns and gloves and masks. Then they draped her, with blue surgical sheets, until only her chest was visible. I could picture it all.

They made a vertical incision down the center of her chest, touching the cautery to the blood vessels, which crackle, and release little wisps of smoke into the air.

They ran the saw up her sternum, wiping bone meal and blood from the blade. They spread her chest apart, and exposed her beating heart for the first time.

They put her on the heart/lung bypass machine, which diverts the blood flow from the heart. They cooled her heart with saline, and then they stopped it with potassium.

A cold, still heart, with the body alive around it, is hard to imagine. But it happens every day, all around us, the product of the rational mind, and so many centuries of inquiry.

They made a tiny incision in the ventricle. They felt for the needle with gloved fingers, and then they pulled it out. Already it was encased in thrombus by the body’s essential resistance, as if dipped in rust-colored ink.

They sutured the incisions tight. They closed the needle’s pinprick in the ventricle. They washed her heart.

Then they released scarlet, oxygenated blood from the bypass machine back into it. They waited, and watched, as her heart slowly grew red and warm.

It’s astonishing to watch a heart spring to life again. I’ve only seen it a couple of times, and many years ago, as a student. But it will stay with me forever.

They took her off the pump. They put in the drains, and they sewed her sternum shut with rust-proof wires that will remain in her future casket for hundreds, if not thousands, of years. Finally they closed the wound—a foot long gash, down the center of her chest.

All of it, from beginning to end, took less than two hours.

They wheeled her to the ICU.

The bodies of the young come back fast. A few hours later she was off the ventilator, and two days after that she was walking in the hall. During the week she spent in the hospital, she was watched all the time, by a sitter, who sat beside her like a friend.

On the eighth day, she was discharged to the mental health center, under the care of the psychiatrists.

The beds there are few, and valuable, and the line for them is long. There are always people coming, people who want to die, people who are psychotic, people who are dangers to themselves, or to others, people who won’t take their medications, whose families have abandoned them, who have no money or insurance, people with one foot in this world, and one in another.

The psychiatrists need to move them through. They have no choice. And so they seize on anything—a promise, an apology. A recognition. The claim of fainter voices, or the desire to live.

The note, on the eleventh day, described her as calm. She was feeling better. She did not want to put needles in herself anymore. She wanted to leave, and continue on to California. She had friends there, someone she would meet. She still had her ticket. She would take her medicine. She was not a leopard in a cage, pacing around and around again.

They got her a cab to the bus station.

Frank Huyler, MD, is an emergency physician living in Albuquerque, New Mexico. He is the author of The Blood of Strangers, among other books.

Details have been changed to protect patient confidentiality.

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The post When Your Young Patient Refuses Life-Saving Treatment appeared first on VICE.

To put saving lives first, Del Pozo has begun an innovative program aimed at getting proven anti-addiction medication into the hands of those who need it—regardless of whether or not they want to quit illegal drugs entirely.

“The number-one job of a police department is to protect and rescue its community from harm,” Del Pozo tells me, “Right now, fatal opioid overdoses are the number-one harm to practically every community in America.”

Traditionally, police departments have measured their effectiveness by completely different markers, mainly tracking statistics like homicide, arrest, and prosecution rates. New York City’s much-debated “CompStat” program, which relentlessly focuses on addressing these numbers neighborhood by neighborhood, is often credited with helping reduce violent crime and is now used across the country and around the world.

But when the number of overdose deaths also becomes a key metric, a shift in priorities is necessary. That’s why Del Pozo and Chittenden County state’s attorney Sarah George recently announced that they will no longer arrest or prosecute people caught illegally possessing the anti-addiction medication buprenorphine in Burlington.

The new policy is part of a belated recognition across the US that drug-war policing can actually undermine public health. Buprenorphine, available in pill or sublingual film form, is one of two medications proven to cut the death rate from opioid overdose by 50 percent or more—but we make these drugs extremely hard to get. (The other is methadone, which is much more strictly regulated on the federal level, and so cannot immediately be made more accessible by cities or states).

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Only about a third of addiction programs offer these medications at all, even as yet another study out last week confirmed both their life-saving value and how underutilized they are. The study, published in the Annals of Internal Medicine, and including data on more than 17,000 people treated for overdose in Massachusetts, found that methadone cut death rates by 59 percent and buprenorphine by 38 percent. However, during the year following an overdose, only 30 percent of patients received any anti-addiction medication. (That figure included some who received a third drug, naltrexone, which wasn’t shown to reduce mortality, although since so few took it, the authors caution, any benefit might not have been measurable.)

Indeed, in most states, fear about diversion of buprenorphine to the black market dominates policy and has led to restrictions on prescribing and prosecution of patients who sell or give it away: Since buprenorphine is itself an opioid, it can cause a high if taken irregularly or by someone who is not already addicted to opioids. As I reported recently, even leading doctors who are clearly expert prescribers have been targeted by federal agencies concerned about diversion.

However—and especially in a street market where contamination of heroin with deadly fentanyl is ubiquitous—public health officials have long recognized that excess concern about diverted buprenorphine can itself be dangerous.

Research shows that requiring counseling or making people jump through other hoops in order to get buprenorphine isn’t necessary for it to be effective. The drug itself is protective against overdose and relapse, regardless. (This is why many addiction experts hate the term “medication-assisted treatment”—the medication is what is proven to cut mortality and relapse, so if anything is doing the “assistance,” it’s the other services.)

Studies also find that, overwhelmingly, people who buy street buprenorphine are doing so to stave off withdrawal—not to get high. For recreational use, heroin and opioids like oxycodone or hydrocodone are preferred. And illicit buprenorphine use by people who don’t already misuse other opioids is extremely rare.

Consequently, since buprenorphine is safer, any time an opioid user—even if not the intended patient—takes it instead of street-sourced opioids, the risk of death is reduced. As George put it bluntly in a recent interview with Vermont’s Seven Days, “I believe we need to be encouraging diversion.”

The idea is to make buprenorphine almost as easy to get as heroin so that even people who aren’t ready to quit entirely can reduce their risk of dying. Such “low-barrier” or “low-threshold” distribution programs have already been started in cities like San Francisco and Philadelphia.

In San Francisco, for example, a street medicine team from the Department of Health visits places like parks frequented by homeless people who use drugs and offers three-day prescriptions to those in need, which they can pick up for free at a nearby pharmacy. Such prescriptions are also being made available at needle exchanges.

“It’s not the lowest of low-barrier programs, but we’re trying,” says Jamie Carter, an addiction medicine fellow at the University of California, San Francisco, who has worked clinically with the team. “I think we should make it as easy as possible for people to have access to buprenorphine.” Ideally, physicians would be able to give out the drug itself on the spot.

In Philadelphia, the Prevention Point needle exchange can also start people on buprenorphine, but in order for them to stay on it and be covered by Medicaid, urine screening and attendance at some type of counseling is required. “I just don’t understand why this is harder than getting a prescription opioid [for pain],” says Silvana Mazzella, the associate executive director of Prevention Point.

Nonetheless, a study of the Philadelphia program published in February found that 56 percent of participants were still enrolled a year later, which is comparable to treatment initiated in more typical medical settings.

Many hospital emergency rooms—including some in Philadelphia, San Francisco, Boston, Denver, and New York—are also offering to start buprenorphine treatment immediately, typically for overdose victims. A few, however, also provide the drug to people who are in opioid withdrawal. And some ERs have very low barriers: The program at Bellevue Hospital in New York City, for instance, doesn’t require counseling or drug-free urine, and the Bridge Clinic at Massachusetts General in Boston is similarly accessible.

Del Pozo wants to go even further. “If somebody’s simply in withdrawal or they want to see how buprenorphine would affect them… or they’re like, ‘I don’t want treatment but I do want buprenorphine…’ that’s great, they would get it at the syringe exchange,” he says. And, he also wants to help those who get buprenorphine outside of official channels by not arresting or prosecuting them.

Adding these policies to structures already in place could give Vermont the best opioid addiction treatment system in the US. For one, it’s already miles ahead of most states in terms of access to medication treatment. In 2012, the state opened a centralized “hub and spoke” system in which people who need more intensive treatment get care at specialized “hubs” and, once stabilized, are transferred to “spokes” for long-term management—or back to the hub if their problems worsen.

In most other communities, in contrast, there is little coordination or centralization, which means it’s hard for people to find out when and where open treatment spots exist or to get back into care rapidly after a relapse.

Vermont’s networked system has dramatically increased access to care while nearly eliminating waiting lists for those who seek help. Overdose survivors who are admitted to the emergency department in the state’s hospitals are also now being offered buprenorphine and instant entry into ongoing treatment when they leave.

And, if all goes as planned, those who just want to try buprenorphine or use it from time to time to improve their functioning and reduce their risk of dying will be able to get it for free or low cost later this summer at Burlington’s needle exchange, Safe Recovery.

To keep on top of the crisis and make sure everyone is working together, Del Pozo holds regular “CommunityStat” meetings with Burlington Mayor Miro Weinberger and representatives of health agencies, the needle exchange, law enforcement, and other relevant groups. As with CompStat in more traditional policing, the idea is to track exactly what’s going on locally, find out what roadblocks still exist, and figure out how to get around them.

At a meeting I attended last month (I was invited to give a talk on my book), a representative from the state medical board gave a presentation on how the board flags doctors who might be running “pill mills.” This is a concern for low-threshold buprenorphine prescribers because, if doctors give out the drug as harm reduction—that is, without requiring counseling or urine screening—they might look suspicious to regulators or law enforcement.

“What we’re going to try to do is make sure that the Vermont Medical Practice Board understands that the standard of care we’re proposing, low-barrier administration, is evidence-based: It has studies that show it unequivocally saves lives,” Del Pozo says.

And by shifting their attention away from street buprenorphine use, Del Pozo and local prosecutors also hope to make it more attractive to people who aren’t ready for any other kind of help. “A person who is seeking out black-market buprenorphine is in a much better and safer place than if she were seeking out heroin or fentanyl,” he says, “If you are serious about what it takes to reduce mortality in American communities, then you have to recognize that any sort of buprenorphine is better than not having it out there.”

He adds, “Every dose of buprenorphine consumed is at least a dose of heroin not getting consumed, if not several.” Moreover, every dollar spent on street buprenorphine is one not spent on heroin or fentanyl. The more treatment is able to compete with dealers, the smaller the illicit market will get.

Other countries like France that faced opioid overdose epidemics in the past have been able to cut deaths by 80 percent by providing widespread buprenorphine access. Vermont has advanced further than any other American state in terms of coming close to providing genuinely easy access and, as of 2017, it had the lowest overdose rate in hard-hit New England.

Now, Del Pozo is trying to make Vermont’s approach even better and offer the system as a model for other states. Working with researchers at Johns Hopkins, the Police Executive Research Forum, and with former Obama drug czar Michael Botticelli, he just released a set of ten evidence-based strategies for police and communities to use to fight overdose. The most important concept is to put saving lives back at the top of the agenda.

Correction 6/27/18: This story has been updated to reflect that the Burlington Mayor’s office is involved with CommunityStat meetings.

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The post Doctors Should Be Handing Out Addiction Meds on Demand appeared first on VICE.

The patient, Cervantes said, was a woman from Mexico with kidney failure who repeatedly visited the emergency room for more than three years. In that time, her heart had stopped more than once, and her ribs were fractured from CPR.

The woman finally decided to stop treatment because the stress was too much for her and her two young children. She died soon afterward, Cervantes said.

Kidney failure, or end-stage renal disease, is treatable with routine dialysis every two to three days. Without regular dialysis, which removes toxins from the blood, the condition is life-threatening: Patients’ lungs can fill up with fluid, and they’re at risk of cardiac arrest if their potassium level gets too high.

But Cervantes’ patient was undocumented. She didn’t have access to government insurance, so she had to show up at the hospital in a state of emergency to receive dialysis.

Cervantes, an internal medicine specialist and a professor of medicine at University of Colorado in Denver, said the woman’s death inspired her to focus more on research.

“I decided to transition so I could begin to put the evidence together to change access to care throughout the country,” she said.

Cervantes said emergency dialysis can be harmful to patients: The risk of death for someone receiving dialysis only on an emergency basis is 14 times higher than someone getting standard care, she found in research published in February.

Cervantes’ newest study, published recently in the Annals of Internal Medicine, shows these cyclical emergencies harm healthcare providers, too. “It’s very, very distressing,” she said. “We not only see the suffering in patients, but also in their families.”

There are an estimated 6,500 undocumented immigrants in the US with end-stage kidney disease. Many of them can’t afford private insurance and are barred from Medicare or Medicaid. Treatment of these patients varies widely from state to state, and in many places the only way they can get dialysis is in the emergency room.

Cervantes and her colleagues interviewed 50 healthcare providers in Denver and Houston and identified common concerns among them. The researchers found that providing undocumented patients with suboptimal care because of their immigration status contributes to professional burnout and moral distress.

“Clinicians are physically and emotionally exhausted from this type of care,” she said.

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Cervantes said the relationships clinicians build with their regular patients conflicts with the treatment they have to provide, which might include denying care to a visibly ill patient because their condition was not critical enough to warrant emergency treatment.

“You may get to know a patient and their family really well,” she said. Providers may go to a patient’s restaurant, or to family gatherings such as barbacoas (similar to barbecues) or quinceañeras (milestone parties for 15-year-old girls).

“Then the following week, you might be doing CPR on this same patient because they maybe didn’t come in soon enough, or maybe ate something that was too high in potassium,” she said.

Other providers, Cervantes said, report detaching from their patients because of the suffering they witness. “I’ve known people that have transitioned to different parts of the hospital because this is difficult,” she said.

Melissa Anderson, a nephrologist and assistant professor at the Indiana University School of Medicine in Indianapolis who was not involved in Cervantes’ study, said the research matches her own experience. She said that when she worked at a safety-net hospital in Indianapolis, patients would come to the ER when they felt sick. But some hospitals would not provide dialysis until their potassium was dangerously high.

To avoid being turned away when their potassium level was too low, she said, patients in the waiting room would drink orange juice, which contains potassium, putting themselves at risk of cardiac arrest.

“That’s Russian roulette,” Anderson said. “That was hard for all of us to watch.”

Anderson eventually stopped working at that hospital and, like Cervantes, has worked on research and advocacy efforts to change how undocumented immigrants with kidney failure are treated.

“I practically had to take a class in immigration to understand what’s going on,” she said. “Physicians just don’t understand it, and we shouldn’t have to.”

Providers in Cervantes’ study also worried that these avoidable emergencies strain hospital resources—clogging emergency departments when undocumented patients could simply receive dialysis outside the hospital—and about the cost: Emergency-only hemodialysis costs nearly four times as much as standard dialysis, according to a 2007 study from researchers at Baylor College of Medicine.

Those costs are often covered by taxpayers through emergency Medicaid, which pays for emergency treatment for low-income individuals without insurance. In a study published in Clinical Nephrology last year, Anderson and her colleagues found that, at one hospital in Indianapolis, the state paid significantly more for emergency-only dialysis than it did for more routine care.

Areeba Jawed, a nephrologist in Detroit who has performed survey research into this issue, said many providers don’t understand how much undocumented immigrants actually contribute to society, while receiving few of the societal benefits.

“A lot of people don’t know that undocumented immigrants do pay taxes,” she said. “There’s a lot of misinformation.”

“I think there are better options,” said Jawed, who has treated undocumented patients both in Detroit and Indianapolis.

As a workaround, some hospitals simply provide charity care to cover regular dialysis for undocumented patients. But Cervantes argues that a better solution is a policy fix. States are allowed by the federal government to define what qualifies as an emergency.

“Several states, like Arizona, New York, and Washington, have modified their emergency Medicaid programs to include standard dialysis for undocumented immigrants,” she said.

Illinois covers routine dialysis and even passed a law allowing undocumented immigrants to receive kidney transplants, she noted.

“Ideally, we could come up with federal language and make this the national treatment strategy for undocumented immigrants,” Cervantes said.

Ultimately, Cervantes said, providers don’t want to treat undocumented patients differently.

“At the end of the day, clinicians become providers because they want to provide care for all patients,” she said.

This story is part of a partnership that includes Side Effects Public Media, NPR and Kaiser Health News. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

The post Another Cause of Doctor Burnout: Being Forced to Give Undocumented People Unequal Care appeared first on VICE.

From the neck up, Robert Gregory looked like an ordinary man, mild, scholarly, with thin wire glasses and bright eyes behind them.

From the neck down he was hardly a man at all. His body was enormous, so full of fluid that he could barely move. We had to lift him from the paramedic’s gurney to the bed as he gasped into the oxygen mask.

His shirt was off. His skin was gray and damp. His hands and feet were blue. He felt cold to the touch, like a bag of flour in the refrigerator.

“I can’t breathe, I’m so nauseated, help me.” The words came one by one, between breaths, like beads on a string. “Help me,” he said, again, and then he began to cry. He cried like he gasped, without restraint.

I asked him if he wanted to be on a ventilator. I asked him what he’d like us to do if his heart stopped. I had to get straight to it.

“I’m DNR,” he said. “Just let me go. I’m so nauseated. I’m so afraid. Please help me.”

“What would you like me to do?”

“Something for nausea. Something for pain. Oh my God.”

So he absolved me: I would only have to watch. He was sobbing like a child, but he had the courage to give up nonetheless.

He was terrifying.

Primary pulmonary hypertension mostly affects women. Nobody knows why. Your immune system attacks your pulmonary blood vessels. The arteries become stiff and inflamed. The heart struggles to pump blood through them, and in a few years, it gives out. There’s no cure. The failure begins with breathlessness, and it ends like it did for Robert. He’d called the ambulance himself. His nurses only came a few times a week—that day, they weren’t there.

He should have been in a hospice. Instead, he was alone in his house.

It comforts us to name things. It comforts us especially when a disease is rare, when the odds are long, when the chances are great that it will never touch us. Something else, we think, but not this, and it’s an uncertainty we embrace. His suffering was safely his. It had chosen him, like a celebrity, like a single star in the sky.

The hospital was full. The hospital is always full. It’s a story that repeats itself throughout the country, because the struggles in America are much greater than we like to see. Hospitals like mine make you see them; they hold them up into the light.

There was no place to put him upstairs, no place for hours. Just the ER, in the afternoon, with a crowd waiting in the lobby.

For a little while, he stopped crying.

“Is there anyone you’d like us to call?”

“My mother is elderly. She doesn’t drive. Please don’t call her.”

So we didn’t call her. But he wanted to talk, and he didn’t want to be alone, and we could see it.

I asked him what he did and where he was from, as if we were getting to know each other.

“I’m an artist,” he said, his lips forming little circles, like rings in a pond.

“What kind of artist?”

“I paint watercolors.”

Then he began sobbing again, opening and closing his hands.

So it was up to me—how much morphine to give him?

***

Once, when I was a child, I rode in a horse-drawn cart for a few miles down the coast of India. We were going to a hotel outside of town. We’d gotten into the cart in the dark, on a soft, hot, windy night, and set off briskly. The horse’s hooves knocked on the dirt road, and the surf roared in the distance past the beaches. The moon was out among the clouds, and it was shadowy and exciting.

But after awhile it became clear how weak the horse was. It could not sustain the pace. We could barely see it in the dark. The driver whipped it, and whipped it again as it flagged, trying to get back to town a little faster, and pick up another fare. I remember grabbing his arm and asking him to stop. He looked at me, puzzled, and annoyed—as if to say, it’s just a horse. Who are you?

Morphine. The question weighed upon me. Too much would kill him, not enough was worse. He was dying, but I didn’t want to kill him. It’s a primal thing, that decision. You want to do something. The desire is very powerful. You have to resist yourself: doing nothing is a greater form of discipline.

But that next step—pushing him over, and being done with it—is an even harder act. It requires a particular kind of courage. You can’t be wrong. You can have no doubt. I was working, and there were many other patients to see. I spent only a few minutes on him. There were new hands to shake, tests to order. There were residents, and students, and EKG’s to read. There were notes to type and questions to answer, and ambulances coming, and people walking by, and through it all the cellphone on my hip kept ringing.

I wanted to turn away, and I did. But I felt his presence as the hours passed. I knew he was behind the curtain in the corner, crying and pleading. His begging was general, like that offered to a torturer, as the nurse sat with him, and held his hand.

So I compromised. I gave him almost enough.

It took hours for his terrible alertness to fade. But finally, inevitably, he became confused. And so he became less terrifying. The gulf between the watched and the watchers grew greater. His breathing slowed, his head started to fall back, his mouth began to gape. He’d gasp awake again, look up, blink a little. He moaned like someone who is dreaming in their sleep.

The nurse still sat with him, and still held his hand, but she had to get up and work also. She got the worst of it. A young woman, not yet thirty, and her life isn’t easy; she has bills and children and troubles. I know this because the nurses talk to each other, and I hear it. They talk to me also, sometimes.

By then we’d turned off the monitor, so the alarms didn’t ring.

The task had fallen to her: it was she who sat with him when she could, and looked straight at him, and tried to comfort him, as the hours passed, and the bright lights fell.

The end of a person’s life occupies, at most, a single room. But it fills that room, and there is a sense of reverence within it. Everyone can feel it.

I felt it. But not as much as I would have when I was young, not even close, and that’s something that’s stayed with me also. If you’re unlucky, the coldness of your own heart gathers strength as time passes, and forces a certain clarity upon you. You become part of the indifferences. Experience makes you stop seeing the cruelties of the world for what they are. It’s something that you must resist, and something that you must remind yourself to resist. You have to cling to the knowledge that no one should be required to suffer like that, in a cubicle of an ER, among strangers.

Finally, he stopped gasping himself awake. His head fell back for good, and his mouth opened behind the mask. His glasses were still on. His breaths became farther and farther apart. His face slowly went blue, until it matched the color of his hands. I was there for enough of it.

A watercolorist—the mildest, the most harmless of men.

***

The hotel was a concrete building, and the nicest place for miles. It was lit up in floodlights, and there were floodlights down by the water too, illuminating the surf for a nighttime swim. It seemed miraculous, after the third class trains, and the heat, and the beggars everywhere.

We got out of the cart, with its faded tassels, its red and blue peeling paint, its worn cushions in the back. As the bellboys converged for the bags, we saw the horse clearly for the first time.

It stood there under the lights, utterly revealed, its ribs like the branches of a tree, its mousy coat worn hairless where the yoke rubbed. It was panting, gathering its strength again, and I stared at it as we settled the bill,. Then the driver shook the reins and clucked, and they moved off together into the dark again.

As a child I didn’t understand that all the horses in that town were emaciated, fed just enough to work, pulling their carts along the beachfront past piles of trash for the tourists. I didn’t fully grasp the poverty that it spoke to. I only knew how deeply the horse shocked me.

Now I wonder if I’d see it at all. I wonder if I’d look through it entirely.

I pronounced him dead, which is a little ritual from the past. I put my stethoscope on his chest and pretended to listen. I shined the light in his eyes. Then I picked a time, and the nurse wrote it down.

It was false precision—3:32 pm. Not 3:30. You don’t round up, or down. You choose a number that looks measured instead of guessed, intelligent instead of mystified.

We covered his body, and moved it to the decontamination room to wait for the funeral home. The housekeeper came, and made the bed again, and wiped the floor. A new patient was wheeled in, someone with no idea of what had just happened there. Then the nurse, who had sat with him, and tried her best for him, stepped out into the hall. I followed her, and touched her shoulder, and said something to her—I forget exactly—but she shrugged me off and walked away.

Ten minutes later she was back, dark eyed, quiet. I knew she’d been crying, gathering herself again, and as I looked at her, I thought—she’s so young. She has so much left to see.

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