Against Medical Advice: Another Deadly Consequence of Our Opioid Epidemic

By Zoe Adams

At 3 A.M., a high-pitched beep rang on my pager from a patient’s nurse. The page read: “Please come to bedside ASAP. Patient agitated and threatening to leave AMA. Security on their way.”

Like many medical trainees, I have received countless pages like this one. Fred (not his real name), a patient in his 60s with a history of opioid use disorder, was trying to leave “against medical advice,” or AMA. He was admitted to the hospital for opioid withdrawal and to treat pneumonia, which required IV antibiotics.

I ran up three flights of stairs. I hadn’t written down Fred’s room number, but I could immediately tell which room was his: three suited security guards, two nurses and the crackling of walkie talkies were giveaways.

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The next thing I knew security guards were strip searching Fred, going through his belongings and throwing them into plastic bags that brandished the hospital’s logo. His nurse demanded he take off his socks and shirt, and empty his wallet. He grew angry, and as he emptied his wallet, dollar bills fell from his hospital bed to the floor. He threw his socks across the room.

“I found him secretly using a vape pen,” the nurse said. “We needed to search his belongings for any other contraband. It’s a safety concern.”

A vape pen? Not exactly contraband.

The security guards and I tried to deescalate, but Fred could no longer withstand being punished. So he decided to leave. The response to his vaping—a minor infraction that posed no threat to staff—was inappropriate, humiliating and unjust. His medical team failed to provide the treatment he deserved. And it all could have been avoided.

Compared with other patient populations, people who struggle with addiction are at the highest risk of leaving the hospital prematurely. A recent study in the Journal of the American Medical Association revealed that patients with opioid use disorder are particularly susceptible to leaving the hospital early.

From 2016 to 2020, the annual rate for patients leaving “against medical advice” after they are admitted to hospitals with opioid use disorder from over 30 states increased from approximately 9 to 17 percent. In contrast, the rate for all nonopioid admissions remained around 1 percent during that time period. These discharges can be deadly and expensive. They are associated with twice the odds of all-cause death and hospital readmission within 30 days.

When people with addiction explain why they leave the hospital, they cite untreated withdrawal, pain, discrimination about their addiction, and hospital restrictions, such as not being able to leave the hospital floor for a walk or smoke break.

Stigma against patients with addiction is rampant among the medical community—from physicians and nurse practitioners to registered nurses and social workers. At the residency level, most physicians do not receive adequate training in addiction medicine, such as how to treat opioid withdrawal or co-occurring pain. This leaves these patients at risk of poor care and serious medical complications.

The phrase against medical advice is dripping with accusation and blame. When a patient leaves prematurely, providers frame it as the patient’s fault. But hospital care teams have a tremendous role to play as to whether someone decides to leave the hospital. And when someone does, it reflects a broader failure of the treatment team.

Hospital policies change constantly to improve patient outcomes. Hospital administrators should see premature discharges among people with substance use disorder as an urgent problem. Preventing these discharges is part of responding to the nation’s addiction and overdose crisis, which kills more than 100,000 people a year in the U.S. One in nine hospitalizations across the U.S. are for adults with substance use disorder.

We need to take patients’ complaints seriously. Hospitals could have designated vaping zones for patients. Or hospital administrators could hire recovery coaches to accompany patients on smoke breaks. Social workers could respond to pages about agitated patients instead of armed security guards. Providers could also begin to normalize that patients with addiction might have their substance of choice on them in the hospital. While use should be prohibited, possession of a substance should not lead to punitive action.

To be sure, it is essential that health care providers continue to prioritize the safety of patients and medical staff—especially nurses—who are on the front lines of patient care. It is not acceptable for patients to abuse staff, verbally or physically. However, a patient threatening physical abuse and a patient using a vape pen must warrant different responses. Stigma against people who use drugs certainly influences a provider’s perceived level of “safety.”

After Fred left, I felt ashamed. He came to the hospital in withdrawal seeking medication for opioid addiction and struggling to breathe from pneumonia. The system failed him on both fronts. Health care providers and hospital administrators must do better so that patients with addiction continue to seek care at our nation’s hospitals. Their lives—and dignity—depend on it.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.

By Zoe Adams

At 3 A.M., a high-pitched beep rang on my pager from a patient’s nurse. The page read: “Please come to bedside ASAP. Patient agitated and threatening to leave AMA. Security on their way.”

Like many medical trainees, I have received countless pages like this one. Fred (not his real name), a patient in his 60s with a history of opioid use disorder, was trying to leave “against medical advice,” or AMA. He was admitted to the hospital for opioid withdrawal and to treat pneumonia, which required IV antibiotics.

I ran up three flights of stairs. I hadn’t written down Fred’s room number, but I could immediately tell which room was his: three suited security guards, two nurses and the crackling of walkie talkies were giveaways.

On supporting science journalism

If you’re enjoying this article, consider supporting our award-winning journalism by subscribing. By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.

The next thing I knew security guards were strip searching Fred, going through his belongings and throwing them into plastic bags that brandished the hospital’s logo. His nurse demanded he take off his socks and shirt, and empty his wallet. He grew angry, and as he emptied his wallet, dollar bills fell from his hospital bed to the floor. He threw his socks across the room.

“I found him secretly using a vape pen,” the nurse said. “We needed to search his belongings for any other contraband. It’s a safety concern.”

A vape pen? Not exactly contraband.

The security guards and I tried to deescalate, but Fred could no longer withstand being punished. So he decided to leave. The response to his vaping—a minor infraction that posed no threat to staff—was inappropriate, humiliating and unjust. His medical team failed to provide the treatment he deserved. And it all could have been avoided.

Compared with other patient populations, people who struggle with addiction are at the highest risk of leaving the hospital prematurely. A recent study in the Journal of the American Medical Association revealed that patients with opioid use disorder are particularly susceptible to leaving the hospital early.

From 2016 to 2020, the annual rate for patients leaving “against medical advice” after they are admitted to hospitals with opioid use disorder from over 30 states increased from approximately 9 to 17 percent. In contrast, the rate for all nonopioid admissions remained around 1 percent during that time period. These discharges can be deadly and expensive. They are associated with twice the odds of all-cause death and hospital readmission within 30 days.

When people with addiction explain why they leave the hospital, they cite untreated withdrawal, pain, discrimination about their addiction, and hospital restrictions, such as not being able to leave the hospital floor for a walk or smoke break.

Stigma against patients with addiction is rampant among the medical community—from physicians and nurse practitioners to registered nurses and social workers. At the residency level, most physicians do not receive adequate training in addiction medicine, such as how to treat opioid withdrawal or co-occurring pain. This leaves these patients at risk of poor care and serious medical complications.

The phrase against medical advice is dripping with accusation and blame. When a patient leaves prematurely, providers frame it as the patient’s fault. But hospital care teams have a tremendous role to play as to whether someone decides to leave the hospital. And when someone does, it reflects a broader failure of the treatment team.

Hospital policies change constantly to improve patient outcomes. Hospital administrators should see premature discharges among people with substance use disorder as an urgent problem. Preventing these discharges is part of responding to the nation’s addiction and overdose crisis, which kills more than 100,000 people a year in the U.S. One in nine hospitalizations across the U.S. are for adults with substance use disorder.

We need to take patients’ complaints seriously. Hospitals could have designated vaping zones for patients. Or hospital administrators could hire recovery coaches to accompany patients on smoke breaks. Social workers could respond to pages about agitated patients instead of armed security guards. Providers could also begin to normalize that patients with addiction might have their substance of choice on them in the hospital. While use should be prohibited, possession of a substance should not lead to punitive action.

To be sure, it is essential that health care providers continue to prioritize the safety of patients and medical staff—especially nurses—who are on the front lines of patient care. It is not acceptable for patients to abuse staff, verbally or physically. However, a patient threatening physical abuse and a patient using a vape pen must warrant different responses. Stigma against people who use drugs certainly influences a provider’s perceived level of “safety.”

After Fred left, I felt ashamed. He came to the hospital in withdrawal seeking medication for opioid addiction and struggling to breathe from pneumonia. The system failed him on both fronts. Health care providers and hospital administrators must do better so that patients with addiction continue to seek care at our nation’s hospitals. Their lives—and dignity—depend on it.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.