The drowsy young woman presented to the emergency department after a motor vehicle collision; given her sleepiness, the staff of a walk-in clinic was concerned that she may have suffered a head injury and transferred her to a university center. She was very difficult to arouse, but could occasionally answer questions, and repeatedly denied any past medical history or medication use. Her boyfriend corroborated this, and the notes from the walk-in visit described administration of a substantial dose of meperidine (Demerol). After her head CAT scan was returned as normal, the patient's mental status seemed most consistent with opioid effect. Her doctors decided to administer a small dose of naloxone (0.2 mg) to reverse the meperidine, allowing for further examination of the patient. She woke up in florid opioid withdrawal and began vomiting profusely. When she was more alert, she revealed that she had been in methadone maintenance therapy for years, currently on a dose of 80 mg per day. Over the next several hours, her physicians treated her withdrawal symptomatically, until she was safe for discharge.

The emergency department (ED) represents an environment where multiple decisions are made within seconds to minutes. Providers are constantly assimilating information in a distracting, fast-paced arena where face time with patients is minimized and the potential for medical error is high. When specific information from patients regarding medication and self-prescribed or recreational substance use is withheld from physicians, patients are set up for adverse drug events ranging from the inconvenient to life-threatening.

The emergency department may be an extremely difficult venue for establishing the "therapeutic relationship". In most cases, your doctor is a stranger with his/her own judgments brought to bear during your encounter. There is often little privacy available, and many providers may simply not ask about recreational substance use or dietary supplement use.

Patients may additionally fear repercussions of full disclosure, including reporting to law enforcement agencies, employers, or parents. However, federal law, and the code of "doctor-patient privilege", prevents physicians from sharing this information unless a patient signs a consent form releasing their medical records, or the medical records are subpoenaed. One unusual exception to this rule (in some states) is in cases of demonstrated risk to the public health (for example, the driver who injures another person while intoxicated).

Many patients worry that insurance companies will be provided with information regarding any admitted use of illegal drugs, and that this may impact the future cost or availability of their health insurance. Unfortunately, the rules covering the sharing of this type of information with insurance companies can be complicated, and patients will almost certainly be asked to sign a release waiver allowing their hospital to share medical records with the insurance company as part of treatment. Further, insurance companies do require that customers release their medical records before they will make a payment for care rendered.

With all of these very real concerns in mind, we continue to make the case for full disclosure. Your physical health should be the first priority:

1. Communicating all pharmaceutical, dietary supplement, and recreational substance use to your physician puts the burden of safe medication administration on him/her. In the ED with chest pain? We would almost universally administer nitroglycerin. Recent Viagra use? Our routine may cause a life-threatening drop in blood pressure. Recent cocaine use may also affect our choice of blood pressure medications.
2. The information you provide may prevent costly, time-consuming, and potentially dangerous testing. If you present to the ED with an unexplained heart rate of 120, you will likely have extensive bloodwork and potentially have CAT scan imaging of your chest performed. While this is a relatively safe procedure, it involves chemical and radiation exposure that should not be undertaken unnecessarily. If you present with the same symptoms and mention your recent high-dose dextromethorphan use, your doctor can use that information to decide against the CAT scan in favor of careful observation and supportive care instead.
3. Revealing recreational drug use may help you get the appropriate treatment for your symptoms. A healthy 20-year-old man presents to the ED with a fever; the doctors will consider a variety of possibilities, many of which are related to viral infections. The same 20-year-old man who reveals a history of intravenous heroin use will have an extensive work-up for endocarditis, a potentially life-threatening bacterial infection of the heart valves.

We realize that many people may have had difficult experiences with the health care system regarding disclosure of their drug use to health care providers. However, we encourage readers not to put their health at risk by refusing to provide emergency department physicians with key information.

Kavita Babu, MD - Assistant Professor, Division of Medical Toxicology, Dept. of Emergency Medicine at University of Massachusetts
Edward W. Boyer, MD, PhD - Associate Professor of Emergency Medicine, University of Massachusetts Medical School