In medicine we are taught to profile. We don’t call it profiling, and it is certainly not done maliciously, but we size patients up during our initial contact based on age, sex, heritage, past experiences, weight, general appearance, etc. in order to formulate our differential and properly rank the diagnoses on said list. That’s why we start every HPI with “The patient is a 76-year-old male with a history of…”.
This is a basic tenant of medicine and it is extremely useful. A 19-year-old with chest pain has a different differential than a 56-year-old. This holds true with the vast majority of diagnoses and chief complaints. You get a few surprises here and there — the 28 year old with chest pain who is actually having an MI (coronary artery dissection…really), the 70 year old with gonorrhea (didn’t even think to ask if they were sexually active). But, in the vast majority of cases, the answer is in the first few rungs of our differential. That’s why we are taught to do it; profiling our patient’s usually works.
It doesn’t always work though. Remember when AIDS only killed homosexual men. Then it only killed homosexual men and IV drug users. Then it also killed hemophiliacs. Then we finally realized that none of those profiles fit. We removed that idea from our cognitive processing and we made major headway into that epidemic. We started asking everyone about their risk factors before they presented with PCP or Kaposi’s — before it was too late.
Perhaps always, but definitely in the past decade, when the diagnosis is substance abuse, there is again no standard profile, especially if you want to catch this disease while there is still hope for intervention. It’s not just the fact that this epidemic affects people from all walks of life, all races, all socioeconomic levels. It does, but that’s not the issue. We all still create a profile in our head for what a drug user looks like, acts like, sounds like, etc. Eventually, they do fit that profile. The track marks, the “meth mouth”, the distant gaze, the slurred speech; all those tell tale signs eventually pop up. But by then we are too late.
It’s time for everyone, medical professionals and laypersons alike, to truly appreciate the ubiquity of this disease, so we can finally make headway into this epidemic.
I am surrounded by drug use and drug related deaths in my forensic pathology practice, so I am obviously biased. But, even those who don’t acutely overdose are often involved in accidents where drugs are involved or suffer from complications of their former habit. And their age, sex, skin color and socioeconomic status have nothing to do with it. When I first started in this field, I would speak with shocked or irate family members who couldn’t imagine that their loved one was using any sort of drug, I would think to myself, “How could they not know? Obviously, they weren’t paying attention.” But I had also created a profile in my head that drug users looked or acted a certain way.
One evening, during my first week of residency, while sitting at a traffic light after leaving the hospital, I saw two girls (early to mid 20s if I were to guess) panhandling between stopped cars. They were smiling. Their clothes were clean. They were just bouncing between drivers’ windows asking for change, saying that they were traveling across the country and needed bus fare. They in no way fit the profile of drug users, at first glance. They may as well have been collecting for an upcoming charity dance marathon. But as the weeks went on, and I saw the same two girls panhandling at the same intersection, it became obvious that they were not just getting some cash together to travel.
Anyone who didn’t sit at that same light every day after work would still have had no idea. They were pleasant and happy; their clothes were clean; they were a couple of kids on an adventure. After a few weeks, I noticed that one of the girls had ballet slippers tattooed on her calf. And then I thought to myself, this girl didn’t come from a home filled with heroin users. She came from a home filled with parents who cared about her, who drove her to ballet practice and videotaped her recitals. Now that she had left home, they probably knew what was going on, but I’m sure it went on for years before anyone had a clue.
And how would they have known? The signs are so subtle. Teens who use drugs are often short tempered and sometimes withdrawn from their parents. You know who else is often short tempered and sometimes withdrawn from their parents? Every teen ever. All those years, all those chances to discuss it, all those routine physicals where no one thought that she could possibly be using drugs.
On my last day as a resident I saw her at the same intersection. Her features were hardened from weather and drugs. Her light-footed skip was replaced with a slow shuffling trudge. Her smile was replaced with a downward gaze and pursed lips. Now she fit the profile. Now it was too late.
Now, for me, that 13-year-old happy, well-adjusted boy who is found unresponsive in his bedroom, that 19-year-old straight-A student found unresponsive in her car outside the gym, that 70-year-old male found unresponsive in bed after yelling at his neighbor for getting spray paint on his sidewalk — they are all possible (maybe even probable) overdoses. Maybe the teens have a cardiomyopathy or myocarditis. Maybe the 70 year old will have a ruptured aneurysm. But, when all three of them come back with positive toxicology (heroin, fentanyl and synthetic fentanyl, cocaine and heroin respectively) I’m not surprised. But, by the time I’m involved, it’s far too late.
Peter Mazari, MD, PhD, is a former research track MD/PhD who trained at Robert Wood Johnson Medical School and the Hospital of the University of Pennsylvania who now practices full time as a Forensic Pathologist and part time as adjunct anatomy and physiology professor in Southern NJ. He has no conflicts of interest to declare.
