Deportation and addiction: My patient died alone

Maria was 42 years old when she died alone.

As an internal medicine resident and future addiction medicine physician, I have the immense honor of caring for undocumented immigrants at a nonprofit community clinic in Philadelphia. As the granddaughter of Cuban political refugees, caring for immigrant populations is central to my identity as a physician. As such, I am proud to work at a clinic that provides care to patients who otherwise cannot access primary care due to their inability to qualify for health insurance.

When Maria first came to the clinic, she confided to us that she drank alcohol to cope with the trauma of immigration. On further evaluation, she was found to have cirrhosis, irreversible damage to the liver that can be caused by heavy alcohol use. With the help of her family and community, she stopped drinking. For the next year, she remained healthy, abstinent from alcohol, and hopeful for her future.

Then one day everything changed.

A couple of months ago, her husband and child were captured by Immigration and Customs Enforcement (ICE) officers. Without access to legal representation or a phone to call for help, they were deported back to their home country in Central America in a matter of days. Unable to cope with the trauma of losing her child and husband, my patient started drinking alcohol again and her health rapidly deteriorated. She was brought into the emergency room with a life-threatening bleed from her esophagus, a known complication of severe cirrhosis. This bleed was likely triggered by her return to drinking alcohol. Despite medical intervention, the damage was done. Her organs had failed, and it became clear that she was going to die. The medical team was able to contact her family back home and communicate the severity of her medical condition. My patient passed away shortly thereafter, alone, without her family by her side.

My patient’s official cause of death may be documented as multi-organ failure due to a severe bleed from one of the blood vessels in her esophagus. However, let me be clear: Deportation of her loved ones killed my patient.

At the community clinic where I work, an increasing number of patients are presenting to the clinic with alcohol and substance use disorders. Many are young men under the age of 40 and some are being admitted to the intensive care unit for life-threatening alcohol withdrawal. Patients who use substances often do so as a means of coping with trauma, including the trauma of immigrating to a new country. These individuals leave family and support systems behind in their home countries. Patients report increased levels of depression and stress in the face of this administration’s aggressive anti-immigrant policies and deportation tactics. At the clinic, I start patients on medications to help them stop drinking, and I refer them to our behavioral health specialists to help them process their trauma. But addiction is a very difficult illness to treat, and trauma is a common trigger for patients to return to use. Trying to cope in any way possible, even if it is maladaptive or unhealthy, is vividly relatable.

Regardless of documentation status, my patient did not deserve to die. As a doctor, I care for my patients no matter their circumstances, but the current approaches to immigration enforcement are undoing much of my efforts to help my patients remain abstinent from their substance use. Our government should not be promoting policies that cause cruel and unnecessary harm as daily trauma promotes daily risk of worsening substance use.

At our clinic, we have seen an uptick of patients seeking care for alcohol use disorder (AUD) in the past several years, including patients presenting in severe, life-threatening withdrawal. However, providing care for AUD has proved a challenge in a population with no access to medical insurance to pay for that care. This stark reality led me and one of the student volunteers at the clinic to develop a needs assessment that was distributed to providers and promotoras (community health workers) at the clinic to explore the facilitators and barriers to improving access to screening and treatment for AUD for our patients.

Through our survey, we identified that facilitators to improve access to care for patients with AUD included having frequent contact with the clinic staff and developing trusted relationships with providers and promotoras. Barriers included medication costs, limited time for screening and counseling at appointments, competing social stressors, high rates of trauma, and limited provider and patient knowledge about AUD treatment.

To address these barriers, we applied for and received a grant to provide access to free naltrexone on-site for patients. I also worked with a few addiction medicine physicians to develop a clinical pathway for treating alcohol withdrawal and AUD in our low-resource clinic and provided information regarding community and clinic resources for our patients. Lastly, we created an internal monitoring system to track our patients diagnosed with AUD and provide outreach and support them in their recovery.

As providers for immigrant populations, especially patients with limited access to medical care, we know that trauma is prevalent among immigrant communities. Trauma is a clear risk factor for substance use. We must proactively screen patients for substance use disorders and advocate within our systems to provide access to medications for AUD and counseling services to the full extent possible.

This essay is cited in the KevinMD record on immigration and medicine.

Amanda Perez is an internal medicine resident.