Patient Case: opioid abuse

[mgriffiths]

Looking for input in how to approach these types of patients/cases/scenarios.  This is not about the opioid crisis as a whole or trying to find a way to avoid these patients as they need help and I am looking for the best ways to approach trying to help them.  With that said...I am unfortunately well aware that sometimes the patient is too far gone to be helped by any means I can provide.

 

Case: 35yo female, new patient with NO patient history prior to appointment other than knowing it is a "transition to care" from emergency visit.  Shortly before visit we are able to locate ED records and learn patient was transported by ambulance for narcotic OD and discharged from ED after several hours in stable condition.  3 months prior she was transported by EMS, required narcan, intubation, and was in CCU for 3 days - upon extubation and "waking up" left AMA shortly thereafter.  NO other patient history other than a controlled substance prescription history showing an obvious (and VERY rapid) narcotics wean over 4 months with last prescription written and filled approximately 18 months ago from previous provider (assume PCP) in outside facility.

 

During intake with my MA - patient claims no recollection of why she was in the hospital either time, but currently has back pain, dizziness, and abdominal pain - and is here for "help."

 

I enter the room and patient is shaking, pupils constricted, and fidgety with elevated BP.  Negative urine hCG - not enough to send for drug screen, no real need anyway.

 

Take it from here:

Do you "confront" regarding overdoses?  Do you ignore OD history and begin workup for presenting symptoms?  Do you provide Narcan? etc., etc.

 

What I did:

I started by asking about the hospital visits and pushed the patient a bit, not accepting her lack of recollection.  I read her portions of the visits, and tried to discuss narcotics abuse.  Basically confronting without being a jerk and trying to not come across as judgmental.  Patient of course denied narcotics abuse and history of ODs, but upon pushing a bit she did accept the Narcan prescription and listened intently when discussing how and when to use.  So, obviously she doesn't have a death wish...but, as I continued to push her about the narcotics abuse she didn't respond well and shortly thereafter walked out "AMA."  I did my best and I know I will not be able to save everyone...but, obviously wish I could have helped her more as statistics don't play in her favor to survive much longer - with or without the narcan script I provided.  So, looking for advice and/or tactics others have used successfully for these patients so that maybe I can be more successful with the next one.

[thinkertdm]

Interesting.  Not much you can do while she is on something currently, as evidenced by your physical exam and observations.  Cover yourself by assessing and documenting for emergent evaluation elsewhere.  Worst case scenario is she dies walking out the door, and it is from sepsis, overdose, stroke, seizure, blah blah blah.  I would document clearly- "low suspicion for x, y, z due to a, b, c.".

Once you are sure about that, then the real fun begins.  Obviously very little information sharing can happen as something is working on her in the office; however, you can't be sure that she is there for more of the same or she truly wants help.  Addiction is a Rakshasa, a demon in the form of a person, and you can't be sure which one is in front of you. 

Be kind but firm- like you were.  Thinking "well, just a little" will get them (and their friends) back for more.  You can only recommend addiction specialists; MH or social workers.  If they don't want the help, that's on them.

The key is document everything.  Even have your LPN nearby as a chaperone. 

I like to think a number of things.  One, we can only reach out our good hand to help, because that's what it's there for.  Two, we hope eventually they will grab on.  If they sink, its not because we didn't reach out.  I also think, when they are nasty and swearing and spitting, its not them, its the drugs.  Sometimes it helps.

That's all I have. 

[mgriffiths]

3 hours ago, thinkertdm said:

Thinking "well, just a little" will get them (and their friends) back for more.

Thanks for the input!  I appreciate it.  As for the above - I definitely am not one to give a drunk a drink...or whatever phrase you want to insert - even if it keeps them coming back.

[ohiovolffemtp]

Before you prescribe Narcan, remember it requires a (near) sober person to administer it to the patient.  It's only when they are altered with respiratory depression that they need Narcan.  It's only worthwhile to prescribe Narcan, which is pretty expensive, especially in some of the easy to administer packaging, if the patient is likely to have someone sober around when they're using.  Make sure they are likely to be found by family, responsible friends, etc. before you go ahead and prescribe.

[rev ronin]

Have you taken an interrogation class? One way to get honesty out of a patient is to tell them you will find out anyways, and/or already know. For example, in my imaginary interplay:

"Ever had a narcotic Rx?"
"A couple, some years ago, with some dental work"
"Really? Looks like a longstanding prescription with an abrupt taper here from Dr. X."
"..."
"So, you want to save me the day it will take me to run your UTox and just tell me what you're on today?"

Mind you, I LOVE LOVE LOVE the firm, tough-love attempts to get an addict to admit it without dehumanizing or humiliating, so you'd wrap that sort of a confrontation in as much genuine, patient-centered care as you could, but the key thing is communicating that you already have all the pieces to solve the puzzle, and encourage them to come clean with you.  May or may not ever work, of course, but patients who aren't going to be truthful aren't in a place to accept genuine help from you in the first place.

[mgriffiths]

7 hours ago, ohiovolffemtp said:

Before you prescribe Narcan, remember it requires a (near) sober person to administer it to the patient.  It's only when they are altered with respiratory depression that they need Narcan.  It's only worthwhile to prescribe Narcan, which is pretty expensive, especially in some of the easy to administer packaging, if the patient is likely to have someone sober around when they're using.  Make sure they are likely to be found by family, responsible friends, etc. before you go ahead and prescribe.

Absolutely...a patient in need of Narcan is almost by definition beyond the ability to think about using/giving it.

[mgriffiths]

5 hours ago, rev ronin said:

Have you taken an interrogation class? One way to get honesty out of a patient is to tell them you will find out anyways, and/or already know. For example, in my imaginary interplay:

"Ever had a narcotic Rx?"
"A couple, some years ago, with some dental work"
"Really? Looks like a longstanding prescription with an abrupt taper here from Dr. X."
"..."
"So, you want to save me the day it will take me to run your UTox and just tell me what you're on today?"

Mind you, I LOVE LOVE LOVE the firm, tough-love attempts to get an addict to admit it without dehumanizing or humiliating, so you'd wrap that sort of a confrontation in as much genuine, patient-centered care as you could, but the key thing is communicating that you already have all the pieces to solve the puzzle, and encourage them to come clean with you.  May or may not ever work, of course, but patients who aren't going to be truthful aren't in a place to accept genuine help from you in the first place.

I have not...but sounds fascinating.  I actually do this quite a bit, and did this with the most recent patient that fits the above description essentially following your script.  I even include diabetic patients sometimes when they claim to be using their insulin...they never even picked up from the pharmacy!

 

But thank you for your input.

[PAinPenna]

Ideally she should have been confronted, without judgement, about her past and current substance use, and if opioid addicted, referred to a medicated assisted treatment (MAT) program and offered Bupenorphine , a partial agonist, while in a mild state of withdrawal . 

[mgriffiths]

6 minutes ago, PAinPenna said:

Ideally she should have been confronted, without judgement, about her past and current substance use, and if opioid addicted, referred to a medicated assisted treatment (MAT) program and offered Bupenorphine , a partial agonist, while in a mild state of withdrawal . 

Yeah...that was the hopeful plan - or at least something similar - but never got that far...

[ventana]

figure you are going to spend a solid hour in that visit if you can get her to open up

 

honest active listening sometimes get the ball rolling

 

remember that very few people with OUD actually want to be abusing substances,,,,, instead they are only stuck in a chronic disease and if you reach out be prepared to have a long visit......   

 

just don't write for controlled meds.....