[Yellow Cohort] Module 7 2018-2019

[Nabil Al-Kourainy]

Please place your responses to this week’s module here

[Nabil Al-Kourainy]

Article #7; CWC Module 6

I recently encountered a middle-aged woman with a history of polysubstance use disorder including crack-cocaine as well as heroin (IVDU). She reported that she started using heroin after a prescription for opiates due to an ankle injury. Now, both her and her husband are using heroin as well as crack-cocaine. She expressed interest in quitting. This is a typical example of a victim of the opiate epidemic nationwide.

Substance use disorder, in particular opiate use disorder, which is illustrated by the 42 y/o F homeless patient in the case, is a problem of epidemic proportions in the United States. As stated on CWC, substance use disorder is often accompanied by mental health disorder. According to the CDC, states with statistically significant increases in drug overdose death rates from 2016 to 2017 included Alabama, Arizona, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Michigan, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, West Virginia, and Wisconsin. In Michigan, there was a 13.9% percent increase from 2016-2017. Data from 2018 are pending (1). In Wayne Country alone, According to Caspio cloud database, there were 438 opiod deaths, 84 heroin deaths, and 665 total overdose deaths (2).

Unfortunately, at present, despite the public outcry, there are insufficient funds directed toward drug rehabilitation and recovery efforts. The mental health component of this growing issue is often marginalized and overlooked. In October 2017, President Trump declared a 90-day public health emergency to call further attention to the problem. The results of which have had mixed response. As clinicians, we are on the front lines of this epidemic, it is a war of conscience and of attrition. When encountering these patients in the hospital, we are challenged to find a balance between treating withdrawal and helping to transition patients to outpatient follow-up for substance use disorder. As a clinician practicing in Michigan, I find it particularly frustrating that we are not able to discharge patients directly to treatment centers, where there are trained physicians and staff that have years of experience addressing the psychosocial components of substance use disorder. This is a glaring issue that calls for legislative action. As physicians we must lead the way in calling attention to this problem. Another area that needs to be addressed is a desperate need for increased funds for substance use disorder treatment as opposed to criminalizing this healthcare epidemic.

Sources:
1. https://www.cdc.gov/drugoverdose/data/statedeaths.html
2. https://www.mlive.com/news/2018/08/look_up_the_number_of_drug_ove.htmlFortunately, this problem has not gone unnoticed by the

[Shivani Agrawal]

Opioid abuse is a big topic in medicine. I enjoyed our discussion on Monday and the input my classmates had on the topic. It is also interesting how other medications are now being medications that have potential for abuse, including some OTC medications. I recently finished my VA rotation where now to prescribe controlled substances you have to go through many steps and then only the attending can sign the prescription. As Dr Nnodim pointed out, it is important NOT to deny people who need them but to use them judiciously.

[Brandon Twardy]

Opioid use is a becoming a major issue in patient care. We have many patients who are on opioids and weaning them off can be challenging. Often times chronic pain is a major contributor to their prolonged opioid use, the majority of which is musculoskeletal in nature. Delineating the underlying cause of the pain can be one approach to help in developing alternative therapy regimens to better manage their pain. Sending patients to physical therapy, as an alternative in this case, will help to alleviate the pain and to identify the specific etiology. However, each decision should be made on a case by case basis as not all patients have access to this type of care.

[Deya Obaidat]

When it comes to social determinant aspects, it seems that you can’t talk about a component separately without talking about the other aspects, this Monday the discussion was about substance use disorder and how does it generally affect the healthcare of people.

From my own experience in the hospital, it seems that patient who do have a diagnosis of substance use disorder tend to be having more acuity in their presentations and tend to have more re-admissions withing 30 days period compared to their piers who don’t carry the diagnosis. And as the endemic opioid problem is still on the rise, we still see the number of patients who have a history of substance use disorder are continuously increasing both in the inpatient and the outpatient settings.

I had an encounter with one of the patient’s in the inpatient setting, where she is well known to use IV drugs, she also has a history of AIDS, infective endocarditis which was treated. The patient presented with an abscess on the chest wall, which later on through imaging studies it turned out that it extends all the way to the mediastinum, luckily there was no involvement of major vessels in that patient and we could manage her infection with IV antibiotics, Now things could have been much worse for this patient if she didn’t seek medical attention or she delayed her medical care, her history of AIDS and infective endocarditis are mostly related to her IV drug use.

People with history of drug use disorder have worse healthcare which could be related to multiple reasons, some reasons are direct like needle sharing which increase the risk of blood stream infections, and the direct effect of the drug itself where you can see those patient being admitted for overdose. Indirect effects could be related to either spending most of their money on the drugs that they won’t be able to have money to seek medical attention for the medical problems, also it seems that most of the patients who have drug use problem tend to be jobless and with that comes other problems like unavailability of medical insurance.

I do believe as physicians, we are the first line of encounter with these patients in most of the cases, as they tend to stay away from the society and usually they shy away from seeking help for their drug addiction, that being said, I believe that physicians play the biggest role to identify those patients and talk about their health care and how it is associated with their drug use directly, also physicians tend to have resources to help those patients out, that most of times they don’t know about, and we have the power to explain and talk to patients about their drug use, and maybe telling the patients it’s another disease that we have to treat rather than dealing with it as a stigma that they need to hide away from society because of it.

[Carli Denholm]

we encounter patient with substance use disorder almost daily, and that is an additional challenge in our daily practice. just few weeks ago I had patient who was admitted for CHF exacerbation and he kept asking me for pain medication however his UDS was +ve for cocaine and he didn’t have a legit source of pain and we decided not to give any opioids. suddenly one day the patient was unresponsive and code grey was called, after multiple teams managing the patients he responded to narcan and apparently the patient brought his drugs with him and hid them in his bags.
his UDS later was +ve for opioids that is just a simple example of the daily challenges, and when we asked the patient, he was actually discharged from one of our hospitals with a prescription of opioids, so we as health care providers sometime contribute to this opioid epidemic and the patients put pressure on us sometimes by yelling and threatening.
we should never compromise when it comes to opioids and pain medication, we should always control the patient pain and make sure our patients are comfortable and their pain is tolerable but we should never prescribe pain medications just because the patient is angry or is yelling or threatening.

[salina faidhalla]

we encounter patient with substance use disorder almost daily, and that is an additional challenge in our daily practice. just few weeks ago I had patient who was admitted for CHF exacerbation and he kept asking me for pain medication however his UDS was +ve for cocaine and he didn’t have a legit source of pain and we decided not to give any opioids. suddenly one day the patient was unresponsive and code grey was called, after multiple teams managing the patients he responded to narcan and apparently the patient brought his drugs with him and hid them in his bags.
his UDS later was +ve for opioids that is just a simple example of the daily challenges, and when we asked the patient, he was actually discharged from one of our hospitals with a prescription of opioids, so we as health care providers sometime contribute to this opioid epidemic and the patients put pressure on us sometimes by yelling and threatening.
we should never compromise when it comes to opioids and pain medication, we should always control the patient pain and make sure our patients are comfortable and their pain is tolerable but we should never prescribe pain medications just because the patient is angry or is yelling or threatening.
unfortunately some substance use disorders starts with legit pain medications prescriptions and then weaning of those patients is a challenge

[Marvin Kajy]

The opioid epidemic is so severe that his has been declared a national emergency. I recently came across an article that stated that every day, more than 130 people in the United States die from opioid overdose. The misuse of and addiction to opioids, such as prescription pain relievers and heroin, is a serious national crisis that affects public health as well as social and economic welfare. The roots of the problem really started in the late 1990s, when pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers. Also, physicians at that time were scrutinized for not adequately controlling pain. In response, healthcare providers began to prescribe them at greater rates.

​As I was reading this article, I cannot help but remember a patient I took care off at DRH floors during my intern year. This woman was in her 40s and had a past medical history of HIV and Hepatitis C and she was admitted for sepsis due to candidemia. This patient was an avid snowboarder in her 20s and 30s. However, 10 years ago she sustained a tibial fracture as a result of snowboarding for which she underwent numerous revision surgeries and required pain management with oral opioids. Her pain was initially well controlled however, eventually she developed tolerance and she required increasing amounts of opiates to control her pain. When the providers failed prescribe her the pain medications, she turned to the streets. She became addicted to heroin and she lost her job, house and her family. This is a patient who is clearly a victim of the opioid epidemic. It is stories like these that have made physicians more mindful of their opioid prescribing practices. The problem is that as physicians cut down opioid prescriptions, the patients will look for other means to get their hands on these medications. At GMAP we have done a great job at cutting down our opioid prescriptions and referring them to pain specialists to help the patient in getting weaned off the pain medications.

In response to the opioid crisis, the U.S. Department of Health and Human Services is leading a campaign to curb opioid misuse and to help those who are addicted. This program focuses on improving access to treatment and recovery services. Promoting use of overdose-reversing drugs. Strengthening our understanding of the epidemic through better public health surveillance. Providing support for cutting-edge research on pain and addiction. Advancing better practices for pain management. In the clinic and on the floors I have taken care of numerous people with addiction disorders. One resource that I use is Substance Abuse and Mental Health Services Administration (SAMHSA), which is a branch of the department of health and human services. I use this website to locate addiction centers/methadone prescribers that are near a patient’s home. I use this as a bridge so that the patients have the right follow up on discharge. ​

[Muhammad Usama]

This week out topic of discussion was Substance use disorder. I enjoyed the different thought my colleagues shared during the discussion. Being the front line people in this opioid epidemic as physician, we should take the lead to come up with novel solutions to decrease inpatient admission of Opiate medications for control as multiple studies show that 3 days of inpatient opioid prescription would lead to greater percentage of patients being dependent on opioids in the long run. If hospitals start recruiting APPs to assess and adequately treat inpatient pain of the patients, I believe it would curtail much on inpatient opioid prescribing practices. Being future leaders in healthcare it is out responsibility of thinking about things which can stop this epidemic. At the same time it is very important to treat acute pain adequately even in patients who have substance use disorder and ensure a referral for them to substance use clinic in discharge. Also, I intend to complete training to be certified in Methadone and Suboxone prescribing so I can help my patients who are definitely going through a very difficult phase in their life due to substance use disorder

[James Bathe]

Substance use disorders are a pervasive problem in our society. But even more pervasive and far more insidious is how we respond to them. For years, society has treated addiction as a moral failing; an lack of fortitude and willpower. And this attitude has led to treating those living with substance use disorders as criminals, subhumans, and as enemies of a healthy populace. The War on Drugs started by the Nixon administration targeted users as the infantry of the “war” while in actuality, users are the major casualties. Use disorder can lead to life derangement as it is as focus on obtaining more of the substance can interfere with one’s day to day life. However, on top of that, we throw incarceration, risk of fatal responses from police, lack of support, and hate onto already suffering patients. Even further, programs such as drug testing social aid recipients have seen a surge in recent years which disproportionately cost so much for so many true positive tests, only to then yank support from those users who test positive. In other words, society is so anti substance use disorder patients that it is willing to cut of its nose to spite its face. Change is sorely needed.

We all have had patients that are substance users. We have also all have had frustrations with these patients. However, it is far to easy for practitioners to fall prey to society’s designs. As physicians, we need to continue to recognize substance use disorder as another aspect of disease rather than a freely made choice. Further, we have a duty to advocate for the treatment of substance use disorders as a disease to be treated rather than a crime to be punished. While I am not advocating for the complete legalization of drugs, I do think that we should support decriminalization use of substances. Substance users should be encouraged to seek treatment and there should be a drive to disincentivise distribution of more dangerous substances. There is already far too much harm caused by the substance use disorder in and of itself; we do not need to add further harm and societal damage through unnecessary incarceration. Further, we already see a disproportionate level of punishment for poor users, especially those of color. No one need look further than the sentencing of users of snorted powder cocaine versus those sentenced for crack use. We must advocate for change in our clinics and in our communities.

In the mean time, we can be accepting and understanding. We can seek causes behind the disorders. We can search for new and more effective and safe treatments for use disorders. And we can strengthen our infrastructure in our clinics and hospitals to deal with substance use disorders as another medical condition to manage and treat. We must make change starting where we are, but always with eyes to the bigger picture.

[Lea monday]

I have a long time patient with bad copd on methadone due to prior heroin use. She also got hep c from drug use but in last 10 years has turned her life around and is now cured after harvoni. Sadly, she relapsed last week after 3 years sober. She tried so hard. But she is back in sobriety now. I told her she should be proud for letting a slip up slide and not falling full back into addiction. She is very resilient

[John Dawdy]

Substance use is a frequent and difficult to address concern in a number of our patients. As residents we can often feel helpless when working with these patients that struggle with sobriety despite recurrent adverse effects of their substance use and recurrent discussions in clinic. Despite our best interests, medical knowledge, and referrals to substance abuse resources available to patients, many continue to struggle. It takes time to understand that we only have so much sway over patient’s actions, but we must continue our best efforts to provide them with the best tool set in order to succeed in their efforts to quit when they are ready. As we discussed in our reflection this week, use of methadone/suboxone is often limited due to prescription limitations. One option open to use is to obtain our license to prescribe suboxone on an outpatient basis, which only requires an 8 hour training session that is readily available. I think that this is a reasonable expectation and a valuable learning opportunity available to us.

[Aliza]

We as a physician come across many individuals who are unfortunately somehow got themselves trapped into the use of addictive substance use. But what made them initiate this lethal path is not an easy answer, since several biological, social, environmental, psychological, and genetic factors are associated with substance abuse. Social categories such as class, gender and race can influence access to resources, exposure to marginalisation, roles and expectations. People from low socio-economic classes have poorer health and are more likely to use tobacco, to drink alcohol in a high-risk manner and to use illicit drugs. Once these individuals are on this track of substance abuse, things becomes even harder for them. Drug-dependent people are particularly likely to be unemployed and to experience criticism , both of which can exacerbate their problems and prevent seeking or benefiting from treatment. But we as a physician should play our role of responsibility and not bring biases while treating these patients who are already being deprived of getting help due to their current addition with several different strings attached. We should recognize these as an individual and take an extra step to address their root cause, provide counseling and if agreeable to get help, provide them resources and information for successful rehabilitation.

[Dana Kabbani]

I have a patient that I was able to wean off opiates over the past few months that he was using for his chronic back pain. He was willing to try physical therapy and non-opiate medications for his pain. Despite physical therapy improving his back pain, he requests opiates at our follow up visits to help with his pain. At our last visit, we agreed to continue with physical therapy and a follow up visit in 10 weeks to assess his pain level.

[Syed Umer Mohsin]

As physicians, we see patients who have substance use disorder on a regular basis. Their story might have started with a prescription from a doctor’s office or through other channels but without awareness of dependency, it escalates into the big crisis that we are in today. We should acknowledge the problem of drug addiction as a conundrum of social, mental and physical issues and address it similarly. It takes a team (including primary care, pain management, rehab, social services) to help these patients and while this task is slow and difficult, but not impossible. These patients should not be abandoned or discharged from our care but monitored closely all the way to a stepwise improvement in their well being.

[Leslie Kao]

I don’t think we do enough to treat substance use disorder or its downstream effects in medicine, partially due to the stereotypes surrounding IVDA, overly restrictive laws and our medical profession’s ignorance.

First, why is heroin so addictive? Why are you “chasing the dragon”? Without having done it, I don’t know and can’t even relate with what the patient is trying to overcome. Do we as physicians even try to understand why this drug is so completely addictive?
https://www.youtube.com/watch?v=-9huWlXFA1s [best video of all time if you want to understand what it feels like to do heroin and how people become addicted, please watch]

Second, after someone becomes addicted to heroin and before they are willing to quit, what are we willing to do as physicians? Do we even know the process of shooting up to teach patients how to do it safely? [https://www.youtube.com/watch?v=Miv8i-slK2w]
I know to counsel patients on clean needles and clean water. But I didn’t know there were filters involved.
Do I know where to send my patients for clean needle exchanges? (I guess I could google, but I don’t know anywhere off the top of my head and have never suggested a patient go to a specific place)
Do I feel comfortable prescribing IVDA paraphernalia for safe IVDA? Absolutely not. Am I even legally allowed? Even if I am, will insurance cover it? (I think we all know this answer)

Finally, we spend so much time on learning when to counsel on smoking cessation, but absolutely none on opiate cessation. When do I intervene and start pushing? When do I take a step back and think, well my patient is not ready yet and I do not want to alienate them for when they may be. When my patient is ready, am I ready to help them handle the inevitable withdrawals? Send them to a methadone clinic? Am I certified to prescribe suboxone (no but I will be taking the course).

Am I the only one that feels like I’m tilting at windmills when it comes to heroin and opiate abuse? If I’m not, no wonder there’s an epidemic when we as medical professionals are so unprepared to relate, intervene or help.

[Eskara]

When it comes to our patients who have substance use disorder our implicit bias runs high. More often than not, we tend to hold their pain medications inpatient just because we do not want to fuel their addiction. What we need to realize is that patients who have this disorder, have real pain and real disturbing symptoms when the substance that they abuse are held. This needs to be managed properly by getting appropriate help on board and needs to be treated as a disease in its entirety.

[wsumed]

The Collapsing Empire • John Scalzi • 9780765388902

[Author]

Posts