One of the nurses, equally exhausted, walks away from curtains shaking her head and hands you the chart of your next patient. The face sheet lists the reason for visit as 'Needs Dilaudid Rx'. You walk in and see the patient, obviously agitated, pacing the room. "How come it takes so long to get help around here? What kind of emergency room is this? This place is full of idiots!" Struggling to get a word in you try to take a history. After some hard work you glean that the patient is usually on Dilaudid Contin 12mg BID (or 'Dilly 12's', as the patient refers to them) for chronic pain due to a chronic leg ulcer and osteomyelitis of the tibia. "My stupid doctor went away for the weekend without filling my per", the patient says, "Just give me a week or so worth until I can get in to see him, I haven't even had any today, and I'm in PAIN!".
You do a detailed physical exam and find a large, deep chronic wound on the patients shin with significant surrounding cellulitis. You also note that the patient has track marks around the left elbow, and appears to have significant oral thrush.
Addiction can be a frustrating issue for doctors and other medical professionals. Most doctors are ill equipped to handle most patients with active addiction, and for many doctors the above patient is a nightmare. That frustration is evident in many popular med-blogs, which frequently contain posts venting about patients like the one discussed above. It's useful to consider where that frustration comes from because it clearly makes the jobs of many doctors miserable, and it also gets in the way of good patient care.
Frustration in caring for addicted patients comes from a number of places:
- Addictive behavior is often manipulative, and manipulation makes people angry.
- Doctors often don't have an approach to managing patients with addiction.
- Doctors often feel like they cannot help patients with addiction, and are therefore wasting their time.
- Addiction is a common disease and most people have at least one friend or family member who has struggled with addiction. Patients with addiction can bring up uncomfortable memories and feelings for doctors.
Like many other conditions that we treat with modern medicine, addiction can be understood in terms of a bio-psycho-social model. That is, the inputs into the condition of addiction come from a number of places. Does addiction run in your family? Did you grow up in a high risk environment? Were you exposed to potentially addicting drugs in utero, or during your youth? Do you work in a high risk profession (like being a doctor)?
All too often the issue is polarized into an argument of 'It's a choice!' versus 'It's physiology and genetics!'. It's both, just like Type II Diabetes, a condition that has a lot of common ground with addiction. Type II diabetes is a condition resulting from some combination of genetics, family eating patterns, social situation, patient choices and patient environment. Both are diseases that involve elements of patient personal choice, as well as patient physiology. Good treatment for both addiction and type II diabetes involves far more than just medications (though in both circumstances medications often have a role to play). Usually the most effective approach is a team approach. In the case of a diabetic that might be a doctor, a nutritionist, a pharmacist and a personal trainer. In the case of an addict it might be a doctor, a counselor, a peer support group and a parole officer. In both cases the system works for the patient when the system works together.
Addiction is a long term, chronic condition. Gone are the days of sending people off to treatment centres for the cure. Treating addiction is not a win-loose proposition. Management of over the long term involves helping patients move towards change and abstinence, once abstinence is achieved it involves relapse prevention and management of relapse. Over the long run it involves reducing both the duration and frequency of relapse. When relapse happens (and it does happen because it's part of the long term reality in addiction) it makes sense to approach it from a management standpoint. Just like managing a diabetic who comes in with an A1C of 12% after a year of good control, it makes sense to figure out what happened, what changed, and how do we make changes to get things back on track.
Addiction is common, with lifetime prevalence usually estimated at around 5% of the population. Addiction is associated with a lot of serious medical issues including Hepatitis C, HIV, cirrhosis, brain injury and premature death. Considering interventions that may allow patients to avoid these serious consequences makes sense on both economic and compassionate grounds. Emergency room doctors have the misfortune of usually seeing addicted patients at their worst, and rarely see them when they improve. It's a tough environment to convince people to take an interest in addiction, but it's an area where it makes sense to develop approaches to the issue.
Most doctors have been taught to recognize the patient I presented earlier in this article as drug seeking, and that the treatment options are either to provide a small amount of narcotics, or to tell the patient they can't have narcotics and discharge them. It's a conflict oriented approach that both frustrates the doctor, and the patient.
My own approach to patients like the one above is to frankly tell them that in my assessment they seem to have an addiction problem and that it looks like it's having some serious health consequences for them (in this case both the infection, and the HIV that the thrush hints at). I tell them that I'm glad that they came into for help and offer them help. I offer them medical detox, and tell them that I'll go to bat for them to get them the help they need. I tell them to think about it, that it's their decision, and I'll come back in a few minutes to see what they want to do. (In clinic I take a bit of a different approach I won't get into here.) The benefit of the approach is that I feel like I've offered the patient the best treatment possible, and I've hopefully caused a moment of ambivalence for the patient where change might be possible.
The patient presented above is fictional.
If you are struggling with an addiction and want help talk to your doctor or click on the links to alcoholics anonymous, narcotics anonymous or cocaine anonymous on the right, and find a meeting near you. Change is possible!