Saturday, June 30, 2007

Changing the way we think about addiction

It's Friday evening, 19:30, and you're the only doctor left in the emergency department. It's been a busy day and you're tired, but you don't finish for another hour and a half. You are still working up 2 patients with chest pain, and 2 weak and dizzy's, one of whom arrived by ambulance without any actual medical information. There are still 10 charts in the 'to be seen' pile and you know the evening rush will soon follow. You're flagging...

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.
Developing approaches and strategies to effectively treat patients with addiction results in benefit for both patient and doctor. The patient accesses effective, evidence based care and allows the treating doctor to feel like they are offering the best available options to the patient. I am not arguing for the Emergency Room to become the main treatment ground for addiction, however as it frequently sees patients who are struggling with addiction it makes sense to develop approaches to treatment that start in this environment, both in the interest of good patient care as well as in the interest of job satisfaction of the people who work in the emerg.

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!


MedStudentGod (MSG) said...

Very thoughtful post. I completely understand the need to be direct with addicts and offer them choices, as I imagine most of the other professionals who lament them would as well, but it is definitely a tough situation with little help. Being a medical student I saw that most of the time addicts walk away, cursing and yelling, threatening lawsuits, and sometimes becoming physically violent when confronted. I've also seen doctors "wash their hands" of the patient.

I enjoyed this post a lot because you've offered your own beliefs and understanding on this topic. I know it's very easy to become jaded (my most recent post profoundly demonstrates that thinking), but as I continue to learn I should always try to remember that addiction is a disease. It's just hard helping people who can be so spiteful.

Doc's Girl said...

Very good post...

Liana said...

Dr. J, I'd be interested in knowing how you handle this situation in the clinic... maybe in another post, please?

I still do not have a good approach to this situation. I stumble when I see someone who I think might be in pain but also has a clear history of drug dependence/abuse issues.

A palliative care doc made the very good point to the residents that patients with inadequately treated pain often end up engaging in some of the behaviours which doctors typically flag as "drug seeking"... double doctoring, for example.

Dr. J. said...

Hi Liana, Thanks for your comments, I'll try to discuss office management of chronic pain and addiction in a future post. I the mean time, a couple of relevent points for when you encounter patients with chronic pain and addiction....

Don't allow yourself to be rushed into making management decisions without having all of the information you want/need.

If you feel over your head with a particular patient it is reasonable to say so and refer to someone with expertise in addictions.

Pseudo-addiction (behavior that mimics addiction but is due to inadequately treated pain) is a retrospective diagnosis. Most people with addiction have what they percieve to be a pain problem (in some ways they are correct, withdrawal is painful and some drugs of abuse can lead to disregulation of the perception of pain).

A urine drug screen is a very useful tool and provides important information.

Perscription drug addiction is one of the most common addictions in Canada.

If perscribing narcotics to this patient a perscribing contract should be in place (one doctor, reasonable doses, attendance at appointments, attendance at a counsellor, no diversion, no injection, daily dispensing, pill counts on demand, taper if no benefit is seen after a specified interval).

Consideration should be given to using methadone in this patient.

Any narcotics perscribed to this patient should be daily dispensed and witnessed injestion.

Concurrent perscription of benzodiazipines should be avoided.

Don't do anything quickly, and set firm and specific boundaries with the patient. The first visit with this patient in an office setting is about agendas and boundary setting. Like I've said previously manipulative behavior is part of addiction and at the first meeting the patient is often trying to get their drug of choice perscribed at the dose they want in the amount they want. Your job as a doctor is to determine what is actually going on and offer the most appropriate care you can, it's then up to the patient to choose to participate in that care or not.

A good article for anyone who sees patients with chronic pain / addiction is: Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain, Douglas Gourlay et. al., Pain Medicine 6(2), March 2005. It can be found as a full text document with a google search.

Dr. J.

Midwife with a Knife said...

Thank you for this post. We get so little teaching about the management of addiction in medical school and residency, yet, it's a very common and important cause of illness and suffering.

Dr. J. said...

MWWAK: Thanks for the nice comment! I agree with you that it really does start with teaching. There is little teaching in medical school or residency around addiction. Often it's because the doctors involved with addictions care are not that involved in the academic system, though they are often happy to teach if they are asked.

In the obstetrics realm for instance, here in Vancouver there's a dedicated group of doctors (mostly family docs here in Vancouver) who care for pregnant women with addiction, but their program really isn't integrated into curriculum of med school or residencies in a way that maximizes potential teaching....I don't think it's because they aren't interested in teaching or because people aren't interested in learning, but rather because it just has never been set up that way.

This post, and my comments on a bunch of other medical blogs of late are aimed at trying to help make addictions care easier for both patients and doctors. Managing thyroid disease would be difficult if no one ever mentioned the thyroid in med school or residency, and I think that is exactly the problem with addictions care (and why people find it so frustrating). Developing stratagies for managing addiction is not only about good patient care, it is about limiting the stress of cargivers in caring for this particular group of often difficult to care for patients....
Dr. J.

Liana said...

Dr. J, thanks for the long reply to my comment.

I'm doing urgent care right now at a downtown clinic, and the staff docs tend to shield me from drug-seekers. I think they think that I wouldn't find interacting with them "useful" but I kind of feel like... hey, I'd better start developing my own approach sometime!

PS Good luck with the packing and moving!

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