During my first post-graduate year working in an acute hospital setting, I had the opportunity to work with individuals seeking medical care who also had a substance use disorder (SUD). I learned how patients with SUDs can sometimes present unique challenges to both residents and well-established clinicians. Herein are a few key points that I hope will guide new psychiatry residents placed in similar situations.
In my clinical experience, a large percentage of people with SUD were intimidated by being in the hospital and did not understand what was going on regarding their care; some even refused care. Listening to their concerns and being transparent helped me to foster a relationship with these patients and better address their questions.
Reconciling Medications May Uncover Substance Use Disorder
One day, I was completing medication reconciliations in the emergency department, when one of my patients, an elderly woman, mentioned that she was taking oxycodone/acetaminophen 10 mg/325 mg three times a day for pain. Based on her previous hospital stay, even though it had been more than a year ago, I noticed she had been prescribed oxycodone/acetaminophen. I was trained in my pharmacy education to get two sources of information for a medication reconciliation: one objective and one subjective, to provide the most accurate medication history.¹
When I checked with the patient’s pharmacy, there was no record of a recent prescription for the oxycodone/acetaminophen. I discussed the discrepancy with the patient, and she told me, “Oh honey, I get those from the street…do you know how expensive they are?”
I found these statements jarring. After the conversation, I discussed the interaction with the treatment team. The team decided that she would not be receiving any opioids, and we would consult our peer specialist in the emergency department to start a conversation with the patient about opioid use disorder treatment.
Takeaway: This scenario provides an excellent example of why medication histories and following a stepwise procedure can be incredibly beneficial to treatment decision-making.
Balancing Pain Management, Antibiotics, and Anxiety with SUD
My second story involves a patient who presented to the hospital with a skin and soft tissue infection on her abdomen. Upon admission, she shared with the treatment team that she had this wound on her abdomen for a prolonged time and was scared to come into the hospital to receive care. I went to her room to conduct a medication reconciliation and found out one of her home medications was buprenorphine/naloxone, a medication that can be used for opioid dependence.
This patient was concerned about her pain management during and after surgery. Specifically, she thought she might relapse, or, if given additional opioids for pain due to the surgery, undergo a setback from the progress she had made with her opioid dependence treatment.
The treatment team discussed with her that the surgical team would need to see her and that she would need antibiotics to treat the infection. We also decided that this patient should be continued on her buprenorphine/naloxone medication while in the hospital and determined that the surgery team would follow up to assess and discuss pain management options after her procedure. I explained to the patient that there were alternative options for acute pain control but that we would need to wait for the surgical team’s input for further treatment.
After initiating antibiotics (IV vancomycin), the patient experienced nausea and vomiting. It was determined that she had vancomycin flushing syndrome,² which generally improves by decreasing the rate of infusion. I spoke with her about the syndrome and how we could provide supportive medications such as acetaminophen (for pain) and diphenhydramine (for nausea), and slow down the infusion rate, but I stressed that antibiotics were still important to help clear the skin and soft tissue infection. She agreed to take the supportive medications and see if slowing down the rate of the infusion would help with her symptoms; there were improvements after the adjustments were implemented.
While we talked, the patient said she was considering leaving the hospital, which would be against medical advice (AMA). I was very concerned that if this patient left, she would become bacteremic and succumb to the infection. I talked to her for more than 30 minutes about her concerns and focused on her staying in the hospital so we could adequately treat the infection. After my conversation, I spoke with the treatment team, and we decided that we should consult our peer specialist to encourage her to stay in the hospital, provide another opinion on the options for her pain, and offer additional support while she was in the hospital.
The following day, I came to work early to see if the patient was still there. She had just received a bedside incision and drainage (I&D) to clean the wound and was upset. She felt that the I&D was abrupt and that her pain was uncontrolled. When I tried to explain that pain medications take time to work, especially when controlling for pain in an acute setting. Unfortunately, our team was unsuccessful in our discussions with this patient and she ended up leaving AMA.
Takeaway: There may be medication adherence difficulties when treating patients with SUD. Transparency and active listening can help to address a patient’s concerns, but sometimes, that is not enough.
Resident Perspective
When working with patients who have SUD (and any patient for that matter) it’s essential to employ transparency, active listening, and follow stepwise procedures to improve care and mitigate errors. While we may not be able to help every patient, we can provide the best care possible treatment while they are in our care.
Disclaimer: The views and information expressed in this article are those of the author alone and do not necessarily reflect the official policy or position of any hospital, clinic, or psychiatric facility in the US.
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