By way of introduction, it’s important for you to know that I’m the hippie of the residency faculty. So with that said, I’m going to write about love. I’ve truly loved all aspects of family medicine, like deep-in-my-heart love, for quite a while now, so it was only a matter of time before I ventured into addiction medicine. This has been the area of my practice which has challenged my beliefs and assumptions the very most. It has included some of the biggest wins of my career to date and some of the greatest losses.
In the spring of 2018, I admitted the first patient to Unity Point Hospital with poisoning from K2 — also known as synthetic marijuana. Our team worked to coordinate a response, care for these 60+ patients, get whopping doses of vit K for them outpatient, and follow their INRs for months to wean them down.
It was in their stories and from our success in not losing a single patient to follow up (our case managers are worth their weight in gold), that I saw the power of a high functioning, primary care team. Being able to fully envelop these folks was an incredible feat and, at various times, exhausting. Like much of medicine, it meant putting others before myself. But far too often, I found myself defending our care of these patients — and here is where the radical love comes in.
It is so easy for people to be judgmental and unkind ::insert comment on Darwinism or bad choices here::, but the truth is it could’ve been me. The fastest growing group of people with opioid use disorder is middle-aged white women.
After my C-section, I was given a script for 30 tablets of Percocet and, when I asked for less narcotic, I was sent home with a script for 30 tablets of Norco instead. The data on opioid use disorder (OUD) indicates that women who become addicted to opioids often do so after taking medication for surgery — most commonly, a C-section. I was lucky to avoid that complication or adverse outcome if you will. I now have two little girls, and one day it could be them.
Too often, we as physicians write unnecessary scripts for opioids. In my opinion, it is also our duty to help clean up the mess we made through harm reduction and medication assisted therapy (MAT).
Drugs and morality
Again, herein lies the idea of a radical act of love: We need to welcome these patients into our practice and treat them with kindness and empathy. What’s radical about that? We need to do it even when it feels contradictory to our preconceived notions about substance use and abuse. We have been trained to think poorly of these patients. There are very few diseases outside of addiction disorders that have been so intimately linked to morality. It’s in the language we use: “his urine is dirty,” or “she’s been clean for 3 years”. We fire patients from the office who violate controlled substance agreements. We report moms with substance abuse disorders to DCFS.
This group of diseases has very real and wide reaching consequences for our patients. I am reminded of the quote from Brene Brown’s work on shame: “If we share our shame story with the wrong person, they can easily become one more piece of flying debris in an already dangerous storm.” We need to contribute to their shelter. We, as physicians, need to be a calming presence in their storm.
The central principle guiding my practice is harm reduction: the idea that we should counsel patients to try to use substances safely and decrease their use if they are unable to quit. The end goal is to reduce the risk of overdose. Someone who lives another day, has another opportunity to try again for sobriety. Another mother who lives to see her kids; another brother who lives to bring the family’s favorite pie to Thanksgiving; another daughter who is able to work to support aging parents. Harm reduction is as simple as it sounds, but again, our personal beliefs often put this principle in direct contrast to our own sense of morality.
For many, something seems wrong about counseling on any form of drug abuse aside from abstinence. It did for me for a long time. I was raised in a very Catholic family by a mother who was a narcotics cop for the city of Chicago. Drugs are bad. End of discussion. I had a lot of biases when I started medicine, and still have to check myself.
Radical acts of love
- Use patient centered language. Everyone. From the phone staff to the checkout people and everyone in between.
- Educate yourself and your staff on what addiction looks like. Learn how to spot it and how to address it.
- Investigate and address your implicit biases. Think about who you’re screening for addiction and why. To actually do this, you need to be real with yourself and know you’ll live with some very uncomfortable feelings.
- Work with a patient who has unexpected findings on their drug screen. Counsel them on the risks of continuing to use these substances. Offer them treatment or referral to services. Keep them as a patient in your practice.
- Remember to screen for and counsel on high-risk sexual behavior, PTSD, depression/anxiety, and childhood trauma/sexual assault.
- Become an X waivered buprenorphine provider! Encourage others in your office to do so as well.
- Prescribe Narcan to your patients and to family members. Encourage them to tell others where they keep it in case it’s needed.
- Counsel patients on the safe storage of medication
- Counsel patients on harm reduction principles: never use alone; if you’re going to inject, use clean needles; use a designated driver, etc.
- Spend time learning about addiction disorders, including alcohol use disorder and other drugs.
- There’s a ton we can do to help patients right from our own office without needing to be board certified in addiction medicine or upend the workflow in the whole clinic.
- Be an advocate for expanding addiction services in your community. In the Peoria area, we’re fortunate to have the JOLT Foundation offering OUD services like logic based peer support groups and homeless/sex worker outreach.
- Call us with questions! The residency has 9 X waivered faculty. Not sure what to do to get started? Reach out. Questions about managing a pregnant patient with OUD? Reach out. Unsure how to get a patient started or how to interpret a drug screen? Reach out.
- Call the UCSF Clinician Consultation Center: 1-855-300-3595. It’s a warm line where you can talk to a physician about any substance use case you need help with, including perioperative pain control in someone with OUD. It operates M-F 8 a.m. to 7 p.m.