CME-MOC

Time Stamps

  • 04:24 Starting the Conversation 
  • 10:43 The Shared Agenda
  • 14:46 Exploring patient goals
  • 18:54 Reducing drug use
  • 24:09 Reducing harm in opioid use
  • 29:06 Recap

Show Notes

Pearl 1: Starting the conversation

  1.  Start by working to earn the patient’s trust 
    1. Prior trauma and negative experiences in healthcare settings are common in patients with SUD
    2. Taking withdrawal seriously and treating it effectively can earn trust and communicate to the patient that their needs are a priority
    3. Aggressively treat pain!
      • It’s ok to use full-agonist opioids for pain and partial agonists (i.e. buprenorphine) to manage withdrawal
  2. Ask about SUD as you would any other chronic medical condition such as diabetes or hypertension
    1. If a patient is hesitant or resistant to answering questions, you can ask permission to help earn their trust 
  3. Use person-first language
    1. Randomized controlled trials have shown that labeling a patient as a “person with substance use disorder” instead of “substance abuser” correlates to recommending more treatment and placing less blame or punishment on patients by healthcare providers
    2. Non-stigmatizing medically based language can improve patient access and engagement in care
  4. Avoiding stigmatizing language
    1.  Refer to urine drug tests as “positive” or “negative” if they reflect presence or absence of substance, respectively.
    2. Avoid labeling patients as “clean” or “dirty”, rather use accurate, non-stigmatizing terminology in the same way it would be used for other medical conditions
      • Instead of “clean” try being substance free, being in remission 
      • Instead of “dirty” try Using [substances], Toxicology test tested positive for [substance] 

Pearl 2: The Shared Agenda

  1. The goals of a substance use history are to learn about your patient’s drug use, look for opportunities to reduce harm in use, and inquire about their goals 
  2. Remember that not all drug use qualifies a person for a substance use disorder
  3. Basic substance use narrative:
    • What drugs are they using?
    • How are they using (i.e. route of administration – inhalation, intranasal, intravenous?)
    • For how long have they been using?
    • Was there a point when their use started causing problems?
  4. Listen for ways the substance use has negatively impacted their lives or caused distress in order to diagnose them with a substance use disorder (DSM-V criteria).
  5. Treatment history:
    • Building on past successes with medications or types of behavioral therapies can guide the treatment plan.

Pearl 3: Exploring the patient’s goals

  1. This sounds obvious, but the patient’s goal is really the goal that matters!
    1. That might mean that stopping drug use is NOT the goal… that’s OK
  2. Transtheoretical Model of Behavior Change or “Stages of Change” may have some pitfalls if we’re not careful 
    • May distract us from the patient’s goal
    • May tempt us to judge or blame patient for not changing if we label someone as “pre-contemplative” 
    • May cause us not to offer treatment such as harm reduction if patient labeled as “pre-contemplative”
  3. In helping patients identify their own goals you can refer back to past successes or hints to what the patient’s priorities are

Pearl 4: For the patient goal of reducing drug use

  1. Run with the momentum, don’t explain to patients what they already know 
  2. Connect patients to MOUD (Medications of Opioid Use Disorder): buprenorphine +/- naloxone, methadone, long-acting injectable naltrexone
  3.  Psychosocial treatment and recovery support are also key 
    • Evidence of additional benefit when added to MOUD, though variable by intervention style 
    • Don’t withhold MOUD if patients are reluctant to engage in psychosocial treatments
  4. Recovery support is an umbrella term and includes different groups and peer coaching

Pearl 5: Reducing harm in substance use

  1. Make it clear to your patient that ongoing drug use does not preclude access to medical care
  2. Emphasizing patient’s safety in drug use
    • Ask about naloxone, prescribe/supply if patient is interested 
    • Fentanyl test strips allow patients to detect fentanyl in unregulated drugs
    • Clean needles, needle disposal/exchange
  3. Good websites that search by location include harmreduction.org, NASEN website (North American Syringe Exchange Network) 

Transcript

Dr. Avery: I think there’s this thought that when we enter the room, we’re going to go in there and somehow save the day that we’re going to say the right word, and it’s going to click with them and they’ll be in recovery. But, you know, the reality of life is, is much different. And so I think the key to a good clinical encounter is really to, in all, all senses of it, to just meet the patient where they’re at to come in, as agenda-less as possible to see where they are on their health timeline. And by being able to just sit there with them no matter where they are, I think that gives them the most opportunity to then, uh, change and figure out what change means to them.

M: This is Dr. Marty Fried, Dr. Laura Kolbe and Dr. Alexis Vien.  This is the CORE IM 5 Pearls podcast bringing you high-yield evidence-based pearls. Today we’re discussing stigma in the treatment of patients with opiate use disorders.  

A: Our goal for this episode is to get more comfortable with discussing substance use disorders with our patients in the hospital.

M: ALEXIS!  Welcome Back!!! Our listeners will remember Dr. Alexis Vien from our 5 Pearls on Inpatient Pain Management.  And this episode we are welcoming a new producer to the 5 Pearls family, right?  

A: Yes, Marty so great to be back.  I am also super excited to introduce Dr. Laura Kolbe, also a Hospitalist at Cornell and current fellow in medical ethics.  

L: Great to be here, thanks for having me Alexis and Marty.  

A: Who you heard in the opener was my mentor Dr. Jonathan Avery, Director of Addiction Psychiatry at Weill Cornell Medical College.

M: A trap that I fall into is that if the patient doesn’t leave that encounter ready to change their life then it was a complete failure – but Dr. Avery suggests we need to let patients figure out what change means to them.  Either way, looking forward to this episode – Let’s get started with some questions on the pearls we’ll be covering.  Test yourself by pausing after each of the questions. 

A: Wait a minute… Marty am I supposed to take Shreya’s line?  

M: You got this Alexis, I know you can do it! 

A: Alllllright – Remember that the more you test yourself, the deeper the learning gains! 

M: Pearl 1 –  Starting the conversation

A: How do we promote positive conversations about substance use with our patients?  

M: Pearl 2 – The shared agenda

A: How do we bring curiosity and patient-centeredness to the addiction history?

M: Pearl 3 – Exploring patient goals

A: How useful is the “stages of change” framework, and how can we encourage our patients to set goals for healthy behaviors around drug use?

M: Pearl 4 – Patients whose goal includes reducing drug use

A: What can we do for the patients whose goals are to stop using drugs?

M: Pearl 5 – Reducing harm in opioid use

A: How can we help patients who continue to use drugs?

A: Before we start we have a few disclaimers to make.  First, in this episode we are really focusing on the addressing opioid use disorder in the hospital. 

L: Many times they’ve come in for a complication of drug use, but might not frame the drug use itself as their chief concern. But the hospital is also a space of opportunity, since research has shown that inpatient care is one of the key encounter touchpoints where providers can make the difference in the morbidity and mortality of opioid use disorders.

M: Right – when patients see me in outpatient addiction clinic it’s often much easier to talk about drug use because that’s why they are there. Today we hope to empower our listeners who meet patients with addiction in the hospital to address addiction and we are going to give you specific strategies and sound bytes to help you through these conversations. 

A: An important thread throughout this episode is appreciating addiction as a treatable chronic illness.  We won’t go into the neurobiological foundation for this – but genetic and environmental factors play a role with who is at risk for addiction and both behavioral interventions and medications are effective for treatment, just like in diabetes or hypertension. 

Pearl 1 – Starting the Conversation

L: So let’s start this episode by bringing ourselves back to the last time we got the signout of a hospitalized patient with either a diagnosed or suspected substance use disorder.  You may or may not have heard other providers talk about a history of quote-AMA’ing-unquote, or maybe you were told about a positive urine drug screen. But whatever it was, you acknowledged early on that this patient’s medical issues are a complication of addiction.  

M: When I’m on the inpatient service and I get signout like this, my heart sinks a little bit. I have to admit it’s often easier for me to focus on the infection and not address their drug use.  What I’m learning is those feelings are often the result of the stigma around substance use and reflect more about our treatment of the patient, and not vice versa. 

Dr. Wakeman: My expectation is that that person may have had traumatizing experiences in healthcare settings in the past. Unfortunately, the way that we structure our healthcare system – bias, discrimination, stigma, policies – often have really harmed people in the past. For many people, their experience with healthcare providers, hasn’t been one of being treated well or being treated kindly, certainly not when it comes to talking about drug use. 

M: Amen to that! That was the amazing Dr. Sarah Wakeman, who is the Medical Director for the Massachusetts General Hospital Substance Use Disorder Initiative and Program Director for their Addiction Medicine Fellowship.  

L: One rookie move is going in there with great intentions, but focusing on the conversation that we want to have, instead of going in there and being open to the immediate needs of the patient. 

M: Yeah, for sure. Another thing to avoid is lumping withdrawal and substance use disorder together. One pearl is to separate these issues in the assessment and plan. This forces us to think about withdrawal as one issue that we will specifically address early in the admission and then separately our patient’s broader substance use disorder that deserves its own attention.

Dr. Wakeman: Many times people come in and they’re experiencing, withdrawal from opioids or other substances, and that pain and suffering is intense and, um, needs to be addressed immediately. And it’s really unfair to the person I’m also totally unsuccessful from a clinical standpoint, to try to take an hour long history or, you know, dive into someone’s past substance use disorder history when they are physically suffering and feel like they’re going to die from acute withdrawal. I think one mistake I often see is people come in, sit down and have, you know, an hour long intake or interview or consultation they want to get through. And meanwhile, this person, you know, feels the worst they’ve ever felt in the bed in front of you. And so, um, not only will they not be able to engage in interview, but also think about what message that sends to the person that sort of your priorities as a provider to get through the questions need to ask are more important than they are sort of suffering in that moment.

A: Yes. If we recognize signs that might indicate opioid withdrawal – dilated pupils, chills, goosebumps, diarrhea, anxiety – we should ask about that and treat it!

M: But, what if our patient is not obviously in withdrawal?  A lot of times it feels strange raising the subject of drug use with patients.  We don’t want to marginalize our patients, but we also want to acknowledge and help patients with this disease. 

L: Right – this can definitely feel awkward so Dr. Avery suggests that we add it to the list of things we’re going to cover in this admission.  For example, “We’d like to give you antibiotics for the infection in your blood. We also noticed that you had fentanyl in your urine and, if it’s Ok I’d like to discuss drug use with you.”

Dr. Avery: In that way you medicalize that, I think you make it like any of the other things on the list that you’re asking them, it doesn’t have this special scariest status, but rather is just a part of the doctor-patient interaction that you’re curious about and that, um, that having those answers and having that teamwork around what will make for a better outcome.

A: In my practice I do just jump in there but if I sense discomfort I will ask if it’s ok for me to keep going with questions. And another thing that probably seems obvious but makes a big difference is using person-first language. 

L: Referring to our patients as someone with a heroin use disorder rather than a heroin abuser has actually been shown to correlate with providers offering treatment for the disorder instead of judgment and blame.

M: Yes – There are several studies to back Laura up. One of my favorite surveyed 500 mental health providers after reading two versions of the same clinical vignette – one version a patient was described as a substance abuser and the other version described them as having a substance use disorder.  The survey respondents were our colleagues – doctors, social workers, psychologists – and those who read about the substance abuser were substantially more likely to blame the individual for their medical issues, they less likely to offer treatment, more likely to recommend punishment and more likely predict the violent behaviors from the vignette character.

L: And the last part of the “words matter” section worth mentioning is how we refer to urine drug screens.  Often you’ll hear “clean” and “dirty” when health care workers talk about a sample with drugs present or absent – but there are some obvious problems with us framing patient’s bodies or bodily products that way.

Dr. Wakeman: So to talk about someone that’s been, you know, clean for X amount of time, meaning they’re either in remission or they haven’t been using whatever problematic substance they’re referring to. And that really applies to someone who’s actively using drugs is dirty. And so that of course has terrible negative connotations. And, you know, I can think of a colleague who, um, as a person in long-term recovery, who is applying for a job as a recovery coach and during an interview, the interviewing team asked him how long he’d been clean for. And his response was that he’d been bathing since he was born. So he’d been clean his whole life, but he’d been recovery for five or 10 years. And, um, so that was a lovely reminder of just, what is it we’re saying with our words when we’re talking about clean and dirty, when it comes to a health condition.

M: Such a great reminder about pitfalls to avoid. Alright Laura – want to summarize this pearl? 

L: Happy to!  First, ask yourself before each patient encounter with someone who uses drugs what they’ve been through in the past? Remind yourself they’ve likely been stigmatized in the past by healthcare workers.  Try to earn their trust in the first few encounters.  For example, treating withdrawal and asking permission to discuss are great strategies to break the ice.  And don’t forget to refer to patients as people and not their disease, which includes referring to drug screens as positive or negative and not “clean” or “dirty”. 

Pearl 2 – The Shared Agenda

M: So at this point, with their permission, we have started the conversation about our patient’s drug use.  The purpose of the next two pearls is to discuss important elements of the addiction history and then offer some strategies for goal-setting in patients with addiction.

L: During the history taking portion, As you ask about what drugs our patients use and how they use them, sometimes it’s actually helpful to remember that not all people who use drugs have a substance use disorder.  

Dr. Wakeman: I think that’s something we don’t talk a lot about. We sort of, um, over anchor on problematic chaotic substance use and substance use disorder in the healthcare setting. And that’s important because, um, by the time people are ending up in the hospital, you know, there is a higher prevalence of folks who have substance use disorder and we want to identify and treat it, but it’s also really important to acknowledge that there is a spectrum of drug use and that most people who use drugs don’t ever meet criteria for substance use disorder.

A: We should actively listen for information to make the diagnosis of a substance use disorder. This comes down to things like does their use cause them distress in different areas of their life including socially, interpersonally, are they having physical or psychological problems due to their use?

M: So we encourage you to be open to the idea that just because a patient is using drugs and is in the hospital doesn’t necessarily mean that they engage in problematic use.  Many times yes… but not always.  

Dr. Avery: I think of it almost less about how much information you’re getting as the sort of stage and the way you’re approaching them, that sort of creates an environment where you can get all the history items that you want. Um, and so I’m often thinking more about the, the environment than necessarily all the details.

A: I’ll ask about their drug use… like what drugs are they using, how much, and what route of administration – like inhalation, intranasal, or intravenous use. This can be helpful when thinking about what treatments or risk-reduction you might offer later on. 

M: Once you understand what and how your patient is using, you can explore more of their substance use narrative.  So start with questions like, when did you start using? Did it ever change from a pastime to a problem, and if so, what made you realize that? This may speak to the ways drugs have caused them harm and again could help confirm a diagnosis of substance use disorder if present.

A: So next, I ask about treatment history and use questions like ‘Have you had any addiction treatment in the past?’ This includes behavioral treatment and medication treatment. 

M: It’s important to know if they’ve tried any medications before and if they had a good experience, or if they’ve been to a certain outpatient program they didn’t like. 

A: I’ve made the mistake of launching into a discussion about suboxone and the patient already knew a lot about it and wanted to try something else. 

L: And a motivational interview-inspired way to ask that might be to inquire about the longest they have gone without using, and how they were able to make it so long.  

M: Ohhh I love that – focus on their successes and build from there. Nice.  

A: The whole time we’re listening for clues to what is important to this person: do certain relationships keep coming up – like maybe their children – or do they value their independence and want to avoid long stays at subacute nursing facilities – or maybe they are just tired of spending too much money on drugs! 

L: Right, because those little nuggets will be helpful in the next pearls when we get concrete about treatment. Now we’re getting to the heart of the matter- the patient’s agenda that should guide what we offer as providers, not the other way around. This is so important it’s our next pearl, but first let’s summarize Pearl 2…

A: Yeah so the initial evaluation or addiction history is a detailed look at your patient’s substance use story – remembering that not all patients who use drugs will automatically have a substance use disorder! As you are listening, pay attention to how their use affected different parts of their lives.  Ask about past successes that allowed healthy changes, while listening for clues to what is important to them now and in the future.  

Pearl 3 – Patient goals

Dr. Wakeman: The only thing that matters is if they see their drug use as somehow getting in the way of a goal they have for themselves or their quality of life and, and, and therefore it’s something that they would like to make changes to. And then my role is to really partner with them on reaching whatever the goal that they’ve defined is, and, um, and offering, you know, what I know from my scientific background about what’s effective to help them get there. So it’s really kind of a patient directed and patient-centered approach.

A: When I hear the patient’s goal is the ONLY thing that matters that makes me a little uneasy. Like, yeah helping patients meet their goals is obviously important, but what if they don’t want to reduce their drug use?? Isn’t that the whole point of treatment?

M: Yeah I agree. Early in medical school we are taught about the Transtheoretical Model aka “Stages of Change” Model- the old precontemplative to contemplative to yadda yadda yada.  

L: Right, in that old “stages of change” framework, the stages are arranged in these linear buckets and we can supposedly map out exactly where a patient is from Precontemplation stage to Contemplation, then Preparation, Action and Maintenance.  It sure does sounds neat and tidy, but I’m not so sure life is that simple.

Dr. Wakeman: It acts as if it’s this static model that people move through these steps and that sort of sequential way. When, in reality over the course of any given day or hours or minutes, people can move between bunches of different stages in terms of what their sort of readiness for changes. Um, and think about any tough change you ever wanted to make in your life. You know, if you’re thinking about, I don’t know, starting to exercise, we haven’t before, you know, in one moment you maybe planning and then, you know, one hour later you may be pre-contemplated because you’re tired and you have an exam and it’s not the right time. 

A: This is much truer to what I actually experience- part of the patient wants to change their use and part of them doesn’t. I feel this all the time. Part of me wants to exercise on a given day and part of me doesn’t.  

L: It’s also hard to hear the patient’s agenda when I’m thinking about mapping the patient to a certain stage of change and how I can move them to the next stage in the cycle. When I do that, my agenda becomes too much of the focus.  

Dr. Wakeman: I think it’s that when it gets sort of oversimplified into this very black and white kind of static model, and when it gets used as a way to either disengage as a provider or sort of put the blame back on the patient that, um, those kinds of rigid buckets are problematic. 

L: So it can be helpful when we hear a patient say things like “I don’t see why my use is a big deal,” to note that this might not be the day that your patient wants to start using buprenorphine, for example. But, if we stop there and label the patient as “pre-contemplative” we may be tempted to say there’s nothing we can do for them. 

M: Exactly -and a totally valid patient goal that’s NOT stopping using might be to – I don’t know – avoid dying from overdose.  Or avoid reincarceration. Or not get HIV… We’ll get into specifics about how to offer harm reduction reduction services later, but the point here is that we should probably reconsider the blanket use of stages of change model as it relates to substance use disorders… 

L: We also should accept that sometimes it’s hard to elicit goals from our patients.  Often I’ll ask in a straightforward way towards the end of their substance use history, “What is important to you moving forward?” or even more concretely “What are your goals in the next year?” 

A: Really the major reason why we are getting patients to identify goals is to align our treatment recommendations to those goals. We’ll go into more detail in the next Pearls, but let’s summarize this section Marty. 

M:  Perf.  So the Transtheoretical model can be misused to assume that people move in a linear path from “precontemplative” to “action” – which is not true for many patients – and it’s often used as a way to disengage from helping our patients with addiction if we find that they aren’t ready to reduce their drug use at any given moment.  Instead, we should try to identify our patient’s goals and priorities – which may or may not involve reducing drug use! As we’ll cover in the rest of the episode there are many ways to help our patients regardless of how much or how little they want to stop using.  

 Pearl 4 – Patients who desire to stop using substances

L: In these next two pearls we’re going to consider two different scenarios – first if the patient sees their substance use causing them problems and wants to stop. And second, if the patient is less interested in reducing their drug use.  (Of course, in real life often people fit into a little of column A, a little of column B.)

M: Perfect. Let’s start with the patient whose goal is to stop using altogether.  

Dr. Avery: When someone’s motivated to change their behaviors, we move as fast as possible. We get the medication started and I think where we are tempted sometimes to still say, Oh, don’t, you know what you’re doing? You’re destroying your liver and your kidney and your family and being that doctor and information dumping. Uh, but we just want to, if we that’s one principle motivational interviewing, they want to do the health behavior that’s positive. We cheerlead them, we get them there. So that’s the spirit of it. 

A: Love that – if we see momentum in our patients we should run with it!  No need to backtrack about why this decision is so important – let’s be honest, they know this!  

L: Ok, so we’re moving forward towards linking to treatment. For severe opioid use disorder this is really about medications.  

Dr. Avery: And so we think the treatment of opioid use disorder also makes it different than all those substance use disorders and that we think you need to be on medications, um, buprenorphine, methadone, long-acting injectable, naltrexone, or Vivitrol. And so for the patient in the hospital, that’s motivated to address their opioid use disorder this is a real opportunity to initiate these medications. But the great thing is no matter what degree of intensity of treatment they want to do, if they have buprenorphine onboard, that’s really winning the game because it’s protecting against overdoses and improving all sorts of outcomes. And so that’s really the goal for the, for the motivated patient.

M: It’s worth noting that we used to refer to buprenorphine, methadone and long-acting injectable naltrexone as MAT, or Medication-Assisted Therapy.  Buuut there is a growing push to reconsider that phrase.  

A: Right. The term Medication-Assisted Therapy implies that these life-saving meds are helping some other component of treatment, like maybe counseling or participation in NA meetings.  But that interpretation can actually be harmful. 

Dr. Wakeman: There’s never been a single study that’s shown that requiring 12 step participation improves outcomes for people on medication treatment or that adding counseling to primary care delivered medication management alone improves outcomes. 

M: Exactly. Medications ARE the cornerstone of treatment!  So we are moving away from the term MAT, and instead use MOUD, or Medications for Opioid Use Disorder.  

L: For our hospitalized patients, multiple studies and meta-analyses have shown that in-hospital initiation buprenorphine has  better outcomes than detox. In terms of both ongoing engagement with MOUD and reducing relapse rates post-hospitalization.

A: Dr. Wakeman also brings up two other categories of addiction treatment that we should offer to our patients on top of MOUD – psychosocial treatment and recovery support.  

Dr. Wakeman: The other components of treatment, so medication is the most effective. It should be available and readily offered to patients whether or not they are interested in engaging in other types of care… psychosocial treatment, which is what we think of sort of therapy like cognitive behavioral therapy and motivational enhancement therapy, contingency management, um, also should be made available, but people should not, not have the option for medication, even if they’re not either able to or interested in engaging in psychosocial treatment.

The other kind of component that we often think about is sort of a broad bucket of what we call recovery supports. So these are not formal treatment, but they can be incredibly helpful to, to patients as they’re navigating, you know, early treatment and engaging in care and really building up sort of the fabric of support in their lives and connecting with people who have shared lived experience.

M: The most common recovery supports are mutual support groups like 12-step organizations.  You’ve heard about these – AA and NA. Something you might want to warn your patients about is that nonspecific spirituality is part of the narcotics anonymous or alcoholics anonymous program.  So if your patient is not comfortable discussing a higher power but might be interested in a support group you might steer them to a secular group like SMART recovery. Also, there is an unfortunate anti-medication bias in some of these support organizations – the old “replacing one addiction with another” fallacy – so I encourage patients to try out several until they find a good fit.  

A: For my patients who are a little more web savvy, I point them towards a website called shatterproof.org that has a great, patient-centered way of explaining different types of treatment. They also have lots of amazing information about how to get involved in advocacy around substance use – again we’ll link in the show notes. 

L: Alright, let’s summarize this section.  Alexis, you’re up. 

A: Thanks Laura – yeah this one is easy.  Medications work.  Start them early in the hospital for patients who are interested in stopping or reducing their substance use, and make sure they have a place to continue getting it on discharge.  Therapy and recovery support are nice adjuncts for those patients who are interested – but we shouldn’t withhold meds if people are ambivalent about participating in those programs.  

Pearl 5 – Patient continuing substance use

A: I used to prefer conversations with patients super motivated to stop their drug use, but now I’ve found talking with patients who aren’t quite sure they are open to change just as rewarding.   

L: Yeah – in the past I might have just labeled these patients “pre-contemplative” and moved on – but one of my biggest takeaways in preparing this episode is that if my patients still want to use – I still have a lot to offer! So it’s not time to end the conversation, in fact there’s a lot of ground we can cover.

Dr. Wakeman: So regardless of what a person’s goals are related to their drug use every single person, including people who continue to use drugs deserve the best possible health care people yet who use drugs have not forfeited their human rights, including the right to healthcare. And I think there can sometimes be some cognitive dissonance for providers or nurses, caring for someone who is actively injecting drugs or actively using drugs in that. Um, the provider often thinks while they’re doing this thing that I perceive to be harmful to their health. And so therefore they must not care about their health. And that’s simply not true. People who use drugs care about their health. They want good health care and irrespective of where they are on the continuum of making changes to their drug use.

M: Oh my goodness!  What a wake-up call.  How many of us have heard comments by colleagues that by providing basic healthcare to patients who use drugs that we are “supporting” or “rewarding” their behavior?  So I think the first step when patients don’t fall in line with us is to just accept where they are and affirm regardless of current or future drug use we are still here to help. 

A:  I might say something like, “I want you to be as safe as possible when you are using, do you have a Naloxone kit or fentanyl test strips?” I’ll ask patients where they are getting their needles and injection equipment.

Dr. Wakeman: I actually separate out the injection drug use part. And in part, just to remind myself to be rigorous about thinking about the steps involved in injection drug use, I think that’s a part we often don’t talk enough about with patients and really understanding what are their injection practices walking through, you know, where did they get their injection equipment? Do they share or reuse any components of their equipment and not just syringes, but also thinking about their cooker or cottons? You know, what type of water did they use? Are they washing their hands before they inject? Are they cleaning their skin before they inject? And do they ask, do they go to a syringe service program or do they go to a pharmacy to get their injection equipment? Um, if they’re injecting, um, solids like cocaine, what are they using to dissolve it? So, because crack, the basic substance people need to use an asset to, um, turn it into a liquid. And, um, if someone is going to a syringe service program and they may be able to access vitamin C powder, which is what’s recommended, but oftentimes people are using things like lemon juice or vinegar, both of which can have associated with medical risks.

L: Using lemon juice to dissolve drugs prior to injection has been associated with candidemia and fungal endocarditis, and vinegar is super caustic to veins. So on top of everything else about opioid use itself, we can do a ton of harm reduction by providing them non-judgmental guidance about avoiding these kinds of illnesses and injuries.

M: Love it. This makes so much sense.  So we should normalize discussing safe injection practices and provide naloxone early and often. Fentanyl test strips are becoming widely available and detect the presence of fentanyl in unregulated drugs and allow our patients to be more informed about the drugs they are using.  

A: Harmreduction.org has tons of resources about helping our patients stay safe while using, and there are websites that can locate needle exchanges throughout the US.  

L: There are many options to help keep our patients safe while using drugs, like not using alone so someone can call EMS if there is an accidental overdose. Of course, there is a lot of work to do in terms of reframing addiction as a medical problem and not a criminal one. 

Dr. Wakeman: We spent a lot of time in medicine talking about the harms of drug use, but endocarditis, like many conditions is actually a harm of drug policy. It’s not a harm of drug use. So heroin doesn’t give you endocarditis, um, you know, methamphetamine or cocaine don’t give the endocarditis. The thing that causes endocarditis is the fact that we have created a system where we criminalize and punish and push into the shadows, people who inject drugs. And the thing that causes endocarditis is because people don’t have access to sterile injection, but that, because we don’t have supervised consumption sites because people are rushing and using in unsupervised in public settings where they’re at risk of getting arrested or criminalized.

M: Couldn’t agree with Dr. Wakeman more.  To summarize Pearl 5 – if your patient would rather set goals around safe drug use instead of reducing it, you can provide a ton of help!  Ask about how patients are acquiring injection equipment and offer resources like narcan kits and fentanyl test strips.  Check out our shownotes to learn about how patients in your part of the world can acquire clean needles and share that with your patients!  They are much more likely to engage in care if we are willing to meet them where they’re at, so come ready to talk about safe drug use if that’s what is most important to them.  

Recap

Alright, we covered a ton of ground in this quick episode.  Let’s review the main points from each of these pearls.  

Pearl 1: Starting the conversation

It’s good to remember that the healthcare system often stigmatized people who use drugs – so if you find yourself caring for someone with addiction try to earn their trust early. Ask permission to address their substance use and be sure to treat withdrawal and pain if they are experiencing it.  

Pearl 2: The shared agenda 

Remember to meet patients where they are at and avoid assuming that all patients want to stop using immediately.  As you learn about their past and current substance use also look for risk factors for comorbid illnesses HIV, Hep C as well as opportunities to reduce overdose risk. 

Pearl 3: Exploring patient goals

 Use the addiction history to formulate some patient-centered goals that may, or may not, include sobriety. Remember the “stages of change” model has some shortfalls and not everyone moves through substance use in a linear path from pre-contemplation to action. 

Pearl 4: Patients whose goal includes reducing drug use

If the patient is interested in reducing drug use that is great!  Start the MOUD while they are inpatient and try to link to an outpatient provider who can continue treatment.  The best MOUD option is the one the patient agrees to and you can coordinate follow-up care.  

Pearl 5: Reducing harm in opioid use

Don’t be fooled into thinking that you are a failure if the patient isn’t interested in stopping or even reducing drug use after meeting them – and also don’t give up there either!  Try to reduce harm by providing nasal naloxone overdose rescue kits and discuss safe injecting to avoid infectious complications of addiction. 

And that is wrap for today! If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! 

If you have a case you’d like to bring on air, please email us at hello@coreimpodcast.com.  Thank you to our peer reviewers – Dr. Jessica Taylor from Boston University School of Medicine and Dr. Peggy Williams from THE Ohio State University Wexner Medical Center. Thank you to Daksh Bhatia for the audio editing and Dr. Kabao Vang for the accompanying infographic. Opinions expressed are our own and do not represent the opinions of any affiliated institutions.  That’s it for this episode, we’ll see you out there. 

References

 

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