Let me say this situation is the latest in a stream of crap that has rolled by me in my professional life. So tonight, a patient presented in the ER, that was reported to the ER physician by his wife and his bishop, as having a substance use problem. For those of you not in the know, a bishop in the LDS church is like a parish priest, although they work a regular full-time job on top of their religious duties. They have very little knowledge in anything except what they do at their day job, except maybe meddling with advice where maybe they should defer to a professional. This patient had been on a long-term opiate contract and was struggling with overtaking his medications. So, in I go to assess the patient. As I started with the assessment questions and working on relevant medical history, I found that asking the patient got a response from the bishop, who continually interrupted the patient while I was asking questions. Finally, after my level of politeness was reached, I asked them to wait in the lobby before Nursie Poo let loose with the fangs and slaughter—I mean had security come in.
Once I had the room with just us in it, I had to start over. The story is heard a hundred times. They wanted this patient to be treated as an inpatient for opiate detox and “to get in a rehab program.” I sat there for a minute and wondered if they even had a clue how substance use programs work. This kid was essentially out of opiates early because he was overusing them. He has a friend who had a few (read 8) spares from an old script and felt sorry for the kid and wanted to help him make it to his fill and gave them to him. His wife saw the extra pills and immediately does what any good spouse does, goes and tells the bishop, who of course, freaks and does an intervention with the wife and drags this kid into the ER. During the exam, the kid told me everything and the fact that he had just tried to tough it out because he was afraid they would take his opiates away if he “needed more.” Is that the culture we are creating with the “opiate crisis?” Believe it or not, there are people who benefit from long term opiates as they may be the only thing that works for their pain management. He is one of them. Microfractures in his back from a combat jump into Iraq as well as a deformity in both knees from an IED explosion while he was a passenger in a vehicle. Well hell, it was obvious those lovely helpful people had no freaking clue what was going on, so, I put my professor hat on and got ready. What my patient had was not an addiction but had built up a tolerance (and not to their bullshit).
Tolerance is defined as a person’s diminished response to a drug that is the result of repeated use. People can develop tolerance to prescription medications. As stated above, tolerance is a physical effect of repeated use of a drug, not necessarily a sign of addiction. For example, patients with chronic pain frequently develop tolerance to some effects of prescription pain medications without developing an addiction to them.
It is simple, opiates and some other medications eventually stop performing like they did when treatment started. After a while, it starts to require more to do the same job. He needed more because his body was able to metabolize the opiate faster. This is what was going on. Since I was able to push the wife and the bishop out to the lobby, I was able to talk to the attending without them eavesdropping. We agreed that it was not an addiction, it was a misuse related to tolerance. We needed to just get this kid back to a primary care doc and adjust what they were doing for medications. He didn’t need rehab, especially inpatient (stop thinking that this is the go-to option instead of listening to the person about their medical conditions).
The words dependence and addiction are often used interchangeably, but there are important differences between the two. In medical terms, dependence specifically refers to a physical condition in which the body has adapted to the presence of a drug. If an individual with drug dependence stops taking that drug suddenly, that person will experience predictable and measurable symptoms, known as a withdrawal syndrome. Addiction is a “chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”
In other words, addiction is an uncontrollable or overwhelming need to use a drug, and this compulsion is long-lasting and can return unexpectedly after a period of improvement.
Neither of these meets what was going on with this former paratrooper. After calming down, I spent about 45 minutes explaining this to the wife and the bishop.
The outcome, I don’t know other than we didn’t admit and recommended a PCP follow up. Here is my take on all this. First off, shut the damn TV off. You do not have the kind of money or insurance to “check into rehab” like Malibu or one of those high-end rehabs and honestly, they are probably not for you anyway. Every little thing does not require inpatient rehab or inpatient status. Now if you are having active withdrawal, that is another thing, because you should be medically supervised. This was not an opiate withdrawal. This is what happens when you watch too much Dr. Phil, Dr. Drew, Dr. Oz, and House.
For the love of dog, see the person prescribing your medications. Surprisingly, they are very able to help you make the correct decisions or maybe do something as simple as a medication adjustment. You would be surprised what a working relationship with your provider will do for your well-being. All this crap could have been avoided if you would join us in reality and stop taking your ideas of rehab from the TV. People should take five minutes to critically think through things and work with a PCP to take care of health issues and not rely solely on Google or television. This is the wrong way to handle the opiate crisis, and it will only get worse before it gets better because of these people with gross misinformation.
Well, the bats are all downstairs having a cocktail while they’re trying to stay out of the polar vortex. Bloody Mary anyone?