Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.

What Every Provider Should Know About Addiction

4/19/2017 11:30:55 AM | 2 comments

What Every Physician Should Know About Addiction MedicineSubstance abuse-related ED visits have more than doubled since 2004. Many of these patients endure long waits for care due to the shortage of treatment facilities and on-call specialists.
 
Emergency medicine physician Stacie Solt, MD, wasn't satisfied with that approach. So she took the unique step of completing a fellowship in addiction medicine. In today's post, she talks about that journey and shares some advice for her fellow providers.
 
How did you become interested in addiction medicine?
 
Solt: Throughout residency, I was surprised by how many patients with addiction issues I saw in the ED. When I asked the attendings how to best help patients, they rarely gave a straight answer. And that made me very curious. I felt like we could be doing more. But what?
 
The question stuck with me all through residency. So I was overjoyed when Stanford, my alma mater, started a brand new addiction medicine fellowship.
 
Can you give some examples of how substance abuse presents in the ED?
 
Alcohol is one of the most common issues we deal with. Intoxication and withdrawal can be emergencies in themselves.
 
And then there are the indirect effects — the alcohol-related complications, if you will. When it comes to trauma, alcohol is the most common contributing factor. It's involved in half of all traumas in the United States. We also see patients presenting with liver disease and other illnesses related to long-term chronic alcoholism.
 
Another population we see a lot of is patients addicted to opiate medications who come in seeking prescriptions and refills. They're probably the most challenging group to work with.
 
What’s involved in an addiction medicine fellowship?
 
At Stanford, the fellowship is based out of the psychiatry department. It's open to all specialties, because addiction really does cut across many areas of medicine.
 
As a fellow, you're learning about the acute and chronic ramifications of addiction in a variety of settings. At our psychiatry clinic, I provided individual therapy and ran peer support groups. I'd also go into the hospital to work with acute detox issues and consult on admitted patients with coexisting addiction issues.
 
For one my rotations, I worked at a methodone clinic. One physician there focused on treating pregnant patients. Seeing them get off heroin and prescription opiates and deliver healthy infants was really powerful. It definitely convinced me I was in the right specialty.
 
I also rotated through an outpatient rehab facility that was treating opiate addiction with an exciting newer medication called Suboxone. And all the fellows spend time in the pain management clinic, because managing chronic pain with opiates always toes the line with addiction.
 
How has training in addiction medicine changed the way you practice emergency medicine?
 
I think that patients with addiction issues are some of the most challenging we treat in the ED. Their problems can be intimidating and overwhelming. It's easy to shy away from them or write them off, especially when they come back over and over.
 
But having trained in addiction medicine, I now understand that relapse is part of the disease. I also know that recovery is possible. So I'm comfortable interacting with patients and exploring different resources, whether it be community programs or medications that can help with recovery.
 
It's also made me more comfortable asking patients about substance use, even when it's not the chief complaint. Screening only takes a minute or two. Sometimes just answering those questions opens the person's eyes and makes them willing to receive help.
 
What advice do you have on caring for patients with substance abuse issues?
 
One of my favorite mantras is be consistent, be honest, and be patient.
 
A classic example of the need for consistency is the patient who comes in seeking opiate medications. It's important not to base your decision on how nice the person is or how convincing their story is. That actually provides variable reinforcement for that behavior.
 
Instead, try to approach all at-risk patients in the same way. Limits and consistency will ultimately benefit them in recovery.
 
Then there's honesty. Be brave enough to raise your concerns if you see a patient cycling frequently through the ED with drug and alcohol issues. Who knows? Maybe you're the first person to raise a concern to them. Or maybe they need to hear it over and over.
 
That conversation doesn't have to be confrontational or accusatory. But do raise the idea that what you're seeing could be problematic and that it might be worth addressing outside the ED.
 
And the last thing is to be patient. I've personally seen patients make remarkable recoveries after struggling for years and making dozens of ED visits. Relapse is part of the disease process, and some people take longer to get on track with their recovery than others.
 
So hang in there. Hopefully you'll have one of those magic moments when the patient comes back and says, "Thank you. You saved my life, and now I'm 90 days sober."
 
What can hospitals do?
 
Treatment of addiction issues can begin in the ED, but it's just a piece of what's needed for long-term recovery. So it's really important to connect patients with outpatient resources, either in the hospital system or the community.
 
At my hospital, we provide a list of community resources and assist patients in making follow-up appointments. It's the same process we'd follow for a broken arm or gallbladder disease.
 
Here at San Mateo Medical Center, we're hoping to start an outpatient clinic that can treat opiate addiction with medications like Suboxone. And there’s already a program to treat alcohol use disorder with intramuscular naltrexone. These medications can be very effective, and ED providers are more likely to start them knowing the patient will be seen for follow-up.
 
What advice do you have for clinicians with an interest in addiction medicine?
 
Come join us! The American Board of Medical Specialties officially welcomed us in 2015, so you can now be board certified in addiction medicine. It's also an exciting time for our field. There's a lot of research underway involving new treatments and medications.
 
Addiction medicine fellowships accept physicians from all backgrounds and specialties. And it's never to late to get that education.
 
Another thing you can do is to really get to know the addiction resources in your hospital and community. What do they do? Who do they help? How can you work with them to improve care for your patients?
 
What's most rewarding about addiction medicine?
 
Any time you see a patient who's in the acute throes of addiction go into recovery and get their lives back together, it's just incredibly rewarding. You get to watch them improve their marriages and their relationship with their kids. Often they get re-employed. And you just feel honored to be a small part of that.
 
I'm sure that's somewhat true for all specialties. We all like to see our patients get better. But with addiction, there's a particular stigma and a lot of challenges to overcome that make it extra rewarding when people succeed.
 
And the patients are often just incredibly grateful. Here at San Mateo, we had a former patient stop by on both Thanksgiving and Christmas with treats for the staff. He told us, "You know, a year ago I was on my deathbed with liver failure because I was drinking so much. And you helped me get into a program and treatment. Now my health is much better. I'm celebrating another holiday, when a year ago, I didn't know if I was going to survive another few months."
 
Really, I just can't think of a better thank you than that.


Comments
Cyndy Flores
Thanks for the reminder to be patient - I know as providers we often feel the pressure increase our patient flow, but maybe we can do that by being patient with an at-risk patient.
4/20/2017 6:28:39 PM

David Carter
Thanks, Stacie. Great article and great reminder regarding consistency of treatment from patient to patient.
4/20/2017 4:13:30 PM