Case Study of an Opioid-addicted Patient: New England Journal of Medicine

aaaaaaaaaaaacase

A doctor friend of mine sent me an article from the New England Journal of Medicine from November 13. 2014. I subscribe to the NEJM, but somehow overlooked this article, so I’m happy he brought it to my attention. My friend reads my blog and knows I have lamented how I was taught in my Internal Medicine residency to treat endocarditis (potentially life-threatening infection of a heart valve), but not the underlying cause, which was addiction (read in my blog post of December 7, 2014).

The journal article he sent me is a case study of a young woman with endocarditis from intravenous drug use. The case study begins in the usual way, describing her history and physical findings. Nothing was uncommon here: the patient told them she was a drug user, and she had track marks, fever, and a heart murmur. The history and physical findings screamed, “Endocarditis! “ A chest x-ray and then chest CT scan showed multiple septic emboli, commonly seen with endocarditis, sealing the diagnosis.

But this case wasn’t only about the diagnosis and standard treatment with antibiotics. To my delight, the first sentence describing the case management was “Methadone was administered orally.”

Huzzah!

But as it turned out, the patient was only put on a methadone taper while hospitalized. She was started on a protracted course of antibiotics and sent to an extended-care facility, where she quickly relapsed. This relapse illustrated the second point of the article: medication-assisted therapy must be continued to be effective.

As the case discussion points out, “As with other medications for chronic diseases, the benefits, at least in the short term, last only while the patient is taking the medication.” In other words, her relapse was predictable, and not due to failure on the part of the patient. The relapse happened because of failure to continue the medication by the doctor.

A little later in the case study I read these wonderful sentences: “Although making a diagnosis of endocarditis is a crucial first step (emphasis mine), understanding the root cause of the endocarditis is a key feature in the diagnosis and management of this patient’s illness. Endocarditis is only a symptom of her primary illness, which is an opioid-use disorder.”

I loved this case presentation for two reasons: it emphasized treating the entire patient, including the underlying disease of addiction, and it pointed out that short-term medication with methadone or buprenorphine doesn’t work, just like temporary treatments for other chronic diseases don’t cure anything.

This patient developed endocarditis again after her relapse, and needed a second hospitalization. This time, she left the hospital on buprenorphine maintenance. She relapsed again after two months, had a third episode of endocarditis, this time due to a fungus, and required a third hospitalization.

After that treatment was over, she was maintained on buprenorphine. At the end of the article, the authors reported that the patient had over a year of abstinence from drug addiction, was taking buprenorphine, and going to AA and NA regularly.

In the discussion of appropriate treatment of both the endocarditis and the opioid addiction, I read this delightful sentence::The opioid agonists methadone and buprenorphine are among the most effective treatments for opioid-use disorder.”

Can I get an “Amen!”?

The same paragraph goes on to describe the benefits seen with MAT, which include decreased opioid use and drug-related hospitalizations, and improved health, quality of life, and social functioning. This article also clearly states MAT will reduce the risk of opioid overdose and death. Many references are cited at the end of the article for non-believers in MAT.

This article also included recommendations about educating patients about overdose risk, and providing them with naloxone.

At the end of the article, the patient who was the subject of this case study discussed her perspectives regarding her treatment. She related how each time in the past, she was treated for whatever medical problem she had, and then sent on her way, with little effort to treat her addiction. She says she’s grateful for the second episode of endocarditis, because she met the doctor who treated the addiction and gave her hope that she had a treatable disease. Prior to that, she doubted she could stop her active addiction, because she saw herself as a bad person, not as a sick person.

This article ends with this patient’s words: “To be honest, I never thought I would be standing here, clean for over a year. I thought that I was going to die.” That effectually describes the hopelessness of patients in active addiction.

I hope such endorsement of medication-assisted treatment of opioid addiction by the prestigious New England Journal of Medicine will help convince more doctors of the legitimacy of MAT.

During my training in the 1980’s, I didn’t learn how to treat the underlying cause of the endocarditis. I am delighted and encouraged to find the New England Journal of Medicine has published an article that does just that. This article clearly and overtly states the importance of treating the real problem, not just symptoms of the problem. Today’s doctors have a valuable opportunity to change the lives of many of their future patients.

Advertisements

6 responses to this post.

  1. Thank you for this post! I came to MAT as a Clinical Social Worker from an acute care public hospital where our visionary Medical Director at the time recognized this fact and all people who came to our hospital with soft tissue abscesses were offered MAT while in the hospital and a post discharge, free detox (that could transition to Maintenance if they met the criteria). This was in the early 90’s. Both the MAT program and hospital were county owned and operated which helped the process along and saved the larger Health and Hospital System $$$.

    Reply

  2. Your release of this article is most timely for me as I am preparing a research proposal for a class in my master’s program for addiction counseling here in Oklahoma and I have been locating supporting information very similar to the one I have just read. For me, the most critical aspect of substance use disorders to forget is that they are chronic, and this forgetfulness is most often compounded when it comes to the treatment of other physical and mental issues as though they are the primary problem rather than symptoms of the “chronic” aspect of addiction. This becomes even more of an issue the longer that a person stays in remission, and has gotten used to having their addiction swept under the MAT, pun intended; one can begin to consider whether medication needs to remain a part of a continuing care regiment. This article has not only reinforced the longevity of this disease, but also reminded me that even current ailments of a serious or not so serious nature can still be symptoms of a lifelong disorder even if it is and has been in remission for decades. Thank you!

    Charles

    Reply

  3. Posted by Dickie Lunden on February 24, 2015 at 8:38 pm

    This is one of the best drug related articles I’ve ever read. I’ve been involved with MAT for more than 40 years and am still around to talk about it so there must be something good about it.

    Reply

  4. Posted by Jonna Maggert on February 25, 2015 at 3:02 am

    Thank you so much! As a Mother of an addict this gives me hope. ❤

    Sent from my iPad

    Reply

  5. Posted by Jonna on February 25, 2015 at 3:07 am

    Thank you so much! I am the Mother of a 23 year old addict whom is on Suboxone, and this gives me hope!

    Reply

  6. Posted by Benjamin K. Phelps on March 5, 2015 at 2:08 pm

    While sad that you weren’t taught to treat the underlying disorder in school, it’s not surprising. In 1995, my trip to the ER for severe heroin withdrawal in Richmond, VA resulted in a script for a few .1mg Catapres/clonidine & discharge to go back home & tear the rest of the house up that I hadn’t already damaged from the intractable pain I was in. Look at our criminal justice system’s absolute refusal to allow methadone or buprenorphine in their jails, our drug courts refusal to allow methadone, etc, etc. When it comes to addiction, docs are taught to loathe us & be on the lookout for us trying to get pills fraudulently from them – but not what to do with us to HELP us (with the exception of a few cities like NYC & DC, & the bupe-licensed docs in the last 13-14 years); police are taught to throw us in jail, where we are allowed to suffer needlessly & cruelly, & the general public are taught that we’re just bad, lazy, undesirables you don’t want around. Some part of that is understandable b/c of what active addicts do in their addictions. But with proper treatment, this all changes!

    Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: