Patient Impairment

Ukrainian art from ETSY: Alex Gru

Patients on MOUD (medications for opioid use disorder) need to dose daily for stability unless they are on depot-release forms of such medications such as Sublocade. We encourage patients to dose daily around the same time whether it’s from a take home dose or at our facility. Patients taking consistent and sufficient doses have reduced rates of overdose death, improved mental and physical health, and better employment.

However, sometimes it’s not safe to dose a patient. This can be due to a medical crisis that must be resolved, or due to impairment from sedative medication. It’s relatively rare for patients to arrive at their opioid treatment program with impairment, but it does happen, and physicians and providers need to be prepared for how to handle these events.

Sedatives like benzodiazepine (Xanax, Valium, Klonopin, and the like), alcohol, and other sedatives do not mix well with opioids. Both opioids and sedatives affect the part of the brain that tells us to breathe when we are asleep. People can die from single large doses of opioids, and they can also die if they mix sedatives and opioids. They go to sleep, stop breathing, and die from lack of oxygen to the brain, heart, and other important organs. This can happen quickly, as with a potent dose of fentanyl, or it can take much longer, perhaps hours, with longer-acting sedatives and opioids.

Before the patient gets to the unconscious stage, there’s often a period of impairment, when the patient doesn’t act or sound like their usual alert selves.

Impairment is defined, for these purposes, as a decline in mental function over baseline. Instead of being alert, the patient may be drowsy or inattentive. Instead of having clear speech with appropriate content, the patient may have slurred words, rambling or incoherent speech. There may be loss of control of motor function, leading to unsteady gait, stumbling, or even falling.

Impairment happens on a continuum; at one end a patient can be so impaired that he’s unconscious and needs to be revived with Narcan and CPR. At the other extreme, impairment might be so light that clinicians can’t detect it.

Part of our job at an OTP is to evaluate risks and benefits. If a patient is impaired, the risk of dosing her that day might outweigh the usual benefit of that dose.

Impairment must be evaluated by medical personnel. While receptionists, security guards or counselors can alert medical staff about a potential problem, the medical evaluation must be done by medical personnel.

This evaluation is done by the physicians or physician extenders unless there are none on site. In that case, an RN can gather data and evaluate for impairment. He or she can decide about the safety of dosing or may call the program physician for help with the decision. In our state of North Carolina, the Board of Nursing has said while RNs can work independently, LPNs cannot. LPNs can collect data but then must consult an RN, physician extender or physician to decide about the safety of dosing.

At our opioid treatment program, we take the patient to a private area. We don’t want to embarrass any patient in front of other people. I walk with my patient to my office, observing gait and balance. I try to be friendly and compassionate, realizing that the patient may be feeling fragile.

Once in my office I ask them how they are feeling, and about recent drug use or new medications. I listen to the content of what they tell me and to the delivery of their information. I listen for slurred speech or softening of consonants, speech content, and flow of conversation.

It’s helpful to get vital signs: temperature, blood pressure, heart rate, and respiratory rate. I add a pulse oximetry reading too. If these readings are abnormal, it can indicate a physical health problem as a cause of impairment. This can be serious and requires immediate medical investigation, usually at the local emergency department.

After talking to the patient, I turn to my computer and take my time typing data. While I do this, I watch the patient too. If she nods or falls asleep during conversational lulls, it’s probably not safe to dose her.

We have several tests we can ask the patient to do to test for motor impairment from sedatives. There’s the tandem gait test, which is what policemen do when they ask motorists to walk in a straight line. There’s the finger to nose test where the patient extends both arms, closes their eyes and brings the index finger to touch their nose.

My favorite is to ask my patient to stand on one foot for thirty seconds. It’s easy to do and I do it with them, so they won’t feel so put on the spot. Most people wobble a little but can keep their balance without touching down with the free foot or reaching for furniture.

We can also look for nystagmus of the eyes. This simple test, often misinterpreted by non-medical people, involves asking the patient to look to their extreme left or right. Then the examiner watches for slight bouncing of the eyes back and forth as the subject tries to keep their eyes in the extreme lateral position. Normal people can have one or two beats of nystagmus, but patients who have taken sedatives such as alcohol or benzodiazepines will have continued movement of their eyes.

Medical providers must remember that some medical crises can look like impairment from sedatives. A few months ago, a patient checked for impairment had a blood pressure of around 70/40 with an irregular heart rate into the 150’s, obviously in atrial fibrillation. We called the ambulance to take him to the hospital and he ultimately recovered.

Patients who are deemed to be impaired by medical providers often say they didn’t get any sleep the night before. This may be true, but lack of sleep shouldn’t cause slurred speech or problems with balance, unless they’ve been without sleep for days, in which case they probably need to go home and sleep before they get their next dose anyway.

It’s difficult for me to tell a patient they can’t be dosed that day. I know it will upset them and make them angry. I just keep trying to tell them that I’m refusing to dose them due to safety concerns, and that I’d rather they be angry with me but still alive.

Medical providers should expect a great deal of anger and should not take it personally.

We also try to get a urine sample for drug testing, thought that test won’t tell us if the patient is impaired. A urine drug screen only tells us if a given drug has been used in the recent past. Patients can be impaired with a negative drug and can be alert and fine to dose with a drug screen positive for multiple things.

Alcohol breath testing is the only drug where levels correlate with blood levels. Depending on the alcohol breath test, we can determine if the patient is under the influence of alcohol or not. The legal limit is .08, but patients on MOUD may be impaired at a much lower alcohol level, due to alcohol/drug interaction. We don’t dose patients if alcohol is detected.

After determining a patient to be too impaired to dose, I ask for help from the patient’s counselor. We must find a way to get them home without allowing the patient to drive. In big cities, public transportation takes care of this, but in our rural community, everyone drives everywhere because there is no public transportation. This can be difficult.

Also, we want to get permission to call a friend or family member to stay with our patient to watch them. We want to educate this person to call 911 if the patient becomes unresponsive and can’t be wakened, and make sure they know how to use Narcan, while waiting for EMS.

Anytime a patient can’t be dosed due to impairment, the physician must meet with the patient the next day, or as soon as possible. Impairment might be a warning that the patient has so little control over drug use that an inpatient treatment setting is indicated, at least temporarily.

Above all, it’s important to encourage the patient and let them know we care about what happens to them. We remind them part of our job is to make treatment as safe as possible. More than that needs to wait until the patient is clear and not impaired.

As I said in the beginning of this blog, impairment events are rare. Most of our patients never have such an episode. But when we do have a patient with impairment, we must be ready to intervene with compassion and good judgment about what is in the patient’s best interest.