Life Stage 2: Early Adulthood
By the time Cynthia was 21, she was married and had two children. Her chronic back pain and migraines had become significantly worse. She was already visiting the emergency department at high frequency. She was also taking up to 8 to 10 hydrocodone per day for pain and receiving prescriptions for it from multiple physicians. Cynthia had been admitted to the hospital a few times in her late 20s for severe hyperglycemia and hypertensive urgency. She was started on oral medications and insulin by the time she was 30, at which point her body mass index was 42. She had two primary care doctors fire her from their practice following missed visits. A year later, at age 31, Cynthia required an emergency cholecystectomy. Her anxiety had been steadily increasing, thus she was started on benzodiazepines by an urgent care physician, which her primary care physician then continued. By the time she was 34, Cynthia was taking up to 15 hydrocodone per day, four 2 mg clonazepam daily, sleeping pills, two antidepressants, two oral medications for diabetes, and had been prescribed insulin, which she did not use. She also was taking nausea medication and was chronically prescribed codeine cough syrup. She was smoking 1 to 2 packs of cigarettes per day and marijuana intermittently. She was not, however, drinking alcohol on a regular basis. Cynthia had a distant and difficult relationship with her daughter and her husband, who although continually supportive and working full-time, was otherwise emotionally disconnected.
The most striking and obvious aspects of Cynthia’s care at this point is the absence of a prescription drug monitoring program to determine whether this patient was receiving controlled substances from multiple physicians. Note that although eliminating the extra prescriptions would decrease the patient's risk of accidental or purposeful overdose, it would not actually address the condition which was driving her to the medications. Also note that the large daily intake of hydrocodone with Tylenol exposes her to liver damage caused by chronic acetaminophen intake. Because the patient is not taking her preventative medications, such as insulin or statins, on a regular basis having her on sedatives in the setting of obesity significantly increases the risk of persistent and worsening obstructive sleep apnea. This in turn would lead to significant daytime emotional brittleness as well as memory problems and associated mood disorder. It would have been helpful to check the patient's urine toxicological studies to determine which medications she was actually taking. It would been just as important for this patient to be aggressively treated for tobacco use disorder. That said, none of this would be possible in a real-world setting without directly assessing whether or not we were dealing with a primary organic disorder, such as a bipolar two disorder, or a personality disorder associated with substance abuse.