Life Stage 1: Childhood/Adolescence

Kayla grew up in a lower middle-class neighborhood in a single-parent household. She lived with her mother and sister from the age of 10. The mother is separated from the father because he had significant issues with alcohol and was abusive. Kayla says her mother took various medications for anxiety but they didn't seem to help, and that she had a sister who had some issues with pain medication. Kayla recalls her other sister had spent some time in jail for shoplifting. She said the family moved often and lived in apartments. Kayla’s mother had various boyfriends and no true steady relationships. The household always seemed disorganized and in chaos. Kayla started smoking at around age 12 by bumming cigarettes off her friends. By 13 she was smoking daily. By 14 she was using marijuana recreationally. By age 16 she was smoking a half-pack of cigarettes a day as well as weed almost daily. Kayla stated she would drink alcohol on the weekend and would generally drink to get drunk. She claimed her friends were a lot like her and felt school was a waste of time. She says she doesn't feel like she fits in with the other kids at school. By the time Kayla was 17 years old she became pregnant. After being persuaded to do so by everyone around her, she had an abortion. She said that after this it was harder to go to school and therefore she dropped out of school and finished only her GED. At age 19 Kayla had a car accident late on a Friday night and totaled her car. She was seen in the emergency department and medically cleared, however she was given a 10-day supply of opioids and some medications for muscle spasms. She followed up with her primary care doctor, complaining of continued back pain. Kayla then had x-rays and an MRI as well as an evaluation by orthopedics. All of her workups were negative and physical therapy was recommended. Kayla never did follow up with physical therapy but was continually prescribed hydrocodone as well as Soma by her primary physician for her back pain.

Questions

Given the patient's earlier life difficulties and utilization of other substances a urine drug screen or an in-depth screening tool would've been able to find that she was a very poor candidate for the prescribing of opioids. The fact that she was not following up with physical therapy and had no abnormalities found on her work-up would be an indication that the medications were being utilized for something other than pain.

Life Stage 2: Early Adulthood

During the last year Kayla has not had a consistent primary care physician. She started feeling nauseous on a consistent basis and followed up at the local community medicine clinic. Upon testing her, the clinic determined a positive urine drug screen for oxycodone, hydrocodone, alprazolam and marijuana. Kayla then admitted she had been taking her sister's pain medication for back pain. Kayla states that with all of the stress she has been going through, she needs the alprazolam to keep her from going "off the edge." She states she has just been trying to treat her pain the best that she can and that nobody has been willing to help her. The alprazolam was prescribed by an urgent care doctor, but she's about to run out of that medication. She states she is "desperate" for a new prescription. During this visit it is found that Kayla is also pregnant. Kayla states the pregnancy was definitely not expected but she wants to keep the child./n /n Upon examination by an OB/GYN, Kayla is found to be 11 weeks pregnant. Patient is still complaining of back pain and is worried that as the pregnancy goes on, her back pain will worsen. Patient is also complaining of significant anxiety despite taking daily alprazolam. Patient also states that she will need the opioids to have any chance of dealing with the pain.

Questions

At this point Kayla has all the signs and symptoms of a life that is generally out of control. Many times these patients will arrive to a primary care physician having not had a urine drug screen and will definitely not confess to the medications they are taking. This is also a time in which many physicians will not check the prescription drug monitoring program to identify that there were many prescribers of medications. /n /n Despite the fact that this patient was referred to an OB/GYN, many patients will not follow-up because they are worried that child protective services will take their child from them. This, coupled with the generally negative interaction they may have with the staff of an uninformed OB/GYN clinic, can deter these patients from obtaining prenatal care. It should also be noted that benzodiazepines and marijuana as well as tobacco all have significant risk to the unborn child, much more than the opioid.

Life Stage 3: Late Adulthood

By the time Kayla is 35 years old she has lost custody of the two children she had throughout her 20s. She's been out of work now for 18 months, with no stable housing and has filed disability claims for her chronic lower-back pain. Kayla has also had two felony arrests for writing hot checks and shoplifting. She is currently on probation. She is using the emergency department approximately 20 to 30 times per year. She has also been fired from the two pain clinics in her city and complains of pain out of proportion to any exam. She absolutely feels depressed most days and does not like to be outside around large groups, where she will frequently have panic attacks. Most recently Kayla applied for and was given a medical marijuana card.

Questions

By this time Kayla's substance use disorder is settled in and will be much more difficult to handle. Given that she has lost custody of her two children, it will also be more difficult for her to find motivation for getting well. That said, given that the patient is involved in the court system through probation, we will have more leverage from a therapeutic sense. Kayla's worsening pain is most likely secondary to opioid induced hyperalgesia. In order to improve this, the patient must be removed from opioids, which can be difficult if the patient needs to be treated for an opioid-use disorder. The patient's depression and anxiety will definitely need to be medicated and working in conjunction with psychiatry would be recommended. The fact that the patient has gotten a medical marijuana card makes it much more difficult to get the patient to stop using marijuana.

Life Stage 1: Childhood/Adolescence

As a young child Tobin grew up with both parents, living in a house they owned. When Tobin was four, he had a witnessed fall while under the supervision of his father. After being treated for the fall, Tobin was diagnosed as having suffered a traumatic brain injury. This injury did not appear to significantly impact his ability to interact with other people at the time; however, it did make him more susceptible to mood swings and put him a bit behind in school. Tobin’s parents got divorced when he was 10 years-old. Contact with his father became rare and brief. By the time Tobin was 12 years-old he began smoking cigarettes. He began using marijuana at age 14. At first he would smoke marijuana only two or three times per month, but by the time he was 16 it was daily. He had difficulty through high school but was able to graduate on time. He had seen a few psychologists and been diagnosed with depression and anxiety but was on no medication. After graduating from high school he started to work full-time in the service industry as a waiter and bartender.

Questions

Medical Intervention Notes: It would have been much easier to prevent or mitigate Tobin’s later substance abuse issues if his pediatrician and other healthcare professionals had evaluated Tobin’s brain injury more deeply. They would have discovered that the injury was actually caused by his abusive father, who would strike or shake Tobin when he got angry. The father had a history of violent outbursts, which is what led to the divorce. Another missed opportunity was the psychologists visited during high school. Any one of them should have been able to link Tobin’s traumatic brain injury as a possible cause of his depression and anxiety symptoms. An appropriate screening for use of tobacco and marijuana would also have been helpful. These events had been appropriately noticed and intervened upon, then a trauma-informed care approach to the treatment of tobacco in marijuana use-disorder may have averted Tobin’s issues that became increasingly more difficult in his early adulthood.

Life Stage 2: Early Adulthood

At the age of 21 Tobin was involved in a car accident in which he was the driver. The accident resulted in some lower-back pain, for which he was given hydrocodone in the emergency department. After using hydrocodone, Tobin felt “normal” for the first time. When he ran out of the initial prescription he went to his local emergency department, who refilled these medications for him. Soon after, he also developed chronic abdominal pain (a common side-effect of the constipation that can result as a result of hydrocodone), for which he was treated at the local community medicine clinic off-and-on. By age 23 Tobin was being prescribed hydrocodone (10mg hydrocodone – 325mg acetaminophen) 3 to 4 times a day and getting up to 120 pills per month. When his primary care physicians discovered Tobin was obtaining these pills from providers other than his primary physician, they cut him off. Tobin then started buying pills from his roommate. When this was no longer helping him feel “normal,” he started buying them from a friend of his at the restaurant where he worked. When it eventually became too expensive for him to keep up with what he “needed,” he opted for the cheaper alternative of snorting heroin. This however led quickly to a need for a more rapid onset of the drug, at which point he started to inject. During this time Tobin would average 20 to 25 visits to the emergency department per year, each time complaining of his chronic abdominal pain or back pain or minor skin infections. At age 25 he developed an abscess in his right forearm which required a longer-term intravenous catheter. He then began injecting heroin through the catheter without using appropriate aseptic technique. As a direct result, he ended up with an infection on one of his heart valves and was admitted to the hospital. While in the hospital he complained of 10 out of 10 pain and would always require IV hydromorphone. If he did not receive this he would become belligerent. By this time Tobin had lost his job, his girlfriend, and most of the contact with his mother and father.

Questions

Medical Intervention Notes: I suggest a brief paragraph stating how, even though there are now obvious signs that Tobin has a substance abuse problem and is far from being a cooperative patient, the medical system is failing him. After the __ visit to the emergency room, the system should have flagged him for more intensive intervention, etc.

Life Stage 3: Late Adulthood

By the time Tobin was 35 years-old, he had been in and out of inpatient rehabilitations multiple times and had had more than five “detox” stays. He had been in two different methadone clinics with short periods of not using other drugs but (although he had stopped taking heroin?) he began using benzodiazepines and increased his use of marijuana. Despite the use of the benzodiazepines and marijuana, Tobin’s anxiety is generally persistent. He shows severe mood swings and is easy to anger. He has been hospitalized a few times for pneumonia and had to have his gallbladder removed when he was 32. He is now seeking disability, has no stable living arrangement and no consistent income. He has developed moderate hypertension, hypercholesterolemia and still experiences chronic abdominal pain. He has been arrested three times and has two nonviolent felonies that limit his ability to get a job or rent an apartment. He has also been fired from multiple pain clinics, primary care offices and continues to frequently visit the emergency department, with the number of visits over the last year number totaling 35.

Questions

Medical Intervention Notes: I suggest a brief paragraph stating how it’s now obvious to any healthcare professional who encounters him that Tobin has a substance use disorder or addiction disorder. Active efforts are being made to treat his multiple physical and psychological health issues. Unfortunately, there are now so many of them, which are now so chronic, that it may require sustained treatment simply to save his life.

Life Stage 1: Childhood/Adolescence

Cynthia grew up in a low-income household with both parents. Her father was verbally abusive to the entire family, accompanied by occasional bouts of physical abuse toward the mother. He would drink to excess on a regular basis. That said, he was never physically or sexually abusive toward Cynthia or her younger sister. Cynthia had trouble throughout elementary and middle school and was only able to obtain a C-average at best. When school finally became too difficult for her she dropped out of the ninth grade to help care for her mother, who suffered from chronic refractory migraines and significant clinical depression. Like her mother, Cynthia herself struggled with depression and anxiety throughout her adolescence, but had never been in therapy or placed on medication. Cynthia also had migraine headaches off-and-on through her early teens, which would last for up to three days at a time. She started smoking tobacco when she was 12 and drinking alcohol intermittently, but heavily, around the age of 15. Cynthia also struggled with her weight. She never exercised on a regular basis, if at all. Around the age of 18 she finally followed-up with her primary care physician and was found to have Type II diabetes, hypertension and hypercholesterolemia. She also started having lower-back pain along with her migraine headaches. Her physician subsequently placed her on intermittent opioids for pain and headaches, but never did a full workup for her migraine headache disorder.

Questions

The missed opportunities for timely medical intervention should be relatively obvious, but let's walk through it anyway. When any adolescent is having significant trouble working through school, swift evaluation and identification of high-risk issues within the household are essential. In addition, recent research reveals that high glycemic foods, particularly those high in glucose, behave in the brain just like a drug. They will significantly increase dopamine above the normal levels. This helps patients who consume them habitually and in large amounts to feel calmer and have an increased level of happiness. Patients with early-life obesity should therefore be assessed very carefully for depression, anxiety and evidence of high-risk drug use. In Cynthia’s case it would also be important to be seen by a neurologist for evaluation of early onset headache disorder. Although the most common cause of daily headache is still dehydration or caffeine withdrawal, thorough examination for a more sinister cause is of the utmost importance. Following up with the pediatrician early in life and focusing on the above issues may have very well stopped the progression towards type II diabetes and hypercholesterolemia. Both of these have a familial risk, however adolescent onset of both can be prevented in most cases. As for the patient's back pain, this is most likely caused by the early onset of morbid obesity and the lack of enough muscle strength to support the bones and discs. Opioids should never be used for the pain treatment in this setting, especially for adolescents.

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.

Questions

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.

Life Stage 3: Late Adulthood

By the time she reached 35 years of age, Cynthia had been on pain medication and anti-anxiety medication for almost 5 years. She was constantly over-taking trazodone, her sleep medication. Upon examination she was found to have cryptogenic liver failure, thought to be secondary to the chronic intake of Tylenol along with the hydrocodone. She subsequently began to suffer intermittent bouts of right-heart failure, leading to worsening lower-extremity pain, thus increasing her use of her various pain meds. When the patient would either run out of her own medication or not be able to get a prescription for her pain medication, she would "borrow" it from her sister. By age 40 Cynthia had been admitted to the hospital an average of five times per year with one to two psychiatric admissions per year as well. Her diagnostic profile now included bipolar disorder, "drug-seeking behavior", liver failure, chronic pain, chronic anxiety, poorly controlled type II diabetes with a hemoglobin A1C of 12, the beginnings of hepato- pulmonary syndrome and insomnia. The patient was still married to her husband, however, they were now two strangers living in the same house. Her sister had died of lung cancer. When Cynthia would show up at her physician's office she would be confused. It would often be difficult for clinicians to tell the difference between her over-medication or the side effects of liver failure.

Questions

By this time we have all but lost the game. We now have a patient who has permanently injured her liver and is requiring admission to the hospital on a relatively regular basis for signs and symptoms of liver failure. Given her reluctance to be stable on medication other than heavy sedative and pain medication she will never be eligible for a liver transplant. Once she develops full hepato-pulmonary syndrome she would no longer even be a candidate. We therefore have to take a long hard look at whether or not we are treating this patient to improve quality of life or purely in the palliative care mode. Although she definitely bears some responsibility for her situation, it should also be considered an epic failure of the medical establishment to do no harm.

Life Stage 1: Childhood/Adolescence

Gloria's early life she grew up in a two-parent household with two siblings. Neither her parents nor siblings had significant mental illness or substance use disorders. Gloria's mother, however, had had chronic migraine headaches for as long she could remember. This would keep her mother incapacitated for 1 to 3 days at a time. Gloria herself began to have migraine headaches at the onset of puberty. She stated that she always knew when she was going to get a migraine headache because she would start seeing colors differently. She would get 3 to 4 migraines per year. Medications such as Excedrin or ibuprofen would be generally helpful. By the time the Gloria was a senior in high school her headaches had become more frequent. She would get at least one severe migraine headache a month and it would last up to five days. The patient's headaches would always start on the right side of her head with pain she described as burning in nature. This would then progress to a pounding pain, which would make her very nauseous and make light and sounds almost intolerable. When Gloria was 18 years old and had started college she had severe migraines before final exams and went to the emergency department. While in the emergency department she received intravenous hydromorphone. This almost immediately relieved her headache and allow her to complete her final exams. She took this information to her primary care physician, who then wrote her for 20 hydrocodone tablets per month, to be taken at the onset of a severe headache. This worked for several months until she started having more disabling headache days per month, to the point where she was having a severe migraine every week. Her response was to increase her intake of hydrocodone to almost daily in order to maintain what the patient stated was even basic function.

Questions

The hereditary connection between a mother with migraine headache disorder and daughters with the disorder is relatively solidified. Therefore, making sure to get a good treatment history can be helpful in treating adolescent migraine headache disorder. Finding out which medications helped the mother will lend insight into the pathway for treating the child. It should also be noted that, despite the rapid improvement of migraine headache disorder with an opioid, opioids are absolutely contraindicated early in treatment. There is a growing body of literature that shows a significant risk of opioid use transforming an intermittent migraine disorder into a chronic daily headache.

Life Stage 2: Early Adulthood

By the age of 21 Gloria had been taking opioids daily for one year. Nevertheless, she still required up to five visits per year to the emergency department. She managed to graduate college but lost her first job out of college because she missed too many days of work due to her headaches. Gloria was sent to a neurologist who started her on topiramate and found that her MRI, lumbar puncture and endocrine workup were all negative. With the addition of the topiramate her headaches significantly decreased to approximately 2 per month. This lasted for approximately 5 years. During this time Gloria started a new job with a significant increase in responsibility, got married and had one child. Per the patient, her headaches suddenly started to become more severe and soon increased in frequency as well. She responded by self-medicating with left-over hydrocodone, which she said “helped a bit.” Gloria subsequently required several emergency department visits over the next one year and found herself back in the position of having a chronic daily headache which would progress to severe migraine approximately once a week. Each of these events would last 3 to 4 days. Gloria states that she had almost no headache-free days per month and mostly disabling headaches three or four days. Given this, the patient was unable to continue her new job and had to quit. Gloria became moderately depressed and started to have issues with falling asleep at night as well as waking up two to three hours after going to sleep. She had tried many other medications for her headache, including triptans, yet felt like she was only getting relief from the opioids. Gloria's primary care doctor started her back on daily opioids, which by now had ramped up to six 10 mg hydrocodone tablets per day.

Questions

Although we do not fully understand exactly how medications such as topiramate decrease the frequency and severity of migraine headache disorders, we do find they can be used for extended periods of time for improvement. That said, endocrine access often has a lot to do with frequency and severity of headaches; therefore, after any significant endocrine event, such as pregnancy, clinicians should closely monitor the patient in order to prescribe other abortive medications if needed, or to use early aggressive treatment that does not include opioids. It’s not uncommon for a patient to come to the office almost begging for relief and specifically asking for opioids. This happens not necessarily because the patient has an opioid use disorder, but because they state this is the only thing that has given them in relief in the past even if it's not currently working. This is where it becomes difficult for a physician to lay out the risks and benefits and take a stand not to use these medications in the setting.

Life Stage 3: Late Adulthood

By the time Gloria was 35 years old she was a regular visitor to the emergency department, with almost weekly visits. She was still on high-dose opioids; however she would come to the emergency department stating she needed breakthrough medication. Often she would receive intravenous hydromorphone, even though she had developed side-effects of this medication including itching and nausea. She was also frequently given Benadryl and Phenergan along with hydromorphone. On occasions when the emergency department physician did not feel comfortable giving her these medications, she would escalate her behavior, and would often call patient relations to complain about the physician not giving her the medications that she "required.” When not in the emergency department, Gloria was generally ineffectual at home and would mostly stay in the bedroom and only come out to eat or do basic things. She was no longer able to fulfill her household duties and had almost no meaningful interaction with her child or husband.

Questions

It’s essential to understand that many times the progression of a patient's disease is directly related to an inadequate treatment pathway by the medical provider. By placing the patient on high-dose long-term opioids we have created severe pathology where there may have only been mild-to-moderate pathology. Opioids are controlled substances for a reason, and it's not just because of the risk of abuse. There are significant possible side effects, and in this case the side effects were realized. The patient now has a significant high risk of suicidality and no apparent lie function. I would argue that the patient's current state of no function, depression and severe pain are mostly iatrogenic.