1、,Addressing Medical Complications of Drug Abuse,Jeffrey H. Samet, MD, MA, MPH Chief, Section General Internal Medicine Boston Medical Center Professor of Medicine and Public Health Boston University Schools of Medicine and Public Health,CRIT 2010,Overview,Medical Complications Case Scenarios 1. The
2、Febrile Injection Drug User (IDU) 2. Chest Pain and Cocaine in the EDPhysician and Patient RelationshipLinkage of Drug Abusers to Medical Care Conclusions,CRIT 2010,Case Presentation 1 A 31 year old man presents to the ED “feeling sick”,10 year history of injection heroin use 6 month history of incr
3、easing cocaine use Symptoms - myalgias, weakness, cough No history of TB or HIVPE - t-101.2, fresh and old track marksNo cardiac murmur, non-tender abdomenLabs - WBC 12000 with normal differentialUrine-trace protein,CRIT 2010,Case Presentation 1 Should the patient be hospitalized?,What clinical diag
4、noses are likely based on this presentation? Which of these diagnoses merit hospitalization?,CRIT 2010,Febrile IDUs-Presentation to Boston City Hospital ED 1/88-1/89,296,Total # of presentations of Febrile IDUs to ED,283,180 (64%) Febrile IDUs with apparent major illness,Samet JH, Shevitz A, Fowle J
5、, Singer DE. Am J Med. 1990;89:53-57,Total # evaluated,CRIT 2010,Major Illness at Presentation n=180,Samet JH, Shevitz A, Fowle J, Singer DE. Am J Med. 1990;89:53-57 Marantz PR, et al. Annals Intern Med. 1987;106:823-828.,37%,34%,6%,6%,17%,CRIT 2010,Febrile IDUs-Presentation to Boston City Hospital
6、ED 1/88-1/89,296,Total # of presentations of febrile IDUs to ED,283,180 febrile IDUs with apparent major illness,103 (36%) with no apparent major illness,Samet JH, Shevitz A, Fowle J, Singer DE. Am J Med. 1990;89:53-57,Total # evaluated,CRIT 2010,Febrile IDUs-Presentation to Boston City Hospital ED
7、1/88-1/89,103 (36%) with no apparent major illness,11 (11%) major illness,92 (89%) minor illness,Samet JH, Shevitz A, Fowle J, Singer DE. Am J Med. 1990;89:53-57,CRIT 2010,Diagnosis of Patients with Occult Major Illness,CRIT 2010,* significant at 0.05,Significant Univariate Predictors of Major Illne
8、ss,CRIT 2010,Febrile IDUs-Recommendations,No combination of clinical characteristics effectively identified the febrile IDU with inapparent major illness. The hospitalization decision in febrile IDUs rests primarily on the need for patient follow-up after blood culture results are known. If follow-u
9、p is not possible, the patient should be hospitalized.,CRIT 2010,Case Presentation 1 Outcome,Tests Chest x-ray-normal Blood cultures negative after 24-hrs. Assessment/Plan Diagnosis-Viral Syndrome Patient discharged home Referred for substance abuse counseling,CRIT 2010,Case Presentation 2 28 year-o
10、ld Latino man presents to ED with chest pain,Crushing substernal chest pain lasting two hours resolved with O2 alone in ambulance 6 year history of regular (2-3x/wk) crack or intranasal cocaine use 10 year history of smoking (2 packs/day) Negative HTN, DM, history of coronary artery disease Family h
11、istory of MI (father, 48 years),EKG normal,CRIT 2010,Cocaine-Related Myocardial Infarction (MI),One of every four MIs in people aged 18 to 45 years linked to cocaine use1 Approximately half of patients with cocaine-related MI have no evidence of atherosclerotic coronary artery disease on subsequent
12、angiography1 Most are young, male cigarette smokers without other risk factors for MI1 Occurrence of MI with cocaine is unrelated to amount ingested, route of administration, or frequency of use2,1Quereshi AI, et al. Circulation. 2001. 103;502506 2Lange RA. Adv Stud Med. 2003. 3(8); 448-454.,CRIT 20
13、10,How Cocaine May Induce MI,Lange RA, Hillis LD. N Engl J Med. 2001;345:351-357.,CRIT 2010,Observation Period,Prospective evaluation of 9 to 12-hour observation period for patients w/ cocaine-associated chest pain (n=302) Detailed follow-up available on 256 (85%) 4/256 (1.6%) patients had nonfatal
14、MI (95% CI, 0.1 to 3.1) All patients with MI continued cocaine use during the 30-day follow-up period Patients with cocaine associated chest pain without evidence of ischemia or cardiovascular complications over 9- to 12-hr observation period have low risk of death or MI during 30 days post discharg
15、e,Weber JE, et al. New Eng J Med. 2003;348:510-517,CRIT 2010,Case Presentation 2 Outcome,Admission-chest pain, rule out MI No further symptoms Discharge after 24 hours with discussion of health consequences of cocaine & tobacco use,CRIT 2010,Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. J
16、Gen Intern Med. 2002;17:327-333.,Physician Management of Opioid Addiction METHODS,Study conducted June - December 1997 on the inpatient internal medical service of a public urban teaching hospitalParticipants: 8 inpatient physician teams and 19 patients actively engaged in illicit injection drug or
17、crack cocaine use (primarily opioid use).Exploratory qualitative analysis of data on the relationship from direct observation of patient care interactions and interviews with illicit drug-using patients and their physicians.,Physician Management of Opioid Addiction: 4 Themes,1. Physician Fear of Dec
18、eption Physicians question the “legitimacy” of need for opioid prescriptions (“drug seeking” patient vs. legitimate need).“When the patient is always seeking, there is a sort of a tone, always complaining and always trying to get more. Its that seeking behavior that puts you off, regardless of whats
19、 going on, it just puts you off.”-Junior Medical Resident,Physician Management of Opioid Addiction: 4 Themes,2. No Standard Approach The evaluation and treatment of pain and withdrawal is extremely variable among physicians and from patient to patient. There is no common approach nor are there clear
20、ly articulated standards.“The last time, they took me to the operating room, put me to sleep, gave me pain meds, and I was in and out in two days . .This crew was hard! Its like the Civil War. Hes a trooper, get out the saw. . .”-Patient w/ Multiple Encounters,Physician Management of Opioid Addictio
21、n: 4 Themes,3. Avoidance Physicians focused primarily on familiar acute medical problems and evaded more uncertain areas of assessing or intervening in the underlying addiction problem-particularly issues of pain and withdrawal.Patient/Resident Dialog Resident: “Good Morning” Patient: “Im in terribl
22、e pain.” Resident: “This is Dr. Attending, who will take care of you.” Patient: “Im in terrible pain.” Attending: “Were going to look at your foot.” Patient: “Im in terrible pain.” Resident: “Did his dressing get changed?” Patient: “Please dont hurt me.”,Physician Management of Opioid Addiction: 4 T
23、hemes,4. Patient Fear of Mistreatment Patients are fearful they will be punished for their drug use by poor medical care. “I mentioned that I would need methadone, and I heard one of them chuckle. . .in a negative, condescending way. Youre very sensitive because you expect problems getting adequate
24、pain management because you have a history of drug abuse. . .He showed me that he was actually in the opposite corner, across the ring from me.”-Patient,CRIT 2010,Physician Management of Opioid Addiction,Medical care of opioid withdrawal requires physicians to simultaneously:Treat acute medical prob
25、lemsManage pain and withdrawalRecognize that the addiction has often caused physical and psychosocial devastation,Potential Benefits of Linking Primary Care (PC) and Substance Abuse (SA) Services,Patient Perspective Facilitates access to SA treatment and PC Improves substance abuse severity and medi
26、cal problems Increases patient satisfaction with health care Societal perspective Reduces health care costs Diminishes duplication of services Improves health outcomes,Samet JH, Friedmann P, Saitz R. Arch Intern Med. 2001; 161: 85-91. Institute of Medicine. Improving the Quality of Health Care for M
27、ental and Substance-Use Conditions. National Academy Press; 2006.,CRIT 2010,Saitz R, Freidmann PD, Sullivan LM, Winter MR, Lloyd-Travaglini C, Moskowitz MA, Samet JH. J Gen Intern Med. 2002;17:373-376.,Professional Satisfaction of Primary Care Physicians Caring for Patients with Addictions and Other Diagnoses,CRIT 2010,Addressing Medical Complications of Drug Abuse: Conclusions,Case-based discussions of drug abuse related disorders can be both evidence-based & provide an opportunity to address the systems and individual approaches to the medical care of drug users.,
