“You know, she just wanted to help me ‘get well’. Someone’s gotta look out for you when you come to the hospital.”
It was a few hours after the chaos of a room search that involved drug-sniffing dogs and the confiscation of a considerable amount of street drugs that had been delivered by my patient’s friend. I was covering the night shift and had just received a different interpretation of this situation in sign-out. The team expressed understandable concern about harm and strict instructions about protocols enacted for safety.
“She really cares about me, you know?”
This friend had been worried about my patient, and was the first to encourage him to get to the ED. She thought he was looking pale, and didn’t like the way that he was sweating through his clothes in their poorly heated boarding house. She thought he was getting weaker, that he needed medical care. She just wanted to make sure he’d be all right. It took a few days of convincing, but eventually he had agreed. The ED noted a gaping “tranq wound” and he was found to be bacteremic. I assured him that following his friend’s advice was going to help him get the antibiotics he needed, that this might have saved his life.
“They tell you the withdrawal doesn’t kill you,” he responded, his sentences punctuated by clearing his rhinorrhea and wiping his tearing eyes. “But that’s not how this feels. She was just trying to help me ‘get better.’ This stash was going to help me last a few days here.”
It was a struggle to treat his withdrawal, and he was anticipating that. There is no easy pharmacy-approved conversion for an appropriate prescription opioid dose to meet a deficit carved by a reported 40-50 bags of fentanyl laced with xylazine per day. While he was ordered some small doses of opioid medications for withdrawal, they were dosed per a conservative protocol that treaded with significant caution due to concern about potential overdose. This cautious dosing was dwarfed by his opioid deficit, and within a few hours he was in an agonizing withdrawal. This was a withdrawal that his friend’s delivery of his usual street drugs was supposed to help avoid. And this was a withdrawal that we could theoretically treat, with safer prescription options, while we worked to treat his infection.
For my patient and many others like him, opioid withdrawal is incompletely managed in hospital settings. In part, this is because withdrawal from opioids in supervised settings does not incur direct risk of mortality, unlike withdrawal from alcohol or benzodiazepines. Left desperate by the symptoms of withdrawal, patients who use drugs may go looking for street drugs while admitted, or have a visitor bring supplies into the hospital. While medical professionals fear the ramifications of use in the hospital setting, and the possibility of overdose, I am left wondering how that might be mitigated by adequate management of withdrawal.
A recent study of patient-directed discharges among patients with infective endocarditis who inject drugs revealed that a staggering 14.2% of patients who inject drugs elected to leave “against medical advice,” compared to only 1.9% of patients with endocarditis who do not inject drugs. Further qualitative investigation of patient-directed discharges among patients with substance use disorders has suggested that undertreated withdrawal and stigma are leading causes of leaving the hospital before treatment is completed. Might we have fewer in-hospital overdoses if we took patients’ symptoms of withdrawal more seriously? Would our patients be more likely to stay and complete treatment?
Use of a scheduled prescription opioid for management of acute withdrawal in the hospital is an important component of initial management for opioid withdrawal. When dosed appropriately, scheduled opioids can help manage the worst symptoms of withdrawal, and can buy time for diagnostics and treatment of acute illness. Adequate management might eventually allow for conversations surrounding transition to medications for opioid use disorder. Use of scheduled prescription opioids in this setting is, however, complicated by significant opioid deficits experienced by patients using high doses of more potent synthetic opioids like fentanyl. Dosing these medications appropriately for withdrawal can be disconcerting for physicians and pharmacists when initial daily morphine milligram equivalents are over 500 mg daily.
Ultimately, in spite of efforts to manage my patient’s withdrawal symptoms, he continued to feel profound discomfort from his opioid deficit. He left as a patient-directed discharge the next day.
I worry that opioid withdrawal can be a highly morbid condition — even if mortality is not a direct effect of the withdrawal itself. Caring for my patient underscored the potential harm of undertreatment, and the need to take patients who use drugs and their experience of withdrawal seriously. My patient needed us to recognize his symptoms and work to treat them with appropriate doses of formulary medications that could be adequately and safely used to manage his withdrawal. He needed us to work hard at this before we would be able to completely address his acute infection. He needed time to receive treatment and feel heard. This didn’t feel possible for him in light of current hospital protocols, and the cloud of stigma that permeated attitudes toward him on the health care team.
On day of discharge, my patient’s medical team worked diligently to provide a “safest possible discharge plan” with oral antibiotics, supplies for wound care, and clear instructions to return to the ER as soon as possible. I hope that his friend continued to look out for him, and that she was able to convince him to get back to a hospital. I hope that there, he might receive more complete and patient-centered treatment. I hope that our health care system can learn to better support patients like him, by managing symptoms and treating acute illnesses simultaneously in order to ensure there is an opportunity for our patients to truly “get better.”
What are your thoughts on how to improve treatment for opioid withdrawal? Share in the comments.
Dr. Michaela C. Barry is a third-year internal medicine resident and aspiring infectious disease fellow currently living in Pennsylvania. She credits her medical school and residency communities for helping develop the thoughts she shares here. Dr. Barry is a 2023–2024 Doximity Op-Med Fellow. Personal details of this case have been altered. This story is shared with the patient’s interest in using a personal narrative to advocate for harm reduction. Dr. Barry extends thanks to Mary Buswell MD, Chance Najera MD, Kaitlyn Stettnichs MD and those who work in the Infectious Disease/Addiction Medicine space for helping to shape her thoughts on these topics.
Illustration by Jennifer Bogartz
