Mutual Mistrust in the Medical Care of Drug Users. The Keys to the "Narc" Cabinet

Abstract

OBJECTIVE: Caring for patients who are active drug users is challenging. To better understand the often difficult relationships between illicit drug–using patients and their physicians, we sought to identify major issues that emerge during their interactions in a teaching hospital. DESIGN: Exploratory qualitative analysis of data from direct observation of patient care interactions and interviews with drug‐using patients and their physicians. SETTING: The inpatient internal medicine service of an urban public teaching hospital. PARTICIPANTS: Nineteen patients with recent active drug use, primarily opiate use, and their 8 physician teams. RESULTS: Four major themes emerged. First, physicians feared being deceived by drug‐using patients. In particular, they questioned whether patients' requests for opiates to treat pain or withdrawal might result from addictive behavior rather than from “medically indicated” need. Second, they lacked a standard approach to commonly encountered clinical issues, especially the assessment and treatment of pain and opiate withdrawal. Because patients' subjective report of symptoms is suspect, physicians struggled to find criteria for appropriate opiate prescription. Third, physicians avoided engaging patients regarding key complaints, and expressed discomfort and uncertainty in their approach to these patients. Fourth, drug‐using patients were sensitive to the possibility of poor medical care, often interpreting physician inconsistency or hospital inefficiency as signs of intentional mistreatment. CONCLUSION: Physicians and drug‐using patients in the teaching hospital setting display mutual mistrust, especially concerning opiate prescription. Physicians' fear of deception, inconsistency and avoidance interacts with patients' concern that they are mistreated and stigmatized. Medical education should focus greater attention on addiction medicine and pain management.

“It’s been an Experience, a Life Learning Experience”: A Qualitative Study of Hospitalized Patients with Substance Use Disorders

“…Participants also noted the importance of staff who knew how to treat withdrawal, 15 and felt that variation in treatment implied that some providers were delivering substandard care. This mirrors the results of Merrill et al, 16 who found that physicians lacked a standard approach to commonly encountered clinical issues experienced by hospitalized patients with SUD, especially the assessment and treatment of pain and opiate withdrawal. Over a decade later, our findings show a continued need for protocols and staff training to improve provider competence in identifying, assessing, and treating SUD in the hospital.…”

Better clinical decision making and reducing diagnostic error

“…How do we ever make a sensible decision? The answer probably lies in the fact that much of what we do is routine, predictable and requires little Obesity [41][42][43][44] Psychiatric illness [45][46][47][48] Age [49][50][51][52] Socioeconomic status 35,53 Sexual orientation [54][55][56] Substance abuse disorders 57,58 Chronic and complex illness 58,59 A 45-year-old woman presents to the emergency department in an agitated state. She is holding a large empty bottle of aspirin and says that she has taken all of the pills a few hours ago to 'end it all'.…”

Smertebehandling av rusmisbrukere innlagt i sykehus

“…det er også vist at smertelindring til opioidavhengige er suboptimal eller ikke-eksisterende (6,9). mangelfulle kunnskaper om hvordan opioidavhengighet påvirker smertebehandling har vist seg å vaere en vesentlig årsak til utilstrekkelig smertelindring (8,10,7). i tillegg til at opioidavhengige pasienter gis utilfredsstillende smertebehandling, blir de også stigmatisert og smertene blir underdiagnostisert (31,12,13).…”

“…det kan synes som om helsepersonell er redde for å bli manipulert og lurt. dette gjelder spesielt ved etterspørsel og foreskrivning av opioider (10).…”

“…smerte er en subjektiv, personlig og privat opplevelse, og det er derfor nødvendig å bruke smertekartleggingsverktøy for å sikre en individuell og optimal smertelindring (44). Bruk av kartleggingsverktøy knyttet til smerte og avhengighet vurderes å vaere av essensiell betydning for at opioidavhengige skal få adekvat smertelindring når de er innlagt i sykehus (10). nøyaktig kartlegging av pasientens smerte kan redusere sjansen for å bli manipulert eller "lurt" (7).…”