"As Time Goes on, It Becomes Your Everything." - Opioid Use Disorder (Part I)

Our first episode explores how our patient, TJ, developed an opioid use disorder, and the steps providers need to take in order to diagnose the disease. Share your reactions and questions with us at  Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction: 0:00
2. Chapter 1 - First experience with Opioids: 4:23
3. Chapter 2 - Transition to OUD/Taking a History and Physical: 10:11
4. Chapter 3 - Neurobiology of OUD: 22:23
5. Chapter 4 - Opioid Dependence and Withdrawal: 27:00
6. Conclusion: 35:07

=== Learning Points ===

1. Remember to use the 3 C’s: control, craving, and consequences when meeting a patient with potential OUD for the first time. Use the DSM-V criteria to quantify the severity
2. Stay away from language such as opioid abuse and instead use patient-centered language such as opioid use disorder or substance use disorder. Instead of clean urine, say negative urine drug screen. 
3. A history and physical are key parts of the evaluation for a patient with OUD, looking for signs of recent use, complications of use (such as infections) or signs of withdrawal. 
4. It is essential to the safety and well-being of our patients that we promptly treat the symptoms of opioid withdrawal, as this can lead to using a batch of opioids that could cause overdose.

=== Our Expert(s) ===

Dr. Carolyn Chan is an academic hospitalist at Yale New-Haven Hospital with interests in medical humanities, quality improvement, and addiction medicine. You can reach her on twitter @CarolynAChan.

 Dr. Lisa Sanders, MD, FACP, associate professor of medicine (general medicine) and author of the popular Diagnosis column for the New York Times Magazine offers her media expertise to the PCP team as a production consultant for the podcast.  


=== References ===

1. CDC Drug Overdose Prevention: https://www.cdc.gov/drugoverdose/prevention/index.html
2. CDC Newsroom report on Overdose Deaths Accelerating During COVID-19: https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html 

=== Recommended Reading ===

1. Buresh M, Stern R, Rastegar D. Treatment of opioid use disorder in primary care. BMJ. 2021 May 19;373:n784. doi: 10.1136/bmj.n784. PMID: 34011512.
2. Alexander GC, Stoller KB, Haffajee RL, Saloner B. An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19. Ann Intern Med. 2020 Jul 7;173(1):57-58. doi: 10.7326/M20-1141. Epub 2020 Apr 2. PMID: 32240283; PMCID: PMC7138407.
3. Hoffman KA, Ponce Terashima J, McCarty D. Opioid use disorder and treatment: challenges and opportunities. BMC Health Serv Res. 2019 Nov 25;19(1):884. doi: 10.1186/s12913-019-4751-4. PMID: 31767011; PMCID: PMC6876068.

=== About Us ===
The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts on various primary care topics, allowing patients the autonomy to share their stories with our audience and for young clinicians to learn from their experiences.

Hosts: Nate Wood, Maisie Orsillo, and Addy Feibel
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Producers: Helen Cai and Addy Feibel
Other Background music: TrackTribe, Jesse Gallagher, Madirfan, The Tides, Corbyn Kites, and pATCHES

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Transcript

Introduction

Addy: hi everyone. I’m Addy Feibel. 

Nate: “And I’m Nate Wood”

Addy: And welcome to primary care pearls. A podcast made by learners for learners. And most importantly led by our patients stories. Today, 

[00:08:16] And becomes your year and your friend, your buddy, your lover, it just becomes your everything. And, uh, you know, and, and then that, and then at the, I think, I think amazing time when it becomes something that you hate, you know?

Addy: Today, we’ll be talking about diagnosing opioid use disorders, part 1 in our OUD series.

Addy: Due to the ongoing opioid epidemic in the United States, the prevalence of Opioid Use Disorders has skyrocketed over the past two decades.  This surge has devastated communities around the country — overdoses are currently the leading cause of injury-related mortality, and opioid overdoses account for the majority of these. 

Nate: And the Covid-19 pandemic has made an already bad situation worse. Death due to drug overdose reached an all-time high between May 2019 and May 2020.    We’ve seen the effects of this first-hand in our local Addiction Recovery Clinic, “ARC”. We providers and our patients have grown to love this affectionate acronym, so you’ll continue to hear it in this series.

Addy: During our discussion, we will be joined by TJ, a patient living with opioid use disorder.

[00:00:28] Hi, I'm TJ. I am one of the patients that the clinic arc and, um, I've been part of arc for about five years.

Addy: Through her experience, we will learn about how opioid use disorder develops. We’re joined today by addiction medicine expert and primary care physician at the Yale School of Medicine Caroline Chan.

[00:00:32] Hey everybody. My name is Caroline Chan. I am so happy to be here and talk about one of my favorite topics, the treatment and care for patients with opioid use disorder. I am an internal medicine physician and an addiction medicine physician. 

Addy: Our conversation today will be facilitated by resident interviewer, Mariah Everts. 

[00:00:00] So I'm Mariah Everts, I'm a third year resident this year at the primary care program at Yale. I've been particularly interested in addiction medicine as a resident. Um, and so I've spent a bunch of time in our addiction recovery clinic. Which has been one of my favorite parts of residency. (Patient Interview)

Addy: My name’s Addy Feibel, and I’m a second-year medical school student at the Yale School of Medicine. 

Nate: And my name’s Nate Wood. I’m an internal medicine physician, and Dr. Carolyn Chan and I are actually also co-fellows together in medical education here at the Yale School of Medicine. Today, I’m so happy to be working with Addy, here, who is not only a medical student but also one of our podcast productionist extraordinaires. And to add to that already-stellar resume, she’s taking a seat at the hosting table for this series on opioid use disorder. Glad to have you here, Addy. Take it away.

Addy: Our discussion today will explore taking a history and physical exam for a patient with potential OUD. We’ll also discuss the neurobiology of opioid addiction and the difference between opioid tolerance and opioid dependence.

Addy: Before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you, or a loved one is suffering from anything covered in today's episode, be sure to discuss it with your medical provider. Now on to the show!

Chapter 1: The Beginning of Opioid Use Disorder  

Addy: Let’s begin by listening to TJ talk about her first experience using opioids.

[00:01:14] Okay. Um, my first experience with opiates was, uh, like a lot of people, um, from pain and, uh, I had, um, an injury in my left leg. Um, and I began to take oxycodone to be honest, to be honest, uh, right off, um, I have an addictive nature.

[00:01:42] So when, um, I started taking the opiates, I, um, I am, I began to abuse them right away. I would take them if I felt sad, actually. And they made me feel bad. I would take them. I would take them if I was happy 

[00:03:08] And so I would, um, need it. I would meet my pills. So I, someone introduced me to heroin. Um, uh, during that time I don't exactly remember how it went, but anyway, so when did you just meeting with the heroin? And I seen. It had the same effect. So when I would go in to my docs appointments, I would have to take a urine and they noticed that I didn't have the opiate in my system and I didn't have the oxycodone in my system.

[00:03:43] they took the. Oxies from me. And they said that, um, you know, well, you know, we can give you the Oxy if you're not going to be taking them. And I said, well, I, I, you know, I take the Oxy, but you know, sometimes I run out and, um, that's what was making me take the heroin. And you start making up all kinds of stories. You just don’t want the opiate taken from you. I’m running out of them, you just don’t want to tell the full truth. That you’re having a problem that you need help. 

[00:04:33] So I continued to use, um, the heroin. The heroin became big because they, uh, because I didn't have the oxycodone anymore. So I started using the heroin on a daily basis. I've been using it for, let me see. I've been clean from heroin. I was clean from heroin for five years, but I used heroin for about seven years.

Addy: TJ’s transition over the period of a year from taking prescription opioids for pain to using heroin is a common pattern seen among our patients with opioid use disorder. As their doctors, we need to monitor when chronic pain management transitions into a substance use disorder.

[00:08:25] Yeah, I think we need to remember that any substance use it's a spectrum, right? Um, at the start there's many medically appropriate reasons to be using opioids in acute and, and sometimes chronic pain management, depending on the situation. I think it's important for any of our patients who are on.

[00:08:42] long-term opioid treatment therapy, who are thinking about initiating her continuing.

[00:08:47] We do discuss that there's always a risk of developing an opioid use disorder. To me, it probably one of the most severe consequences for somebody on long-term opioid treatment therapy and feel comfortable talking and talking to patients about this, you know, um, screening intermittently to just check in and see how things are going.

[00:09:05] Because if patients start to sort of move further along that spectrum, then you've kind of have to reassess and, and think about, is this. Just appropriate medication for this patient. Uh, is there a new use disorder going on where we would change treatment management? It can be quite challenging in those cases.

[00:09:20] So I encourage you if you're ever not sure to engage an addiction medicine specialist. And you know, I'd say, err, on the side of caution, labeling a patient with opioid use disorder, unless you're really confident you can make that diagnosis accurately and appropriately. 

[00:09:56] So thinking about the opioid epidemic that we find ourselves in and particularly this patient, and some of the things you just said about how people are often started on opioids and opiates for really legitimate reasons.

[00:10:21] And I think sometimes we carry this really large weight on ourselves as primary care physicians for this opioid epidemic, because we really do feel when we prescribe these medications, sometimes that it is the best thing for our patient and it's, uh, for a net benefit after we weigh the pros and cons and then, you know, despite doing so cautiously, this prescription sometimes does set off a cascade where it seems to lead to a substance use disorder.

[00:10:49] And so for a lot of us, that transition takes place gradually and outside of our purview outside of the office. And so to a lot of us, we don't really see what's happening there. Quote unquote, behind the scenes. So what is driving maybe physiologically psychologically, socially that transition from being prescribed opioids or opiates to having a substance use disorder and how might we tune in, um, to be able to really understand that transition and intervene at an appropriate time.

Nate: For an answer to that question, let’s turn back to our patient, TJ. 

Chapter 2: Transition to OUD and taking a history and physical exam

[00:07:44] Okay. How has your relationship with opiates or heroin changed over time? 

[00:07:50] I think I started with it being, like I said, a comfort, uh, a feel-good high, um, I can get up. I can, I can, um, I can step to my day. I can, you know, uh, participate. Um, and as time goes on, it becomes your everything.

[00:08:16] And becomes your your friend, your buddy, your lover, it just becomes your everything. And, uh, you know, and, and then that, and then at the, I think, I think amazing time when it becomes something that you hate, you know? Um, 

[00:08:36] and at what point did you begin to think this is getting out of hand and the solution might be to try and cut down?

[00:08:42] my daughter told me that I was talking to her and I fell asleep. I didn't know I was doing that. She said, uh, mommy, mommy, you talk to me and you fall asleep. And I said, what she talking about? You know, I fall asleep, you know, and that's during the time, I didn't know.

[00:09:11] I didn't, I didn't, I kinda didn't know about the, I mean, I know about the nodding, but I didn't really know. To what extent that, that, that nodding affected. Cause I didn't know that you, you know, I actually could fall asleep and not know I fell asleep. That was, that was kind of an indication that wow this is getting bad, you know, and I really still didn't tell them to what extent.

[00:09:37] That it was bad. It really was at, you know, I just told him that, you know, um, I think it's too strong. I think, I think I didn't use that word. I think this is too strong and I, maybe I need to, um, you know, cut down on the milligrams. 

Addy: Around this time, TJ’s primary care provider referred her to the Addiction Recovery Clinic here at Yale. Here is how Dr. Chan would approach talking to a patient like TJ for the first time.

the very first thing I do, one is just confirm that the patient truly has a diagnosis of opioid use disorder. I think so often there are diagnosis is listed in chart that it's really important for us to actually confirmed that they are indeed medically accurate. So I often like to just open the floor to my patient and be very open-ended and say, Hey, you know, I see in your chart, this is listed that you have a diagnosis of opioid use disorder.

[00:02:46] Can you tell me a little bit more about your history of opioid use? 

[00:03:09] Um, so I was actually just curious too, a little bit more about how you, um, use patient centered language when you're having this type of visit and, and how important that is for you in these.

[00:03:23] Words words matter a lot. They matter in medicine, they matter for physicians. They matter for our patients. And unfortunately, a lot of individuals who use substances have been highly, highly stigmatized within the healthcare system. So I really like to focus on patient centered language and this applies truly to all of our patients, not just those with substance use disorder.

[00:03:43] So I really like to use one medically accurate terms. So using diagnosis is like opioid use disorder, substance use disorder. I really. Stray away from language such as opioid abuse. Cause I think that has a lot of, that's a loaded term. You know, there's a lot of negative connotations with that. And one isn't at least currently that's not how the DSM five listed, you know, it's really an opioid use disorder. so it's important that we, we use proper terminology. And in addition, I really try and stay away from other terms that can be stigmatizing for our patients. You know, instead of describing, for example, urine drug screens as like clean or dirty again, which are loaded terms and have a lot of negative connotations.

[00:04:26] I like to just say, you know, a urine drug screen is positive for a substance X or it's negative. You know, when we use words like clean and dirty, I think it adds the sense of morality, um, to, to the issue. And that's just not the case. You know, addiction really is a chronic disease.

So besides using this patient centered language, you know, they come in, you confirm that they actually have this diagnosis, or if they don't, you might

[00:05:05] Go down this path of trying to help diagnose it. And so you mentioned the DSM and how we kind of use those criteria in the DSM to help inform our diagnosis of opioid use disorder. So broadly speaking, I was hoping you could just, um, kind of take us through what those categories of, uh, you know, types of use.

[00:05:22] And as far as the DSM criteria for diagnosing opioid use disorder, 

[00:05:28] So to me, criteria for opioid use disorder, you do have to meet the DSM-V criteria. And there are 11 criteria, which when I was first starting out doing this, I'm like, there is no way I'm going to be able to remember 11 criteria with that looking super awkward and Googling it. And I'm probably making the patient more uncomfortable.

[00:05:47] So a quick mnemonic to sorta remember are the three CS. So I think of them as control. So, for example, if you start to use substances, do you have a hard time, you know, stopping yourself? Um, I think of craving when you're not using substances. Do you have thoughts of using sort of that urge and desire. And lastly, consequences has the substance use impacted your social life at all?

[00:06:11] Has it impacted things at work and. If individuals meet at least two of those criteria, they meet criteria for opioid use disorder. If they've had those symptoms in the past 12 months, now you can make the diagnosis, but you can't really comment on the severity of ODI unless you do the whole 11 criteria.

[00:06:31] But if you're just meeting somebody for the first time, or maybe this is your first assessment, it is a way to get an accurate diagnosis. 

Addy: To recap, there are 11 criteria in the DSM V to determine an OUD diagnosis. But when you first encounter a patient, you can use the “three Cs”: loss of control, cravings, and consequences. If at least two of these criteria are met, then the patient has an opioid use disorder. 

Addy: So now that we have a better understanding of which questions to ask, how do we ask them in a sensitive, patient-centered way? 

These questions can be challenging to ask. So instead of asking directly, do you have any cravings? I will often just be open-ended about it. I'll say, Hey, can you tell me about how your opioid use has impacted your life and leave it really  open-ended and, and let the patient tell you their story after I've like decided whether they have a diagnosis or not.

[00:07:01] Um, cause not all of our patients do. I do think it's really important to remember that patients who are on opioids for chronic pain. There are DSM criteria that include tolerance and withdrawal to opioids. Now, if an individual has been on oxycodone for 10 years, you would expect them to have physiological dependence and tolerance to opioids.

[00:07:22] So if individuals are on long-term opioids, you would actually exclude those two criteria from the DSM 11, they would have to have two, a separate criteria in order to meet criteria for opioid use. 

Addy: When we’re taking a history for a patient with a potential opioid use disorder, what we say and how we say it really matters. We have to make sure that we do not jump to diagnosing OUD without gathering the right information. This means asking open-ended questions that let our patients tell their stories while still paying attention to whether or not the patient fits the DSM V criteria for OUD. Lastly, we must use medically accurate language that does not stigmatize our patients. Two important examples to remember: say opioid use disorder, not opioid abuse. And refer to urine drug screenings as positive or negative, not dirty or clean.

Addy: We’ve discussed how to take a history during our first appointment with a patient with OUD,. Next we’ll discuss the other side of the coin: how to do a thorough physical exam. 

[00:18:00], you know, we think about people who are maybe actively using opioids and would come into your office about having pinpoint pupils. That's kind of one of   the classic ones, but, but what are some of the other physical exam findings we could?

[00:18:22] Yeah. That's, that's a Good question. That's honestly, it's a very challenging question, right? Because it depends on somebody's tolerance and their, their recent use because for many patients, or I shouldn't say for many, but for, uh, for some patients, they, they need those opioids to actually be normal. Like they, like individuals can come in and they can look like any other patient and. That is their normal physiological state. And they need those opioids to maintain that stability. If their blood pressure looks fine, there's no runny nose, right. Maybe their pupils are a little bit smaller, but what is the exam room light look like? Right. Like sometimes that's not always perfect as well.

[00:18:55] We're not doing those exams in optimal circumstances. 

[00:17:07].I do also like to look at, look at the skin. If someone has a history of active injection, you sell, look for abscesses. Cellulitis, I'll listen to the heart and see if I hear any new murmurs. And I do ask about like how the individual uses cause that that affects the physical exam.

[00:17:29] So usually I'll ask them an individual to say, Hey, if you know, if you inject substances, can you just show me where I just want to take a look to make sure that there's nothing we need to worry about or no signs of any infection. If somebody uses intranasally, I will take a look sort of within the nares to see if there's any like irritation or perforation going on there as well.

[00:17:49] And for individuals who have exposure to cocaine, cause some of our patients do with opioid use disorder. I'll do like a quick look at the skin and look for complications of that such as like vasculitis as well.

[From 18:55 clip] Now, if somebody is like, I'm more if, if there's somebody, maybe why I'm worried about it. And maybe I'm, maybe they're falling asleep, you know, being sedated, having low respiratory rates, if I'm coming into a situation or where I'm not sure what's going on.

[00:19:15] Um, so low respiratory rates, sedation, somnolence, like those could be signs of an opioid overdose.

[00:19:24] Good context to hear that they don't always exhibit that though. Sometimes they're just, like you said, they look like someone who is not using opioids and, uh, really it does come down to the history which warms the cockles of my PCP heart.

Chapter 3: Neurobiology of OUD

Addy: One of the reasons taking a really thorough history is so important is that OUDs do not develop inside a bubble. They really are biopsychosocial diseases. They’re influenced by the environment and even by the biology of one’s brain. Opioids have the power to co-opt people’s brains so it’s opioids and nothing else. TJ talks really powerfully about the duality of this problem: your brain, which usually tells you what is good and what is bad, is telling you the opposite.

[00:30:24] That same brain that keeps you sober will get you high. Don't listen. When, when, when, when your brain is telling you that, that same great brain, that kept you sober and kept you sober all week long on Friday night. That same brain will tell you 

[00:30:53] Everybody's out. And everybody is getting high. Let's go now. No, come on. No, you got that's what you got to pick up the phone, you got to pick up a phone, you have to, you have to reach out and pick up that phone because that brain , it gets you high. And then to see that's what this was so insidious about this disease, you know, because you have this old and the new brain the old and the new. And that old brain that wasn’t keeping you sober, it was keeping you high had that thought process of high. It didn’t know anything about sober. But now there’s a new brain.

Addy: What TJ’s describing has a biological basis. Addictive substances like opioids alter functioning of the brain’s rewards system. This is known as the neurobiology model of addiction. Let’s let Dr. Chan walk us through the three phases of this model. 

[00:11:25] Traditionally, if we think about the neurobiology model of addiction, it kind of has three steps to it. And I think that's probably worth talking and thinking about, so the very first step of using.

[00:11:48] Using a substance is sort of this binge or intoxication. So your brain is getting a bunch of dopamine it's lightening up. It's, it's kind of having this reward effect from it. And honestly, many of us have used coffee. Many of us have tried alcohol, right. We know substances that have, have an effect on it.

[00:12:04] That's often pleasurable. That's why people use substances. Right. And people do it for. Different types of reasons. So over time the brain does have neuro-plasticity and it can start to remodel and things can start to change over time. And it's not going to happen generally after just a one-time use.

[00:12:20] Right. These things take time. So the second sort of cycle is, is this withdrawal and negative effect. So because your brain has remodeled, all of a sudden, you may notice when the substance is removed, that they may feel irritable. They may feel more stressed, a loss of motivation for rewards. And then that leads to kind of the third piece, which is the preoccupation and anticipation, which is the craving piece of your brain.

[00:12:45] So we believe that when patients sort of have. Come to full terms and have that diagnosis of opioid use disorder. This, this cycle is likely kicking in.

Addy: In review, there are three phases in this cycle of addiction. First is the binge/intoxication — individuals experience a surge of dopamine after using a substance, which incentivizes them to continue using and eventually leads to brain remodeling. Second is the withdrawal and negative effect phase. When individuals stop using the substance, they feel worse - perhap s more anxious or stressed or less motivated. Lastly is the preoccupation and anticipation phase. When individuals do not take the substance, they crave it. This leads to drug seeking behavior and often, relapse, thus restarting the cycle.  

Chapter 4: Opioid dependence and withdrawal 

[00:13:13] And, you know, as you, as you were describing that, um, I was thinking about, I've heard a few different terms and I kind of wanted to, to distinguish them. Between, uh, opioid tolerance and then dependence. Could you just kind of clarify the difference between those and how you separate that out with patients?

[00:13:31] Yeah. So I would say opioid tolerance means I need to u se more to get the same effect. We see this, not infrequently with patients who are on opioids for extended periods of time, where at first they may only need oxycodone five milligrams, but over time they build tolerance. So they need oxycodone 10 milligrams in order to achieve adequate analgesia relief, which is just part of being on an opioid long-term, you know, eventually tolerance w we'll we'll develop, um, just like tolerance can develop to other medications, Right.

[00:14:02] In chronic disease. If you have diabetes, patients can develop insulin resistance and sometimes individuals need more insulin. Um, our bodies are amazing and they continually change and remodel. Uh, opioid dependence is when a person is physically dependent on it. And if the substance is withdrawn, they experience withdrawal. common causes of opioid withdrawal is removal, opioids, and the symptoms would be muscle aches, runny nose, myalgias, diarrhea, nausea, vomiting, very flulike, but very, very uncomfortable. Um, really a terrible experience. It's awful watching patients suffer and be an opiod withdrawal.

[00:14:49] Um, so it. can see why people want to stop feeling that terribly

[00:14:58] just to clarify for everyone out there, we know that some substances, when you withdraw are potentially deadly and others are extremely uncomfortable. Where do opioids fall on that?

[00:15:13] That's a good question, Nate. I think, I think it's complicated to be honest, right? If somebody stopped alcohol, they're at risk of having seizures, delirium. Tremens you know, now. would argue that honestly, opiod withdrawal can also be very deadly and dangerous, not so much that this, the symptoms themselves are going to be life-threatening, but it could lead somebody to, um, use in a less safe manner, right.

[00:15:39] Than they normally would. It could lead them to use a substance or batch that they would never normally do or use because they're desperate to stop that that could lead to overdose and death. So while it may not cause, you know, a life-threatening seizure. I do think that there are consequences of opioid withdrawal that, that are life-threatening. 

[00:15:58] I love how you put that. Like you mentioned before, it's not just about the biology, but also about the psychosocial implications of use and how that can contribute. And especially even thinking about, um, danger of withdrawal. And besides that you mentioned some of the symptoms that patients experience the diarrhea, the nausea, um, and some of these other things that are so extremely uncomfortable, if a patient is going through withdrawal, other than these kinds of symptoms that they might experience, what are some of the physical exam findings that we might see as. 

[00:16:31] Yeah. So if they're going through active opioid withdrawal, the first thing I'll see often I think of in the room, I see their runny nose. I hear the sniffling, I see the eyes watering And I'm like, oh no, I want to help make you feel better. Um, to me, that's the first thing I often notice yawning can also is also a symptom of opioid withdrawal.

[00:16:49] That's when I know its symptoms are probably starting to get more severe, uh, as long with dilated pupils. For anybody with opioid withdrawal, my first priority, we want us to get them out of opioid withdrawal so they can feel better and we can have a more so they can just feel better so we can have, have a conversation.

[00:17:07] Cause it's hard to have any conversation. If you're feeling kind of crummy.

Addy: For TJ, the fear of withdrawal was a constant, motivating her to continue using opioids.

[00:33:13] Can you talk about the fear of withdrawal and how difficult that is? That within itself 

[00:33:21] kept me high and not so much high that kept me using, you know, uh, one of the providers told me, that you think you're going to die, but you're not.

[00:33:40] You're not, you, you think that you're going to die, but you're not, but the sickness, the, the aching and and the yarning in this sneezing, and yet eyes watering and your back is hurting and you have to use the bathroom. Oh, your body's going through all these changes. And it's like, oh, I don't want to do that. I’d rather use. So I’m going to use until I feel better. The fear of withdrawal is big and you know the mind that brain again can make it real big. There you are in the grips of it. And you may not be in it yet but 

[00:34:39] You may just maybe yawn or your eyes may be watering, but you know, what's coming, you know, more is coming. So just that fear that, you know, you're in the grips of it. It's like, oh God, now I don't want to do this. I don't want this to happen. So you use, 

Addy: First encounters with patients with opioid use disorder can seem really overwhelming. But after listening to the perspectives of TJ and Dr. Chan provided me a lot of clarity on how to get started. The truth is, no matter our level of training, substance use disorder always has the potential be a tricky and sensitive topic to broach with patients.But as we will continue to see throughout this series, these sometimes difficult discussions are essential — What starts as maybe a few open-ended questions can make a really profound difference in the lives of our patients. 

Addy: Through this discussion today, we all have learned how to better recognize and treat patients with OUD. Of course, we need to have a good understanding of the DSM V criteria for OUD and pathophysiology of addiction. However, I’d argue that of equal if not more importance is that we learn to talk to our patients with OUD — many of whom have faced great stigma before coming to us— in a way that makes them feel safe and cared for. At the end of the day, it comes down to approaching the patient as a whole person, not just as a substance use disorder, and really taking the time to really listen to their story. 

Nate: Absolutely. I’ve found time and again in ARC that one of the most challenging but important aspects of caring for patients with opioid use disorder is honoring the courage that it takes for these patients to come see us, their provider. They show us such vulnerability by asking for our help or support — or by even just showing up, depending on where they’re at in their journey with addiction — and they deserve our respect for that. First, our respect. Then, evidence-based, patient-centered care. And like you said, Addy, it all starts with listening. 

Addy: And that concludes our episode today. 

Here are some key points to take away from today’s episode:

1. Opioid use disorder often starts with an opioid prescription for pain. As doctors, we must monitor our patients with past opioid prescriptions and screen for opioid use disorder.
2. Due to the stigmatization of addiction, patients with substance use disorders are often hesitant to open up and speak honestly with medical professionals. During our first encounter with a patient who might have an opioid use disorder, we need to make sure to create a safe, non-judgemental environment by asking open-ended questions and using correct medical terminology that does not moralize.
3. Opioids alter the neurobiology of the brain and can cause individuals to act differently than they normally would. Due to physical dependence on opioids, individuals can experience withdrawal, which in the case of opioids includes intense flu-like symptoms. Though opioid withdrawal symptoms themselves aren’t life-threatening, they can cause individuals to use a dose or batch of opioids they wouldn’t normally do, which can lead to opioid overdose and death. It is therefore essential to the safety and wellbeing of our patients that we promptly treat the symptoms of opioid withdrawal. 

Be sure to tune in next time wherever you listen to your podcasts to catch part II of the OUD  series where we’ll be discussing medication treatment.

We hope you enjoyed the episode which was made possible by contributions from our patient TJ, our resident interviewer, Dr. Mariah Everts, and Dr. Caroline Chan, who provided faculty peer-review for the project and served as our expert. Special thanks to our producers Dr. Joshua Onyango and Helen Cai, as well as our faculty advisor Dr. Katie Gielissen.

Be sure to follow us @pcpearls on instagram where you can expect to get sneak-peeks, additional learning content, and the most up-to-date details on show release times. And if you enjoyed this episode, please share it with a friend or colleague who would be interested to learn about the health issue we discussed today.

Thanks again for joining us today. Farewell from all of here us at the Primary Care Pearls podcast, and we’ll catch you in the next one.

Nate: Bye, everyone!