Welcome, and this is Dr. Steve Wyatt. I'm sitting with Dr. Will Wright, and we are going to present a case that includes a variety of things that have been covered in the previous module. This is a 19-year-old university student that comes to you asking for treatment for her heroin use. She's been using heroin intranasally for the last 15 months, but daily over the last three months, she's now using about a gram a day. Again, a gram is typically a bundle of heroin, that's what we talk about or 10 bags which are typically around 100 milligrams a piece. Some of her friends are now switching to intravenous use because it takes less heroin to keep from getting sick. But she says that she does not want to do that, but maybe forced to because she can't keep paying the extra cost to use intranasally. She's used all the money the parents had given her for her school expenses to buy heroin, and her credit cards are maxed out, she's borrowed money from her friends. Until last semester, she had an overall B average, but this semester she is in academic difficulty. When she doesn't use heroin, she has muscle ache, diarrhea, insomnia, and anxiety. She recognize these symptoms as heroin withdrawal and was surprised because she thought she couldn't develop dependence when using intranasally. She has no prior history of drug treatment. So Will, what do you think about this patient, and what's your diagnosis? So obviously when you hear of all these particularly reserves, there's hitting a lot of the categories for an opioid use disorder. She's starting to use more and more. She's showing signs and reports of withdrawal symptoms and so also tolerance. She wasn't quite using very much or very consistently for about 15 months, but here in the last three months has definitely cranked it up and using on a daily basis. Problems with school, problems trying to max out and using money that was supposed to be for school in other ways I'm sure her parents are not aware of, where discovery would definitely cause some problems with their relationship. So definitely seeing opioid use disorder mirrors with these categories and criteria being hit with this young female student. Yeah, I would agree. I mean, the progression of the disease, some people would point out that it's in months and only three months of daily use. But at the same time, once the disease is there, the disease is there. She clearly has tremendous salience for drug as we've talked about before, and a down-regulation for any consideration of the consequences of drug use in terms of letting her grades fall, and making those choices, and how she's using her money. So what should be a candidate for buprenorphine? So I definitely think with some of these criteria and the physical stuff, I definitely think that she could benefit from medication such as buprenorphine. Ultimate scenario depending on where we're seeing her, were we able to see her when she was first in that 15-month period before she really started daily use, or we now form on a daily use things. Sometimes we can again divert earlier on if caught earlier, but it sounds like we are seeing her when she's starting to suffer more of the consequences, both physical as well as relationship and responsibility wise. I think with those parts of the picture, it doesn't mean she could be using buprenorphine as the stabilizer and can get some of these particular things a little more under control. So I definitely think she could be a candidate for treatment but we have to keep in mind, being naive to probably a lot of medications in general. She's only 19. She may not have experienced much medications regardless, and so we really need to have good psychoeducation with medications before maybe starting. I do think that you would need to review with her the potential that she could be a candidate for [inaudible] is something else that we didn't want to keep in mind and certainly let her know about. I don't think, typically she would be a candidate is point per methadone. Probably she could end up quite well without necessarily being referred to opioid treatment program, but it wouldn't be inappropriate. I think that for her to understand however, that there are other treatment options is always important. So what would the goals of treatment be that you would establish? So obviously with some of this problematic use scenario starting to, and I guess what her concerns are over her own use. So again, coming out from that motivational interviewing standpoint, what is it that she feels is problematic? Is she more concerned about the financial or is she more concerned about the schoolwork? Is she really concerned about the physical or all of it? So targeting the goals that she is saying that this use is interfering with her life. Starting at the springboard, now obviously then from our side, then maybe proposing some of our own treatment goals as far as decreasing use and starting to get more stability from therapy and medications to get her back into a more stable footing. I guess she's young, 19-year-old student with a lot of life before her. So using that as well as far as some of the treatment goals to establish rapport as well as what her own goals are, why did she go to college? What is she hoping to get out of going to school? So using that as also treatment goals. Well, if you're continuing to use and you're using money for school for your use as opposed to actually paying for tuition or whatever, you may not be meeting your hope for goals. So having all these is part of the motivational interviewing standpoint. Meeting her where she's at, and also getting a good sense of what she is wanting to get out of treatment. I think of them as really hooks. How do we hook them into treatment in a way that. In a good way. In a very positive way that can start to open their eyes to ways in which they thought of their life in the path, and how opioids have taken them off that path. So briefly, if you were going to initiate a treatment in this young woman, what would it be? If we were going to, again I totally agree, giving all the options for current treatment modalities for over-use disorder, and if she were to pick one or the other or maybe she picks [inaudible] , maybe she doesn't pick buprenorphine. If we start with buprenorphine, that again, a lot of psychoeducation as far as what it is, what it isn't, how we appropriately take it, how we from the treatment community are going to hopefully engage and support her in this endeavor, especially in the beginning. Because again, 19 years old, I'm confident she's probably never gone through this type of a treatment before. So really understanding and really getting across what that's going to mean, what that's going to look like. Because again, at this age, there's a lot of responsibility; you versus learning autonomy versus feeling that I'm invincible. So there's actually some dangers there that she may not really understand what the potential pitfalls and dangers are if she doesn't engage in treatment. So probably more frequent, more intense on the outset to make sure that she's engaged and she understands some of those particularly as a treatment and recovery. So let's see what this particular provider did. The clinician gives her a prescription for six days supply of buprenorphine, four milligrams a day. She's given information on starting a participation in the clinic's relapse prevention workshop six days a week, and then to schedule individual counseling at the clinic once a week. So these things were just given to the patient. With expectation. With the expectations that she would follow through. She returns three days later having taken eight milligrams of buprenorphine a day over a three day period. She has not attended relapse prevention workshop nor scheduled an individual counseling session. The counselor is not available to see her. So she's essentially turned away. So what would you have done at this point? So hopefully, that came a little bit, obviously, with inductions, again, of somebody this age or somebody that's naive to treatment, you would hope that there had been earlier on reaching back out there to see on how things are going. How's the medication treating you, are you feeling relieved, are you not feeling relieved? So even if it's a phone call, obviously I always prefer face-to-face, but some interaction with the patient before it got to the point where she was doubling up on her medications, running out even before she was technically supposed to. So having that interaction earlier, and even though the counselors out there this year, now that's for you to start having discussions about what was going on? Why did you feel like you needed to take more medications? Was it a physical symptom, a psychological craving, what was going on? Yeah, so even with home inductions, which is what this appears to have been, there's still should be a follow up with them the first day or two, typically within the first day to just see how they're doing. In particular, as you mentioned earlier, this is a young woman, and to do a little bit more hand holding to help her through it. If on Day 2, there was recognition that she didn't feel comfortable at the end of Day 1 staying on four milligrams, that she was still experiencing some withdrawal symptoms potentially, then you know that right away. You get her in. You start to talk to her a little bit more about it, and potentially, you began to recognize that she's not going to necessarily follow your instructions to a T. This could be a person that you need to engage a little bit more. I will say that engagement often results in people being more honest as opposed to necessarily her thinking that you're going to get mad at her, that there's going to be a problem that she needed more medicine. So instead of calling you and saying, "Wow, this four milligrams doesn't seem to be holding me. What am I supposed to do?" Instead, she just freaked out and took extra medicine. Again, that guilt and stigma can sometimes come back because they're assuming that you're going to assume the worst of them. But you are, again, just like we said in previous case models on our discussions of drug seeking behavior when we are here, obviously she's coming for treatment of this condition, so showing her that this is a safe spot to be honest, to be open, this is why we're here. We're not trying to discharge you or kick you out. We're here to help. Yeah. So this just doesn't need to happen, I think, is really the point, and if people are engaged appropriately, you've done a good assessment, you do an appropriate induction, then you're not going to see that. They're not going to be drug-seeking. They're going to be engaged with treatment. So she returns the following day hoping to get more medicine, but, in fact, the group and individual counselors weren't available. She's told by the medical staff that she had to attend these relapse prevention workshops to get medication. She doesn't return to the clinic for another four weeks. When she does, however, she's smoking more heroin than before, but not having difficulty with finances because she dropped out of school and is now working as a stripper, a dancer in a gentleman's club. So I think it's important to really recognize what's happened here. The tragedy of this particular patient and this young woman is that these cases that we're presenting are based on real cases. In this particular case, this young woman was found dead in this gentleman's club with a needle in her arm a few weeks later. This is a young woman that had every potential for getting control of her disease. But as a result of the plan not being set up appropriately, that recognition of her strengths and weaknesses was not taken into consideration in actually providing adequate care. It resulted in death, and I point this out in part because of the importance of good care, but also, that for those of you that are listening to this presentation that you recognize these are lethal diseases. This is not somebody just wanting to get high. These are behaviors and drug use that doesn't have a point where it says, "I'm in so much pain. I need help." In fact, unlike let's say heart disease, where if you start to exercise more, your chest pain becomes worse, and so you turn to help. In fact, drug use disorders drive the disease. They only make the disease worse. So as it gets bad, people want more or they have a drive to use more. It's very difficult to get to that place where we talk about a bottom. What is the bottom? We've seen bottoms happen over, and over, and over again to the point where then people like this young woman actually die. So again, I really encourage those of you that have taken these modules to consider this and think about how you could play a role in your own community in combating this disease. That really means identify those people that have been using or have the potential for using opioids and appropriately that you're starting medication with. Then identifying people in your practices that have the disease and understanding that there are evidence-based treatments for the disease that can help get it under control, and then using it. I'm really strong on this, that those of you taking this training that you use the medication, that you do offer this to patients and people in your community. I can tell you it is hugely rewarding to watch a young woman like this turned her life around, graduate college, and move forward. So again, it's a fatal disease untreated. For me I think it points out that you can have the best treatment, the best follow-up care protocols in place, but remembering that not everybody's the same. Everybody's particulars can be different. So not simply rubber stamping people along, that everybody gets the same kind. You're really wanting to individualize and treat each patient as a unique patient, that this 19-year-old may need a lot more hand holding, encouragement, direct care, interaction, kind of stuff as opposed to somebody that maybe a little more older or more mature. They've got other health conditions that they've gone through. They may not need as much of that directive at the beginning, so every patient is different. Or even you may have a 50-year-old that acts like a 19-year-old. So you're really engaging each person individually even if they at the end still have the same IOPs or therapy in your programs. But each person, the assessment, the engagement, and what they need. What's going to be their strengths and what's their weaknesses? Make them unique. Remembering that and situations like this poor young girl may be avoided. Absolutely. Well, I think that'll wrap up this particular case, and hopefully, you've learns more in depth concepts that are indicative of what we've covered. I agree.