misboxie, MD

@runner-kat, this is an EXCELLENT question. 

Let me make one thing clear: I am no saint. I did not come out of life or medical training aware or ‘woke’ about this issue. I learned, as my hero and inspiration for this blog, Anthony Bourdain did when he acknowledged his contribution to toxic masculine kitchen culture: by fucking up, listening to people who knew better than me (patients themselves, social workers, addiction psychiatrists, my attendings, residents), changing my ways, and continuing to learn. If I can change, you can, too. 

I think there are two very major, pervasive biases I see across disciplines and healthcare professions that can also be easily remedied. 

Common bias #1: Language What we do: “This is a 28 year old heroin addict” “This is a 32 year old IV drug user” “This is a 48 year old opioid abuser”

Addict, user, and abuser are words with blatant value judgement behind them. It changes the way we think about the patient before we even see them. It hurts our patients, too. We as physician know better, we know that illness does not make a patient more or less valuable as a person. 

We KNOW that addiction is a physiologic illness. It’s not “all in your head” or “weak will” or “poor upbringing”. One that comes with stigma, its symptoms manifest as behaviors, its side effects and endpoints catastrophic to patients, families, children, and communities. One of the saddest things I heard in the past year was when a twenty four year old with terrible septic arthritis told me, “I’m a drug abuser. I don’t deserve this surgery, you guys should just leave me to die.”  It told me how little she thought of herself and how hopeless she felt. It told me that someone who claimed they loved her said that to her. That’s fucked up. Use instead: “This is a 28 year old with heroin use disorder” “This is a 32 year old person who injects drugs” “This is a 48 year old person with opioid use disorder” This is non-judgmental language that succinctly addresses the medical illness of the patient at hand. Disorder, of course, in the medical sense, and not the colloquial sense. Common bias #2: Patients with a history of or current usage of opioids do not provide learning value.What we do: Residents. Attendings. Med students. Raise your hand if you’ve ever heard or said: “Ugh, another opioid user you’re going to learn nothing” or “I prioritize teaching on my service, so you’re not gonna get the annoying stuff like placements or drug users.”

I’ve said all those things before. I’m not proud of it. I don’t say shit like that anymore. And I educate residents to not say that, either. 

There is teaching and learning value so long as you look. But why do we say shit like this? Because we’re burnt out and patients with opioid use disorders need a LOT of multidisciplinary services, time, and help we often cannot give as a lone med student or resident. Their suffering and sometimes their behavior forces us to confront things about ourselves, our healthcare system, our society that we’d rather look away from. These patients can also often press our buttons and stir up emotions that we’d rather not feel and can test our compassion. 

Let me offer some suggestions for teaching points for both teachers and learners:

-Ask your patients about the first time they injected or took more pills or fentanyl patches. The stories will break your heart. The number of patients I’ve met who were given an injection against their will? Too many. Patients who took pills because they felt their life and future was going nowhere? Too many as well. -Learning about injection habits and learning how to educate people on safer injection habits if they’re not ready to stop to prevent life-threatening infections is seriously interesting and lifesaving medical education. Maybe I’ll do a post someday soon.-Learning about medication-assisted treatment (MAT) to help patients ready to stop using opioids. Interesting and educational from a pharmacologic perspective, physiologic, and medically. Attendings out there, find out if you can get certified to provide MAT! I’m in the process of certifying!-**Framing injection drug use as a medical condition with its own focused review of systems, questions, physical exam, and work-up. Ask about fevers, night sweats, systemic symptoms. Injection methods: you must ask because it will address where infection lies on your differential and what else you need to work-up. Ask about prior methods the patient has tried to stop injecting. Have they tried quitting cold turkey, tried methadone, suboxone, vivitrol, etc. What were those experiences like? What have they heard? Would they like to try? Looking for back pain (potentially a concern for an epidural abscess or vertebral osteomyelitis), a good MSK exam for septic arthritis or muscle abscesses, murmurs for endocarditis, etc. Work-up for transmissible diseases like HIV, Hep C, blood cultures for bacterial or fungal bloodstream infections. Do I have your interest yet?

Obviously there’s more to do. But I think if medicine as a whole could do just these two things, we’ll be doing a whole lot better.

Fantastic question, thank you!!