On Trust Open Access

It was 3:00 am on my first shift as an intern when I went to the bedside to assess a young woman who requested additional opioid medication. The desperation in her voice has stayed with me all these years later. I was faced with a difficult ultimatum: prescribe her IV opioids or she would likely leave the hospital against medical advice. She needed antibiotics to treat her infective endocarditis. I weighed her request against my sign-out instructions from her primary team, which simply said “absolutely no additional opioids.”

Addiction is “cunning, baffling, and powerful,” according to Alcoholics Anonymous (AA) literature. Patients taught me about those factors, one at a time. Fourteen years after that night float rotation, I work as an attending physician in a clinic at that same medical center.

My third patient of the day was a 30-something-year-old man named Angelo. The “Trust No One” tattoo on Angelo’s neck was the second thing I noticed about him, after his strong handshake. It was immediately clear to me that he had not had an easy life.

Angelo came to my clinic for treatment of his opioid use disorder (OUD) as a referral from the county drug court. After a recent arrest for a drug-related crime, he had the opportunity to enroll in a treatment plan in lieu of a drug-related felony charge. Like many other patients referred to me from the drug court program, he needed medication for his substance use disorder.

Addiction treatment is largely disconnected from general medical care in the United States. Patients can expect that their primary care doctors will provide them evidence-based treatment for many chronic medical conditions. That is not always the case for substance use disorders.

As a primary care doctor, I used to be fine with having my patients go elsewhere for their medications for opioid use disorder. Personally prescribing buprenorphine was not something I was interested in doing. I had more than enough challenges to deal with already, like prior authorizations and denial of insulin prescriptions.

Several years ago, I made referrals for a patient with opioid use disorder to get addiction treatment. He did not follow up on those referrals but said he would start medicine for his addiction if I prescribed it to him. I prescribed him buprenorphine and wished I’d done it sooner. It was amazing to see his improvement week after week. He started taking camping trips out of town with his dog again, after years of despair. Treating him and other patients for OUD reminded me of why I went into medicine in the first place. I hoped for a similar outcome for Angelo.

At his intake appointment, Angelo told me about his life in a matter-of-fact way. His childhood was bleak. His parents used drugs while he and his siblings raised themselves in an Appalachian-esque neighborhood in Cincinnati. His response to neglect was learning to trust and rely only on himself for survival.

Angelo became a father while he was a teenager. He also started regularly using opioids and methamphetamine during this time. When Angelo talked to me about his son, it was with a mix of love and frustration. His son, now an adult, has also struggled with addiction.

After many stints in jail related to his drug use, Angelo’s main motivation to get back on buprenorphine was, he said, to help him stay out of trouble. I prescribed Angelo buprenorphine, and things started looking up for him. I noticed steady improvements as he kept showing up. He let me know that the treatment was helping. Generally, he did not elaborate much. However, during one visit, after a couple months of treatment and seemingly out of the blue, he opened up to me.

He described his new factory job and showed me his new cell phone. He shared his plans with me to celebrate his one-year anniversary with his girlfriend. I was thrilled for him. Unfortunately, as fast as he had initially embraced recovery, he seemed to be back down in the darkness the next time I saw him. At his next appointment, he was on edge and did not engage well with me. He had returned to drug use. For some people, life successes are a trigger for drug use. The following appointment, he did not show up. Or the appointment after that. I wondered what I could have done differently to better engage with him. I called him on the phone but couldn’t reach him.

Six months went by without a word. Then, I heard from his case worker. She had spotted him downtown near the courthouse. She said he did not look good. I called his cell phone again. No answer.

Last month, Angelo was admitted to the hospital for a life-threatening soft tissue infection. The infection was secondary to injection drug use. I was relieved he was still alive. He went to an inpatient rehab facility after the hospitalization.

What will come next? That remains to be seen. I’m haunted by the ghosts of patients who had OUD and were later found dead. This haunting prevents me from blindly trusting that Angelo will pull through. Angelo’s survival is up to him, and all of us who are willing to take up this battle.