question re patient

Buprenorphine Post
Posts: 267

Postby peterorrin » Mon Dec 15, 2014 10:22 am

Why did she leave her psychiatrist in the first place?

Cheryl Seaman
Posts: 11

Postby Cheryl Seaman » Mon Dec 15, 2014 10:22 am

Well the rather belated follow up is: She understood I would not let this topic go without more discussion as well as UDS. She chose to return to her former psychiatrist who does not do UDS. That way she can continue to do cocaine as she pleases. Her husband is aware and I can tell no one.

Posts: 267

Postby peterorrin » Mon Dec 15, 2014 10:22 am

This thread about a complicated patient reminds of Mark Vonnegut's memoir "Like Someone Without Mental Illness Only More So" (2010). He was a schizophrenic/bibolar/manic depressive with several psych admissions and lots of drug abuse. He graduated from Swarthmore with a 1.6 average. An. d then he improved, applied to 19 medical schools, and after his Harvard medical school interview, the interviewer told him 'You need to be a doctor." He is now on the Harvard staff and has been voted Boston's best pediatrician.

I mention this extreme example to remind us have seen turn abounds. Cheryl, you say your patient is 'cooperative and sweet' (hooks!). We would tell her 'this' level of care is not for everyone, but it has definite advantages (discuss). Complete abstinence has a better outcome. Increase her group attendance and mutual-help attendance, change friends. Be patient but insistent; the group (do you hold weekly groups?) knows!

Happy New year!!

Posts: 187

Postby Dave » Mon Dec 15, 2014 10:22 am

I disagree with the harsh punishment of those who would withhold bup from anyone unable to stop smoking tobacco or marijuana, or to stop drinking alcohol. Stopping these addictions should be an ongoing process for the physician who treats opioid addiction.

Posts: 198

Postby NoDrugs4u » Mon Dec 15, 2014 10:22 am

Bravo Dr Czelnick! I agree completely. If you are in drug treatment then NO addictive drug (or alcohol) use should be permissible.

Posts: 3

Postby czelnick » Mon Dec 15, 2014 10:22 am

In Maine, Medical MJ is legal. I only allow my bup patients to have positive UDS if they have Medical MJ card; and I won't give them one for PTSD without a psychiatric consult.
If they are not legal for Medical MJ (chronic pain, cancer, PTSD), then they have to get their MJ from people who are drug dealers, or they are growing their own and often tempted to become drug dealers to supplement income.
In either case,****ociating with the drug using culture is detrimental to treatment for opioid dependence and I do not allow it.
I give them a deadline for clear urines 60 days form the date of confrontation- UDS should be clear after 30 days if they are not using.

I also tell them about the experiment where 4 guys are packed in a VW and 3 smoke week- the nonsmoker has a clear urine! (ie no secondhand positive screen!)

Posts: 24

Postby finkelmd » Mon Dec 15, 2014 10:22 am

Hi Cheryl, regarding your patient with HIV, BIPOLAR, OPIATE DEPENDENCY, who requires such a complex medication regimen, it is easy to identify that she has 3 deadly diseases. You describe her as sweet, compliant (except for sporadic cocaine)and grateful. In my experience it would not be easy at all to find another Psychiatrist who would take such a complex patient, I know it would be too much for me!
You do not mention her age but in my opinion she is a SURVIVOR. I would not be so cavalier about making suggestions to discharge her from your care. I would clearly document in her chart the pros and cons about her treatment, your recommendations, include family members in the conversations, but I would continue to try to keep her alive for as long as possible,being aware of the seriousness of the case and the potential final outcome. Great job Cheryl, do not give up on her.

Posts: 267

Postby peterorrin » Mon Dec 15, 2014 10:22 am

New patients arrive ready for action re: opioids, but precontemplative with regard to THC and alcohol. Its challenging but, like Kevin, we have our schpiel. We try to get them to understand 'sedativism' and the need to be honest at self-help meetings. Of course we have found that some of those resisting self help are drinking.


Posts: 1404

Postby drpasser » Mon Dec 15, 2014 10:22 am


I totally agree with everything you said. Cannabis is clearly the safest intoxicant on the planet. I won't terminate a pt just for a positive THC on drug testing.

On the other hand, I think that young people especially, may fare better in general by avoiding cannabis or using sparingly compared with a heavy, daily user.

I believe, I've read an article which suggested that pts on bupe who don't use cannabis tend to have a more favorable outcome compared with pt's receiving bupe while using cannabis.

(Of course, I can't at this moment provide the reference for that article, sorry. I bet someone could search and find it though)

"If one is getting high with one part of the brain, and trying to stay clean at the same time, like with a different part of the brain; that tends to be a problem, as it is the same brain." That is part of the schpiel I give to pts about the subject of smoking weed while taking bupe. While it's a simplified notion, but pts seem to understand the concept.


Posts: 70

Postby mack86 » Mon Dec 15, 2014 10:22 am

I live in a state where MJ is legal and easily available - seem to be MJ stores everywhere. I don't condone its use, but it is less likely to cause the kind of very serious problems****ociated with some other drugs, such as meth and coke. So I don't always insist on UDS free of THC, especially if use appears occasional and they are otherwise functioning - holding a job, etc. Employers here might not care about THC in the urine.

I believe alcohol is****ociated more violent crimes than MJ. As a former ER doc, I've seen my share of out-of-control, angry drunks, but I've never seen an angry pot-head.

I have pts who never took opiates to get high in the first place. They had chronic pain and became physically dependent on their prescribed opiates. Bup helps with pain and they don't have to keep escalating the dose. Some of these are prescribed "medical MJ" (not by me). I am told that some components of MJ cause less euphoria and are better for pain.

I'm not condoning MJ, but I am more tolerant of it.

That said, I do have one patient who did smoke too much MJ, in my opinion, and his family's, it interfered with his motivation to work. Made him something of an underachiever. Yet he did hold down a job.

I think I'd push for cigarette cessation before I'd push for MJ abstinence.

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