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Posts by ezahradnik

Dual Diagnosis, aka Substance Abuse, Mental Illness, and Palliative Care

It seems innocuous, but the term ‘dual diagnosis’ describes a very complicated subset of patients — those who have a substance use disorder as well as a primary psychiatric disorder (anything from depression to schizophrenia). Throw a serious medical illness into the mix, and you have a recipe for one very overwhelmed palliative care physician.

Moving along, I’ve paraphrased key info from the case that was presented –

  • Presenters describing patient: “Opiate dependence, stopped methadone maintenance therapy, mood disorder, trauma history, cocaine, family estrangement, new cancer diagnosis.
  • Most of room: “This doesn’t sound good…”
Never fear, this patient is manageable! The most important thing is to recognize that a team approach is essential — involve psychiatry, social work, the patient’s outside providers, clinic staff, etc. Try proactive measures like a pain contract (though not infallible), and encourage the patient to bring her sources of support with her to appointments, whether they be friends or family.

  • Presenters: “Now she’s your patient and you’ve been noticing she’s missed a lot of appointments with you and her oncologist, she’s had a number of early pain med refills due to lost scripts and stolen meds, and she’s still having a lot of pain despite very high opioid doses. She refuses to switch over to methadone because she doesn’t like the side effects. Now what?”
  • Most of room: “Refer patient to someone else!”
    Wait! Let’s think about it first and consult with the interdisciplinary team. This is a patient who has had a long history of opioid addiction who is now back on opiates. Of course she’s going to fall back into addictive habits, so let’s figure ways to help the patient change some of those habits. But also don’t forget the phenomenon of pseudoaddiction, which is an iatrogenic syndrome of abnormal behavior that’s a direct consequence of inadequate pain relief.
    There are some strategies we can implement – prescribe only small amounts of opioids at a time, do pill counts, and get random urine drug screens (remember that standard UDS dont’t test for oxycodone, so you have to add that separately). Can we combine her psych/substance abuse counseling appointments with her already-scheduled palliative care appointments? And of course, ask the patient about her perception of the obstacles preventing her from full compliance (if you went to the Motivational Interviewing session, this is a perfect time to practice those skills).
    Now, say the patient is in remission, but still on high dose opiates due to continuing pain. Keep her on these? Since our ultimate goal is to manage pain while also optimizing function, we should probably wean her off the opioids. She’s wary of methadone, but lets explore those fears and discuss it with her substance abuse counselor. The addiction psychiatrist probably has some other ideas as well.
    This is the sort of patient who can be very trying yet ultimately very rewarding to work with. Though keep in mind that It’s especially important to have an outlet to vent the jumble of emotions that these patients stir up, which is another crucial function of the interdisciplinary team.
Erin Zahradnik, MD, Yale University Dept of Psychiatry

Concurrent Session – Delirium

Trust psychiatrists to give an afternoon session that makes you completely forget about that nap you were craving! “Delirium: A Study of Difficult Cases” consisted of 3 vignettes about various forms of delirium, complete with very realistic role playing and chock full of wisdom from palliative care psychiatrists.

First there was a case of reversible hyperactive delirium. We were reminded that just about anything could be the culprit behind it, including common HPM meds like opioids and benzodiazepines, minor infections, metabolic derangements, and overstimulating environments.

How to treat the agitation in reversible delirium? First try to reduce stimulation and create a soothing environment. Can you eliminate any unnecessary meds? AVOID benzos! Use 1st generation antipsychotics such as haloperidol or chlorpromazine (more sedating than haloperidol), and dose the way you would dose pain medications.

What about irreversible delirium? This is the kind that occurs during the dying process, so a good clue that it’s not reversible is that there will be physical signs of dying. In this case, you can use antipsychotics, but you could also use benzos like lorazepam or midazolam. Remember that the goal is to reduce suffering by reducing the agitation of delirium — this is NOT palliative sedation, this is medical managment of a medical symptom.

Sometime benzos won’t be effective, and in those rare cases you could try propofol or phenobarbital. The key point is to treat agitation like a breakthrough symptom.

The final vignette illustrated a case of mixed delirium in pediatric palliative care (complete with role playing where the parent was as much the patient as the kid). Yes, delirium happens in kids too! This is a sneakier form of delirium (and can happen in adults too) that presents with waxing/waning symptoms. The gist is that you treat kids the same as adults (though with lower doses) — haloperidol and risperdal (both antipsychotics) are effective and safe in kids and infants.

I left with the understanding that delirium is a form of suffering, and as patients who come out of it later say, is a terrifying and disorienting experience. Treat it proactively and don’t hesitate to consult psychiatry for tough cases!

Erin Zahradnik, MD, PGY-3 Yale University Dept of Psychiatry