In this issue of Stories from the Field, two different case studies are presented that center on opioid dependency.
CASE STUDY 1
Marc was a 17-year-old White male adolescent who was admitted to our treatment facility for heroin abuse. Marc had been transferred from an acute care hospital. I had the pleasure of completing Marc's history and physical examination on admission.
Marc's case and story are very interesting. He had one of the most unusual presentations that I had encountered.
Marc stated that he began snorting heroin secondary to peer pressure. He resided in a low-income city, and drug abuse was rather rampant in his community and school. He was encouraged by his peers to try snorting heroin. He did it for the first time, and although he was not certain if he really liked the effect of the drug, it did not do him any harm, so at another outing, he decided to try to use it again when encouraged by his peers. This time, when he snorted heroin, a terrible thing happened. Marc's only memory is that he passed out and, when he awoke, he was in a critical care unit in his community's hospital on a ventilator. Upon snorting the heroin, Marc developed a spontaneous bilateral tension pneumothorax. Thank goodness, some of his peers were coherent. They immediately dialed 911, and Marc's life was saved by two paramedics. Besides the ventilator, Marc had two chest tubes in place to pleurovac drainage. The chest tubes remained in place for around 4 days. They were removed, and then Marc was transferred to our facility for substance use treatment and rehabilitation.
Marc was fortunate in that he was still alive and in that he had only used heroin for the second time.
I was relatively new at the treatment center. I spontaneously asked Marc if he believed in a God or a higher power. He said that he believed in God. My next question was "Do you then realize how close you came to your maker?" He answered in the affirmative. My second question followed, which was "Are you going to ever snort or use heroin again?" He responded that he would not. He had learned his lesson.
Marc did well in treatment and was able to be discharged 2 weeks later. To this date, I have not seen Marc back in treatment. This incident happened several years ago, and my belief is that Marc is a success story from a treatment standpoint. I did encourage Marc to share his story with others. I told him that God saved his life for a reason and now he had to share what happened to him so that, hopefully, the same set of circumstances can be prevented in others.
Marc's case echoes to me how adolescents have the idea that they are somehow invincible. They always take care of the immediate need and tend not to think of long-term consequences. It is now a well-known fact that the adolescent brain is not fully developed until around the age of 25 years or so. This makes total sense to me as it provides a rational explanation on why adolescents do what they do. It also makes one realize that the time that parents and support are needed most is during adolescence.
CASE STUDY 2
Rachel's drug use began in adolescence. According to Rachel, she did not have a strong family support system. Her father left her and her mother when she was very young. She has had no contact with her father since then. Her mother became the sole support of the family and had a difficult time trying to keep a "roof over their head." Rachel turned to heroin at a young age. She first began snorting the drug and then began intravenous injection. Rachel became homeless at this time. She turned to prostitution as an adolescent to earn some income primarily to purchase the heroin from her drug dealers. She could not afford housing so she resided under the boardwalk in Atlantic City, New Jersey. She continued to maintain this life style for the next 20 years using up to three bundles per day of heroin. She was encouraged by a nurse, who knew Rachel, to come into treatment. Rachel had a desire to maintain sobriety but never could. When detoxified to a certain level, she could no longer maintain sobriety and then she would leave treatment against medical advice (AMA). This was the case in our facility as well. Rachel was doing well for the first 3 days, but then she left AMA. Rachel returned to treatment three times. It was the third time that the nurse practitioner decided that the patient would leave AMA again around Day 3. Discussion with the treatment team and the medical director led to a different treatment plan. As the patient had been admitted on a weekend, the treatment goal was to stabilize the patient on a steady dose of methadone and then transfer the patient to a methadone clinic on the third day of treatment for long-term methadone maintenance. This last treatment was successful. Rachel was transferred to an outpatient methadone treatment program. She needed a high daily dose of methadone to stop her from using heroin, but Rachel's story is one of success. She became a functioning citizen of society. She worked two jobs. She got an apartment. Most important, she stopped abusing heroin. It was the feeling of the treatment team that Rachel's neuroreceptors were most likely so damaged from a 20-year period of abusing high doses and amounts of heroin that Rachel may never be opioid naive. At least by being maintained on a maintenance dose of methadone, she would be heroin free and she would have continued contact with health care providers who can continue to monitor her and gradually work with her to become totally drug free.
The brain is an amazing organ. We know much about plasticity today and how the brain can actually grow new neurons.
Over a course of 10 years, Rachel eventually weaned off of heroin and was placed on suboxone for continued maintenance. She then weaned off of the suboxone and was drug free for the first time in many years.
It had been noted on the admission history and physical that Rachel had a significant mitral valve heart murmur. Ten years after her initial treatment, Rachel had the mitral valve replaced. She was on short-term opiates for pain management after the surgical procedure. She remains healthy and drug free at this time.
These two cases clearly show how substance use disorders are quite different in patients. As a nurse practitioner, I learn from my patients every time that I practice. The uniqueness of each human being is what makes practice and learning so interesting.