"Diane" a 35 year old woman who presented to the ED for second time for a "flare of severe pain" and "refill medication of oxycodone and dilaudid" that she had been on for 20 years since the age of 15. Diane had been a victim of a violent crime and had surgery as a teenager. She had been placed on an opioid medication, which had been escalated and continued by her primary doctors and her "pain medicine specialists." She was living in her car, recently moved to Los Angeles County.
The first visit to our ED a week before our first lectures, she got the "usual care" - an abdominal CT, EKG, full set of labs. She was given a week of opioids, to bridge her to a new primary care clinic in our county. The second week, she returned and the triage team because she didn't find a primary care doctor. Our triage team recognized the case as a possible opioid use disorder, with complex pain. I was contacted by triage to start buprenorphine, which I did successfully.
I was able to send Diane out with social work resources for housing resources and psych services, and a follow up appointment to continue buprenorphine in our continuity clinic. Her first visit to our ED lasted 6 hours. Our second visit lasted 45 min. I saw this patient in our local buprenorphine bridge clinic, and continued her buprenorphine. I also explored her substance use history, learning of illicit benzos, amphetamines, and cocaine issues.
Diane has a long way to go, and she has made strong strides in returning to our bridge clinic. She is reluctant to continue with buprenorphine, asks for oxy at every visit. Because our system learned new treatment pathways, we stopped providing inappropriate and dangerous opioids and instead started buprenorphine to successfully treat her pain and likely overlying opioid use disorder.
Diane keeps coming back, each visit making slow but steady progress. Diane is changing her behaviors, and our ED is learning to change our behaviors as well.