Kayla

Meet Kayla

Kayla’s prescription drug dependency and marijuana use are complicated by pregnancy, criminal behavior, chronic anxiety, and depression.

Is there a way to help a patient who seems so unable to help herself?

Life Stage 1: Childhood/Adolescence

Kayla grew up in a lower middle-class neighborhood in a single-parent household. She lived with her mother and sister from the age of 10. The mother is separated from the father because he had significant issues with alcohol and was abusive. Kayla says her mother took various medications for anxiety but they didn't seem to help, and that she had a sister who had some issues with pain medication. Kayla recalls her other sister had spent some time in jail for shoplifting. She said the family moved often and lived in apartments.

Kayla’s mother had various boyfriends and no true steady relationships. The household always seemed disorganized and in chaos. Kayla started smoking at around age 12 by bumming cigarettes off her friends. By 13 she was smoking daily. By 14 she was using marijuana recreationally. By age 16 she was smoking a half-pack of cigarettes a day as well as weed almost daily.

Kayla stated she would drink alcohol on the weekend and would generally drink to get drunk. She claimed her friends were a lot like her and felt school was a waste of time. She says she doesn't feel like she fits in with the other kids at school. By the time Kayla was 17 years old she became pregnant. After being persuaded to do so by everyone around her, she had an abortion. She said that after this it was harder to go to school and therefore she dropped out of school and finished only her GED.

At age 19 Kayla had a car accident late on a Friday night and totaled her car. She was seen in the emergency department and medically cleared, however she was given a 10-day supply of opioids and some medications for muscle spasms. She followed up with her primary care doctor, complaining of continued back pain. Kayla then had x-rays and an MRI as well as an evaluation by orthopedics. All of her workups were negative and physical therapy was recommended. Kayla never did follow up with physical therapy but was continually prescribed hydrocodone as well as Soma by her primary physician for her back pain.

Questions

Given the patient's earlier life difficulties and utilization of other substances a urine drug screen or an in-depth screening tool would've been able to find that she was a very poor candidate for the prescribing of opioids. The fact that she was not following up with physical therapy and had no abnormalities found on her work-up would be an indication that the medications were being utilized for something other than pain.

Life Stage 2: Early Adulthood

During the last year Kayla has not had a consistent primary care physician. She started feeling nauseous on a consistent basis and followed up at the local community medicine clinic. Upon testing her, the clinic determined a positive urine drug screen for oxycodone, hydrocodone, alprazolam and marijuana. Kayla then admitted she had been taking her sister's pain medication for back pain. Kayla states that with all of the stress she has been going through, she needs the alprazolam to keep her from going "off the edge." She states she has just been trying to treat her pain the best that she can and that nobody has been willing to help her. The alprazolam was prescribed by an urgent care doctor, but she's about to run out of that medication. She states she is "desperate" for a new prescription. During this visit it is found that Kayla is also pregnant. Kayla states the pregnancy was definitely not expected but she wants to keep the child./n /n Upon examination by an OB/GYN, Kayla is found to be 11 weeks pregnant. Patient is still complaining of back pain and is worried that as the pregnancy goes on, her back pain will worsen. Patient is also complaining of significant anxiety despite taking daily alprazolam. Patient also states that she will need the opioids to have any chance of dealing with the pain.

Questions

At this point Kayla has all the signs and symptoms of a life that is generally out of control. Many times these patients will arrive to a primary care physician having not had a urine drug screen and will definitely not confess to the medications they are taking. This is also a time in which many physicians will not check the prescription drug monitoring program to identify that there were many prescribers of medications. /n /n Despite the fact that this patient was referred to an OB/GYN, many patients will not follow-up because they are worried that child protective services will take their child from them. This, coupled with the generally negative interaction they may have with the staff of an uninformed OB/GYN clinic, can deter these patients from obtaining prenatal care. It should also be noted that benzodiazepines and marijuana as well as tobacco all have significant risk to the unborn child, much more than the opioid.

Life Stage 3: Late Adulthood

By the time Kayla is 35 years old she has lost custody of the two children she had throughout her 20s. She's been out of work now for 18 months, with no stable housing and has filed disability claims for her chronic lower-back pain. Kayla has also had two felony arrests for writing hot checks and shoplifting. She is currently on probation. She is using the emergency department approximately 20 to 30 times per year. She has also been fired from the two pain clinics in her city and complains of pain out of proportion to any exam. She absolutely feels depressed most days and does not like to be outside around large groups, where she will frequently have panic attacks. Most recently Kayla applied for and was given a medical marijuana card.

Questions

By this time Kayla's substance use disorder is settled in and will be much more difficult to handle. Given that she has lost custody of her two children, it will also be more difficult for her to find motivation for getting well. That said, given that the patient is involved in the court system through probation, we will have more leverage from a therapeutic sense. Kayla's worsening pain is most likely secondary to opioid induced hyperalgesia. In order to improve this, the patient must be removed from opioids, which can be difficult if the patient needs to be treated for an opioid-use disorder. The patient's depression and anxiety will definitely need to be medicated and working in conjunction with psychiatry would be recommended. The fact that the patient has gotten a medical marijuana card makes it much more difficult to get the patient to stop using marijuana.