Case Study: Plan of Action for Opiate Addiction in a 23-Year-Old Male
Opiate addiction (including opioids) is the compulsive use of an opiate despite detrimental consequences. Individuals suffering from an opiate addiction use the drug to the degree that it takes over their life. People who are addicted to opiates continue to use the drug even though they are aware it will cause problems. Tolerance leads to using more of the substance to achieve the same high while cravings and withdrawal symptoms occur if the person attempts to stop taking the drug.
Jason is a 23-year-old male, who has recently graduated from college and moved back in with his parents since he has not yet found a job. Jason comes from a Jewish family of Mediterranean descent. The community is very close, and he has a number of extended relatives living nearby who frequently visit.
Jason has been suffering from back pain for several years after sustaining a rugby injury. Over the past two years, the pain has worsened. About six months ago, he reported that it had become "unbearable." He has been seen by several doctors and expected to be given a prescription for pain medication. However, since surgery was indicated, he has been told to use over-the-counter medication until he is ready to have the operation.
Jason has been instructed to increase his exercise and stretching. He has been given a series of exercises that will help increase his mobility. He stated, however, that he does not feel motivated to do them. When encouraged to exercise by his relatives, he refuses stating that he is in too much pain to complete them. He has become depressed over his inability to play rugby and the loss of a romantic relationship. He reported that his girlfriend ended the relationship because he is no longer a school sports star.
Jason’s family and extended family have been sympathetic and nurturing about his pain. However, Jason is frustrated by this. His relatives routinely use medication for pain, illness and injury and in light of this, he feels that it is unfair that they will not help him obtain pain medication. Additionally, his parents have always taken him to the family doctor whenever he is ill or hurt and he has received some type of medication to treat the problem. He stated that he does not understand why the current situation is different, such that he is not provided with a prescription.
Jason's father uses sleeping pills regularly since he has anxiety that prevents him from sleeping. His mother uses anti-anxiety medication fairly regularly when she feels “overwhelmed by life.” One of his uncles could not understand why the doctors were making Jason suffer and has secretly given Jason morphine tablets he obtained after a previous surgery. Jason has noticed that his pain lessens and his mood improves with the morphine, but now that he has run out, he feels worse than ever. When no other treatment option was offered, Jason agreed to have the surgery.
Jason has undergone spinal fusion surgery. When he first regained consciousness, he reported feeling nauseous but immediately noticed the pain seemed to be gone. He was euphoric, convinced the pain was gone for good and that he would be able to play rugby again. He also stated that he hoped to win back his ex-girlfriend. The nurse explained the effects of the anesthesia and other medications used that were affecting his experience of pain. She told him that while it would wear off they would keep him as comfortable as possible with other medications.
After they’d moved him to his room, he visited with his parents and sister, and they were overjoyed to see him pain free and in a positive mood. The doctor explained to them and Jason, that recovery from this type of surgery was not always easy and even with pain medication there was likely to be discomfort. Thinking the worst was past, Jason was suddenly awakened in the early evening in extreme pain. He pushed the call button and told the nurse who had orders to administer intravenous Fentanyl if the pain was severe. The nurse started the medication and Jason felt significant relief within 10-15 minutes.
Over the course of Jason’s three days in the hospital, he learned that the Fentanyl had the same euphoric effects as those he’d felt when coming out of surgery. He admitted to telling the nurse that the pain was getting worse to get the dose increased. Over the last two days of his stay, however, the nurse explained that they would have to start decreasing the medication to get him ready for discharge. He noticed the decrease immediately after the nurse administered the first decreased dose although she said that wasn’t possible.
Jason complained of increasing pain before and after discharge despite being given a prescription for the Fentanyl patch to control his pain. Over the next several months, Jason continued to report increasing pain and his doctor increased his medication twice.
As the pain continued, Jason became fearful it would never remit. He spoke with his uncle who got him a regular supply of morphine to take. This was not unusual in his family as they believed that “psychological mumbo jumbo” takes far too long to help when you are not feeling good compared to medication. Jason’s mom stated, “If God didn’t want us to take medication, he wouldn’t have created it.”
Over time, in addition to a very strong Fentanyl patch, which is a long acting pain control method, Jason was given a prescription for oxycodone, which is short acting and has a more noticeable effect for limited periods of time. After several months, Jason noticed he needed more and more of the medication to feel the same as he initially did, and his uncle managed to obtain a prescription for extra patches and oxycodone. He also continued to provide him with morphine. His uncle cleared this with Jason’s parents, who weren’t completely comfortable with all the medication but agreed to the plan for the short term.
Signs and Symptoms of Addiciton
Over time, Jason’s parents began noticing differences in Jason’s behavior that worried them. He seemed to need more of the drugs he was taking to get the same effect. Jason seemed to be focused on the drug more than anything else. Most of his time began to be spent obtaining, taking, and recovering from the drugs. He began arranging his life around the addiction. What events he went to, when he got together with friends, how he interacted with family were based on how he felt and where he was in the drug effect cycle.
Jason’s parents have become increasingly concerned as they noticed he no longer displayed the motivation to look for work, that his relationships with friends and family didn’t seem important to him anymore, his financial state was suffering and one day he was pulled over for reckless driving. His family tried to talk to him about these problems. Although Jason acknowledged the difficulties, he didn’t alter his behavior. Jason’s parents felt like his personality had changed and they stated it seemed as if he were an entirely different person. When Jason began having blackouts, they knew they had to do something to help him.
For a serious addiction such as this, residential treatment is the most appropriate option. Many people addicted to prescription medication feel that if the medication is legal can't become addicted and that they shouldn't have any significant side effects when the stop taking a medication. However, most medications have some withdrawal symptoms and often cravings, which may be physical of psychological, that occur when an individual stops taking the drug.
With chronic pain, individuals fear as well as anticipate a worsening of the pain should they stop taking the medication. Often, with narcotics, in addition to pain relief, the individual will experience a more positive mood, become more motivated to carry out life tasks and be more involved in social interactions. This also leads to a fear of stopping the medication as individuals often anticipate a negative impact on their mood, motivation and social life.
While there are physiological withdrawal symptoms when an individual stops taking strong narcotics to which they are addicted, there are also psychological side effects that lead to dependency on the drug. The physical withdrawal symptoms may seem serious but it is the psychological withdrawal that is the most difficult. People addicted to these drugs, feel like they will never be able to function normally without them.
The treatment plan would include a stay at a residential treatment center that has a program for treating opiate addiction, dual diagnosis, co-morbidity and pain. The first step would be a detoxification program. The detox program should be medically monitored 24 hours a day to ensure their safety and comfort as the drugs begin to leave Jason's body. Sometimes it can be useful to utilize other medications to help with the anxiety, depression and other symptoms of withdrawal though care must be taken not to establish another addiction in place of the one for which they are being treated.
After detox has been completed, therapeutic work will begin. Components of therapy would include individual sessions which would allow Jason to have one on one time with a therapist to discuss topics he is not yet ready to bring up in a group environment. Group sessions would be scheduled based on Jason’s individual needs and what groups are available. Group work will be a combination of process oriented work and psycho-educational groups. Relapse prevention groups will be ongoing.
Once Jason feels able to incorporate family into his therapy, family session will be held. Family dynamics and modeling will be carefully processed. For example, the families reliance on medication to handle difficult life circumstances will be examined and new coping strategies taught. A family plan will be constructed for when Jason returns home.
Nightly Narc-anon groups will be available and Jason will be encouraged to attend as soon as he is ready. He will be aided in finding a sponsor who will continue to support him after discharge.
When discharge arrives, continuity of care will be discussed. It is likely that Jason will not feel ready to go straight into outpatient therapy. Partial Hospitalization Programs and Intensive Outpatient Programs will be discussed and the best option chosen with the input of Jason and his family.
This case study discusses an example of helping someone with a serious addiction. It is important to be aware of the signs of drug use and abuse, as once someone is addicted to a substance they are unlikely to seek help on their own which includes informing friends or family that they have a problem. One major reason for this is that often people with addictions have attempted to quit on their own by stopping “cold turkey.”
Along with the physical withdrawal symptoms, often the person has psychological withdrawal symptoms when they stop using a substance. This can included beliefs that they are unable to function normally, especially in social situations, without the drug. This may lead to avoidance of social settings and result in feelings of isolation and loneliness, which will likely make the attempt to resist the desire to take the drug more difficult.
Ultimately, while some are successful at quitting their habit, most individuals find the consequences of going cold turkey too aversive to maintain sobriety. Thus, it is crucial for those who care about the person to help them find a treatment option that will help them without judgments or criticism. Although it can be difficult when negative behaviors related to drug abuse are displayed to keep calm and not respond in kind, the goal for everyone is to aid the person in finding a way to sobriety.
Additionally, as this case study reveals, sometimes addiction can result in families that rely on medication as a coping method. Through modeling, parents can influence children in such a way that the child grows up to believe medication is the accepted method of handling pain, both physical and emotional. Families can also enable a member to take medication, even when they are using legally prescribed drugs.
It is important to understand that just because a medication is legally obtained, this does not mean that it is impossible for addiction to occur. There are increasingly high rates of prescription medication use and abuse in this country as well as many others. The same experiences and rules that have been determined to be formative in the development of addiction to illegal drugs are applicable to prescription medication as well.
Yet, given that the medication is legal and acceptable, the process of addiction is often far more longstanding and established prior to the understanding that addiction has occurred compared to illegal drugs. There is also frequently the belief that seeking help for addiction to prescription medication will make someone appear weak since their perception is that most people never get addicted to prescription medication. Insight oriented work is therefore often an important component of helping the person accept that they are addicted and in need of additional help.
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