This is the seventh article in a series of eight articles by Ilene Robeck, M.D. regarding difficult conversations a primary care provider may have when dealing with patients with chronic pain. This series is meant to be a guide for primary care providers facing these situations.
Difficult situation #7: A patient appears to be intoxicated or somnolent when they come in for a visit.
Advice: Keep in mind that problematic behavior that is seen in the office frequently follows a period of time in which the behavior has been apparent at home. The medical office may be an unlikely place where the patient exhibits deteriorating function. Many patients can function during a 15-minute office visit, only to deteriorate upon returning home or to work.
Family members may be a good source of information about how the patient is doing, if you have permission to speak with them. If the patient refuses to let you speak to a family member, either on the phone or at the next visit, that may help guide your future decisions. While it is a violation of confidentiality to confirm that you are seeing a particular patient, a family member may decide to pass on information to you.
Patients who are intoxicated while on opiate therapy are at very high risk for opiate related adverse events. All of the studies from the past few years have shown that this is the patient population at highest risk of death from overdose, either accidental or intentional.
The conversation about the need to stop opiate therapy now is easier for the clinician if there was an opiate agreement or a documented discussion with the patient ahead of time. Even if this was not done, the patient needs to be told that opiates will be stopped when alcohol, medication that has not been prescribed to them, or illicit substances are used, due to the increased health risk.
These patients will need immediate referral to an addiction specialist for evaluation. They should be offered help with detox during the time their opiates are being discontinued, as well as an ongoing offer for treatment for their pain condition. Discontinuing opioid therapy does not mean discontinuing care of the patient. A substance use disorder is a treatable disease. Successful treatment can lead to a very positive outcome when weighed against the risk of ongoing opiate prescriptions without treatment.
While it is beyond the scope of this article to review the effects of marijuana when mixed with opiates, it is important to remember that even when marijuana is used as medical marijuana, there are significant interactions between opiates and marijuana that need to be understood by any provider prescribing opiates. I will not use opiates in a patient using marijuana at all.
A patient can be somnolent for a variety of reasons so this requires more of an assessment. Somnolence may be related to intoxication, drug interactions, overdose, overmedication, and/or an underlying medical problem, such as uncontrolled diabetes or infection.
It is important to remember that many patients take over-the-counter medications that you may not know about, and may have been prescribed a medication from another provider that you are unaware of. They may have taken their medications in an un-prescribed way. The truly somnolent patient may need hospital admission or an Emergency Department evaluation to safely determine the best next step.