CASE

Your patient is a 58 year old gentleman with cirrhosis from Hepatitis C and ongoing alcohol dependence. His condition is complicated by hepatic encephalopathy and ascites. He's been to the ER six times in the last three months and is currently staying at an emergency overnight shelter.

QUESTIONS & DISCUSSION

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  • Medication Compliance
    The patient is supposed to take a regimen of furosemide, spironolactone and lactulose. However, even though he understands the need for the meds, he admits he misses at least half his doses. What are some of the potential barriers, and how will you address them?
    Solution
    Assuming he's even able to afford his medications, there are still a number of problems. Both the diuretics he uses and the lactulose (which causes diarrhea) require easy bathroom access. Most shelters require people leave during the day, and most municipalities are short on public toilets. Therefore, remind your patient to take the medications whenever is most convenient in terms of bathroom access, rather than trying to stick to a rigid schedule. In addition, if you can get the prescription covered, rifaximin is much easier to handle than lactulose when living an unpredictable life on the street.

  • Communication
    Your patient agrees to take his meds more regularly, and you want him to come back for a chemistry panel in a week. How will you get the results back to him?
    Solution
    After assuring the patient has a way to return for the lab draw, you still need a way to communicate the results, especially if there is a potential need for urgent action. There are several possible approaches.
    • Ask the patient to wait around for the result.
    • Ask the patient to return in person the following day.
    • Ask that the patient call your clinic for results.
    • If he does have a phone, make sure he expects to have enough minutes to take your call.
    • If he doesn't have minutes, consider sending a text message. Best to keep messages generic and avoid personal identifiers or sensitive information. ("Results were fine" or "Please call as soon as possible")
    • If he doesn't have a phone, direct him to local resources such as community voicemails or the Lifeline Program.
    • Depending on your institution, email or secure messaging should be considered. Internet access is sometimes easier to find than a phone.
  • Addiction Treatment
    The role of primary care in the treatment of substance use disorder should be greater than simply referral to a specialist. In addition to motivational interviewing, we should be considering greater use of pharmacologic therapies. The most common of these are Antabuse (produces aversion but does not necessarily reduce cravings), acamprosate (primarily studied in the setting of maintaining abstinence), and naltrexone (which reduces cravings and can be used even if patients are still drinking).