I was talking to a patient recently about her different experiences using heroin vs fentanyl. She’s been using opioids a long time. Too long, by her count.
She explained the difference to me like this (shared with permission):
1/x
Me, to myself at urgent care: play it cool so he won’t know you’re in healthcare and will just treat you normal
Him: so where does it hurt?
Me: about a centimeter distal to the lateral aspect of the ulnar styloid process, worse with supination/pronation 🤦♀️
You know what WOULD stop her selling fentanyl? Easier access to
#MOUD
like methadone, buprenorphine, sustained-release oral morphine, and prescribed injectable heroin to stabilize her dependence. No need for fentanyl ➡️ no need to hustle ➡️ less fentanyl bought and sold.
9/x
Jayde briefly escaped into the neighborhood through an ajar side gate today and for 30 minutes I lost my will to live. In that time, she made friends with the woman who found her, conned her out of all of her cheese, and now the woman wants to dog sit this weekend 😂
As a doctor, I counsel patients on nausea as a possible med side effect all the time. Usually mild and self-limited, yadda yadda.
Turns out all nausea is mild until it’s your nausea.
Yes I’m whining about my med effect nausea, and also Zofran should be OTC.
That is all.
@dieworkwear
Man, these threads are great Twitter palate cleansers. Such a small detail but makes such a big difference, visually, even if you don’t know exactly what you’re looking for. Anyone can see it. Cool.
For the people asking “but can’t she be on methadone or buprenorphine?!” - yes. We discussed both options in great detail, as that is literally my job. She’s engaged in care and getting the best possible treatment under the circumstances. I won’t be sharing anything more.
I’ve put needles inside of living people’s necks, abdominal cavities, and spinal canals without supervision but my mom will still be like “let me show you how to cut the tomatoes.”
She would love to stop selling, but will never be able to as long as she herself is reliant on an unforgiving, unpredictable street drug supply. Given a safe supply, she WILL use it and be under considerably less pressure to sell herself.
10/x
Increasingly harsh punishments for possessing and selling fentanyl, like those under consideration in the CO legislature, won’t solve the problem when most people who distribute are doing so at low levels to support their own dependence.
8/x
She’s housed now, but “with fentanyl, it’s like I’m homeless in my mind. I can’t let my guard down to rest, not even for one second. I have to stay in the hustle every moment to stay safe, to stay well.”
6/x
@LAPDMarcReina
Hi. Board certified addiction medicine physician here. You cannot overdose on fentanyl through casual exposure to the drug in any form. You’re spreading medical misinformation. Delete this.
@WTFentanylBot
With heroin, she had a 6-12 hour period after using when she could reliably expect to feel well. She could work, or visit with family. She could get a full night’s sleep and know she had enough left over to get well in the morning. She managed this way for years.
2/x
With the transition of our street drug supply from heroin to fentanyl, all that relative stability and predictability was lost. Because fentanyl is so short acting, she has to use every 3-4 hours to stay well. She wakes up in the middle of the night sick, forced to use.
3/x
With heroin there was some reprieve, but with fentanyl the hustle to stay well is relentless. She likened the stress of her fentanyl habit to being homeless - constantly worried about how she’s going to get this basic daily need met, and what will happen if she can’t.
5/x
Just so we’re all on the same page on this: I will not be performing CPR during a pandemic without proper PPE. Not today, not ever.
If
@American_Heart
thinks I should be fired for disregarding their recommendations, they’re welcome to come do my job in my place.
Because illicit fentanyl is so unpredictable, she never has enough to make sure she can stay well until tomorrow. What if this batch is bunk? What if the next one is? With such variable potency she is constantly worried about running out and becoming sick.
4/x
Also shared with permission: she sells fentanyl to make enough money to support her own dependence. She doesn’t like doing it, but day labor has become nearly impossible with all the time and energy it takes to manage her habit.
7/x
Tattoo artist: So, what do you do?
Me: I’m a doctor
Her: No shit, I didn’t know they let doctors have tattoos these days
Me: Lol who’s ‘they’?
Her: I don’t know, probably old straight white guys?
Me: *Nods* 🤷♀️.....😏
#medtwitter
, let’s see yours!
Hello, I’m a board certified internist who has had to review the diagnostic algorithm for hyponatremia twice in the last 48h. So no - it does not get better. 🤦♀️
@colleenmfarrell
You’re not alone. When residents in Boston brought up the idea of hazard pay for extra hours and extra risk we were quieted by accusations that we sounded greedy, unprofessional, and like putting profits before pts (our profits, that is; the institutions’ I’m sure will survive).
Wow, I’m blown away by the overwhelmingly positive response. For every 1 stigmatizing or uninformed comment, there have been 100+ wanting solutions rooted in evidence-based
#harmreduction
, NOT punishment & incarceration. We are not in the minority, and we ARE voting constituents.
FYI I never stopped seeing patients with a mask on and I might never stop.
1. I had Covid once and I’d like to avoid getting it twice, if possible.
2. I’ve had 80% fewer colds since I stopped sitting, maskless, in small exam rooms with sick patients. It rules.
@drcopps
I looked at the photo and was thinking “what does she mean, she looks great!” And then I realized a pillow that’s cold on both sides is a good thing to wish someone and not a curse 😂
The only thing comforting me today is watching my entire TL absolutely drag these CDC recommendations and that’s a sentence I never thought I’d say as a doctor looking for guidance amidst a global pandemic but here we are.
Sitting at a bar alone on Christmas Eve, 286 miles away from home, listening to one bro earnestly tell his other bro that therapy really helped him this year. My heart needed that.
Dear emergency medicine colleagues,
When this mess is over, I vow to never again ask you what the urine lytes looked like. I will never expect you to give one single flying fuck about the urine lytes.
Thank you for doing what you do. Please stay safe.
Dear Emergency Medicine colleagues,
When this mess is over, I vow I will come do any pelvic exam you ask me to and see any patient with a positive pregnancy test. You are rockstars and I am so grateful for all your are doing through this crisis.
CDC says it wants to give people a “break” from masking. But kids under 5 who can’t be vaccinated and people who are immunocompromised don’t get a break from being at risk for serious Covid complications.
My mask stays on to protect others.
Finally, before I mute replies, hello to all my unexpected new followers! I tweet about
#harmreduction
, addiction medicine, and heavy metal. I love people who use drugs and pitbulls. That’s all you really need to know about me. 😘
I will be sure to share your messages of support, compassion, and hope with my patient. Imagine if *everyone* who struggles with chaotic substance use could feel this outpouring of unconditional love.
@DreAllDay
@maybegabrielle
Are you implying that carrying and birthing a baby has no effect on a woman’s health?
Eclampsia, gestational diabetes, HELLP, cardiomyopathy, stroke, hemorrhage, incontinence, post-partum depression, etc, would all like a word.
4 years ago tomorrow would have been my 1st
#residency
interview, at
@mghmedres
. I know this because 4 years ago today my dad died unexpectedly in Denver while I was in Boston. I cancelled the interview from the tarmac at 6am the day of, and flew home.
It’s a whole 🧵
@mominmedicine
I love this. None of this is innate, no one is born with the knowledge of how to care for sick patients in a complex health system. If I were a sick patient, I would rather have a doctor who is willing to try hard than one who thinks they’ve automatically nailed it.
If anyone was wondering what it’s like to be a childless adult in your 30s finally with some disposable income: it’s like eating overpriced GrubHub sushi, drinking craft beer, and watching Harry Potter and the Sorcerer’s stone on HBOMax. 🤷♀️
A patient just wished me a “happy 420” to which I replied “no it’s only 1:45,” so I guess these tattoos I got to make me look cool are gonna have to work harder.
Well, my landlord’s chicken is clearly sick. They’re out of town and the neighbors upstairs who were tasked with taking care of the chicken are nowhere to be found to tell me wtf is going on. So I guess I’m just cross covering this chicken with no sign-out. TYPICAL 🙄
If you’re seeing this post, consider this your friendly reminder that clean needles and overdose prevention centers save lives. Support your local harm reduction program!
Alright since it’s officially the Monday after Match Day I feel justified in making a little announcement of my own:
In August, I’m moving home to join Colorado Coalition for the Homeless
@COCoalition
as a Primary Care and Addiction Medicine doctor 🤗 - the dream!
Just finished my first hospitalist moonlighting shift in which I got paid 10x what I did as a resident to do 1/3 of the (significantly easier) work. Makes complete sense to me I don’t know why you look so confused.
#medtwitter
You wouldn’t believe how far it goes to tell a patient: “I’m glad you’re here.” Especially in addiction treatment and 100x especially when someone is struggling. That’s when we should be GLADDEST a patient is there and still coming back, and for God’s sake, let’s tell them that.
After 8 hours of street medicine in the Denver snow, what a luxury it is to come home to a hot shower.
My patients deserve this, too.
Everyone deserves this.
My friend died of an overdose in 2015. She was 26. One day very much alive and working hard to get her life back on track. The next day dead alone in a bathroom.
Today on medical street outreach we went to a camp that has been “posted” for sweeping tomorrow. Everyone was frantically trying to pack up their few worldly belongings and scout a new spot to survive a few days until the next inevitable sweep.
✅ First day of medical street outreach
We’re managing cirrhosis, chronic wounds, blood clots, substance use disorders, and psychiatric illness on the street - not because we think that’s the best place for people to get care, but because that’s where people who need care are.
A homeless patient needed to go to the ER but had no one to take care of her…laundry basket of 5 tiny puppies and mama!!! Cue our outreach team looking after them all day and our nurse fostering them until they’re old enough to be adopted…probably by the outreach team 💖
Only in my first month as an attending would I be UpToDateing differential diagnosis of the common cold to make sure I don’t somehow unwittingly miss cancer.
#medtwitter
consultants, what’s your most utilized dot phrase?
Mine is:
“From an addiction perspective, NO CONTRAINDICATION for full opioid agonists as needed to manage acute pain, and patient may in fact require higher doses than expected due to baseline opioid tolerance.”
Sir, I am here to give a lecture on injecting, smoking, and booty bumping drugs to a bunch of interns at home in their pajamas using a smart board over Zoom, so I’d wager I’m capable of doing a lot of things that you could never.
Shout out to the white-haired Profesor Emeritus of whatever who clocked my badge as I was walking in to the hospital and felt the irresistible need to comment “in my day, a doctor could never wear jeans to the hospital.”
@jtrebach
That’s pretty funny. We had liver rounds but it was just all the residents drinking (not water) after work at the bar across the street from the hospital every Friday.
Please send your best suggestions for TV series, movies, and podcasts to fill up a 10-day Covid-19 isolation period. I will also accept pet pics and silly animal TikToks. Asking for me ☹️
@KaniveEdward
@jbullockruns
@813JAFERD
Off the top of my head:
Bipolar disorder. Sleep dysregulation is known to be a risk factor for mania.
Pregnancy. There’s robust evidence that pregnant residents working nights have worse birth outcomes.
Working nights is definitely not benign and may be unsafe for some.
After my friend’s dad died ~a decade ago I bought $80 worth of ceramic plates from Goodwill and then we got drunk and smashed them in an alley. (We cleaned up after.)
Healthcare workers: we’ve talked about our fatigue and sadness.
How are we dealing with our anger?
I swore I’d never use a kindle or other e-reader. “Paper books only for me!” I declared with conviction to absolutely no one who asked. Now I read on my kindle every day and it’s great.
Post something you were super wrong about so we can all learn from each other’s foolishness:
How I know all you new interns are gonna be ok: a brief story
My first rotation of residency was in the ED. Day 2, I was managing a patient w/ septic shock, persistently hypotensive after the 30cc/kg bolus, on abx but not looking good.
1/x
What if there was just a clinic space where PWID could get methadone/bupe, sterile syringes/pipes, drug testing, wound care, psychiatry, primary care & HIV/HCV treatment, peer support/community activism, and lots of hot coffee. Does it exist? What else would you want to include?
People who don’t really understand what I do as an addiction medicine doctor wanna be like “I don’t know how you do it!” and “God bless you!” 🤦♀️ I get that you’re trying to be complimentary but, please...don’t be.
Rant —> Rave 🧵
Dear Twitter,
When an actual professional expert in a field corrects your verifiably false statement or use of unacceptably outdated language, it’s ok to say to yourself “hmm, maybe I was wrong. I’ll think on it.”
You don’t HAVE to double down on being wronger, louder.
@NussbaumMD
What about instead of assuming that every order you write as a PGY-1 is perfectly correct, you assumed that any question from an experienced pharmacist probably deserves a second look and thoughtful answer?
In addition to its well-documented public health and safety benefits, the main reason I support full drug legalization is:
👏👏👏there is nothing fundamentally or morally wrong with using drugs*👏👏👏
*written after taking my daily Wellbutrin, while drinking coffee
Shout-out to the nursing student who, when I asked about her background prior to nursing school answered “well, I’m 21, so I guess my background is…high school.”
😂😂😂
My friend died of a heroin overdose at the age of 26 because she relapsed and, in her shame as isolation, used alone.
It didn’t have to happen that way.
#IOAD2023
@DrBryanLeyva
We all know the exact visceral reaction you’re talking about, but most of us haven’t identified or honestly addressed it like you did - that takes a lot of self love and courage. Proud of you for speaking up, and I hope you get the rest you ~DESERVE~
Hey
@NPR
, hard to “lift the stigma from addiction,” as you aim to do with this morning’s story, while claiming things like there are certain “behaviors associated with addiction, like lying or stealing.” 🙄
13/ When you’ve lived with imposter syndrome, it’s easy to fall into the scarcity mindset that you have to gratefully accept any old thing that comes along.
YOU DON’T.
The right program will want you and show it. And when they show it - try, for God’s sake, to believe them.
I didn’t want my friend to inject heroin. But I really, really didn’t want her to overdose & die alone at 25. I wish she were alive & using today. Or alive & getting help. Or alive & sober. Alive & anything is better than dead, no matter what people who hate drug users say.
If you’ve lost someone you love to preventable drug harms I want you to know I’m sorry & they’d be proud of you working to help others who use drugs instead of punching down on drug use & drug deaths as “a choice” or “crime” since nobody chooses to die & we could prevent deaths.
High quality, peer reviewed research published in a prestigious academic journal, using *Denver-specific data* suggests that constant encampment sweeps lead to more overdose and infectious disease-related deaths among people experiencing homelessness.
The policy is indefensible.
Our study found that encampment clearance/sweeps could increase deaths among people experiencing homelessness by 25% by 2028. "Sweeping" people is not a solution to
#homelessness
, but is rather a form of (costly) state-sponsored violence.
30% of my fellowship is just writing the phrase: “from an addictions standpoint, there is NO contraindication to using full opioid agonists as clinically appropriate for treatment of acute pain” in all my consult notes.
@KaniveEdward
@jbullockruns
@813JAFERD
2/
Epilepsy. Sleep deprivation/dysregulation can increase risk of seizures.
Depression. Sleep dysregulation can be a trigger for a major depressive episode.
ADD/ADHD. Sleep deprivation/dysregulation can exacerbate symptoms.
I’m sure I could go on
@KaniveEdward
@DeirdreAndres
I love this and honestly wouldn’t be as upset about today had she not crossed a MAJOR heavily trafficked road to end up where I found her. If she would agree to keep her cheese scam artistry within a 2 neighborhood block radius I’d find it much more charming 😂
@samjcohn
A friend’s parents are house hunting in my neighborhood (Park Hill) and preparing to go $300k above asking. I’m going to be renting forever 🤷♀️
As a primary care and addiction specialist:
Cocaine is very not good for the heart.
Do what you’re gonna do as safely as you can - I’ll support you - but know cocaine has real risks so that you can mitigate them.
Risk denial is antithetical to harm reduction.
@Surgeon_General
Is this your official position on
#COVID
ー19? Because I’m here to tell you that in hospitals and clinics and community triage centers what we need more than “just love” is TESTING and SUPPLIES.
#medtwitter
Can anyone tell me what hydrogen peroxide is actually FOR? Like, why does it exist? Should it even exist? If it disappeared from the face of the earth tomorrow we’d have a lot fewer non-healing wounds and the downside would be…?
Finally a board certified addiction medicine specialist! Many thanks to
@MGH_SUDs
and everyone listed below for teaching me not only the content of this work but also -and much more importantly- the history, philosophy, and practice.
Denver’s policy of constantly and relentlessly sweeping homeless encampments isn’t ending homelessness. This policy is only making it increasingly impossible for outreach workers to do our damn jobs, while costing the taxpayers millions/year.
While overdose deaths rose, emergency calls fell in 2023 following passage of the Fentanyl Accountability Act which increased criminal charges for possession of small amounts of fentanyl.
I do believe we warned about this.