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A New Mental Model for Treating Substance Use

Grover, Casey MD

doi: 10.1097/
    substance use

    I worked a shift recently where two patients raised a question that I hadn't thought of before. The first was a 25-year-old man brought in after his friends found him unresponsive. He had tried a street Percocet for the first time, and it took 16 mg of nasal naloxone to revive him. His Percocet, we later found out, had been laced with street fentanyl. The second patient was a 60-year-old man experiencing homelessness with severe alcoholism; all of our ED providers had cared for him multiple times. He was brought in for being intoxicated in public.

    Both patients had problems with substance use, but they were so different that I realized I couldn't consider them as having the same condition. I tried to figure out how to think about substance use as a condition. Did they have the same condition but with different presentations or did they have fundamentally different conditions?

    So often we hear that a patient has substance use as a diagnosis, and we think of the chronic alcoholics we care for all the time. But what about this 25-year-old? This was his first ED visit, and clearly his presentation was different. I tried to compare substance use with other medical and mental health conditions, and I finally found a mental model for substance use that compares it with leukemia.

    Acute leukemia = short-term/recently started substance use: Both are high-risk, require aggressive treatment, and have a higher chance of success when treatment is begun as quickly as possible.

    Complication of leukemia = overdose: Hyperviscosity syndrome, tumor lysis syndrome, PE, and other conditions are all complications of the illness that increase morbidity and mortality risks for the patient and happen on top of the existing leukemia. An overdose is an acute complication of substance use disorder.

    Remission = successfully treated patient: Leukemia can recur, as can a relapse with substance use disorder. Both patients require monitoring and ongoing care.

    Comorbidities = comorbidities: Both conditions can be complicated and made worse by other physical illnesses (COPD, diabetes, etc.) and mental health conditions.

    Relapse = relapse: Leukemia can recur, as can substance use disorder. Again, like the acute phase, both are high-risk, require aggressive treatment, and have a higher chance of success when treatment begins as quickly as possible.

    Chronic leukemia = chronic substance use: These patients have these illnesses as a part of their daily lives. We should not give up on them, but they are much more difficult to treat given the chronic nature of their illnesses.

    Palliative/terminal leukemia = terminal substance use: These patients are actively dying from their diseases. We've all seen alcoholics drink themselves to death or patients die of congestive heart failure from stimulants. We can still provide them with respect, and help them receive end-of-life care.

    This mental model isn't perfect, but it has helped me look at patients in the broad category of substance use and focus on where they are on the spectrum of substance use disorders. It also stresses that substance use disorder can be life-threatening and need treatment. We all know how dangerous an acute presentation of leukemia can be, but we may not realize how dangerous substance use can be. A recent study found that the one-year mortality for patients after a nonfatal opioid overdose was 5.5 percent. (Ann Emerg Med. 2020;75[1]:13.) By comparison, a quick review of acute lymphoblastic leukemia in children and adolescents on UpToDate reveals that the five-year mortality is 10 percent. (

    Give this a try when taking care of patients with substance use disorder. Patients with chronic substance use and terminal substance use can be frustrating to take care of because of their frequent presentations to the ED, and they often introduce bias into our opinions of all patients with substance use. By separating out the different facets and types of substance use disorder, you can stay positive by remembering the patients with substance use who you have successfully treated. It always makes my day when I see a patient in the ED, and he thanks me because I helped him get sober or into a treatment program.

    Dr. Groveris an emergency physician and emergency department medical director at Community Hospital of the Monterey (CA) Peninsula. He is also a physician champion of the Monterey County Prescribe Safe Initiative, a collaboration among law enforcement, hospitals, and physicians in response to prescription medication abuse. More information is available at

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