Case Study Assignment
Using Beauchamp and Childress’s Principlism theory, analyze what happened in To
ee McGowan’s “Will You Forgive Me for Saving You?”.
Your case study should be no more than 2 pages, and should conform to the requirements on the Powerpoint included on Blackboard, “How to Write a Case Study”. There is also a grading ru
ic attached.
Will You Forgive Me for Saving You?
PERSPECTIVE
8
Methadone in Primary Care
n engl j med 379;1 nejm.org July 5, 2018
ed with methadone (from 36.1 per
1000 person-years among people
not receiving methadone to 11.3
per 1000 person-years with meth-
adone treatment); 3 of the 16 stud-
ies described care by general prac-
titioners and showed similar safety
profiles.1
The ability to obtain a pre-
scription for methadone in the
course of routine primary care is
especially valuable for people liv-
ing in nonu
an areas, in which
the infrastructure required for a
methadone clinic may be too ex-
pensive and disproportionate to
the level of need. Regardless of
cost, establishing a new metha-
done clinic can be challenging in
any setting, given the common
“not in my backyard” sentiment,
which pits perceived local con-
cerns against public health ben-
efits. Allowing physicians to pre-
scribe methadone in primary care
settings obviates both of these
challenges. What’s more, it could
educe the stigma associated with
opioid use disorder and place its
management more in line with
that of other medical conditions
that are treated seamlessly in pri-
mary care.
In the United States, metha-
done has been prescribed in pri-
mary care settings under rare
circumstances in which extensive
efforts were made to meet all
pertinent regulations. Our expe-
ience in Boston over a 10-year
period with a very limited num-
er of patients who were transi-
tioned into a primary care–based
methadone program after being
stable on treatment at a metha-
done clinic was excellent. Medi-
cation prescriptions and clinical
care were provided without ad-
verse incident. Indeed, one patient
in the program, in which she re-
ceived a prescription for metha-
done treatment as well as general
health care in a primary care set-
ting, told us that the experience
“is to me like winning the lottery
— better actually.”
The last act of Congress that
expanded access to effective med-
ications for opioid use disorder
in primary care, the Drug Addic-
tion Treatment Act of 2000, en-
abled buprenorphine to become
available to thousands of patients
in the United States. Expanding
access to methadone in primary
care will require more than legis-
lation. It will also be necessary to
enhance training for physicians
on opioid use disorder, consider
incentives for prescribing medi-
cations to treat it, and integrate
treatment into existing models of
care. But the solution to a complex
problem often begins with small,
pragmatic steps. We believe the
time has come to update laws that
egulate the prescription of metha-
done in primary care in order to
educe ba
iers to access and ex-
tend the benefits of a proven, effec-
tive medication to people through-
out the country.
Disclosure forms provided by the au-
thors are available at NEJM.org.
From the Boston University Schools of
Medicine and Public Health and Boston
Medical Center ( J.H.S.), the Grayken Center
for Addiction, Boston Medical Center (J.H.S.,
M. Botticelli), and the Massachusetts Depart-
ment of Public Health (M. Bharel) — all in
Boston.
1. Sordo L, Ba
io G, Bravo MJ, et al. Mor-
tality risk during and after opioid substitu-
tion treatment: systematic review and meta-
analysis of cohort studies. BMJ 2017; 357:
j1550.
2. Dole VP, Nyswander M. A medical treat-
ment for diacetylmorphine (heroin) addic-
tion: a clinical trial with methadone hydro-
chloride. JAMA 1965; 193: 646-50.
3. Fiellin DA, O’Connor PG, Chawarski M,
Pakes JP, Pantalon MV, Schottenfeld RS.
Methadone maintenance in primary care:
a randomized controlled trial. JAMA 2001;
286: XXXXXXXXXX.
4. Me
ill JO, Jackson TR, Schulman BA, et
al. Methadone medical maintenance in pri-
mary care: an implementation evaluation.
J Gen Intern Med 2005; 20: 344-9.
5. Saloner B, Karthikeyan S. Changes in
substance abuse treatment use among indi-
viduals with opioid use disorders in the
United States, XXXXXXXXXXJAMA 2015; 314:
1515-7.
DOI: XXXXXXXXXX/NEJMp1803982
Copyright © 2018 Massachusetts Medical Society.Methadone in Primary Care
Will You Forgive Me for Saving You?
Will You Forgive Me for Saving You?
To
ee McGowan, M.D.
I remember the day I first met you. It was a quiet Sunday, ear-
ly in the morning. I heard a com-
motion out by the check-in desk,
and your mom’s scream: “My ba-
y’s not
eathing!” The first time
I saw you was in your mom’s arms.
Heart
eakingly, you weren’t
snuggled like a baby should be,
or even limp. Your tiny body was
twitching, seizing. The cold clin-
ical term “decorticate posturing”
that flashed in the physician part
of my
ain seemed too rigid to
e applied to your chu
y toddler
arms.
We rushed you to our trauma
oom, and the entire hospital
came to help you. In moments, I
had every hand available, every
heart pulling for your tiny body.
All those hands let me do the
hardest thing: step back and start
making decisions that would alter
your life forever.
Your tiny heart was so slow.
Children’s hearts should be fast,
like running feet and quick smiles.
Yours beat at the slow stuttering
pace of a heart about to su
ender.
The New England Journal of Medicine
Downloaded from nejm.org at KENT STATE UNIV. LIBRARIES on August 28, 2018. For personal use only. No other uses without permission.
Copyright © 2018 Massachusetts Medical Society. All rights reserved.
PERSPECTIVE
9
Will You Forgive Me for Saving You?
n engl j med 379;1 nejm.org July 5, 2018
I knew your heart was strong, but
your
ain was so hurt that your
ody was fading.
The next minutes were a blur of
activity. I barked sharp, pointed
orders, like the needles we used to
drill into your bones. Monitors
started to beep, not a single num-
er reassuring. I was looking at
you, every inch of you, measuring,
assessing, cataloguing all the plac-
es that needed our gentle fingers.
My eyes kept wandering to your
forehead. It was on your right side,
just above your eye
ow. A big, vio-
lent, purple lump — my gaze kept
stumbling over it. Such an ugly
wound on the surface, and still it
was no match for the devastation
hidden underneath.
My team worked so hard for
you. I had so many smart people
helping me with medications, IVs,
monitors. Hands so big there
wasn’t enough of your minute body
for them all to touch still reached
for you, stroked gently, as we talk-
ed softly so as not to scare you.
I clearly remember the moment
I put you on the ventilator. I’ve
done this procedure hundreds of
times, but I noticed that my view
was shaky. No, it was my hand. I
had to stop, stare at those trem-
ling fingers until they steadied.
Two deep
eaths for me, and
your
eathing tube was in.
After the ventilator began its
metronome to mark the time,
things quieted down. Your body
started to respond to the seizure
medicines, and your curling arms
elaxed. Your heartbeat, once so
frighteningly lethargic, had re-
sponded to medication and ticked
along. The pupils in your beauti-
ful blue eyes shrank back, evenly
sized once again.
The beat of the helicopter an-
nounced the a
ival of your next
phalanx of guardians. I had called
for them in the first minutes you
were here, shouting information
across the trauma room as my
hands prodded your body, plead-
ing for help to come. This small-
town hospital was not equipped
for your tiny life and its huge in-
jury, and I am forever grateful to
those who answered my call and
stood ready to help you.
The frenetic pace of doing
slowed as you rolled out the door,
mummified in pumps and vents
and tubing. As you left my care, I
looked over to the people who
loved you, who came to be with
you during your fight. There was
one man, the one who told me
the first lies of your day, who
would not meet my eyes. You fell
and hit the corner of a wall, he
said. He knew I knew better.
I wondered about you and
wo
ied about you. On the backs
of my eyelids, I can see your fore-
head, the dividing line between
that part of your life and this. I
see your left hand, spasmed to
your chest, then finally falling
lax. I hoped for your miracle.
In the way of small towns, I
heard bits of your story. I heard
umors of your surgery, saw pic-
tures of you in day care as a
smiling, happy child before that
Sunday. I felt a sad pride the day
I heard you went home. I read
the newspaper account of the evil
of the man who did this to you,
all because you wouldn’t hold
still for a diaper change.
Then one morning, I was back
in the same ED, sitting in the same
chair as when I first heard your
mom scream. The radio crackled,
fading in and out: “recent TBI,
trach/peg . . . difficulty
eath-
ing.” My skin felt too tight; I
knew it was you.
The lump on your head was
gone, replaced by a curlicue of
scars. Your skin had taken on the
slightly waxy appearance that
seems so common in
ain-injured
patients. I’m not sure if that’s
something that happens because