Life Stage 1: Adolescence

Clinical and Social History

• Family history of substance use disorder
• Early life trauma
• Early substance use
• Elective pregnancy termination at 17

Kayla grew up in a lower middle-class neighborhood in a single-parent household. When she was 10 years old, her parents separated and she lived with her mother and older sister. Kayla’s mother separated from her father due to his abusive behavior and alcohol addiction. Kayla said her mother experienced anxiety and was prescribed various medications for anxiety which did not seem to be effective. Kayla’s mother had several boyfriends and no long-term relationship. Kayla described the household as disorganized and in chaos. The family moved several times. Kayla’s older sister was perhaps addicted to pain medication, and had spent some time in jail for shoplifting.

Kayla started smoking cigarettes at age 12, and within a year she was addicted to nicotine. She began using cannabis recreationally at 14, and by age 16 she was smoking about 10 cigarettes and using cannabis daily. Kayla reported alcohol use on weekends, with 5+ drinks per day. She had a group of friends who, like her, felt school was a waste of time. Kayla did not feel like she fit in at school. When she was 17 years old, she became pregnant and had an abortion. She said it was harder to attend school after these experiences. She dropped out of school and received her high school diploma by finishing a GED.

When Kayla was 19, she was in a car accident and the car was totaled. She presented to the emergency department and was medically cleared. She was prescribed a 10-day supply of opioids and other medications for muscle spasms. She followed up with her primary care doctor, and reported continued back pain. Her doctor ordered x-rays and an MRI as well as an evaluation by orthopedics. All of these work-ups were negative and physical therapy was recommended. Kayla did not seek physical therapy and her primary care doctor continued to prescribe hydrocodone as well as Soma for her back pain.

Missed Clinical Opportunities

• Given the patient's earlier life difficulties and family history with addiction, the primary care doctor should have administered a screening tool to assess for substance use.
• Because no abnormalities were found on her work-up, when she did not follow up with physical therapy, her primary care doctor should have followed up with Kayla about her pain and reconsidered next steps.

Kayla's Strengths

• She has completed her GED, which shows that she can focus and accomplish goals.
• She wants to get a job. This gives the provider an opportunity to talk about what she wants to do with her life, while helping her articulate a pathway to attaining these goals.

Life Stage 2: Early Adulthood

Clinical and Social History

• Addiction to oral opioids
• Poorly controlled anxiety
• Physical dependence and addiction to benzodiazepines
• Pregnant
• No social support

During the past year Kayla had no access to a primary care physician. She started feeling nauseated on a consistent basis and sought treatment at the local community medicine clinic. During routine testing, the clinic found a positive urine drug screen for oxycodone, hydrocodone, and cannabis. Kayla reported taking her sister's pain medication for her back pain. She reported being under a lot of stress and says the cannabis keeps her from going "off the edge." She states she has been trying to treat her pain the best that she can and has found few strategies that actually help her. During this visit, Kayla is diagnosed as 11 weeks pregnant. Kayla states the pregnancy was not expected but that she wants to continue the pregnancy. Kayla expressed concern about her ongoing back pain and is worried that it will worsen as the pregnancy progresses. Kayla also feels she will need opioids to continue dealing with the pain.

Missed Clinical Opportunities

• Kayla is now likely addicted to the prescription opioid medications she was first prescribed a year ago, and has continued to receive prescriptions from other clinics. An opportunity to improve care was missed when the physicians who treated Kayla did not check the Prescription Drug Monitoring Program to identify multiple prescribers.
• Along with referral to an OB/GYN, Kayla should have received information about treatment options for her addiction, and psychosocial support for her pregnancy. In the absence of sensitive, humanistic care, many women in Kayla’s situation may not seek prenatal care, especially if they encounter negative, judgmental interactions with the OB/GYN and/or the clinic staff. Other reasons for not seeking prenatal care include concerns that child protective services will remove the baby, especially in states with punitive policies toward pregnant women who test positive for substances; or inability to promptly start prenatal care in states where there are barriers to Medicaid eligibility in pregnancy.

Kayla's Strengths

While the pregnancy is unexpected, Kayla now feels more motivated to actively work toward a more healthy, positive lifestyle for herself and her baby. This newfound motivation is an opportunity for the health care provider and Kayla to work together toward shared goals. Her willingness to show up to her appointment means she has moved into the contemplative state. She may be ready to find help.