As the day's on-call physician for the UHN's new pilot service – the Substance Use Intervention Team (SUIT) – Dr. Jon Mong travels around Toronto Western Hospital providing consult support to hospitalized patients with substance use disorder (SUD).
His morning begins in the Emergency Department (ED) with a man in his 40s brought in by Emergency Medical Services for displaying erratic behaviour and disordered thought.
Dr. Mong frowns as he reviews the patient's chart. Decades before, the patient suffered a fracture and was prescribed Percocet. A long-running battle with opioids followed.
"We see addictions start like this a lot," says Dr. Mong. "We can help by approaching patients in a non-judgmental way and treating SUDs as medical conditions."
In a darkened room, he asks the patient questions. About the drugs found in his system. About the last time he used fentanyl. If he has access to a clean supply and if he wants to take home a naloxone kit (an emergency-use medication to reverse a known or suspected opioid overdose).
The patient is hesitant at first, but becomes responsive, openly discussing his substance use, withdrawal symptoms and thoughts on proposed medications. He offers his hands to Dr. Mong to be tested for shakiness and reluctantly submits to a pupil examination by phone light before retreating underneath his bedsheet.
Dr. Mong will record his observations in the patient's file and complete a Clinical Opiate Withdrawal Scale (COWS) score – a measurement tool recently adopted in areas of UHN to assess the severity of opiate withdrawal. He'll return in the afternoon to check on the patient before recommending Kadian, an evidence-based morphine treatment to counteract withdrawal symptoms and stop opioid cravings.
Reframing the interaction with patients with SUD
Substance use-related visits to UHN are increasing across almost every major clinical program area. UHN annually sees between 4,000 to 5,000 unique patients who require support, often in key service points like the ED.
These patients have high rates of chronic illness, hospitalization and readmission, and often co-existing medical disorders that complicate their care.
They often face stigma and discrimination, including from health care workers, which can drive patients to avoid care. It is not uncommon for them to leave the hospital before finishing their medical treatment.
SUIT is focused on patients who use opioids and alcohol. The multi-disciplinary team – physicians from emergency, family and internal medicine as well as psychiatry are on the roster – provide assessment and counselling, recommend medications (for managing withdrawal, cravings or as replacement therapy) and refer patients to other services upon discharge.
"The consult service is about providing patient-centered care to people who use substances," says Dr. Hasan Sheikh, Medical Lead, UHN's Substance Use Services. "It's about working together with patients and their care team, so that patients never have to choose between staying in hospital to have their acute medical concern addressed and leaving hospital to self-treat their incredibly uncomfortable withdrawal."
Dr. Mong, a physician in General Internal Medicine (GIM) and clinician in Quality and Innovation, was introduced to addictions medicine during his residency at the University of Toronto. More training came during a fellowship that included rotations on addictions consult teams at St. Michael's Hospital and Women's College Hospital.
Dr. Mong has applied this training to UHN's Rapid Access Addictions Medicine (RAAM) clinic since 2021.
"It's been an invaluable set of skills to have and to teach to learners and other physicians who may not have had the opportunity to learn about addictions," he says. “More and more, I see trainees and colleagues having and trusting addictions expertise simply because of the scale of the problem nowadays."
Dr. Mong cites the lack of training among health care providers as the biggest obstacle to understanding SUDs, which had traditionally been attributed to a patient's "moral failing."
"I try and include some education in my patient notes so that other teams can understand the things that I'm doing and hopefully become a bit more familiar with the methods and the reasoning behind the decisions," says Dr. Mong.
To increase awareness and understanding across TeamUHN, Substance Use Services has partnered with The Michener Institute of Education at UHN to develop short training modules that are expected to be available in this spring.
"They will help providers get comfortable with the medications we can prescribe for different conditions and better understand how to, for example, treat pain in a patient who has a really high opioid tolerance because they use fentanyl," says Dr. Sheikh. "We're hoping education initiatives like this will transform the way we provide care throughout UHN."
Non-judgmental approach
Dr. Mong's second consult of the morning, a man in his late 30s who uses opioids in high doses, is in the hospital for an infected leg ulcer – a common consequence of opioid injections. The patient is also under police watch, handcuffed to his bed awaiting the results of a bail hearing.
"I take a non-judgmental approach to patients and ask how I can help," says Dr. Mong. "It is a very simple and basic thing to say, but we need to have empathy and respect for these patients and make sure that we give them the best care that we can."
The patient is experiencing severe withdrawal and is unable to eat or sleep. Dr. Mong recommends a rapid adjustment of methadone levels and consults with the patient's nurse about inserting a catheter to improve hydration.
Next, he's off to the Orthopedic Inpatient Unit to connect with a psychiatric and acute pain nurse before assessing a patient recovering from a double leg amputation, the necessary result of long-ignored leg infections from excessive injections.
Dr. Mong had hoped to review medication and comparative dosage-equivalent questions with the nurses, but it's too late. The patient discharged himself before sunrise. The care team hopes he will return.
"Withdrawal is a profoundly unpleasant experience," says Dr. Mong. "Imagine the worst flu in your life – nausea, vomiting, sweating, joint aches, agitation, tremors – and sitting in hospital.
"Of course you'd want to leave [and resume substance use]."
By mid-morning, Dr. Mong revisits an elderly patient who a day prior was experiencing psychosis and reporting hallucinations of insects crawling on the ceiling and onto his skin.
Today, the patient is in good humour, in spite of a COVID-positive result that came in overnight. The patient is known to have an alcohol use disorder, and Dr. Mong checks for withdrawal symptoms. None are present, and he takes the opportunity to discuss non-medication approaches and strategies to decrease consumption.
That sometimes involves connecting patients to community programs – in this case booking an appointment with Community Outreach Programs in Addiction (COPA), a service that help adults 55 years and over.
A smooth discharge plan is crucial for patients to avoid falling through the cracks after leaving the hospital. This can involve follow up assessments with family doctor or RAAM clinics, arranging transitional care for injection wounds or helping others navigate prescriptions like Suboxone or methadone that can have their own peculiarities with pharmacists.
SUIT is available Monday to Friday, 8:00 a.m. to 4:00 p.m., to Toronto Western Hospital patients in the ED or inpatient units with known or suspected SUDs. Consults can be requested by physicians and nurse practitioners (NPs) via Locating or Webpaging.
SUIT is currently limited to TWH patients, but has been providing phone advice to physicians and NPs across UHN. The pilot is scheduled to run for about six months before further steps are contemplated.
