Talk Less, Listen More

A young man is found unconscious after heroin use. On arrival to the ER, he has low blood pressure and muscle aches. What should you do next?

This was a question recently posed during nephrology class during my second year of med school. Although my classmates and I are still learning the knowledge and skills to help patients in clinical settings, my own answer to this question was largely informed not by the textbook, but by a patient I had met years before when I was working as an undergraduate with the addiction medicine team at Yale.

While connected to various machines, drips, and monitors, “Phillip” told me how he ended up in the hospital after taking pills laced with fentanyl. He knew that I was an undergraduate working at a teaching hospital, and said, “Ask me anything, nothing is off limits. Because at the end of the day, you’re going to see more folks like me. You have to understand what we’re experiencing out there.” I was surprised by his candor; most of the patients I had met were reluctant to talk about their drug use, maybe fearing stigmatization. For the next hour, we talked about everything—how to spot fentanyl in a heroin packet, the price of Suboxone strips in the area, the effect of using Gatorade instead of distilled water for injections . . .. From Phillip, I learned more about the experience of someone using drugs than I could have learned from any formal educational setting. By speaking honestly with me about his experience, he provided a blueprint for how healthcare professionals can initiate conversations with patients about drug use.

As counterfeit pills have become increasingly involved in overdose deaths, I’ve drawn on my experience with Phillip when thinking about to engage in conversations about drug use. Particularly with patients using substances, I am guided by these principles:

1. Talk less, listen more.

What’s the patient’s experience with the counterfeit pills? Have they or any friends experienced loss as a result? Do they have questions or concerns? Do they know of local resources available for testing whether pills contain fentanyl or other substances?

2. Ask intentional questions.

Ask thoughtful and respectful questions using person-first language and avoid stigmatizing words.

3. Admit when you don’t know.

The landscape of the drug market is constantly changing, and the prevalence of counterfeit pills may rise or fall in certain geographic regions based on a variety of factors. If you don’t know what the local market is like, ask your patients. Be honest about your understanding of the market, current statistics, and the risks associated with certain substances that may be present in pills.

4. Be the patient’s ally, not their judge.

Dr. William Osler, one of the Johns Hopkins founding physicians, wrote, “Facts alone will not be of much service to you unless studied in connection with others and with the phenomena displayed during life.” Learning how to best serve patients doesn’t end when we leave the classroom. It’s a daily practice as we listen and seek to understand patients’ experiences. In this case, the radical honesty that Phillip embodied has inspired me to continue to look to patients as a source of wisdom and knowledge. Our shared humanity provides a strong foundation for healing and the journey toward health.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.