ABSTRACT
Opioid withdrawal is common among hospitalized patients. Those with substance use disorders exhibit higher rates of patient-directed discharge. The literature lacks information regarding the patient perspective on opioid withdrawal in the hospital setting. In this study, we aimed to capture the patient-reported experience of opioid withdrawal during hospitalization and its impact on the desire to continue treatment for opioid use disorder after discharge. We performed a single-center qualitative study involving semi-structured interviews of hospitalized patients with opioid use disorder (OUD) experiencing opioid withdrawal. Investigators conducted in-person interviews utilizing a combination of open-ended and dichotomous questions. Interview transcripts were then analyzed with open coding for emergent themes. Nineteen interviews were performed. All participants were linked to either buprenorphine (79%) or methadone (21%) at discharge. Eight of nineteen patients (42%) reported a patient-directed discharge during prior hospitalizations. Themes identified from the interviews included: (1) opioid withdrawal was well-managed in the hospital; (2) patients appreciated receiving medication for opioid use disorder (MOUD) for withdrawal symptoms; (3) patients valued and felt cared for by healthcare providers; and (4) most patients had plans to follow-up for opioid use disorder treatment after hospitalization. In this population with historically high rates of patient-directed discharge, patients reported having a positive experience with opioid withdrawal management during hospitalization. Amongst our hospitalized patients, we observed several different individualized MOUD induction strategies. All participants were offered MOUD at discharge and most planned to follow-up for further treatment.
ABSTRACT
No one has described more passionately than Ferenczi the traumatic induction of dissociative trance with its resulting fragmentation of the personality. Ferenczi introduced the concept and term, identification with the aggressor in his seminal "Confusion of Tongues" paper, in which he described how the abused child becomes transfixed and robbed of his senses. Having been traumatically overwhelmed, the child becomes hypnotically transfixed by the aggressor's wishes and behavior, automatically identifying by mimicry rather than by a purposeful identification with the aggressor's role. To expand upon Ferenczi's observations, identification with the aggressor can be understood as a two-stage process. The first stage is automatic and initiated by trauma, but the second stage is defensive and purposeful. While identification with the aggressor begins as an automatic organismic process, with repeated activation and use, gradually it becomes a defensive process. Broadly, as a dissociative defense, it has two enacted relational parts, the part of the victim and the part of the aggressor. This paper describes the intrapersonal aspects (how aggressor and victim self-states interrelate in the internal world), as well as the interpersonal aspects (how these become enacted in the external). This formulation has relevance to understanding the broad spectrum of the dissociative structure of mind, borderline personality disorder, and dissociative identity disorder.
