This document summarizes a mental health consultation for a female patient with a long history of drug addiction and multiple treatment failures. Key findings and recommendations include: 1) Discontinuing Suboxone and several other medications due to contraindications and side effects. 2) Establishing a routine pain management regimen without PRN orders to prevent drug seeking behavior. 3) Observing the patient for opioid withdrawal symptoms. 4) Interacting cautiously with the patient due to signs of a histrionic/borderline personality disorder characterized by manipulative behaviors.

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Mental Health Consultation
Patient Name: drug addiction Facility: XXXX
Date: 7-30-13
Additional history can be found elsewhere in this chart and will not be repeated here.
Reasonfor Referral: xx-year-old, white, xxxx, female… I was asked to evaluate her because of her
extensive history of drug abuse.
Background Information: She said she became addicted to opiates in 2003 “because of a motor
vehicle accident”. She has been involved in chemical dependency treatment with little success both
outpatient and inpatient off and on for the past 10 years. She has been treated with Methadone and
Suboxone. She has abused heroin and cocaine addition to prescription drugs. During the past year she
has had multiple surgeries for bowel necrosis caused by a bowel perforation. She currently has a
colostomy.
Current Medications: Flexeril 10mg tid, Suboxone SL 8mg qd, Synthroid, Neurontin 100mg tid,
Trazodone 200mg qhs, Prozac 20 mg qd, Strattera 8mg qhs. On 7/24 she was started on OxyContin
10mg bid and Dilaudid 2mg q4 hours prn.
Medical History: GERD, depressive disorder, Hyperthyroidism, asthma, fibromyalgia and as above.
Mental Status Exam: She was a curt and irritable but more or less cooperative young woman with
slightly pressured, fragmented and circumstantial speech and thinking. She had numerous complaints
about the healthcare she had received in the recent past and was taking notes concerning her current
healthcare. Her affect was labile and she often lapsed into fleeting tears. She complained about her
mother giving her mixed messages about money and the fact that she hadn’t seen her three-year-old
daughter in sometime “because her father will not let me”. She asked for medication for anxiety and
when I raise the issue of her drug addictions she responded “I never have problems with benzos”. There
were no overt signs of psychosis. Her insight and judgment were both poor. She was well oriented.
Findings and Recommendations: This young woman has a long history of drug addiction with many
treatment failures. She seems to see each encounter with a health professional as an opportunity to
obtain one of her drugs of choice. Hence her request of me for benzodiazepines; “Can I have something
for anxiety?” She can’t control the impulse to try and obtain more mood altering drugs when the
opportunity presents itself. As a result, there are many problems with her current drug regimen:
1. Suboxone is Buprenorphine and Naloxone a potent opioid antagonist which produces opioid
withdrawal signs and symptoms in individuals physically dependent on full opioid agonists. She
is currently taking OxyContin and Dilaudid. Suboxone should only be used when the patient has
been withdrawn from opioids. It is also contraindicated with many of the non-narcotic drugs she
is taking. Therefore, would DC Suboxone ASAP. She was not on it in the hospital.
2. She is taking Strattera at hs and Trazodone 200mg qhs presumably for sleep. Strattera is a
psycho-stimulant. The two drugs are in conflict with each other and Strattera is normally given

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bid with the last dose in the afternoon. The indications for the Strattera are dubious and she did
without while in the hospital. The Trazadone dose is high and likely causing daytime sedation.
Therefore, would DC Strattera and reduce Trazodone to 100mg qhs.
3. She has asthma and she is taking many respiration suppressing drugs. Therefore, would reduce or
DC these drugs wherever possible
4. She has very real pain but we are providing a drug addict with several drugs of abuse. Therefore,
would consider substituting Methadone or possibly a non-narcotic analgesic for OxyContin and
Dilaudid. She did without OxyContin and Dilaudid while in the hospital
Also with her participation, would establish a routine regimen of pain control medication, which
relieves her discomfort but is not pain contingent. All analgesic medication should be given in
routine doses; prn orders should be discontinued.
5. If she continues to complain of anxiety would offer to switch her from Prozac to Lexapro but not
to start her on a benzodiazepine.
6. We should observe for signs and symptoms of opioid withdrawal including: rhinorrhea,
diaphoresis, nausea, vomiting, intestinal cramping, diarrhea and goose flesh
She appears to have a histrionic/ borderline personality disorder which is characterized by: a) difficulty
achieving intimacy in relationships b) use of physical symptoms as an appeal for help c) symptoms
which are dramatically described and vague d) a tendency to alienate others with demands for attention
e) frustration in situations that involve delayed gratification f) actions which are directed at obtaining
immediate satisfaction g) a tendency to become angry, demanding and coercive when needs are not met
h) fleeting, shallow emotions i) a pattern of manipulating others into gratifying her needs J) seeing
others as the source of her problems k) a lack of empathy l) unstable emotions.
Therefore, when interacting with her:
7. Do not allow her to make you feel responsible for immediately solving her problems. Do not be
intimidated by her (note taking). Do not try to win her approval.
8. Remind her that she is ultimately responsible for her own health and health care. Others can
make recommendations but in the final analysis the choices and outcomes are hers.
9. Do not allow her to lure you into agreeing with her criticisms of any other members of the staff.
Present a united front and rest assured that others will not accept her criticisms of you.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist