Objectives
Focus on • OUD screening• Approach to OUD management
No disclosures• Buprenorphine = Subutex• Buprenorphine/naloxone = Suboxone
True or False
• Staff alert you that a 35 year old woman is slumped in a waiting room chair, and is unresponsive. Staff said she appeared very drowsy upon arrival and check‐in.
• You do not personally or professionally know this women, but she is unconscious with shallow respirations.
• As you evaluate her ABCs, you consider if she is overdosing on opioids.
True/False: it is important to know her medical history before giving naloxone.
True or False
• Staff alert you that a 35 year old woman is slumped in a waiting room chair, and is unresponsive. Staff said she appeared very drowsy upon arrival and check‐in.
• You do not personally or professionally know this women, but she is unconscious with shallow respirations.
• As you evaluate her ABCs, you consider if she is overdosing on opioids. She appears to be pregnant.
True/False: You should not give naloxone.
True or False
• Robert and Blake occasionally use heroin together. Blake prefers pills, but uses heroin when he cannot afford them. Robert has been using heroin more regularly.
• Robert shares some of his new bundle with Blake today, and they shoot up together. Within 10 minutes, Robert notices Blake is not arousable, with classic signs of overdose.
• Robert panics because he does not have any naloxone.
True/False: If Robert calls EMS, he risks being arrested himself for possession of drugs/paraphernalia.
Harm reduction interventions
• Naloxone prescribing• Substance use disorder (including opioid use disorder)• Chronic opioids
• Daily MME >50• History of overdose• Concurrent benzodiazepine use
• Safe injection practices• Clean needles and other supplies• Avoid injecting alone• Use test doses
https://harmreduction.org/issues/overdose‐prevention/overview/overdose‐basics/https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htmhttps://ccp.jhu.edu/2018/07/30/reducing‐overdose‐deaths‐baltimore/
Harm Reduction Principles
• For better or worse, accept that drug use happens• Work to minimize its harm rather than ignore/condemn it• Also do not minimize/ignore the real harm and danger of drug use• See drug use over a complex continuum, and that some methods are clearly safer than others
• Aim to help persons using drugs to recognize their actions and consequences, with an offer of self‐empowerment for making change
• Recognize that poverty, discrimination, stigma, trauma and social inequities and inequalities affect people’s vulnerability to drugs, as well as their ability to effectively help themselves
True or False
• Janet is a 70 year old women admitted for COPD. Because she was a bit confused upon admission, you held her Roxicodone 5mg tid prn medication that she uses for her back pain.
• By day 2 of her admission, she is improving.• Early on day 3 of her admission, she has acute abdominal pain with nausea and heaving, diaphoresis, and body aches. You astutely recognize likely opioid withdrawal.
True/False: Janet has OUD.
True or False• You see Tim, a pleasant 63 year old male you’ve know for 10 years. • He has been mostly stable on his chronic pain regimen for low back pain: • Gabapentin 400mg po tid• Oxycontin 10mg po tid• Percocet 5‐325mg po tid prn breakthrough.
• You typically prescribe him a 3 month supply, as he has no red flags (attends his appts on time, no unexpected UDS findings, is polite, keeps up with his med supply).
True/False: There is no concern for him having opioid use disorder.
OUD Screening Tools
• Single Item:• How many times in the past year have you used an illegal drug or a prescription medication for nonmedical reasons? (positive = 1+)
• DAST‐10
• TAPS Tool Part 1 (past year, 5 questions)
• TAPS Tool Part 2 (past 3 months, 9 questions)
Dig deeper:
• If positive screen for opioid misuse• If patient discloses opioid misuse• If patient shows signs/symptoms of opioid misuse
True or False
• You have been managing Penny’s neck pain for 15 years since she was injured an MVA.
• At today’s encounter, you obtain more history and realize that she meets criteria for OUD.
• You use sensitive language to offer a brief intervention, and she accepts a recommendation for treatment.
True/False: The only thing to do is to refer her to a drug treatment center.
True or False
• You take the opioid epidemic seriously. • You have been reviewing your patient panel of those who receive long‐term opioids from your clinic.
• You follow CDC’s recommendations when it comes to a goal of <90 MMSE and/or concurrent benzodiazepine rx, and tapering protocols.
True/False: Tapering opioids may increase the frequency with which you see such patients.
Infectious Complications of OUD
• Hepatitis C• Hepatitis B• Human immunodeficiency virus• Bacterial infections (sepsis, heart valve, skin, bone…)• Other STDs
We are seeing “syndemics.”
Approach to OUD• NC’s Opioid Action Plan, 2017‐2021
https://files.nc.gov/ncdhhs/NC%20Opioid%20Action%20Plan%208‐22‐2017.pdf
True or False
• Sierra has OUD recently diagnosed (po Oxy for past 4 months), but has good social support and would like to avoid daily dosing with MAT.
• She has PMH of obesity and NASH with elevated LFTs.
True/False: Naltrexone is a good option for her.
True or False
• John has ESRD and is on Tue/Thur/Sat dialysis. He has OUD.
True/False: Methadone is his only option for MAT.
True or False
• Brianne is your patient, a 28 year old G3P1011 at 20 weeks gestation. • She is being treated for OUD, and is doing well on Subutex maintenance.
True/False: Subutex is the only medicine that can be safely used in pregnancy for medication‐assisted treatment for OUD.
True or False
• Frank experienced cardiac arrest with torsades de pointes in the emergency department, with QTc 540. His QTc prolongation appears to be congenital.
• He has a history of OUD, most recently using 8 bags of IV heroin daily.
True/False: MAT is contraindicated in this patient.
True or False
• John presents as a new patient from Kansas.• He was on methadone tabs for chronic neck pain, despite attempt cervical fusion. MMSE = 105.
• He asks you to take over the management of his methadone, as there are few pain mgmt. specialists around.
• You screen him, and he demonstrates no evidence of OUD.
True/False: You can competently manage his pain.
MAT:
https://www.pewtrusts.org/en/research‐and‐analysis/fact‐sheets/2016/11/medication‐assisted‐treatment‐improves‐outcomes‐for‐patients‐with‐opioid‐use‐disorder
• Methadone…daily liquid• Buprenorphine…films or sublingual tabs or implants• Monoproduct• Combo product
• Naltrexone… daily po tabs or monthly IM
Provider Clinical Support System Medication Assisted Treatment Training for Buprenorphine
http://pcssnow.org/wp‐content/uploads/2015/02/Buprenorphine‐Waiver‐Training‐Advanced‐Review‐module‐CME‐7.3.41.pdf
OTP vs OBOT
• OTP: opioid treatment program• Federally regulated treatment program• Directly observed daily dosing• Methadone or buprenorphine product
• OBOT: office‐based opioid treatment• Office physicians who have received waiver/X license• Office setting, with rx sent to pharmacy• Buprenorphine
• No special setting or training needed for naltrexone
Further resources
• North Carolina Harm Reduction Coalition (NCHRC)• http://www.nchrc.org/
• NC Medical Society “Project OBOT”• https://projectobot.com• In partnership with UNC Project ECHO for MAT, MAHEC ECHO, and others• Extension for Community Healthcare Outcomes for Rural Primary Care Medication‐Assisted Treatment.
• SAMHSA TIP 63: Medications for Opioid Use Disorder• https://store.samhsa.gov/system/files/tip63_fulldoc_052919_508.pdf
• CDC Guidelines for Prescribing Opioids for Chronic Pain• https://www.cdc.gov/drugoverdose/prescribing/guideline.html