The Opioid Crises and Treatment Outpatient
Managing opioid abuse is challenging, as it remains a taboo, politically charged issue with limited support. Despite this, healthcare providers are encouraged to obtain their X-Waiver to prepare for the worsening opioid crisis, which will inevitably affect all areas of practice, not just specialized clinics.
Medication-Assisted Treatment (MATS) providers face strict regulations, making prescribing opioids complex and often frustrating. Additional training and education are vital due to the severity of the crisis and the shortage of psychiatric prescribers.
Frequently Abused Opioids:
- Fentanyl (Synthetic Opioids): The leading cause of fatal overdoses, often mixed with heroin. It is 100x more potent than heroin. Sufentanil, even stronger, is FDA-approved for specific patients.
- Heroin: Derived from morphine, it is illegal in the U.S. but medically used in limited settings abroad. Most U.S. heroin is unregulated.
- Morphine: A natural opioid from the poppy plant, primarily used for pain relief.
- Oxycodone & Hydrocodone: Semisynthetic opioids for pain treatment. Often linked to addiction due to overprescription. OxyContin is a controlled-release version of oxycodone.
Opioid Dependency Medications – Buprenorphine, methadone, and naltrexone are used to treat opioid use disorders to short-acting opioids such as heroin, morphine, and codeine, as well as semi-synthetic opioids like oxycodone and hydrocodone. These MAT medications are safe to use for months, years, or even a lifetime. As with any medication, consult your doctor before discontinuing use.
- Buprenorphine – suppresses and reduces cravings for opioids. Learn more about buprenorphine.
- Methadone – reduces opioid cravings and withdrawal and blunts or blocks the effects of opioids. Learn more about methadone.
- Naltrexone – blocks the euphoric and sedative effects of opioids and prevents feelings of euphoria. Learn more about naltrexone.
Learn more about MAT for opioid use disorders and download TIP 63: Medications for Opioid Use Disorder – 2021.
Opioid Overdose Prevention Medication – Naloxone saves lives by reversing the toxic effects of an overdose. According to the World Health Organization (WHO), naloxone is one of a number of medications considered essential to a functioning health care system.
- Naloxone – used to prevent opioid overdose, naloxone reverses the toxic effects of the overdose. Learn more about Naloxone.
The Pros & Cons
-There’s not one method more superior than the other but there are certain treatments that have particular considerations:
Methadone: extremely difficult withdrawals or to discontinue. Decreasing the dose usually requires treating with benzodiazepines (BZD) and anticipating the flu-like symptoms. The methadone clinic is a federal facility and usually just offers methadone -no therapy, additional medications, and have strict guidelines; weekly drops, inconvenient; physically have to obtain the medication on a weekly basis. I’ve also heard horror stories including, drug dealers selling in the parking lot, people cheating the drug tests, etc. I usually encourage my patients to switch to Suboxone because it’s more tolerable -has less relapse risk.
Suboxone Vs Subutex: Suboxone has naltrexone, which prevents the medication from being injected/snorted/crushed or causing an OD. Subutex is good for inpatient but many times, Suboxone is the standard for outpatient.
Switching Methadone -> Suboxone: At my clinic, methadone should be >20mg in order to switch to Suboxone without major withdrawal reactions. According to TIP 63, the dose can be 20-40mg. Just keep in mind the higher the dose to switch from, the more you may have to aggressively treat the withdrawal symptoms.
Suboxone: is more tolerable, more convenient, it can be prescribed monthly -no refills so similar to prescribing stimulants. The biggest issue with Suboxone is how much MORE responsibility will be on the prescriber. Including, the random Rx tests, you’ll also be responsible for the benzo regimen, and if the patient fails the Rxtest, it’ll be the prescriber’s responsibility to remedy the entire situation as well, so more difficult patient interactions. Therefore, I usually recommend Suboxone to my most compliant and cooperative patients but I still inherit those that are problematic…
Vivitrol: an opioid antagonist formulated as an extended-release once-a-month injection (referred to here as the brand name Vivitrol). This medication is delivered once every 4 weeks, instead of every day, and might help address concerns about needing to take the medication daily as well as the potential problems that could arise if someone is also taking other drugs (in addition to opioids) like alcohol. –Recovery Answers. The biggest drawback is some people don’t want injections, others report the medication lasting only 3 weeks so a high chance of relapse, and cannot be on opioids so it can be difficult for people dealing with pain symptoms.
Naltrexone PO: maybe for long-term maintenance of the FULLY recovered but people barely adhere to PO. Others, don’t want the injections and will try to use their willpower for the PO, but it usually never works out. I at least offer this option for my cocaine users to deal with cravings. There’s also a subdermal option.
Extra Considerations
Pain Management and Opioid Use: Methadone and Suboxone could benefit from FDA approval for pain treatment, as patients often continue these medications for pain management. However, misuse can occur, with some patients exaggerating symptoms to access opioids. Psych providers must balance understanding patient struggles with ensuring proper care and preventing relapse, even though managing pain isn’t typically their scope of practice.
Drug Test Issues: Unusual drug test results (e.g., high buprenorphine/naloxone and low norbuprenorphine levels) or evidence of sample tampering should prompt detailed urine analysis and transparent discussions with patients. Treatment adjustments, such as weekly supply limits, may be necessary, and a collaborative approach with the care team is recommended, including the possibility of returning the patient to rehab.
Benzodiazepine Management: Managing patients on benzodiazepines (BZDs) is complex, especially when reducing methadone doses. Providers should consider adjunctive PRN medications (e.g., clonidine, hydroxyzine, Zofran) to manage withdrawal, sleep, and psychiatric symptoms.
Risks of Fatalities: The combination of BZDs and opioids, particularly synthetic ones, significantly increases fatality risks due to respiratory depression and oxygen deprivation. Accidental overdoses often occur when users are unaware of the potency of mixed substances.
Key Challenges: Caring for such patients is demanding, requiring a multidisciplinary approach and careful monitoring to address risks and improve outcomes. Other considerations include:
- Adulterants include quetiapine (Seroquel), quinine, caffeine, lidocaine, or fentanyl. Heroin is now also being sold in capsules. Capsules are red/white or blue/white. These capsules have heroin contaminated with quinine, procaine, cocaine, and diphenhydramine.
- “Safer heroin” it’s been reported to be on the streets. It is heroin mixed with antibiotics with the premise that it prevents infection. The heroin is tan and packaged in antibiotic capsules which ID to amoxicillin or cephalexin. If you receive a patient with this, please consider methods for the capsule identification.
Key Points of the Plan of Care for Treating Opioid Use Disorder:
- Initial Assessment:
- Conduct a comprehensive history and physical (H&P) and history of present illness (HPI).
- Engage openly and without judgment to understand the patient’s experience and preferences.
- Document the patient’s prior use of medications (e.g., dose and formulation of buprenorphine/naloxone) and any side effects.
- Drug Testing:
- Perform an initial drug screen to identify substances being used, including opioids, benzodiazepines, cocaine, and methamphetamine.
- Communicate that the first test establishes a baseline, not a final judgment, and subsequent clean tests are needed to continue treatment.
- Address any positive findings with clear communication about treatment plans and contraindications, emphasizing safety.
- Initiating Treatment:
- Start buprenorphine/naloxone (e.g., 4 mg QD or 8 mg BID), tailoring the dose based on the patient’s opioid tolerance and disorder severity.
- Educate the patient on the medication’s use and adherence.
- Psychiatric Medication Management:
- Evaluate the effectiveness of existing psychiatric medications (e.g., escitalopram) and make adjustments as needed.
- Coordinate care to avoid conflicting prescriptions, particularly with controlled substances, and ensure the patient isn’t “doctor shopping.”
- Backup/Emergency Planning:
- Prepare the patient for possible medication mishaps or withdrawals, explaining policies on stolen or lost medications.
- Prescribe symptom management medications (e.g., for flu-like withdrawal symptoms) and advise ER visits if needed.
- Emphasize responsibility for medication security and adherence.
- Relapse Prevention and Long-Term Goals:
- Create a strategy to minimize long-term reliance on opioid treatment, focusing on eventual tapering.
- Encourage participation in psychotherapy to address underlying issues and support recovery.
- Highlight the risks of long-term opioid treatment and the importance of transitioning away from it to avoid dependency conflicts.
- Follow-Up and Monitoring:
- Schedule regular follow-ups with routine drug testing to ensure adherence and progress.
- Reassess treatment effectiveness and address any barriers to compliance or new challenges.
Medications or Strategies for Managing Cravings in Addiction Treatment
Some Takeaways:
- Cravings & Relapse Management: Relapse is common; patients need clear plans for cravings and emergencies to reduce failures. Approach early appointments positively, setting expectations and prevention strategies.
- Medication Options for Opioid Cravings:
- Clonidine: Useful for restlessness and hot flashes, best dosed at night to avoid daytime sedation. Alternatives include guanfacine or hydroxyzine (less cardiac risk, can be dosed multiple times daily).
- Ondansetron (Zofran): Effective for nausea, flu-like symptoms, and anxiety-related nausea.
- Benzodiazepines: Reserved for transitions from methadone to suboxone; prefer clonazepam for microdosing. Use cautiously to minimize the risk of new addictions, with tapering plans once stable.
- Additional Medications:
- Avoid mood stabilizers (e.g., Depakote, except in rare cases) and sedating/high-maintenance drugs.
- Desvenlafaxine (Pristiq): A good antidepressant choice with fewer liver concerns.
- Antipsychotics: Useful for microdosing to aid sleep, anxiety, and placebo effects.
- Stimulants: Consider for ADHD symptoms, ensuring functionality for work and family life.
Cautions:
- Minimize the risk of polypharmacy, overdose, and secondary addictions. Keep regimens simple and focused on functionality.
- Narcan: Not routinely prescribed unless necessary for emergencies, as well-managed patients are less likely to seek street drugs.
Rehab Protocols:
- Do not prescribe scheduled medications while a patient is in rehab to avoid misuse or theft. Reassure patients of support upon rehab completion.
Overall Philosophy: Proactively manage cravings and symptoms to reduce relapse risk. Tailor medication regimens thoughtfully, prioritizing functionality and safety.
Relapses Vs Rehab Key Points
General Perspective on Relapse
- Not the End of the World: Relapse is a natural part of recovery and not a failure. Most patients battling addiction experience relapse, often multiple times, before achieving sustained sobriety.
- Self-Compassion for the Patient: Patients often feel guilt or shame after relapsing. It’s crucial to help them reframe the experience as part of the process rather than a defeat or self-pity.
Approach to Relapses
- Individualized Treatment Adjustments: Treat relapses as complex psychological symptoms:
- Analyze what worked and didn’t work in previous treatment plans.
- Adjust medications as needed (e.g., dosage changes, additions, or eliminations).
- Continue adherence to Rx screening protocols and therapy.
- Reassess goals and tailor treatment to the patient’s evolving needs.
- Monitor Severity: For milder relapses (e.g., semi-synthetic opioids like Vicodin), careful outpatient management is often sufficient. Severe relapses, including overdoses or clear loss of control, may necessitate rehab.
Criteria for Rehab Referral
- Consecutive Relapses: Recommend rehab if a patient repeatedly struggles to control cravings.
- Severe Situations: Immediate rehab is needed if:
- The patient has overdosed.
- They present in the office visibly intoxicated.
- Their behavior indicates a loss of adherence to protocols.
Protocols and Boundaries
- Adherence to Protocols: Strongly enforce treatment protocols to ensure stable care:
- Require honesty about slip-ups.
- Conduct regular screenings.
- Monitor medication adherence.
- Encourage therapy participation and goal-setting.
- Patient Responsibility with Provider Support: While patients are ultimately accountable, addiction treatment requires structure, including boundaries, rules, and guidance akin to managing a dependent child.
- Flexibility with Accountability: Patients can refuse protocols, but doing so limits treatment options and may necessitate rehab.
Principles for Long-Term Success
- Tough Love: Setting clear expectations and holding patients accountable helps them appreciate the care they receive.
- Focus on Stability: The absence of structure risks destabilizing the patient’s progress and could lead to fatal outcomes.
- Empathy and Support: Balance accountability with compassion, helping patients feel supported rather than punished during setbacks.
By following these principles, patients are more likely to view relapse as a stepping stone in their recovery journey rather than a reason to give up.
