The Opioid Crises and Treatment Outpatient
Treating people for opioid abuse and their management is difficult and grueling. It’s still taboo, political, and scarcely supported. I always encourage psych providers to get their X-Waiver even if they’re not dealing with the population directly because the opioid crisis will be getting worse. Therefore, it’ll knock on your door even if you’re not a methadone/opioid tx clinic.
Even if you’re a MATS provider, you can’t just start prescribing any kind of way, it’s very regulated and many times you’re stuck between rock and a hard place. Not to scare anyone, but this is why getting the extra training and education is important. The real crisis is also the lack of psych prescribers because overall the reality is brutal but here we go:
Opioids Frequently Abused
- Fentanyl (Synthetic Opioids): This is the MOST common reason for fatal overdoses due to being mixed with heroin. Fentanyl is 100x more potent than heroin. Sufentanil, an opioid 5-10x more powerful than fentanyl, and also approved by the FDA to treat patients who have become tolerant to weaker forms of opioids.
- Heroin: processed from morphine and although illegal in the US, heroin (diacetylmorphine) is available medically in some limited circumstances, particularly in Europe and Canada to treat drug abuse versus using methadone. In the U.S., almost all heroin comes from the unregulated market.
- Morphine: a naturally occurring substance derived from the opium poppy plant often used to alleviate pain and other physical symptoms.
- Oxycodone and Hydrocodone: are semisynthetic opioids derived from the opium poppy plant, are chemically similar to morphine, and are used to treat acute and chronic pain. Unlike illicitly produced heroin, their production is regulated, which means they have consistent effects and can be made available in specified doses. OxyContin is a controlled-release form of oxycodone so it is released gradually over a period of time. Many times people start their opioid addiction from being prescribed these medications.
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 Symptoms: Methadone and Suboxone should consider getting FDA approved for pain meds because many times people will continue these medications to treat pain. This may be controversial but sometimes patients will fake the symptoms just to get the “opioid treatment” prescribed for pain. Don’t judge but understand how difficult healthcare and situations can get, and overall the psych provider can still do their job and make sure the patient doesn’t relapse to real drugs…(information about pain and opioids are at the bottom, but it’s not the psych’s scope of practice)
Failed Drug Tests: I’m going to make another post about this but as far as people having unusual results i.e. unusual patterns consisting of high concentrations of buprenorphine and naloxone (>1000 ng/mL) and low concentration of norbuprenorphine (<50 ng/mL) or tampering with the urine sample, I recommend getting a more detailed urine analysis, and of course a frank conversation about proceeding with the treatment. The provider can limit the supply dose like weekly pending an accurate Rxtest instead of monthly. Usually, this needs to be a team effort while ruling out possibly sending the patient back to rehab.
Benzos (BZD): these are the patients that I inherit on a BZD or I have to consider it just to deal with decreasing the methadone doses. But I don’t forget to PRN meds such as clonidine, hydroxide, Zofran, and targeting sleep and psych symptoms (maintenance medications discussed below). So, as you can see the care, can be very demanding…
Fatalities: BZD mixed with opioids, especially the synthetics significantly contributes to the fatality rate. Deaths are related to respiratory depression and/or depriving oxygen to the brain. Another problem with opioids is the ability to hide the potency when being mixed with pills, leading to ODs. This is usually accidental because people who OD are usually not aware of these risks or didn’t intend to die. 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” is 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 call the PCC for capsule identification
Plan of Care
Treating opioid disorders are not easy because the provider has to hash out if there’s an addiction, miseducation/misuse, complicated pain control, medical situations, etc… What also makes this hard is how we can’t cold turkey a patient or risk another relapse that could be fatal. Also consider how there are usually other addictions involved including, ETOH, benzodiazepines, cocaine, etc. (like the graphic mentioned above). For the sake of simplicity, I’ll just discuss a regular case:
DB is a 48y/o male who was being treated for minor dental care 3 years ago and was prescribed hydrocodone (Vicodin). Eventually, it wasn’t prescribed anymore, and he started getting it off the streets about 2 years ago. He reports only using heroin once and recently tried his friend’s buprenorphine/naloxone (Suboxone) and said how that really helped him. He has no other medical or surgical history, lives alone, and wants to go back to college and complete his degree in education. Now DB is in the office inquiring about starting a regimen and currently taking escitalopram for anxiety prescribed via PCP. This is the first encounter with the patient so where to begin:
- Complete H&P and HPI: in contrast with kids, what I love about adults is that they know what they want. They usually will bluntly tell you what did/didn’t work and I can use that to my advantage instead of wasting time. Remember this is an assessment, not judgment day so don’t shame the patient and simply work with them. Ask DB what was the dose that he took? was it a film or sublingual? any side effects or issues? in addition to the assessment and document this so it’s not like you’re just winging it. If the patient doesn’t know you can start with the lowest dose 4mg QD or higher to 8mg or BID, depending on the tolerance and severity of the opioid disorder.
- Rx test the patient: with opioid use disorders, testing is mandatory since this is the main addiction that easily leads to fatalities and is usually state-regulated. We have to r/o other substances and make sure we are working with a clean slate. If someone tests positive or admits to heroin, meth, or cocaine, then I simply let the patient know, we can’t start certain treatments until we have a clean drug screen. Those are the main red flags that I check for to start scheduled medications. Positive for BZD depends on the situation, let the patient explain their Xanax story and make sure the patient understands the policy or what is permissible but it’s not a contraindication. Quick side note: the FIRST drug screen is NOT an ultimatum, it’s how you start utilizing a standard so you can still start opioid treatment, regardless of the results (unless the patient just admitted to using street drugs)…and then in the next follow-up appointment, test the person again, to make sure the Rx screen is clean (also so the patient understand to stop doing drugs) and if it’s still positive, then express how the treatment will discontinue unless they enter a rehab program or they can test clean again. Once the Rx screening is clean, resume treatment AND regularly test.
- Manage the symptoms: start managing the patient’s psych medications/symptoms. Go over if it’s helping, if the dose needs to be increased, or if we need to add medications. I don’t let the PCP or whoever keep prescribing the psych meds because that will create confusion but it’s ultimately up to the patient. I just let the patient know that it’ll require more strict prescribing rules. If another doctor is prescribing a BZD or something scheduled, I don’t prescribe anything additional or do refills unless we have an understanding. Always run a controlled substances prescription report to also make sure a person isn’t “doctor shopping” or trying to get access to more meds.
- Create a backup/emergency plan: with treating any addictions, you want the patient to be prepared for possible withdrawals/relapses and weird occurrences i.e. the dog ate the medications, or the patient wants to go out of town… I let the patient know, that if (scheduled) medications were stolen or missing, it’s still not going to be refilled and will possibly have to deal with withdrawals symptoms or go to the ER. Therefore, I usually prescribed medications to deal with the flu-like symptoms. Reassure the patient that they’re not going to die but can go to the nearest urgent care if necessary. I usually go over this in the beginning, to let patients know that it’s their responsibility to handle the medications or there are consequences (with schedules). If the medications were stolen, the patient needs to do a police report in case they magically pop back up but I still don’t refill. Most insurances don’t refill before the due date anyway so if the patient is being legitimate and want to go out of town, for example, I would increase the frequency if I wanted to give extra coverage.
- Try to AVOID the long haul: most of these patients may be on opioid tx medications for 10-20+ years. DB is not dealing with chronic pain but if some injury did occur, treatment could possibly last a long time. For patients who don’t have serious pain symptoms, really try to get the person off the opioid treatment. It’s a lot of maintenance because treatment should include intensive psychotherapy, which most people can’t comply and if the person really does need pain medications or something stronger, it’ll be a conflict/contraindicated, and ultimately put the person at risk for a relapse…It’s one of my pet peeves with substance abuse treatment, most of the time the care is great at the beginning, and then it wanes off so this is really not meant for a lifetime.
Particular Medications for Cravings
Let the patient know what to do in case of increased cravings/emergencies. Most people who battle addictions for decades have multiple failures/relapses because there are usually NO plans for the cravings. I’m saying all this because it’s RARE if not impossible for a person to come into your office, get treatment, and have a 100% success rate. Remember this isn’t judgment day, so don’t get bummed out if your patient relapses a few times before getting it right.
Think about the first appointment/intake as the “honeymoon” phase, where everything should be happy and relaxing so be HONEST about Rx testing and planning for cravings. Don’t wait until the patient is crashing and struggling because we want to prevent that. Quick side note: this is different from the cocaine blues (cravings) because people with opioid addictions are more of a tolerable/functional population so try to be less aggressive with adding medications than with cocaine treatment. Here are my go-to’s to deal with the opioid cravings/flu-like symptoms:
Clonidine: this helps with restlessness and I had someone report how it helps with hot flashes. Try to dose this only at night, because it can make a person tired. Remember people with opioid addictions are your everyday people/populations so we don’t want to make them sleepy. Also, consider guanfacine and hydroxyzine (if the patient has cardiac risks) or if you want to dose BID, or TID.
Ondansetron (Zofran): this is can be SL and dosed multiple times for n/v or flu-like symptoms. I’ve also had patients tell me it helps with anxiety since that can also cause nausea.
Benzodiazepines: these are mainly for my patients who are trying to switch from methadone to suboxone. It’s almost like the only way I can get the patients to keep decreasing the methadone dose in addition to prescribing the above medications. It’s truly HARD to switch, so definitely be supportive because of course BZDs already have a horrible reputation so I would avoid alprazolam (Xanax) and just about all of them except clonazepam (Klonopin) because we can microdose it. You don’t want to cause another addiction but don’t forget how the ultimate goal is to overcome the opioid addiction because of the death rates so the (BZD) benefit outweighs the risk. Once the person becomes stable then discuss a plan to taper the BZD.
Additional Medications: I tend to stay away from mood stabilizers with this group, mainly because I don’t want to worry about liver issues, the patient getting sleepy, or having high maintenance medications. Topiramate (Topamax) may be an exception if you need to use one. Depakote helps with agitation but this group is not usually hostile. With antidepressants, desvenlafaxine (Pristiq) is a great option since it bypasses the CYP450 system. Antipsychotics are also a good option just because you can microdose them, good for sleep/anxiety, or use them in other ways (taking advantage of the placebo effects) to help fight cravings.
Stimulants: yes if they have a hx of ADHD or symptoms r/t to untreated ADHD. You want these patients to continue to be fully functional and usually, they are working, dealing with families, trying to go to school, and maintaining employment. This is not the cocaine user that’s fighting everyone and taking off their clothes. Yes, that’s the population that needs to calm down, but NOT opioid users…As you can see a person’s regimen can easily add to 5-6 medications so the last thing we need is an overdose or another addiction, related to dealing with untreated psych disorders.
About Narcan: I personally don’t prescribe it because if you adequately treat the conditions or symptoms, the patient will not go to the streets. I get how providers will prescribe it in case of emergencies but I just didn’t have that experience. However, I did have a patient who couldn’t stay clean, sent her to rehab, and she still requested scheduled meds while in rehab (I declined) she left rehab anyway and went back to the streets but she was dealing with multiple addictions. If a person is dealing with addictions or can’t manage their cravings, rehab is usually necessary and I’m more strict with prescribing schedules. Side note: if the person is in rehab, reassure that if they complete treatment, you can start prescribing the scheduled medications but DON’T prescribed them while they’re in rehab, to be frank, rehab employees/workers will steal the medications because it has happened so I let the patient know, they have to be discharged from the facility…
Relapses Vs Rehab
Remember it’s not the end of the world and I usually anticipate some form of the patient relapsing with any addiction. No one battling these disorders gets it right the first time or they wouldn’t be in your office. The patient will beat themselves up, but don’t let them! I wrote some notes about helping a person remain sober. This isn’t based on any books or anything special like everything on this website, I do have a page for standard resources and created another one for the submitted sites….but they usually don’t reflect the real world or something practical.
With opioid addictions, meet the patient where they’re at, remember these people are more functional and easier to tolerate. Also, most people are abusing the semi-synthetics (i.e. Vicodin) versus heroin so the relapses shouldn’t be too severe but for any OD, a person should go to rehab.
With relapses, I treat them like it’s a complicated psych symptom; what worked/didn’t work, do I have to increase dosages, add/subtract medications, continue Rx screening protocols, etc. So with every relapse, you have to tailor the treatment plan to be more individualized as possible. We don’t want the patient to be back on the streets or risk a fatal overdose. However, I would recommend rehab if there are consecutive relapses/the person just cannot control their cravings or the patient just showed up high like the previous patient that I sent to rehab. Like they are obvious reasons but most of the time, if the patient is really trying to get right and we don’t want the person to feel like relapses equal an end of the world punishment.
Lastly, stick to your protocols. I treat relapses like psych symptoms because the patient must be adherent i.e. the person agrees to the Rx screenings, is honest about slipups or mistakes, not doctor shopping, going to therapy, actually making an effort, taking medications as prescribed, working towards a goal…etc. They can refuse the protocol but their treatment options will be limited or go back to rehab, but some providers will do whatever at their own risk.
Without protocols then the patient and/or the care would be unstable, unreliable, substandard, and will put the patient back at square one. Yes, the patient ultimately has to be responsible but with addictions, we’re not dealing with a fully functional adult (so think of the situation as a child). They need boundaries, rules, stipulations, and guidance while overcoming whatever addiction. Trust me, the patient will appreciate the tough love and won’t be another statistic.
