Cases of Patients with OUD Soraya Azari, MD Objectives To dive - - PDF document

10/15/2018 1

Cases of Patients with OUD

Soraya Azari, MD

Objectives

• To dive further into cases of patients related

to OUD, including some more challenging cases from the inpatient setting.

• To refine your skills at counseling patients

about options for management of their OUD.

• To consider additional resources to aid with

management in your respective health systems.

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Case 1

• A 32yo F with a history of low back pain, obesity,

prior motor vehicle accident with hardware in, and recurrent UTIs that is admitted with urosepsis.

• She states that she is prescribed “Percocet” by

her primary doctor for control of her chronic pain.

• VS and exam are notable for T38.2, HR 106,

normal BP, and O2 sat. She is diaphoretic, anxious‐appearing, and has CVA tenderness.

Question

• What additional information do you want to

know on history & physical? What tests do you want to order?

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Additional Info

• History

– She states that she is “getting hassled” more to get her

• medication. She’s had to visit several doctors to get her “usual

meds.” She has needed more pills recently to keep up w/her pain. – She reports the car accident was 5 years ago and she was “basically run over” and now has hardware in her ankle. Her medications were started them and she’s needed them since then to manage her ankle pain. – The meds allow her to “function.” She is currently staying with her mom and has a five year old child, who is in daycare. She is currently not working and hopes to apply for SSI for her ankle pain. – She denies use of drugs (except marijuana, which she uses for pain), no alcohol use (“I drank before my accident and I would never go back to that”), and no tobacco use.

Additional Info

• History

– You check a prescription activity report that shows 5 different providers in the past 3 months – You are not able to access records from her primary doctor’s office.

• Physical

– Pupils are 5mm and reactive; +rhinorrhea; +diaphoresis; +anxious appearing and with arms stretched out she has a visible tremor

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Additional Info

• You check a prescription activity report and

see the following:

– 4 different prescribers, with all prescriptions for a quantity of 5‐10 days

Labs

• Urine drug screen: positive opiates and
• xycodone

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Question

• What do you want to do with this patient

(besides fluids, antibiotics, VS monitoring, etc)?

Wesson, D. R., & Ling, W

• 2003. J Psychoactive

Drugs, 35(2), 253–9. Available online as pdf

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From: Interpretation of Urine Drug Testing in Pain Patients

Pain Med. 2012;13(7):868-885. doi:10.1111/j.1526-4637.2012.01350.x Pain Med | Wiley Periodicals, Inc.

• 4Rs

– Risk of bodily harm – Relationship trouble – Role Failure – Repeated attempts to cut back

• 4Cs

– Loss of Control – Consequences** – Compulsion – Craving

Does this patient have an opioid use disorder?

Tolerance** Withdrawal

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DSM-5 Criteria for Substance Use Disorders Recommendations and Rationale

Source: Am J Psychiatry. 2013;170(8):834-851.

a One or more abuse criteria within a 12-month period and no dependence diagnosis; applicable to all substances except

nicotine, for which DSM-IV abuse criteria were not given.

b Three or more dependence criteria within a 12-month period. c Two or more substance use disorder criteria within a 12-month period. d Withdrawal not included for cannabis, inhalant, and hallucinogen disorders in DSM-IV. Cannabis withdrawal added in DSM-5.

Loss of Control Compulsion

Consequences

Craving Compulsion

Risk bodily harm

Relationship trouble

Role Failure

Repeated try cut back

Case Continued

• What will be your next steps?
• Role play for 5 minutes

– Patient – Provider – Goal of the conversation:

• Communicate your concern for an opioid use disorder
• Describe treatment options while she’s in the hospital
• Explain the plan moving forward

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Remember…

• You do NOT need an x license or waiver to give

buprenorphine or methadone to a hospitalized patient with OUD and withdrawal

www.projectshout.org

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www.projectshout.org

Case Continued

• The patient receives a dose of buprenorphine and

feels “much better”

• She completes treatment of her pyelonephritis

and is referred to outpatient buprenorphine‐ naloxone waivered providers (if she desires).

• She is offered prescription of naloxone for
• verdose prevention.
• She is not discharged with opioid analgesics for

pain.

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Case 2

• KB is a 57yo M with a hx of poorly controlled DM, CAD,

cocaine use disorder, HTN, depression, severe LE neuropathy now primarily using a power wheelchair,

• pioid use disorder on methadone maintenance p/w

non‐healing foot ulcer that probes to bone and elevated ESR c/w osteomyelitis. He is admitted for IV antibiotics and surgical consultation.

• He is on methadone 30mg daily in a methadone

maintenance program.

– He was previously on 60mg, but had his dose reduced because of sedation.

Case 2

• Meds include:

– Glargine insulin 12 units q bedtime – Atorvastatin 80mg daily – Metformin 500mg bid – Zinc 220mg daily – Melatonin 3mg q bedtime – Venlafaxine XR 150mg daily – Pregabilin 150mg BID – Aspirin 81mg daily – Docusate 100mg BID – Ondansetron 4mg

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Case continued

• You get an ECG and he has a QTc of 600msec.

Question

• What do you want to do to manage this

patient? Who do you want to talk to?

– Talk as a group x5‐10 minutes & then report back

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Case continued

• The astute hospitalist contacted the medical

providers at his methadone clinic. They were able to explain:

– He has old ECGs on 60mg daily with a QTc of 460msec – He has had ongoing use of cocaine and opioids, especially since his dose has been reduced. His providers at methadone clinic wanted him to “come back at peak [methadone dose]” to assess for sedation so they could increase his dose, but he was never able to do that. Nevertheless, he has been dosing most days.

Methadone Clinic Pearls

• Goals of treatment

– Cessation or reduction of opioid use in

• rder to minimize harm

– Functional improvement – resumption of work, reunification with family

• Right Dose?

– Dose that allows the person to meet these goals – Impossible to say exactly, but at/above 80mg is considered important to decrease craving – Consistent attendance is important to establish a therapeutic level of the medication

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Approach to Sedation

• Perspective of a methadone clinic

– Methadone effect?

• Drug interaction

– Illicit or licit substance use: prescribed opioids, illicit opioids, BZDs, cocaine, speed, atypical antipsychotics (esp olanzapine), anti‐cholinergics – Secondary medical disease: pulmonary disease, thyroid disease, metabolic disease (i.e., DM), CNS process, liver disease (i.e., HE) etc. – Psychiatric disease

• Interventions

– Dose reduction – Observe patients at peak methadone dosing (2‐4 hrs after dose) – Urine drug screen – Medical evaluation

QTc Prolongation and Methadone

• QTc prolongation

– >450msec (men) and >470msec (women) – QTc >500 is “clinically significant” risk for developing arrhythmia and torsades de pointes – In case series of TdP and high‐dose methadone, 16/17 patients had other risk factors for TdP – MOA: possible blockage of potassium channels, leading to prolonged repolarisation and QTc prolongation – Variable recommendations for patients maintained in methadone programs

• Universal screening v.
• Screening at >150mg/day
• UK Pharmacovigilance Expert Advisory Group (MHRA criteria) recommended: ECG monitoring if on

high dose (>100mg), and/or other reasons to have QT prolongation such as heart orliver disease, electrolyte abnormalities, taking CYP 3A4 inhibitors, or other drugs that can prolong the QTc

– Study: 57% would need screening ecg (75% if include cocaine as QTc prolonging drug)  18% had prolonged QTc (none above 500), no TdP. – Daily dose and use of stimulants associated with prolonged QTc

• Protocols within clinic (ours)

– Screening starts at 100mg daily, unless patient has a history of cardiac disease, prolonged QTc,

• r other risk factors

– Repeat ECGs after every 20‐40mg increase above 100mg

• Elevated QTc: risk‐benefit assessment

– How are they doing in treatment? [remember their OUD is a fatal disease!!!] – Do they have reversible causes of the QTc prolongation? – Is there a new culprit medicine? Check for drug interactions and other meds that prolong the QTc.

Mayet S, et al. Drug and Alcohol Review. 2011;30(4):388‐96

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Case Continued

• The hospitalist stopped all medications that

were QTc prolonging, corrected electrolyte abnormalities, and checked daily ECGs for the QTc interval.

• Repeat ECGs still showed a QTc of 500msec.

Question

• What do you want to do with the patient’s

methadone? Do you want to switch him to buprenorphine?

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Methadone to Buprenorphine

• Reasons to switch

– Buprenorphine is less sedating because of the “ceiling effect” – Buprenorphine might better address his chronic pain – Buprenorphine allows irregular dosing – Methadone does not seem safe – Disposition options?

• Reasons to not switch

– Patient engaged with methadone treatment (10+ year hx in the clinic), including working w/case management – Patient preference

Epilogue

• Patient had serial EKG monitoring and his QTc

decreased back to 460msec. He continued on 30mg daily of methadone. He was taken off telemetry.

• He continued to receive IV antibiotics in the hospital,

but about 5d after normalization of his QTc, he had an arrest and died.

– This 58‐year‐old man with type 2 diabetes mellitus, viral hepatitis C cirrhosis, hypertension and moderate to severe atherosclerotic cardiovascular disease developed chronic ischemic heart disease superimposed on hypertensive heart disease lead to a lethal arrhythmia and sudden cardiac death.

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Case 3

• DS is a 58yo M with a hx of Afib, CHF, prior
• rthopedic injuries, OUD, and obesity coming

in with new patellar fracture after a fall.

– He is on bupe‐nal 8mg PO TID

Group Discussion

• How will you manage his acute pain

complaints?

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Summary

• Consider yourself a front‐line provider for

diagnosis of an opioid use disorder in the hospital.

• You CAN and SHOULD administer methadone
• r buprenorphine to anyone with an opioid

use disorder during their acute hospitalization.

• Utilize the Project SHOUT resources if this is

unfamiliar to your hospital system.

Summary Continued

• Methadone to bupe transitions are complicated –

seek addiction or pain med consultation for assistance.

• Remember the drug interactions and QTc

prolongation of methadone.

• For acute pain treatment for patients maintained
• n bupe or methadone, use full agonist opioids

as needed (but remember multi‐modal treatment) and coordinate w/the patient’s

• utpatient provider if rx’ing upon d/c (or taper
• ff while in the hospital)