Cases of Patients with OUD. Objectives

Transcription

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. 1

2 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? 2

3 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. History Additional Info 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 3

4 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 oxycodone 4

5 Question What do you want to do with this patient (besides fluids, antibiotics, VS monitoring, etc)? Wesson, D. R., & Ling, W J Psychoactive Drugs, 35(2), Available online as pdf 5

6 From: Interpretation of Urine Drug Testing in Pain Patients Pain Med. 2012;13(7): doi: /j x Pain Med Wiley Periodicals, Inc. Does this patient have an opioid use disorder? 4Rs Risk of bodily harm Relationship trouble Role Failure Repeated attempts to cut back 4Cs Loss of Control Consequences** Compulsion Craving Tolerance** Withdrawal 6

7 DSM-5 Criteria for Substance Use Disorders Recommendations and Rationale Risk bodily harm Relationship trouble Role Failure Compulsion Compulsion Loss of Control Repeated try cut back Consequences Craving 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. Source: Am J Psychiatry. 2013;170(8): 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 7

8 Remember You do NOT need an x license or waiver to give buprenorphine or methadone to a hospitalized patient with OUD and withdrawal 8

9 Case Continued The patient receives a dose of buprenorphine and feels much better She completes treatment of her pyelonephritis and is referred to outpatient buprenorphinenaloxone waivered providers (if she desires). She is offered prescription of naloxone for overdose prevention. She is not discharged with opioid analgesics for pain. 9

10 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, opioid 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 10

11 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 11

12 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 order 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 12

13 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, or 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):

14 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? 14

15 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. 15

16 Case 3 DS is a 58yo M with a hx of Afib, CHF, prior orthopedic 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? 16

17 Summary Consider yourself a front line provider for diagnosis of an opioid use disorder in the hospital. You CAN and SHOULD administer methadone or 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 on bupe or methadone, use full agonist opioids as needed (but remember multi modal treatment) and coordinate w/the patient s outpatient provider if rx ing upon d/c (or taper off while in the hospital) 17