MAT Training

if adolescents are exposed to opioids prior to 12th grade what are the risks?

- 1/3 higher risk for non-medical use in emerging adulthood (19-23 y/o) - 3x higher risk of nonmedical use for purpose of getting high - pts 10-12 y/o that used opioids non rx have 2x risk of abusing heroin later in life note: therapeutic use is still exposure and has risks.

what is the risk of prescribing opioids to pts with mental illness?

- 3x increased risk of receiving long term opioids and needing them chronically. So if they have mental illnesses then you need to be even more causous prescribing opioids. This goes for child and adolescents as well.

what is the correlation between heroin and other drug use? hint: 45% heroin & Prescription opioid correlation

- 9/10 people who use heroin have used at least 1 other drug - 45% of people on heroin were addicted to prescription opioids

If they are on naltrexone therapy and need emergent acute pain management what do you do?

- DC naltrexone - Consult anesthesia - High dose analgesics under close observation (have to be able to intubate) - Consider nonopioids and regional anesthesia

what are the fetal risks with opioid use disorder in pregnancy? hint: not opioid use d/o causes fetal risk, b/c if they are on MONO therapy bup/methadone they are fine. but if not the WITHDRAWALS are what cause FETAL RISK

- LBW - cogenital heart defects if codeine used in 1st trimester - fetal growth restriction - abruptio placentae - fetal death - preterm labor - intrauterine passage of meconium note: all of this is due to withdrawal cycles of mother not the intoxication

Risks of methadone and buprenorphine use in pregnancy

- LBW and decreased head circumference (not long lasting) - NAS up to 2-4wks after delivery - QTc prolongation - Constipation - Complicates pain management during delviery

how does women opioid use differ from men?

- Men have more opioid use disorders but women have increasingly closed the gap - pregnant women are less likely than non-pregnant women to use opioids - takes women less time from first use to developing SUD - women SUD is more severe with worse impairments - women inject more often

How do you do SBIRT?

- Screen: NIDA, CAGE, AUDIT, DAST, CRAFT - Brief Intervention with steps: counseling, pt education to reduce risky behavior. 1. Express concern if screen positive 2. Assess readiness for change 3. Discuss obsticles, prior attempt success/failures 4. Discuss benefits of quitting 5. Make recommendation for healthy behavior and suggest tx, this may just be a trial of abstinence (if low-moderate severity) or MAT. 6. Make goals and encourage them to get family/friend support, provide resource info 7. Schedule follow up apt (q2wks-1mo best to work towards short term goals together & monitor success) 8. have MAs do follow up calls during week 9. at follow up problem solve barriers, assess mood, give support - Referral: when they have co-morbid psych problems. So we are who they refer to.

how do adults read emotions vs teens? HINT: teens more intese emotion b/c amygdalal; but adult feel emotion frontal cortex

- adults read emotion in the frontal cortex - teens read emotion in the amygdala, resulting in them lashing out or using substances to suppress that feeling

how do you assess a pt considering using vivitrol?

- assess motivation - evaluate social supports - LFTs less than 3x normal - last opioid 7-10 days ago - do they abuse alcohol? - UDA negative for all opioids before every injection - pregnancy test for all females of childbearing age (contraindication if pregnant)

what information to provide to the pt?

- brochure of info on bup - copy of rules/expectations they sign - providers name, address, phone number, office hours - emergency contact info - payment procedures

hwo to rule out poppy seed ingestion

- codeine concentration more than 300ng/ml w/o morphine means probable codeine use - morphine/codeine ratio less than 2 means probable codeine use - morphine concentration over 1000ng/ml without codeine present means probable morphine use

what are the recommendations if on bup tx and they need analgesia?

- continue bup but divide doses q8hrs to take advantage of analgesic properties - titrate short acting opioids for additional pain management

how do you treat acute pain if they're on methadone maintenenace?

- continue usual methadone maintenance tx - tx acute pain with 1.5x higher doses and shorter intervals - avoid mixed agonists/antagonists like stadol as they'll cause precipitated withdrawal

risk factors for SUD development in C&A?

- early aggressive behavior - lack of parental supervision - substance abuse (past) - drug availability - poverty note: so if they have self-control, active parents, get good grades, higher income homes etc. they would be lower risk.

documentation required when prescribing bup

- evidence of appropriate opioid use disorder criteria - length and severity of pts opioid use disorder - number, type, and intensity of previous txs - any legal consequences due to opioid use - psychosocial issues due to opioid use - mental illness diagnoses - document consent that adequate info was given, pt is competent to process the info, and consent was given freely and voluntarily, they were informed of practice rules and policies - insurance companies review medical records and so pt has to consent for disclosure of tx (inform pt this will never be sent to employer) - state you sent your pt to counseling and self help groups (NA) (this is required by DATA 2000) note: cannot prescribe bup without these in their chart as bup isn't approved in outpt use for anything but addiction. Remember DEA regulations require maintenance of records for at least 2 yrs. Most states though require even longer. Must be kept in a locked secure place and if kept in another place other than practice you have to inform DEA of where.

what do you need to address in your rules and expectations policy?

- expectations for non-pharm txs (must be involved in counseling, including NA/AA) - contacting provider when office is closed (have to honor its closed, call ahead if running out of meds) - payment of fees (tox screens, office visits, meds) - cancellation of apts - confidentiality - UDA testing procedure (if missed without an excuse are considered positive, if positive take a step back and discuss what caused use. If repeated relapses in first 1-3 months then move them to higher level of care, esp if opioids are in the urine vs other drugs because if we aren't even addressing the opioids then we are nowhere where we want to be) - Illicit drugs/abuse of alcohol (usually offices don't allow its use while on bup, including marijuana) - arriving intoxicated (very rare) - diversion/drug dealing (refills will not be given early, lost or stolen meds will only be refilled once) - aggressive acts/theft/destruction of property (inform police will be called, this is very rare)

what marijuana use puts adolescents at risk for use disorder?

- first use prior to 14 y/o - used more than 50 times prior to age 19

what is the issues unique to tx with adolescents? hint: asses HCG test for all female before bupnophrene

- have to have supervision of take home doses - risk of diversion is even greater - must have indivudal or family counseling - must assess for pregnancy, all female adolescents must be tested before buprenorphine is administered

how do you prevent relapse?

- help them develop coping skills - ask about previous triggers in neutral manner - develop plan for potential slips -- this is not a full blown relapse, but just limited use. Try to identify negative affective states, interpersonal conflict and social pressures prior to slip. Once its occurred, don't make them feel guilty and reframe the slip as something that allows us to learn more about their triggers and then develop a plan to identify warnign signs of a slip. common relapse causes: - inadequate buprenorphine dose or not taking SL correctly - secondary drug/alcohol use - DCing counseling, tx, self help etc - returning to their environment and having to deal with normal life stressors

Signs of NAS

- high pitched cry - reduced quality and length of sleep - increased muscle tone, tremors, convulsions - frequent yawning - sweating - sneezing - increased RR - excessive sucking - poor feeding - regurgitation/vomiting - loose stools note: all these usually star within 24 hrs after birth (for heroin) or 72 hrs after birth (methodone and buprenorphine). Can appear 5-7 days after birth in some.

Pts not physicially dependent on opioids that could be good on buprenorphine

- high risk populations for opioid abuse such as recently released from prison - pts struggling with sobriety on naltrexone XR (vivitrol) - pt that never met criteria for dependence (no tolerance or withdrawal) but meets DSM 5 criteria for opioid use disorder - pt who was once on buprenorphine then came off and did well but is now struggling although they aren't physically dependent they may restart buprenorphine or put them on naltrexone. note: for all these start with 2mg SL, most pts like this stabilize on 2mg. Many pts may just need 4-6mg. Very rarely will they need 16mg. - monitor in office for 2+ hrs after 1st dose - increase dose 2mg/day over several days PRN - stable dose is what dose eliminates cravings - typical dose is 6-16mg

who is risk of OD after DCing tx highest in?

- highest in pts DCing PO naltrexone - PO naltrexone higher than vivitrol - vivitrol and methadone is comparable note: long serum XR naltrexone provides protection during early drug free period

what pts have best response to tx with naltrexone?

- highly motivated pts - older pts with long hx of use and multiple relapses - young adults living with parents who supervise tx - pts with long periods of abstinence between relapses

What do you need to teach them if they do a home induction?

- how bup/nx works and how its absorbed (use the graph of full, partial agonists and antagonist) - teach COWS and withdrawal sxs - start scoring 12 hrs after heroin or opioid pills and 24-36 hrs after methadone use - self administer 4mg when COWS is 12+ - self score COWS agian in 1-3 hrs, if still 12-16 then administer 4mg again - self score a third time on day 1 6-12 hrs after 1st dose, if still 12-16 on COWS give 4mg final dose. - total daily limit for day 1 is 12 mg - day 2 if you feel ok when you wake up take same dose as on day 1 (either 4, 8, or 12mg). If you wake up withdrawing (COWS 12-16) then take day 1 dose plus 4mg. - day 3-5 come to office and visit with prescriber, at this point they should just stay on this same dose. They will start to feel more and more comfortable. note: many of these pts have used buprenorphine before on the street, so they know how to use buprenorphine they just have to be taught how to use it appropriately.

what do you need to document if you do in office induction?

- inventory and dispensing of controlled substances - if medication is dispensed in the office, a record of whats dispensed has to be in the pts record - have to take a separate inventory of medication kept in the office note: it is just not worth it to keep in the office because they also have to be in a double lock system and there is more scrutiny by the DEA if you do this. So just send to the pharmacy to dispense the medication and have the pt bring to the apt.

how does naltrexone work?

- its a long acting mu antagonist - behaviorally blocks positive reinforcing effects (euphoria) of use leading to decreased craving and compulsive use. They start to lose the urge to use.

how does opioid use disorder alter the pain experience? what if they're on MAT?

- less pain tolerance in remission - less pain tolerance on opioid maintenance tx - methadone maintained women have increased pain and need 70% more oxycodone after c-section - pts on MAT have an opioid dept so they need maintenance on daily equivalence before any analgesia for acute pain and then opioid analgesic requirements are higher due to increased pain sensitivity and opioid tolerance (due to being on MAT) - if they're on MAT and they don't have adequate pain management with acute pain they're at higher risk for relapse. But if adequately treated they are not at higher risk for relapse.

what are the recommendations for bup tx for chronic pain?

- mean dose of 8mg/day with range of 4-16mg in divided doses - mean duration of tx is 9 months - 86% got relief - 6% DC'd due to SEs or worsening pain - all studies show its effective

what MAT med is approved for use during pregnancy?

- naltrexone isn't adviced for use due to lack of long term data - neither methadone or buprenorphine is FDA approved during pregnancy

MAT medications and breastfeeding guidelines hint: naltrexone - not during breast feeding. bup will be fine methadone : can breast feed to.

- naltrexone: enters breastmilk, recommends not breastfeeding - buprenorphine: enters breastmilk, okay to breastfeed because infant won't keep in mouth long enough for SL absorption required - methadone: enters breastmilk, 2-3% gets transferred. Can breastfeed, but if mom uses illicit drugs then pump and discard until sober.

how does analgesia change for post c-section women on buprenorphine or methadone?

- no difference in opioids required during surgery - those on bup required less opioids pre-operative and in first 24 hrs post-op - no differences in postop complications or length of hospitalizations between women on bup vs methadone - no differences in PCA requirements post-op if on either - no difference in pain scores, incidence of N/V or sedation if on either

Techniques of MI

- open ended questions - express empathy - try to understand their motivations and explore ambivalence - use reflective listening - repeat what you've learned from them - highlight discrepancies (to increase change talk)

who is a good condidate for XR-naltrexone?

- pts entering tx in active addiction or after short term detox/rehab - pts who succeeded on agonist tx and successfully tapered off (take for a few months to get comfortable not being on any agonist anymore) - highly motivated pts - older pts with long hx of use and multiple relapses - young adults living with involved parents - pts in residential tx - pts with long periods of abstence between relapses theres a 21% reduction in relapse with vivitrol after tapering off opioids.

what is qualitative vs quantitative UDT and when do you use each?

- qualitative is the cup, allows bedside testing but less accurate (many false negatives and positives), just tells you if positive or negative. note: Don't use this for major clinical decisions without more advanced quantitative testing. - quantitative uses labs to show the amount of drug/metabolite found in the sample (urine, serum, sweat or saliva). note: Doesn't tell us exposure time, dose, frequenty/pattern of use. But can help monitor parent vs metabolite vs pharmaceutical contaminant, steadily falling tHC levels from a previous heavy user, and OTC meds (pseudophed etc).

how does pts on MAT change total joint arthroplasty pain control?

- require more pain service for intractable pain post-op - require 8x higher opioid doses - no difference in length of stay, outcomes, or complications

what are the 6 core processes of ACT?

1. Acceptance of private experiences: willingness to experience uncomfortable thoughts, feelings etc. 2. Cognitive diffusion or emotional separation/distancing: observing one's own uncomfortable thoughts without taking them literal or attaching value to them 3. Being present: focusing on present rather than past or future 4. A perspective-taking sense of self: being in touch with whats going on around you 5. Identification of values that are personally important 6. Commitment to action for achieving the personal values identified

how do you taper off of methadone or bup and transition to naltrexone?

1. If on methadone transition them to bup. 2. Pts then taper down to bup 2-4mg for at least 1 month before DC. 3. May use medications to help with sxs of DC. Clonidine for agitation etc. 4. Start PO naltrexone and wait for UDA to be negative of bup. 5. Once negative and no reactions to PO naltrexone give vivitrol.

How do you transfer from methadone? hint: 1-2 week lowest methadone to 30mg then 15 mg on last day then 0 methadone one day; then bup induction

1. Stabilize on 30mg for 1-2wks 2. Last day on methadone cut dose to 15mg 3. Next day no methadone 4. Following day do buprenorphine induction

what are the 10 common cognitive distortions: all or nothing thinking, overgeneralization, mental filter, disqualifying the positive, jumping to conclusions (mind reading and furtune teller error),

1. all or nothing thinking: black and white thinking, if you fall short you see yourself as a failure. 2. overgeneralization: single bad event is a never ending apttern of defeat. 3. mental filter: they pick out a single negative defeat and dwell on it so your whole reality is darkened. 4. disqualifying the positive: dismiss positive experiences by saying they "don't count" for some reason, to maintain negative beliefs. 5. jumping to conclusions: make negative interpretation without convincing support. - mind reading: conclude that someone is reacting negatively to you but you don't investigate it. - furtune teller error: anticipate things will turn out bad and you believe your prediction is already a fact. 6. magnification (catastrophizing) or minimization: exaggerate importance of things (like your goof-up or someones else's achievement) or you shrink things (your own good qualities or others imperfections). AKA binocular trick. 7. emotional reasoning: assume that your negative emotions reflect the way things are. 8. should statements: try to motivate yourshelf with should and shouldn'ts, so you have to be punished before you can expect to do anything. This causes guilt and when you direct should statements towards others you get angry and frustrated. 9. labeling and mislabeling: extreme overgeneralization. Your errors are attached to labels like "i'm a loser". If someone else does something do you, you label them "he's a louse". Mislabeling is highly colored and emotionally loaded. 10. personalization: you see yourself as the cause of some negative external event that you aren't responsible for.

how should you handle problem behaviors?

1. ask for self evaluation: ask the pt to problem solve and generate a plan 2. negatioate from strength: refer back to clinical agreements to defend integrity of tx while considering violations in the context of their situation note: have to be aware there are impacts on your staff and other pts if theres no consequence to the pt. Boundaries then become loose and this becomes very problematic as well.

what do you do if they come not in withdrawal? hitn: if withdrawal means "they are free of any opioid for long time and i can induce them on Bupronerphine"

1. assess time of last opioid use 2. have them come back (if it was just recent) or wait in office until they start to get into withdrawal (if its just an hr or so outside the window)

how do you manage severe pain with vivitrol?

1. full doses of NSAIDs (ketorlac injection) 2. regional nerve blocks if persists and intolerable 3. high potency opiates (fentanyl or bup) can override blockade but anesthesiology has to be involved

what do you do if you cause a precipitated withdrawal?

1. give another dose of buprenorphine to try and get enough agonist effect to supress the withdrawal 2. Stop induction and give symptomatic txs for symptoms like giving some clonidine and have pt return next day. - issue with this is you risk losing the pt because they think they had a reaction to the medication.

what determines the chance of precipitated withdrawal with buprenorphine tx? hint: dose of full agonist more =more withdraw; recently taken =more withdrawal; and hgiher dose of buprenorphin=more withdrawal

1. level of dependence (their daily dose currently of full agonist, higher means more withdrawal) 2. time interval between last dose of agonist and 1st dose of buprenorphine (more withdrawal if get buprenorphine shortly after taking full agonist) 3. dose of buprenorphine (low dose, could still have some full agonist working) note: remember that buprenorphine has higher affinity, so they could feel sick when they are given it because it is only a partial agonist.

what are the options for medication access with induction?

1. pt fill prescription and brings first days dose to the office to be administered - most frequently used, esp initially as a new provider. Can see severity of their withdrawal and assess the correct dose. Then later you can better educate them when doing a home induction about what they are experiencing because you have seen it with your office inductions. - it is extremely rare they pick up the prescription and don't come back to the office. - have these take place mon-wed to allow for office to be open the 2nd day so they can come in if needed if they respond poorly. 2. you keep a supply of medication in the office for induction (maybe 150 tablets of combo product) - could be audited by DEA making sure you are handling the medication appropriately. Where do you keep the medication, do you have lists of exactly where every pill went and does this match up with your current pill count? 3. pt fills a prescription for home induction

how do you respond to an OD?

1. recognize the OD 2. call 911 3. rescue breathing with chest compressions if no pulse 4. administer naloxone and continue breathes if needed, readminist naloxone at 3-5 minutes if no response 5. stay until help arrives, put in recovery position if breathing

How do you start vivitrol?

1. take PO dose 3-5 days after any opioid of 1/4 pill (12.5mg) QD x2 days 2. take PO dose 1/2 tab (25mg) QD x1 day 3. take PO dose 1 tab (50mg) QD x1 day 4. if no reactions then give vivitrol observe them in the office for signs of withdrawal for 45-60min.

recommendations for bup dosing prior to a surgery or procedure and how pain should be controlled during hospital stay

1. take last bup dose on morning of day prior to procedure 2. hold bup dose day of surgery 3. pre-procedure give single dose SR morphine 15mg day of procedure 4. post-procedure opioids given using standard dosing protocols and pain management monitored since their opioid addiction often decreases pain tolerance requiring higher opioid doses and shorter intervals. Also due to possibility of bup acting on the receptors fentanyl is the opioid of choice during surgery and in PACU 5. post-procedure inpt continue to hold bup and put pt on SR morphine 15mg BID for baseline requirements to control pain and use PCA for breakthrough pain (fentanyl, dilaudid or morphine) with no basal dose. If pt doesn't require PCA for breakthrough control use short acting opioids (oxycodone, morphine) and continue SR morphine. 6. post procedure outpt continue to hold bup and continue SR morphine. tx breakthrough pain with short acting opioids and schedule them to be seen by their bup provider to restart bup maintenance when they no longer need opioids for breakthrough pain

how many kids aged 12-17 y/o have a SUD?

1/20

what is common with pts after injection and what can you do about it?

1/3 of pts test blockage within 1-2 days after injection as blood level is low first 24 hrs. Give PO supplement on day 1 to prevent this. Most pts will test 1-2 times with small amounts of opioid during first wk, but when they see it doesn't work they usually don't try again. Some will try large amounts for 1-3 wks but as long as they get no effect very few will persist to try to override the blockade. Usually these pts will prefer to stay on medication despite this.

AUDIT question scoring guide

10 questions scored 0-4. 8+ means potential alcohol misuse.

what is the max required for most pts?

16mg

what are we mandated to report with SUD?

17 states require reporting of mothers with SUD to child services (considered child abuse) - MN, SD, WI considers it grounds for civil commitment 15 states require reporting suspected prenatal substance abuse - 4 states require us to test if we suspect it 18 states have programs esp for pregnant women 10 states give pregnant women priority access to state substance abuse programs note: idaho and oregon does not require any reporting but Utah does and considers it child abuse if used when pregnant, testing not required.

how often should someone come in to be seen with buprenorphine tx?

1x/wk for 3 months but they are in group during these days and you will pull them out during group to refill their prescription. This motivates them to get involved with group.

what formations is suboxone SL available in? hint: quotient = 4 b/c B:N is 4:1 4/1 or 8/2.....

2/0.5mg 4/1mg 8/2mg 12/3mg want to try to keep from having open medication infants can get into. No infants/toddlers were able to get into these. Also with pills, if a toddler opened a bottle with pills they could get a really high dose right away whereas with the films its unlikely they'll get really high doses.

when does the brain finish maturing?

24+ y/o and substances appear to be irreversible so substance abusing teens may never achieve their full intellectual potential. Also because they just turned to substances to learn to cope they may never be able to learn how to cope with their emotions. So if they have abused substances since a young age attending counseling and groups like NA/AA regularly and frequently is going to be extremely important because they will require even more support.

what is the risk for relapse and fatal OD if just in counseling wihtout MAT? hint: DOUBLE?

2x increased risk

how long does naloxone block the receptors?

30-90 minutes

what is buprenorphine metabolized by? what are common reactions?

3A4 interactions: erythromycin, rifampin, OCPs, phenytoin, carbamazepine, paraxetine, TCAs, grapefruit juice - rifampin reduces bup levels - atazanir/ritonavir increases bup levels note: taking both doesn't mean they'll OD, but there is just an interaction here

what are the 4 Ps of opioid use disorder screening tools in pregnancy?

4 P's/4 P's Plus - parents: did either of your parents ever have a problem with alcohol or drugs? - partner: does your partner have a problem with alcohol or drugs? - past: have you ever drunk beer, wine, or liquor? - pregnancy: in the month before you know you were pregnant, how many cigarettes did you smoke? how many beers/how much wind/how much liquore did you drink? how many times did you use opioids non-medically?

what percentage of kids who start drinking at 14 or younger will develop alcohol use disorder?

50%

how many times the normal dose of opioids is needed to overcome naltrexone blockade?

6-20x the usual dose - theres not significant respiratory depression or sedation with this

what do you have to do to overcome a naltrexone blockade?

6-20x the usual opioid dose resulting in analgesia is required. But risk for resp depression is great so have to be in a setting where they can place an airway if needed.

how long do you have to be detoxed before using naltrexone?

7-10 days - this is the major barrier for pts who can't tolerate withdrawal as residential/inpt tx programs to detox in are hard to find - pts won't feel well at the beginning of tx due to the fact that they likely will not have detoxed completely - ensure abstience with UDA negative for all opioids (morphine, oxy, bup, methadone, fentanyl) have to also check specifically for kratom. Even if UDA is negative (heroin wasn't used within 48-72 hrs) they can still be dependent and withdrawal will be precipitated unless its been 5-7 days. - start with naloxone challenge - naltrexone will precipitate withdrawal within 30-60 min (can result in delirium)

how long do they have to be abstinent from a full agonist before vivitrol?

7-10 days, which is the main barrier for most pts to use this

what percentage of women that're addicted to drugs esp heroin have traded sex for drugs or money?

85%

Billing Codes for Drug and Alcohol tx

99406: smoking and tobacco use cessation counseling (3-10 min), usually 2-3 sessions 99407: smoking and tobacco use cessation counseling (10+ min), usually 4 sessions 99408: alcohol or substance use (other than tobacco) screening and brief intervention (15-30 min) 99409: alcohol or substance abuse (other than tobacco) structured screening and brief intervention (30+ min)

what is the DAST-10?

A screener for drug abuse

What 2 properties explain why buprenorphine works so well?

Affinity: it has a very strong affinity for the mu receptor, so it will displace a full mu agonist. This does not mean it is strong in regard to its activation, just that it will displace other things. Dissociation: speed that the drug uncouples (leaves) the receptor. Buprenorphine does this very slow, usually 72 hrs. Doesn't mean it has full activation, but it does mean its bound so other things can't displace it. This is why for 24 hrs or longer after buprenorphine mu full agonists are ineffective. So you could do buprenorphine MWF for example. note: if they take an opioid after buprenorphine they will get some effect but just not the full euphoria/analgesia.

what is brief treatment?

After brief intervention they move to brief treatment which is longer intervention that requires more time per visit and usually more than 4 visits with medications and more intensive counseling. Discuss relapses as needed. Have to adjust short term goals and seek outside support for wrap around services to support the patient.

Can buprenorphine ever cross over to a full agonist? hint; more dose=more analgesia but never.....

At higher doses it will cause more analgesia but it never becomes a full agonist.

Pros of buprenorphine vs methadone

Bup: - fewer dose adjustments - fewer drug-drug interactions - ceiling effect - officed based - less NAS, shorter hospital stays - more drop out compared to methadone (half as many) Methadone: - more data on long term developmental and behavioral outcomes - structed clinic - easier acute pain management - more familiarity with providers/hospital staff

CAGE-AID questions and scoring guide

CAGE: - have you tried to cut down? - have you gotten annoyed by others comments of your drinking? - have you felt guilty about your drinking? - have you ever had to drink in order to wake up or settle your nerves in the morning? positive = 2+ - risk = 1+ note: positive screener then you go to an AUDIT

what 4 psychotherapy modalities are most used with substance abuse?

CBT ACT MI 12 step facilitation Support groups

what genetic polymorphism puts them at much higher risk for developing schizophrenia if they smoke marijuana?

COMT val/val. if they're non smoker they have a 1% chance, but if they smoke they have a 14% chance of developing it by age 26. note: if you have the met/met there is no increased risk if they smoke. So inform these kids of the risk based on their genetics.

What is the dose schedule for induction?

Day 1: 1st dose: 2-4mg SL combo product - monitor for 1+ hrs for sxs (they can go for a walk or get coffee and come back), withdrawal should start 30-45 min after this dose. - if you caused a precipitated withdrawal this will be evident in the first hr. - redose q2-4hrs if withdrawal subsides then reappears. Usually if they have a 6+ on COWS you repeat dose. target dose: 8-12mg in first 24 hrs. Day 2: come back to office, assess opioid use and sxs since 1st dose. Increase dose with withdrawal sxs, lower dose if was overmedicated (sedation etc). Adjust by 2-4mg increments until 12-16mg, avg dose is 12mg. - naive addicts may stablize on 4-8mg, while severe addicts with polysubstance or injection abuse may be 16mg; almost never go to 24mg and never go to 32mg (at huge risk of diversion at this dose). Remember the goal is just to reduce cravings. If they get to 12-16mg and say its not holding them; wait it out a few days, most pts will stabilize after 5 half lives. Inform them they haven't reached steady state yet. Their symptoms will go away, only if their cravings are horrible do we go up. - its rare they go home and use an opioid the same day as induction. Days 3 and beyond: if requests dose increase at 16mg wait 5-7 days and then reassess technique in taking dose. - standard range: 8-16mg - most stbailize at: 12-16mg - max dose: 32 mg but very high diversion risk - most insurances have issues at higher doses than 24mg and many at 16mg

what is the FRAMES brief intervention approach esp with relapse?

F: feedback specific to the relationships between behavior and possible consequences and seek reaction from pt to help them understand how this contributed to the problem R: responsibility for change is the pts, they need to accept making the change is their responsibility A: advise specific strategies, but allow them to make the choice M: menu of possible options E: emapthy facilitates change (not the same as approval), this is not easy and maybe early childhood may be making it much more difficult for them. It doesn't just come down to strong will. S: support self-efficacy, their belief in their ability to succeed. Change is possible tell them "You can do it". They are responsible to do it but say "I'm here to help but you must decide for yourself, no one can do it for you."

What is the most important aspect of recovery and staying sober? hint: because of "salient atrribution" cues related to addictive substance grab their attention far more than other cues

Getting out of the environmental influences reminding you of use causing increased cravings.

what medical condition is extremely common to this population?

Hep C due to IV use and high risk sexual activity. Note: HIV also very common. Both of these can be treated with buprenorphine. Bup may mildly elevate liver enzymes but not much. As long as its not 3x greater than normal, but even if they are above this injectious disease usually still says to start bup because this will stabilize them to tx the hep C or HIV better.

metabolism of opioids

Heroin > 6-MAM > morphine > hydromorphone Codeine > morphine > hydromorphone Codeine > hydrocodone > hydromorphone Oxycodone > oxymorphone

how do you assess your pt? hint: APO: [OPQURST [ onset with tobacco; palliative(tried to stop?); provoke to smoke?; quality..... O: PMH: sam-mph ros social. social: elmo farts [ r=recreational iliciit OPQURST ; T=Tobacco OPQURST]

History 1. start with first substance used (usually nicotine) 2. ask about all substances (licit and illicit) 3. determine changes in use over time (frequency, amount, route) - important to determine dose of buprenorphine and formation 4. assess recent use (past several wks) 5. determine relapse/attemts to abstain (what happened, what was their longest period of abstience, identify methods of abstinence and triggers for relapse) 6. what has happened with them during intoxications or withdrawals (any ODs? medical problems?) 7. get tx hx (counseling, MAT, response to tx, attendance of 12-step programs, did they have a sponsor?) 8. get hx of social impairments due to addiction (have them verbalize, can be an awakening for them) 9. what is their psych hx (hospital stays, untx psych illness, psych meds, diagnoses) 10. medical hx (current meds, illnesses, accidents/injuries, PDMP) 11. family hx (SUD, BPAD, Schizo etc.) 12. social hx (early development!!, education [struggled? high anxiety?], were they able to hold their alcohol well early, employment, marriages/children, legal, transportation) note: initially choose pts that do not have a lot of polysubstance use or have multiple comorbidities so that you are comfortable treating them as you start out and then you can accept pts with more complications.

NIDA quick screen questions

In the past yr how many times have you used the following? - alcohol (men - 5+ drinks/day, women - 4+ drinks/day) - tobacco - prescription drugs - illegal drugs

psychosocial therapies for substance use disorders

MI motivational enhancement therapy (MET) CBT community reinforcement approach (CRA) contingency management (CM) couples/family therapy

Medicare and Medicaid codes for tx

Medicare - G0396: Alcohol or substance abuse (other than tobacco) screening and brief interventions for 15-30 min - G0397: for more than 30 min Medicaid - H0049: alcohol or drug screening - H0050: alcohol or drug service, brief intervention per 15 min

if pts DC buprenorphine what should they really be put on?

Naltrexone ER, esp post detox. After 7-10 days free of opioids, buprenorphine or methadone you would do this.

what are the MAT options? How do they work?

Naltrexone: opioid antagonist Methadone: full opioid agonist Buprenorphine: partial opioid agonist note: theres not a 1 size fits all, try 1 of the other options if 1 doesn't work for the pt.

what is better for pts if they want to eventually DC methadone or buprenorphine?

Neither show to be effective for this, when DC'd after 16 wks in studies most pts resumed opioid use. so this is not a cure, we get their drug use stable and under better control (control the cravings) so they can live their life. Convince them to find a good maintenance dose to stabilize their life and then gradually decrease their dose as long as their cravings are controlled and some pts may be able to DC. But this may never happen. This is just like a pt with DM who changes their lifestyle but may never be able to fully be off of glycemic medications because their pancreas is too weak, with addiction the same thing may be the case as brain changes for them may never be reversible. There is no evidence that buprenorphine is dangerous long term. Most pts will be able to DC but they will relapse in the first yr, but you can just try again. But for some their mood and life is just better on medication long term, and for these pts you just try to get them at the lowest dose possible but don't force them to DC. Regardless everyone should be motivated to use buprenorphine maintenance tx not withdrawal or detox tx as this is much less effective.

Naltrexone induction algorithms

Note: Based on severity of anticipated withdrawal none: already abstiencne for 7-10 days (from opioids are after a bup taper and DC). You just start naltrexone on day 1 at 25-50mg for 1-2 days and then give vivitrol. mild: classified as 1-2 bags/day of heroin or less than 50mg/day of oxy. Can do bup dose of 4mg day 1 with clonidine 0.1-0.2mg TID of QID and clonazepam 0.5mg BID. Give NSAIDs for pain. Must really hydrate. Day 3 give naltrexone at 12.5mg QD. Day 4 25mg QD and day 5 50mg QD. Vivitrol given on day 6. - if transitioning from bup maintenance to naltrexone do 2mg bup QD on day 1 then abstinent day 2-3 and naltrexone 1-3mg day 4, 6-9mg day 5, 12-25mg day 6 and vivitrol day 7 with supportive meds available throughout. moderate: classified as 3-6 bags/day of heroin, oxy 50-100mg/day. This is done following a methadone or bup taper and only partial hospitalization with inpt back up. Give bup 4-8mg for day 1 and 2 with 0.2mg TID-QID clonidine and clonazepam 1-2mg TID-QID. Can also give NSAIDs for pain, sleep meds or GI comfort meds. Must hydrate! Give naltrexone days 3-4 at 6mg BID. Days 5-6 titrate naltrexone to 25-50mg QD. Day 7 give vivitrol. Severe: classified as more than 6 bags/day of heroin, opioid use more than 100mg/day and significant medical problems. Only done inpt or partial hosp with inpt backup. Day 1 give bup 8mg or more PRN. Taper on days 2-3. Clonidine 0.2-0.3mg QID, clonazepam 1-2mg QID. Comfort meds as in mod. Hydrate, may need IV hydration. Days 4-5 (or later if needed) give naltrexone 3-6mg QD-BID. Day 6-7 titrate naltrexone to 25-50mg QD. Day 8 give vivitrol. note: the problem with these low doses of naltrexone is that they're only available at compounding pharmacies so if they need this they probably will have to be in a partial hosptialization program.

what was the CARA act in 2016?

Obama passed this to expand addiction and recovery tx by expanding prevention, education, naloxone, PDMPs, evidenced based opioid use DO tx, and MAT programs. this is what allowed NPs and PAs to prescribe buprenorphine but this expires in 2021, which it would then need to be renewed. They cannot, however, up to the 275.

Tx of NAS

Opioid supplement, usually morphine but bup and methadone have been used. Taper for 8-12 days and DC. morphine: 0.24-1.3 mg/kg/day q3-4hrs - 50-70% of infants will need meds - FNASS usually used to assess q1-4hrs

what does TWEAK and T-ACE stand for and whats it used for?

Opioid use disorder/drinking in pregnancy - TWEAK: Tolerance, Worried, Eye-opener, Amnesia, K/Cut Down - T-ACE: Tolerance, Annoyance, Cut down, Eye-Opener Tweak better for detecting past 6 months usage, T-ACE better to detect lifetime alcohol use

Symptoms of Substance use disorder mneumonic and criteria for mild, moderate, and severe

Over last 12 months: - mild = 2-3 - moderate = 4-5 - severe = 6+ CHEW THAT COP - cut down: unsuccessful attempts - health: continued use despite physical/psychological problems - excessive use: larger amounts and longer time than intended - withdrawal (not all substances) - time: time spent on getting/recovering - hazardous use: use in unsafe situations - activities: give up activities - tolerance: larger amounts needed - craving - obligations: failure to fill them - personal problems: continued use despite problems

Pharmacokinetics of methadone hitn: 30 min onset ; but "the elevant sit on you 1-2 days ; PCP toni prescribe it for 6-8hr pain control not for addiction b/c pcps can't do that.

PO or oral solution. PO onset 30-60 min. Duration is 24-36 hrs that it prevents withdrawal and cravings. Provides 6-8 hrs of pain control. note: they could miss a dose and be fine if taking for withdrawal purposes.

what is the half life and blockade time for PO naltrexone vs IM?

PO: - half life is 14 hrs - 50% of the blockade is gone after 72 hrs note: have to DC at least 72 hrs preoperatively IM: - peak level within 2-3 days, decline begins in 14 days note: have to delay surgery for a month after last dose if you can

what to do if on PO naltrexone and IM naltrexone for perioperative pain management

PO: half life is 14 hrs so DC 72hrs preoperatively. 50% of blokade is gone after 72hrs. IM: peak plasma within 2-3 days, decline begins in 14 days. Delay elective surgery for a month after last dose, ideally 6 wks and may want to bridge with naltrexone tablets leading up to the planned procedure.

how often should bup be dosed?

QD, its long acting. Only if they're on more than 24mg should they do split dosing.

how do you assess adolescents for an SUD?

S2BI: 1. in the past year how many times have you used: tobacco, alcohol or marijuana? 2. if never to all then stop and move on. 3. if yes, get frequency they use. 4. in the past year how many times have you used prescription drugs that are not prescribed for you? 5. ... illegal drugs? Inhalants? herbs or synthetic drugs? 6. each time get frequency of use. no use = positive reinforcement 1-2x/yr = give brief advice to stop monthly use = assess for problems, do brief MI, advice to quit and make a plan. Try to reduce risky behaviors.

instructions for formulation administration

SL: hold under tongue for minutes to dissolve and then let it sit in there for another minute after it dissolves. It becomes kind of gummy, wait another minute and then spit out. If they don't wait they won't get the effect. If they then spit it out vs swallow this may reduce SEs esp HA. Buccal: take fewer minutes and get stuck to buccal mucosa. Can swallow this one. PO: wait for it to dissolve, then swallow. With both avoid acidic drinks (coffee or fruit juice), nicotine products for 15 minutes (interferes with absorption). instruct them as they wait to dissolve tell them to think about their recovery, their day, how it went and tell themselves some positive affirmations.

Withdrawal in short acting vs long acting opioids? hint: heroin/oxycodone are short acting means high for 6hr and withdraw 6ht; methadone is long so high for 36 hr, and withdraw after 36

Short - heroin, oxycodone - withdrawal: begins 6-12hrs after last dose, peaks at 36-72hrs. Can last 5 days note: its half life is why they have to inject heroin 3-4x/day. Longer half lives - methadone - withdrawal: begins 36-72hrs after last dose. Takes longer to peak. Less severe withdrawal, this is why a slow taper with buprenorphine and methadone works to get off. note: we are able to load them and taper them down pretty quickly due to the long half life.

what are the urine detections times for heroine/morphine, cocaine, marijuana, and benzos?

Stays in the urine for: heroin/morphine: 1-3 days cocaine: 1-3 days marijuana - occasional use: 1-3 days - chronic use: up to 30 days (sometimes greater if smoking for months) Benzos: up to 30 days (same as with marijuana, if just used a couple times will be in for days but if regular use will be in for a month plus)

why is methadone better than heroin? hint: Methadone is like "Heroin" but all the bad things gone

Their mood is stable (vs getting mood swings), they can't get high, their cravings go away, normal intellect returns, normal range of motion, improved relationships. All of these things heroin does the opposite and so although the MOA is similar it doesn't cause the same effects as heroin.

what are MAT tx outcomes like if they have legitimate chronic pain and abuse substances?

There is no difference between those with chronic pain and without chronic pain that are using MAT. Tx retention is also no different.

how do you explain buprenorphine tx to help pts understand that we will take tx 1 step at a time? hint: buprion tx? think of it as anti htn

Think about those with HTN. If medications are just withdrawn there is no reason why we would think the disease wouldn't just come back. It is the same think with addiction. There are physical, likely permanent, changes in the brain. We don't know if coming off of medication will cause them to just have another relapse. So instead its preferred to just stay on medication. But if they are motivated we can try trials and see how it goes but if they need it long term that is completely fine just as being on an antihypertensive is okay.

whats protracted abstinence syndrome? hint: protracted means "like jaw" right so when people are treated with MAT and then stop, they even become more sensitive to withdrawal and craving.

This is why people relapse. This occurs when their opioid receptor system is changed. They get generalized malaise, fatigue, insomnia, poor tolerance to stress and pain and they get opioid cravings. They get a conditioned trigger and then they relapse in order to feel normal again.

What are the time of abstinence required for induction for short acting opioids, SR opioids, and methadone? hint: time of abstinece = time since last used! "our objective is "when we induce them with Buponrphine we don't want them already on a high horse like methadone or SR(sustained release Opioids etc) b/c buprenorphin will crash them wiht withdrawal if already high; 1. so if methadone, they will be free at 36 hours , then you can induce them with bup after 36; 2. for SR opioid at 24 they will be free of it so induce bup atfter 24hr 3. if heroin, cody (oxy cody or hydro cody) then wait 12 hours only and induce bup b/c shorta cting is free by 12 hr.

Time since last use: - short acting (heroin, oxycodone, hydrocodone): 12-16 hrs -- instruction: take last dose around 6PM and then come in at 8AM for induction. -- assessment: do COWS and it should be greater than 8, frequently look for greater than 11 because at 8 it can be subjective withdrawal whereas at 11 its more objective signs. But remember they don't have to be horrible to induce. - SR opioids: 24 hrs - methadone: 36-48 hrs

whats risky use of alcohol? Tobacco? Other drugs?

Tobacco: any Other drugs: any Alcohol - women: more than 1 drink/day or 7 drinks/wk - men: more than 2 drinks/day or 14 drinks/wk - under 21/pregnant/on meds that interact with alcohol/medical issues like cirrhosis/while driving etc.: any

why do we use UDAs vs blood?

UDA has a longer window of detection compared to blood (1-3 days for most metabolites), costs less, and is less invasive.

How do you use buprenorphine to detox off of drugs?

When withdrawing from opioids you can do 1 of 3 things to help them detox and taper off of opioids: 1. short-perioid rapid withdrawal: less than 3 days. Usually done inpt. Reports are that buprenorphine suppresses opioid withdrawal sxs better than clonidine. - day 1: 8-12mg SL - day 2: 8-12mg SL - day 3: 6mg SL 2. moderate-period withdrawal: 4-30 days, usually done outpt. You stabilize them on this for 30 days and then rapidly taper them off of buprenorphine and then transition them to naltrexone (improved abstinence rates when this is done). DO NOT JUST DC BUPRENORPHINE. - success rates are not great long term, this is more effective than clonidine over this time period but theres higher rate of return to opioid use after the 30 days. 3. long-perioid withdrawal: greater than 30 days, often 6 months or years long. Start at an 8mg dose to help them withdraw and taper off cold turkey. Its better to taper off slowly than quickly. Best to taper over more than 30 days. Taper rapidly to 8mg and then slowly from there. Which likely means maintenance for a period of time and then tapering off is best. But again they should be put on naltrexone for a period of time after DCing. The main reason to use buprenorphine during a detox is that detox will be more comfortable than without buprenorphine.

why do you have them come back in a few days? hint: to assess "craving" we increase dose if they crave. withdrawal is also assessed but not reason to increase dose.

You don't know the lowest maintenance dose until 5-7 days later so this is why you have them come in 3-4 days later to see if they are having any other withdrawal sxs. But you don't go up on the dose due to withdrawal sxs, you go up on dose due to cravings because if we can control their cravings then they don't have a drive to use opioids.

what percentage of kids who smoke at ages 15 or younger will have a marijuana use disorder?

about 20%

what level of mu opioid receptor binding with full agonist causes OD? Hint: kassu breath by o2 lowering; rest of us co2 lowering. when opioid depress your cns, you stop responding ot lowerr RR and build up of CO2

about 95%. At this level there is sedation that slows RR, but the main reason for OD is that chemoreceptors in the medulla stop responding to CO2. Usually when these build up it triggers us to breathe.

meds for alochol use disorder

acamprosate (campral) disulfiram (antabuse) naltrexone (revia, dpade, vivitrol)

what are the tx approaches for withdrawal?

agonist assisted tx: low doses used like methadone 10-20mg or bup 4-8mg for 2-4 days to prevent severe withdrawal. - best if medically or psychiatrically ill and thsoe with physical dependence on alcohol or sedatives. - agonist is tapered slowly to prevent severe withdrawal - clonidine is used if tapered quicker - taper speed is adjusted based on level of dependence, if co-morbid psych dx or dependence on alcohol/sedatives too then taper over a few weeks - initiation is a Bup taper over 7 days and then 7 days abstinence and then naltrexone induction symptomatic care only: meds to decrease sxs - initiation is clonidine and benzos usually for 7 days, abstinence for 1 day and then naltrexone induction. Washout is shorter as not using an agonist like bup shortens the washout period needed. rapid withdrawal using antagonist: naltexone given 2-3 days after last dose of opioid - start at 3-6mg - withdrawal sxs tx with meds to minimize discomfort - initiation is bup for 2 days (4mg BID) then abstinent on day 3 (with low doses with clonidine/benzos; 0.1-0.2mg QID clonidine, clonazepam 0.5-1mg TID, zolpidem, trazodone for sleep) gradually titrating the naltrexone over 7 days; 3mg day 4, 6mg day 5, 25mg day 6, 50mg day 7. Then give vivitrol day 8. - taper for bup after heroin use prior to rapid naltrexone induction is day 1-10 8mg of bup, days 11-16 6mg bup, days 16-20 4mg of bup, days 21-25 3mg bup, days 26-30 2mg bup. Then abstinence for days 31-32. Then days 32 naltrexone 1-3mg, day 33 6-9mg naltrexone, day 34 12-25mg, day 35 vivitrol injection. Here too supportive meds available from days 26 on. ultra-rapid withdrawal under anesthesia: withdrawal is precipitated with large dose antagonist while under deep sedation or gen anesthesia. - not recommended due to higher complications including death and minimal advantages - only used in low risk cases

what does MAT do?

alleviates physical withdrawal alleviates drg cravings restores brain changes

what is CFR42?

another layer of HIPAA specifically around substance abuse (drug and alcohol) disorders. They have even more regulations for confidentiality. This is a checkbox that when checked allows you to get this additional info released by the pt having to do with his drug and alcohol tx. So the MA would not be able to have this but the doctor would be able to access this.

whats the median age of onset for mental illness: anxiety/impulse control, SUD, mood?

anxiety and impulse control d/o - 11 y/o and 50% occur before this age SUD - 20 y/o mood - 30 y/o

how long should they stay on the naltrexone?

at least 6 months but many pts want to stay on it for 18 months because they know its a safe guard for them.

why do babies whose mothers were on bup has NAS most commonly?

because 75-90% of mothers on bup smoke tobacco and neonatal nicotine withdrawal mimics opioid withdrawal. so most often its actually nicotine withdrawal not opioid. So we really need to try and motivate them to stop smoking while pregnant.

why is naltrexone XR better than PO? hint: Naltrexone XR is the Goal!!!!

because our main goal in tx is retention in tx. Main reason for dropout is relapse, those that stay in tx stay abstinent. The XR has double the retention rate of PO (50-70%) at 6 months. For this reason, vivitrol is the injection of choice. note: retention with vivitrol is similar to bup and has lower opioid use than bup tx so vivitrol is really the goal and bup if they fail it.

why are methadone clinics so few? hint: guess what stimagma

because people don't want methadone tx centers in their back yard due to the stigma. This is why buprenorphine is great because it can be done in any clinic whereas before they didn't have any tx options. note: the hope over time is the stigma will decrease so methadone can be used more often if needed as more clinics could open because the stimga will decrease.

why is MAT important?

because places where MAT is implemented heroin deaths have decreased

why are relapses after vivitrol so dangerous?

because the vivitrol makes them more sensitive to lower doses of opioids and then they try to use large doses of opioids and they OD.

why do some pts on naltrexone actually drink more and not less?

because their euphroic feeling is blunted and so they try to just drink more to override the naltrexone.

why does it seem like methadone doesn't work?

because theres a stigma with methadone tx. If its working for someone you don't know they're taking it. You only know people are taking it when its not working.

why can PCPs prescribe their pts methadone?

because they are prescribing it for pain control. If you are prescribing it for opioid withdrawal and addiction tx it has to be done at a methadone clinic.

why is giving a dose higher than they need a risk for diversion?

because they just take what they need and then sell the extra on the street.

what should you not prescribe buprenorphine with?

benzos, do not allow a pt to have a prescription for buprenorphine and benzos.

what is bunavail available in? hint: another brand 'bun=buccal

buccal film you put against your cheek. 2.1/0.3mg 4.2/0.7mg 6.3/1mg recommended maintenance dose: 8.4mg/1.4mg

can you use bup if they have hepatic failure?

bup is metabolized by 3A4 so reduced hepatic function could cause increased bup levels. note: bup does not cause hepatotoxicity, so they just need to be monitored for increased levels. If they have hep C or 3x greater liver enzymes most of the time we still will do bup because this has to be controlled before the other things can be treated effectively due to improved compliance.

what is the efficacy of buprenorphine vs methadone?

buprenorphine is equally as effective as moderate doses of methadone (60mg/day). The higher dose of buprenorphine they got the less pts abused heroin or other opioids and more likely their urine with be opioid free. Higher doses will also decrease cravings. Studies show 8mg is typically the most effective dose, esp if they have a stable environment and are motivated to stop drugs. For these types of pts even right in the beginning low doses may be just as effective as higher doses and they also have a lower risk for diversion.

meds for opioid use disorder

buprenorphine/naloxone (suboxone, zubsolv) methadone naltrexone (revia, depade, vivitrol)

what are the formulations of buprenorphine tablets? hint: for every four-butterfly we "use one LOCK" BUPREONERPHINE TO NALOCKXONE = 4:1 EX: 2/0.5mg

buprenorphine/naloxone: 2/0.5 or 8/2mg Buprenorphine mono: 2 or 8mg note: all are in a 4:1 bup:naloxone ratio

Who would you use buprenorphine for vs naltrexone?

buprenorphine: - if adherence will be an issue (reinforcing effects promote adherence) and they don't want naltrexone XR injection - if they are also on opioid based pain management - they dropout of naltrexone XR tx (bup adherence may be greater) naltrexone: - pts are highly motivated and don't want to be on any opioid agonist (esp if profession frowns on agonist therapy like healthcare professionals, pilots etc) - pts who're abstinent but are at risk for relapse (just released from jail, residential program, increased stress, co-morbid psych dx, moving back to living with exposure to drugs) - failed previous bup tx (continued to have cravings, misused/diverted) - pts who want to DC bup tx - less severe SUD (short hx, less amounts, used sporadically) - young adults living with involved parents who can supervise, esp if they won't commit to long term bup tx - have long periods of abstinence between relapses - if you're worried theres increased risk of OD after tx dropout - if they're having bad opioid SEs (constipation, sexual dysfunction, sweating) - if you're worried about euphoric effects with misuse/diversion - if you're worried they will combine with sedatives and OD - if you see tolerance is developing with Bup or worried it will note: overall in the few studies comparing the 2, treatment retention is similar but there is lower ongoing opioid use with naltrexone XR than in bup tx.

can you use a full agonist with buprenorphine ever? hitn: short term you mean>?

can be used short term for a pain problem but not long term.

what benefit of buprenorphine is taken away if taken benzos concurrently? hint: bup have ceiling meaning don't cause resp.depression but if you take benzo that effect is taken away and you depress rr.

ceiling effect for respiratory suppression is taken away if taking benzos too

how benzos are metabolized

chlordiazepoxide > norchlordiazepoxid > demoxepam > oxazepam > temazepam diazepam > temazepam diazepam > nordiazepam > oxazepam > temazepam lorazepam > alpha-hydroxyalprazolam alprazolam > 4-hydroxyalprazolam and alpha-hydroxyalprazolam clonazepam > 7-aminoclonazepam

how do you detect meth?

d/l isomer test (chiral chromatography): - d form = CNS active form (actual meth) - l form = prescription/OTC (vick's inhaler, selegine)

Whats teh NIDA-CTN buprenorphine detox protocol?

day 1: 4mg + 4mg PRN day 2: 8mg day 3: 16mg day 4: 14mg day 5: 12mg day 6: 10mg day 7: 8mg day 8: 6mg day 9: 6mg day 10: 4mg day 11: 4mg day 12: 2mg day 13: 2mg This is the best studied detox protocol with the best outcomes. Ideally they'd then be on vivitrol once buprenorphine is DC'd.

what is the major risk with methadone? hint: "diversion is major risk"! - at the methadone clinic they come and asked to swallow the methadone but becareful they may cheek it and divert it after leaving your office.

diversion, this is why they only get dispensed 1 day at a time. They can also OD so make sure they aren't cheeking it.

dosing for methadone

dose is increased until opioid cravings and withdrawal goes away. If they get excessive SEs they need a reduction dose. note: a pt may get their methadone and then come see you and be overly sedated. This may be because at the clinic they were fine and the medication hadn't peaked at the methadone clinic yet and so they didn't know they were on too high of a dose. But make sure they didn't take anything to potentiate their methadone dose to cause this. If they did, then talk to them about it but form an alliance and problem solve.

what is the issue with oral swabs for testing for drugs? hint: yeah naaah

drugs aren't picked up in oral swabs as long.

when is buprenorphine considered with opiate use disorder?

during moderate or severe, so they have 4+ criteria in DSM 5. Would not use it with mild, would probably just get them to a counselor or tx their comorbid psychiatric problems if they are just mild. note: everyone will have 2 criteria of tolerance and withdrawal if they have taken them for much time at all (more than a couple wks) on opioids.

what do you do if a pt is pregnant? how do you change the buprenorphine when pregnant?

during pregnancy give the mono product. Its a 1-1 switch, so if on the 8/2mg combo then switch to the 8mg mono. note: when pregnancy is over, then just switch back to the combo product. Pts will try to say the dose has to increase when switching back because theres naloxone but the naloxone has no effect and so its just to 1-1 switch between the 2.

whats the engagement focused approach vs the rule focused approach to behavioral problems?

engagement focused: privders keep pt in care no matter the level of readiness/adherence. Your alliance with them facilitates the change. But at the same time you use consequences but only use them to move them forward in a positive way. rule focused: care is contingent on following the rules of the office. Consequences facilitate the behavioral change. Abstinence is paramount here and minimizing consequences enables the pt. in general you want to balance both of these approaches. Maintain an alliance but have firm boundaries and rules to facilitate change.

what do they have to do with oral naltrexone use?

family members have to monitor medication ingestion

which opioids are synthetic?

fentanyl oxycodone methadone because these are all synthetic they're not picked up in a normal UDA

what is the CRAFFT?

for adolescents less than 21 y/o and pregnant women. screens for alcohol and drug use. - have you ever ridden in a CAR with someone who was high or had been using alcohol or drugs? - do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? - do you ever use alcohol or drugs while you are by yourself, ALONE? - do you ever FORGET things you did while using alcohol or drugs? - do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? - have you ever gotten into TROUBLE while you were using alcohol or drugs?

questions for a risk reduction plan

for pt: how do you protect yourself against an OD? how do you keep your medications safe at home? for loved ones: what is your plan if you witness an OD? have you received training to prevent, recognize, or respond to an OD?

what order does pruning happen? hint: PRUNING is "more frequently used neural connection prevail"; so PFC fails last b/c hence no judgment "Over adolescence there is a pruning back of these connections. The brain decides which connections are important to keep, and which can be let go." Scientists call this process synaptic pruning, and speculate that the brain decides which neural links to keep based on how frequently they are used.

from the back of the brain to the front this is why adolescents have coordination and sensory processing happen first (in cerebellum) and then it goes to the NA (for motivation), amygdala (emotion), and PFC (judgement) is last.

what is protective against NAS? hint: skin to skin as soon as born ; then "breast feeding" by mom reduce NAS issues.

get them on skin to skin and breast feeding (okay with methadone and bup, minimal medication gets into the breast milk and infants would have to hold the breast milk and allow the bup to absorb [just as mom has to do with SL bup] in their mouth to get any) - reduces need for tx for NAS by 30-50% - breastfeeding mothers and NAS are able to go home about 10 days sooner

why don't we use methadone often? hitn: who likes to take stuff daily anyway?

gets to brain slowly but only available in approved outpatient programs and has to be dispensed daily.

at what concentration does naltrexone fully block all opioid effects?

greater than 2 ng/ml

how do you store vivitrol? how do you administer?

has to be refrigerated. Take out 1 hr before injection to let it warm up to room temp. Can stay out for 7 days. Reconstitute the medication after pt arrives, once mixed give injection quickly so medication doesn't solidify (if you don't it will clog). Then alternate sites.

whats the key to success for induction?

have the pt be in mild to moderate withdrawal at the time of 1st buprenorphine dose note: if they are above 40% binding it will drop them to the 40% and they will feel horrible.

what trends have occurred by reducing opioid prescriptions in last 5 years? hint: increase, hence we give "Methadone" so they maintain on that and don't OD on heroin

heroin use has gone up, so people are just switching to heroin and so people are ODing on heroin.

who is naltrexone XR (vivitrol) good for?

highly motivated don't want to be on agonist therapy in occupations/situations that don't allow agonist tx pt is now opioid free (from jail etc) had poor response to agonists

what is more common, home induction or office induction?

home induction by a mile, esp if you have experience doing buprenorphine. Unless you get the sense they would be much more comfortable doing an in office induction then do an at home induction. Esp if they have used buprenorphine in the past.

who wouldn't naltrexone be good for and bup be better for?

hx of ODs esp after detox limited social supports pts whose psych illness emerged/worsened after detox (with or w/o naltrexone) pts with chronic pain requiring opioid tx pts with GI disorders that exacerbate during withdrawal pts with liver disease (naltrexone may cause hepatotoxicity)

what are risk factors for OD?

hx of SUD or OD socially isolates and uses alone uses alcohol, sedatives, or street drugs just got a new supply or changed opioids/dose uses more opioids than prescribed has medical illnesses reduced tolerance due to incarceration, hospitalization, detoxification, or abstinence note: released inmates 56x more likely to OD and die

who is methadone good for?

hx of poor bup response need closer daily follow-up have poor psychosocial supports co-occuring psych dx dependence on CNS depressants not expected to be compliant to tx co-occurring pain syndromes (easier to add opioids to methadone than buprenorphine) have biomedical conditions (Hep C, HIV)

How to confirm an opioid use disorder and buprenorphine should be used?

hx of previous tx records physical signs (withdrawal, track marks) UDA (at least 1 positive screen before starting buprenorphine) exceptions: documentation of hx of use or currently high risk due to recent DC from detox, residential tx or jail

whats the first priority of pt assessment? hint: like Dr ROss, find what kills like "psych sucidal, ODs, infeciton or heart attack etc..

identifying appropriate urgent or emergent medical or psych problems like ODs, risk for harm to self or others, and unstable infectious diseases or other medical issues.

how long does methadone maintenance tx work for acute pain?

if dosed q24hrs then it gives analgesia for 6-8hrs.

what do you do if they are also taking marijuana?

if they want to start buprenorphine, they need to cut down or stop their marijuana use. Alcohol, benzos, cocaine, or marijuana use significantly decreases the effectiveness of buprenorphine.

how do you detect benzos?

immunoassay but not all are equally detected, whether they're detected depends on the molecule they base the test on depending on the metabolites. - lorazepam may or may not be detected - clonazepam is usually missed with common immunoassays

can you use buprenorphine for acute pain?

in opioid naive post operative pain you can do SL form 0.2-0.8mg q6-8hrs. note: theres a CNS and respiratory depression ceiling and may be an analgesic ceiling effect but thats unlikely, doubling the dose increased peak analgesic by 3.5x while respiratory depression was unchanged.

what are some consequences for problem behaviors that support the therapeutic alliance?

increase in tx intensity: be sure to inform them this isn't punitive - increase frequency of visits and UDAs - observed dosing (3x/wk) - increased outpt counseling or meetings - higher level of care needed (OTP or residential)

why is buprenorphine administered SL?

increases bioavailability. Its combined with naloxone because naloxone has poor bioavailability, so it only acts when someone tries to abuse the buprenorphine by injecting it and then the naloxone kicks in. PO: get primarily buprenorphine Injected: get primarily naloxone

who is inpatient hospitalization, residential tx, IOP and self help groups for? hint: IOP=intensive outpatient program

inpt: severe withdrawal or medically complicated pts residential: pts that lack motivation and social support but are medically and psychiatrically stable IOP: gives strucutre to pts who have a support system but need more counseling self-help: usually free, provides peer support

how does induction, withdrawal, and dosing for adolescents differ from adults?

it doesn't, both guidelines are the same.

why is heroin so risky in pregnancy? hint: "HEROIN" : cross the placent but that is not the problem mainly, it is the "WITHDRAWAL' within hours caused by Heroine.

it easily crosses the placenta and creates a 6x increase of OB complications and 74x increase in sudden infant death syndrome note: these too are due to heroin withdrawals, methadone and buprenorphine ensure constant levels of opioids.

whats the problem with using buprenorphine for acute pain?

its a partial agonist so it may antagonize effects of opioids. But in rats combining buprenorphine and full agonists resulted in additive effects and buprenorphine doesn't impair mu receptor accessibility.

how do you tx chronic pain with bup?

its better for the pt to be on methadone rather than bup for chronic pain and then they add on short acting opioids for pain control. But start with splitting the bup dose, its a 30:1 morhphine equivalent so its very powerful still. If this doesn't work they would need to be sent to an OTP for methadone tx.

what is special about the MOA of buprenorphine?

its the only opioid agonist that is a partial agonist. All others are full agonists. Its less abused because its less reinforcing (releases less DA) but it essentially the same as an analgesic.

which receptor activation can induce psychosis? hint: Kappa makes you KUKU [psychosis]

kappa, if a drug were to activate just kappa would induce psychosis.

why do kids with ADHD often have more pain medications?

kids with ADHD have 2x risk for accidental injury for which they need pain medication. so treating ADHD better could decrease these rates. This leads to increased rates of SUD in ADHD. note: but abuse of stimulats is also associated with increased risk of accidents so this could be the cause as well.

when someone has cardiac risk factors why is buprenorphine better than methadone? hint: Methadone will sit on your heart with "LONG CUTIE QT"' and torsade depoint.

less QT prolongation and risk of torsades de pointes than methadone.

what is a sample integrity check?

look at: - appearance (color) - temp (if within 4 min of void should be 90-100 F with volume of 30mL or more) - pH (4.5-8.0 is normal, less than 3 or more than 8 has been tampered) - creatinine (shows concentration, should be greater than 20 mg/dL less is diluted and less than 5 mg/dL isn't human urine) - nitrite (if more than 500 ug/ml its been tampered)

detox outcomes hint: detox is where "you go abstinent from the drug", then just manage the withdrawal. but "treatment" is the after care of "Detox"; meaning after Detox treatment is the key here example treatment means "Maintaing them on Methadone, Bupronerphoine or naltrexone post detox"; if you don't "treat" after detox then "they relapse, retion wil be lo

low rates of retention in tx high rates of relapse post tx note: detox is not tx, tx is the aftercare of detox. There is less than 50% of abstinence at 6 months, and less than 15% at 12 months if they just do detox. This is why we do buprenorphine.

how do you dose bup with elderly?

lower doses due to slower metabolism and more med interactions. Also tx of pain in elderly may complicate bup dose. But the bup may tx their pain well by itself and doesn't cause the depressed RR like with opioids.

what do you have to make sure they did before using naltrexone? hint: gradual detox must occure before you use naltrexone; or you will be in pain& Nausea vomit all over the place if you take it before detoxing.

make sure they have already detoxed to avoid withdrawal.

If a pt has HIV why is buprenorphine better than methadone? hint: less drug interaction for butterfly

methadone has a lot of ASEs with HIV medications, bup only has 2 (rifampn, atanzanir/ritonavir)

what is used for pregnant pts?

methadone or Bup mono product - don't wean off in pregnancy, best for fetus to just have a stable dose of opioid - no teratogenic effects with bup but avoid naloxone so this is why we use mono product because its a class B drug so we avoid it but also if the women were to abuse bup and inject then they would go through severe withdrawal causing problems for the fetus - still only dose QD to suppress withdrawal unless they get mild withdrawal sxs throughout the day then you can split the dose. - bup mono has lower NAS risk and length of stay in hosp is 7 days shorter. Infants were born later with normal birth wt and length. Women on subutex less leikely to use illicit drugs near delivery. But realize that women on methadone likely have comorbidities contributing to these. There is higher drop out in bup use but theres higher medical complications at delivery with methadone. Bup has milder withdrawal sxs for the infant. - clinically it seems that women do much better on bup than on methadone

what percentage of middle schoolers vs high schoolers have abused marijuana and any rx drug?

middle school marijuana: 10% high school marijuana: 35% high school any rx drug: 10% middle school any rx drug: none

how long is it recommended to continue naltrexone tx to achieve full remission and abstinence?

min: 6 months optimal: 1 yr but longer prevents relapse risks further

are females or males overdosing on heroin more? hint: males more on heroin females more od on prescription only opioids

much more males

how is follow up different in elderly?

must monitor more frequently esp during onset to make sure comorbidities aren't being exacerbated.

what are your challenges you can do prior to vivitrol?

naloxone challenge naltrexone challenge (12.5-25mg) - wait 60 min and if tolerated can give vivitrol

what is the difference between naloxone and naltrexone?

naloxone is short acting and naltrexone is long acting. Both are mu opioid antagonists.

which option has the highest receptor binding affinity? hint: think of the full ANTAGONIST we use to reverse OD, if it has no highest affinity it won't work to reverse right?

naltrexone, more than burpenorphine and methadone.

should you switch from methadone to bup when pregnant?

no because transitioning to bup has significant risk of precipitated withdrawal. note: if they prefer bup to methadone it is best to start her on bup over methadone

what are the use categories for adolescents use?

no use no SUD - 1-2x in last yr mild/mod SUD - use 1x/mo or more severe SUD - use 1x/wk or more

How do you know you are at the buprenorphine induction dose?

no withdrawal sxs no cravings (may have thought but can turn it off quickly) minimal to no SEs DC'd or significant reduced use of other opioids

does being on buprenorphine prevent analgesic effects of acute pain tx?

no, pts receiving morphine post op still get effects. But may require about 50% higher doses.

can you use any medication that will help addiction tx to tx addictions? HINT: out paitent the only approved is "buprenorphine"; b/c methadone is only methadone clinic[chedule 2]

no, there are 3 rules that have to be followed due to DATA 2000 1. it has to be FDA approved to be used in an outpatient office - currently only buprenorphine is approved. Methadone is not approved for an outpatient office, its only approved for methadone clinics. 2. Has to be schedule 3, 4, or 5 drug - Buprenorphine is a schedule 3 drug and methadone is a schedule 2 drug. 3. Buprenorphine is only drug currently approved for outpt OUD tx

can you prescribe naltrexone and buprenorphine? hint; not separetly

no, this would stop the effects of the buprenorphine.

what is the correlation between smoking cigarettes and mental illness?

now days only 18% of the population smokes cigarettes but 2/3 of those have mental illness, this makes it much more difficult for them to stop. When asking about smoking, you should also ask whether they have been diagnosed with any mental illness.

what are opiates vs opioids? hint: "Oids" means "Look alikes" so synthetic wait for it "Heroin & bupronorphine are semi synthetic; while elefant & fantasy-fantanyl are "synthetic ; That's why heroine shows up as heroin in first 6 hours, then as morphy later on , because heroin is synthesized by putting "Mopphy on a steroid" hence her real persona come out later on. Opiates on the other hand are natural form [ morphy, cody];

opiates: from opium poppy plant. Morphine, codeine. opioids: manufactures, semisynthetic or synthetic. - semisynthetic: heroin, buprenorphine - synthetic: methadone, fentanyl note: if you just draw opiates then heroin, buprenorphine, methadone fentanyl doesn't show up. Often pts use the opioids the most. You have to test specifically for buprenorphine. Heroin shows up as 1 way the first 6 hours after use and then shows up as morphine after that. If fentanyl shows up educate about the huge risk of OD.

what does constricted pupils mean?

opioid intoxication

what does dilated pupils mean?

opioid withdrawal

why do people with SMI usually not have heroin addiction? hint: SMI=SEVER MENTAL ILLNESS

people have to get heroin 3-4x/day and these pts do not have the mental capacity to keep this up. They pts more often use cocaine or alcohol as its easier to maintain this addiction.

what profession can't have buprenorphine?

pilots

what conditions can be caused by opioid use in pregnancy?

preterm birth fetal distress fetal growth restriction infections due to IV drug use the on again off again effect of opioids like heroin (withdraw and euphoria rapid cycling) is really what causes these

when does relapse usually occur on vivitrol?

pts get increased cravings 3-4 wks after injection. For the pts that do relapse you should do mroe frequent injects (q3wks) or oral supplement. If suspect relapse get additional therapy and wrap around services. note: the first sign of relapse is missing injections as blockade wears off 2-3 days after oral and 5-6 wks after injection. May need transitioned onto agonist at this point.

why use the SL form of buprenorphine? hint: when sleep good= wake up with good energy [ energy b/c stabilization for having no drive to seek drug ]; wake up with clear head [ b/c mood stabilizing effect of opioids

pts report they are more clear headed and improved energy/sleep. Remember that opioids have a mood stabilizing effect, so this is expected as far as clearing their head. The improved energy is likely due to the stabilization and reduced drive for drug seeking.

what is the TWEAK?

screener for alcohol use in pregnant women

how long does it take to OD on fentanyl? hint: fental "fintew in "secondas" where as "Heroin is in min hence if one smoke in bathroom...yhou od in minuete

seconds, where as heroin overdose took minutes. So pts will literally die where they used (often in secret in the bathroom). This is very dangerous because it can be released in the air if in powder and anyone that goes into the room can then OD.

tx options for severe, moderate, and inpt pain?

severe: - regional anesthesia - continue bup and titrate short acting opioids - DC bup and use opioids then re-induce bup moderate: - non opioids are first line - divide bup q6-8hrs - increase bup dose by 25% and dividie total dose q6-8hrs - use supplemental doses of bup (2/0.5 or 4/1mg) inpt: - DC bup - start methadone 20-40mg - use short acting opioids then re-induce with bup when acute pain resolves

what dose do you give during induction? hint: start low, don't be cruel and make them withdraw fast

single low dose to produce minimal effects because higher doses can precipitate withdrawal. This should feel opioid-like but not euphoric. If they do have some full agonist still present, we will not cause a precipitated withdrawal by starting with just a low dose. But if they just took the full agonist and lied, they will still get a withdrawal.

why is it important they are clean off of full agonists before induction?

so they don't experience a precipitated withdrawal

whats the most common SE of vivitrol?

soreness at injection site for 1-3 days (almost everyone gets this). also make sure you get into the muscle if its in the fat it can cause an abcess. This is because it is very thick.

what is precipitated withdrawal vs spontaneous withdrawal? hint: self explanotry "precipitated means "we precipitated the withdrawal using an agent to maek it faster using opioid antagonist like naltreaxone.;;;; "; while sponatnous means just "DC [Discontinue] and let it withdraw at its pace

spontaneous is when you DC the agent spontaneously, precipitated occurs when you administer an opioid antagoist to someone on mu agonist. Characterists are the same as spontaneous but with precipitated theres faster onset.

what do you have to do to get your waiver?

submit in writing name, address, DEA number, registration and proof of training to HHS secretary and this is then sent to DEA and waiver is given. note everything has to be submitted electronically online. within 45 days you will get notified by HHS, usually goes close to this 45 days. You will get a new DEA number which is in addition to current DEA number. This new DEA number has an X number attached to it. You still use your old DEA but when prescribing buprenorphine you have to attach your new DEA with X to it, so you will have your old DEA and new X-DEA number on all prescriptions. note: most EMRs don't allow 2 DEA numbers so you usually have to write these prescriptions and write in your 2nd DEA number or else the pharmacy will reject the prescription.

what is suboxone vs probuphine? hint: suboxone= is combo to help avoid abuse with naltrexen probuphine: is like birth control implant device; for 6 months

suboxone: buprenorphine + naloxone (antagonist) to ward off attempts to get high by injecting. Naloxone would then induce withdrawal sxs. probuphine: implant with continuous delivery for 6 months

what is naltrexone tablet vs injection approved for? hint: injection prevents relapse b/c "once injected even if you do heroin some time after inj. you will not feel high, and say "wow heroin doesn't work"; so no relapse!

tablet: to block all exogenous opioids injection: prevention of relapse following detox both are good choices for pts seeking detox from all opioids as first stage of tx

whats the preferred form of buprenorphine given?

the combo product, you should really only use this unless they are pregnant.

what is so damaging about opioid use while pregnant?

the injection drug use and potential for OD is whats damaging. The actual drugs aren't. Tobacco and alcohol are much more damaging substances than opioids but its the associated behaviors that are so damaging while pregnant.

what is the risk if they DC naltrexone?`

the risk for OD is even greater after they stop (receptors have upregulated) so you have to educate them of this. In case of a relapse they cannot take the dosage they took before and provide them with naloxone. Have them sign a treatment agreement saying: "I understand that after I stop naltrexone I ma ybe more sensitive to the effects of heroin and any other narcotics. The amount of heroin or narcotics I may have been using on a routine basis before I started naltrexone, might now cause overdose and eath. I fully understand the nature and seriousness of this possible consequence. If I am not sure that I can avoid opiate use, I understand that I can be referred to alternative tx programs, such as methadone maintenance, which is an effective tx for heroin dependence and has a reduced risk of fatal overdose."

why are adolescents at higher risk for addiction?

their PFC isn't as developed so they have even less impulse control when they get the desire for DA from the NA causing even more impulsive acts. The earlier the onset, the higher likely they will have a drug disorder and other mental illness up to 24 y/o.

Can you die on buprenorphine? Hint: No, except dessalegn childish, toddlers can

there has been no deaths in adults, but there has been deaths in infants/toddlers. So educate your pts to keep these medications safe and away from infants/toddlers.

why is buprenorphine better than methadone?

there is less risk for OD and abuse including respiratory depression

how many pts can you have in an outpatient treatment setting (methadone clinic)?

there is no limit, only a limit in the traditional outpatient office. This is because you aren't actually writing prescriptions, they come to you to get the medication. If you write prescriptions then there is a limit because you are treating them like a traditional outpatient office.

how does methadone dosage change during pregnancy? hint: surprise need for 2 mom & pregnacy so increase dose

theres increased clearance and decreased half life in 2nd and 3rd trimesters requiring increased dosing and frequencies.

is there risk of increased depression with naltrexone?

theres no clinical evidence saying it does but pts will have depressive sxs during first few wks of tx due to withdrawal sxs. But depression actually improves during early abstinence from opioids as Opioid use disorder increases risk for suicide 10x. note: theres a suicidality warning for vivitrol on the package insert, bup does not have this.

what is zubsolv available in?

these are SL tablets that comes in individual packaging for protection with infants. Also has a different taste which some pts like. 1.4/0.36mg 5.7/1.4mg recommended maintenance dose: 11.4/2.8mg

what can the DEA ask to see when they come and visit your clinic?

they can see the number of pts your prescribing to, but they cannot say they want to see our charts and review our charts, they can't read our notes. They will ask for a list of pts, so we need to keep a list of pts. Many EMRs keep a record. If you keep a sheet, make sure its password protected on your G-drive for example. Make sure you have a system in place. Then if you store buprenorphine on site they will make sure you are following guidelines for that as well. If they come to see you and you're there you have to see them. You cannot say, I have pts to see. If you aren't there then you can make an apt with them to come back (by your front office staff). tip: keep a file in the office with your license, DEA, and CV. Then have a place where you have a list of your pts either in your EMR or in an excel sheet in the G-drive that all providers can update in the office. Also keep a list of where you are referring pts for counseling.

why doesn't opioids for acute pain not give excessive CNS depression or respiratory depression if they're on mehtadone maintenace tx?

they have opioid cross tolerance due to being on maintenance therapy.

how do you use bup for pain?

they have to be on a maintenance dose equivalent to their normal dose before they get any acute pain management and remember they have hyperanalgesia due to upregulation of pain receptors so opioid requirements are usually higher before they get the effect. Studies show doses were between 2-24mg SL but also available in patch. But remember the effective parenteral analgesia of bup is short (6-8hrs) so they need multiple dosing daily. Bup SL isn't approved for pain though in outpt so we cannot tx pain with Bup SL oupt. But during surgery they are still able to get additional acute pain relief with full opioid agonists. This was one initial concern due to the affinity of bup. But studies show bup doesn't inhibit IV PCA morphine, theres no difference in their pain control if they are on bup/methadone and not on it and getting a PCA.

whats the difficulty with methadone tx? hint; drive daily ; for some worst affected helpful; for others daily visit may exacerbate addiction.

they have to drive their daily and that may not be possible and this may limit their ability to be employed. note: eventually they may be able to take home, but this takes a really long time before they are eligible for a take home. But these pts may really benefit from going to the clinic daily for all the support so for some pts this works great. But for others being around all addicts daily may exacerbate their addiction. For this reason, if they fail buprenorphine then try out methadone but realize it may just not be possible for some pts and can actually worsen their addiction possibly.

what should they do if they need 24mg or more?

they need to split the dosing, they can even split the dosing by 30min if they want. - do 3 8mg tablets/strips at once and then do the rest later.

what usually determines which formulation we use?

usually insurance will have a preferred form they have contracted with so they require you to use that unless contraindicated or they have a bad reaction, then you can do a PA and get the others.

meds for smoking cessation

varenicline (chantix) buproprion (zyban, wellbutrin) nicotine replacement (patch, gum, lozenge, inhaler, nasal spray) combos

what is the LD50 of buprenorphine? hint: dunnno

we don't actually know the lethal dose, there has not been one found. But if mixed with other drugs or alcohol there could be an OD theoretically. In france there has been injection of mono product + benzos that has caused OD deaths. But these have been rare, using benzos + buprenorphine doesn't mean they will die but there is that potential.

whats the right dose of methadone? hint: Methadone elephant gives 80-100 candies of methadone to eleimiate craving and withdrwwas of addicts

when it eliminates the withdrawal and craving but they aren't sedated. This is usually between 80-120mg.

when should bup be used in adolescents?

when previous attempts at abstinence have failed and oral naltrexone also failed. And there is disruption in their lives. note: don't use vivitrol in under 18 y/o.

how does smaller doses of combo product prevent withdrawal when abused?

when they try to inject it, since they have a smaller dose it prevents precipitated withdrawal as less naloxone will be activated.

why may MAT treatment improve the likelihood of recovery even if DC'd?

while on MAT they likely aren't doing the negative behaviors so they can clean up legal history, build back their social supports and improve their mental history. All things that compound the difficulty of remaining clean when trying to fight addiction. This ultimately may increase the likelihood of them remianing in remission of their addiction.

why isn't hair samples good to use for drug testing?

will only pick up long term use.

how do you know if someone is taking their buprenorphine as prescribed? bup: norbup ration 1:3 means they are taking as directed. .. if less NOT!

with the UDA you test the bup:norbup ratio. If taking correctly it should be 1:3 ratio. Differences means they haven't taken it regularly or they just took it just before the apt. If they just put some bup in their urine you will only see bup and no norbup.

what happens when the brain is on drugs? hint: DA reinforce "frontal lobe" feel pleasure; first by choice, then become convulsive to feel normal not even euphoric once addicted. drugs are short acting, heence they "constantly trying to find out where to get it.

within 3 minutes there are chemical changes. The reward center is activated. DA is released to reinforce this behavior. Overtime this pathway remembers this, and the memory of this hijacks the brain so that the frontal lobe seeks that pleasure to feel normal. So initially its voluntary but over time its a compulsive act where without it you cannot feel pleasure. At first you get euphoria, but then you are just using the drug just to feel normal again because you are in withdrawals without it. And these drugs are all short acting so you are constantly trying to figure out where you will get the drug next.

can you use bup if they have renal failure?

yes there is no problem.

can you call in buprenorphine prescriptions? hint: methadone is sch-3 you can't call in pharmacy or anywhere YOU HAVE TO WRITE PRESCRIPTION

yes, because it is a schedule 3 drug where as methadone is schedule 2 so they have to have a written prescription.

is buprenorphine abuseable?

yes, it has relatively low abuse potential compared to others but it can be injected. This is why we combine it with naloxone.

what ages are most affected by heroin overdose?

young adults (18-25 y/o) and middle adults

yearly limits

yr 1: 30 pts/provider yr 2: 100 pts/provider yr 3: 275 pts/provider - have to have a credential having to do with addiction psychiatry (ABAM, ABMS etc) and apply for this waiver, have to reup your application q3yrs (don't have to do this with the 100) at least 90 days before waiver is up or you have to work in a qualified practice setting (has wrap around care [24 hr coverage for tx, case management, on-call services, using an EMR, using PDMP, accepting 3rd party payment]). SAMSA approves or denies this application within 45 days. means 30 pts at a time, if 1 pt drops out of care and you wrote a prescription for 30 days they are still counted until those 30 days are up and then after then you could take on another person. If they have refills tho and you didn't cancel those refills then they are still your pt until those refills are also up. note: for each increase you have to submit a waiver, so when you increase to the 100 make sure you submit another waiver and application. It is not an automatic increase.