Traumatic Brian Injury and substance Use Disorders
There is a long history of using a token economy to reward people for positive behaviors. It’s been practiced successfully for decades. Cash can be problematic as it may be used to purchase illicit substances. Rewards such as gift cards or small gift items have been demonstrated to be very effective in shaping positive behaviors as they mirror the small successes that patients experience in recovery.
There is definitely a roll and as a psychiatrist I would work collaboratively with a neurologist to order and interpret results.
We want to avoid excessive sedation when people have TBI so it’s best to start “low and go slow.” It is also important to avoid other potential CNS depressants. If a patient has co-occurring pain, consider dividing the usual buprenorphine dose into a TID schedule. In general the dose is the same and the goal is the same – to address craving and withdrawal while avoiding any significant side effects.
After assessing the appropriateness of the patient for the outpatient treatment the clinician needs to determine which treatment may be most appropriate at that time and engage the patient in a shared decision-making. I would start with evaluating prior treatment history, have they previously tried any of the medication(s), was it effective and well-tolerated? If people were treated in the past with buprenorphine and were successful then that might be your first line of treatment. For those with difficulty adhering to daily buprenorphine, and those that did not stabilize (still had cravings, continued to use on top of the buprenorphine) or were misusing or diverting the medication then you might consider treatment with XR-naltrexone. Alternatively you may try a higher dose of buprenorphine or buprenorphine under supervision. Another issue is the frequency of monitoring, many patients cannot come to the clinic weekly (if necessary), and since XR-naltrexone is given once a month that gives you more flexibility for patients living in a remote areas. Insurance coverage always has to be considered as well. It’s important to explain the differences to the patient so they have a clear understanding of the differences between the medications.
Patients tend to overestimate the risk of painful conditions that would necessitate acute treatment with opioids. For acute pain, the anesthesiologist can mange pain well using high-potency opioids or non-opioid strategies. For non-acute pain, blocks work extremely well and should be recommended. For most patients we’ve treated they didn’t need acute opioid analgesia and could wait if they had to have scheduled surgical procedures.
There have been controlled trials done where patients were unaware if they are receiving active naltrexone or placebos. Within the first week, patients treated with naltrexone reported less craving, even though they did not use opioids so they had no way to tell if they were treated with active naltrexone. We often see patients with very little cravings during the first week after the injection, though they are certainly patients who continue to have cravings, albeit diministed, since they do not experience opioid withdrawal. Not every patient on naltrexone will have reduction of cravings just as not every buprenorphine patient will have reduction of cravings.
We use the disease model and approach each separately. For example, if we have a patient with diabetes and asthma, we won’t stop treating the diabetes if they start smoking again and the asthma gets worse. Likewise, we try not to tie buprenorphine treatment to poorly controlled cocaine or alcohol use disorder. The other rationale for the harm reduction approach as opposed to the abstinence model is that the longer someone is in treatment the higher the odds of them getting better. We use motivational interviewing and try to let natural consequences be a platform for discussion. We also use relapse prevention groups and we see people more frequently if they continue to use other substances to try to provide an incentive to decrease use. Often, we will require group 3x weekly along with weekly scripts with the aim of helping them reduce use.
We get a urine test as early as possible since many people don’t expect it the first visit. That helps us understand what substances we need to be concerned about. We will still enroll people with other substance misuse but advise them we will be dealing with their other substance problems and we won’t be able to progress (to monthly scripts for example) if those don’t improve. We get releases from their other physicians. We won’t treat if they won’t let us talk to their physician and we prefer to take over all their psychiatric prescriptions. We also use mouth swabs on occasion as those are harder to alter – not to be punitive but to understand the problem. And we let them know the dangers of combining substances. A huge risk factor for any substance use disorder is untreated ADHD so we do want to treat it, if it is legitimate but we do need to be meticulous with the diagnosis and with ongoing monitoring to make sure that amphetamines are being used therapeutically. We try to document functional improvement with the amphetamines and use the ones with the lowest abuse potential.
We have a recovery based model but we also embrace harm reduction. One good thing about motivational interviewing is that we can work with them to become less harm reductive and more recovery based. If it interferes with the group process we see them individually. We indicate that patients need to be “present” in the group setting. If they cannot be present then we refer them to individual treatment.
Some of the best groups I’ve had have been three. Optimal group size is probably 6-8 and maximum would be 10 in terms of dynamics. Small groups allow for more time with each individual and going above 10 can be problematic in that regard. However if the group is too small it can seem overwhelming to the patients to be outnumbered by the team members.
Patients sign a Group Consent Form as well as a Consent Form for Treatment. The Group Consent Form explains the treatment in a group setting. With concern about federal confidentiality regulations, it’s important to have your forms vetted by someone knowledgeable of the law to ensure that you are adhering to these regulations.
In general for more minor surgical procedures such as dental work and ambulatory surgical procedures I would continue the buprenorphine and compliment with acetaminophen and NSAIDs. If the buprenorphine dose is low I would increase temporarily as needed. For patients who need major surgery, I would discuss their pain management prior to the surgery. If they are concerned about pain, I would taper them off buprenorphine (not completely), use the full agonist for pain and afterwards return them to their full dose of buprenorphine.
My opinion is that it is illegal. The Drug Treatment Act of 1972 and the DATA 2000 makes it clear that there are two medications that are currently approved by the FDA for the maintenance and withdrawal management of opioid use disorder. The first is methadone which has been in use for the past fifty years. The other drug that can be used is the sublingual formulations of buprenorphine. The use of any other opioid product to treat opioid use disorder doesn’t meet the criteria and is therefore not allowed.
Somewhat yes. I think that’s more extensive than the actual guidelines. Fifteen minutes is a bit much. I would say five minutes beforehand. If their mouth is dry they can swish and spit just so there is some moisture. There is no talking while it’s dissolving which can take 5-10 minutes. And then I would wait five minutes afterwards before eating and drinking. However I think fifteen minutes is too much to ask in terms of what people can tolerate.
The vast majority of patients that come to me from another provider are on 24 mg of buprenorphine. There are many non-pharmacologic reasons for this: physicians read that it is the maximum dose, they feel it is the safest dose, it’s what the patient wants, etc. If they are stable on that dose, it’s usual pretty easy to get them down to 16 mg. I like to get them down to 16 so there is some wiggle room if I need to increase for pain management.
It is generally problematic to continue to use marijuana or abuse alcohol when beginning treatment for an opiate use disorder. From the harm reduction perspective, I have a degree of tolerance because for many patients who are in a dangerous situation with opioids having them enter treatment for opioids could be life or death while using marijuana is not a life threatening drug. However if patients are completely unwilling to discuss their particular use of alcohol and marijuana and consider changes, this is a red flag which suggests that more intensive treatment approach will be necessary.
No we don’t have to have those things to start treatment. For patients in dire situations, having them delay treatment to first get the lab work done would possibly lose the patient to their continued opiate abuse. Product literature says that getting liver enzymes is recommended. Is it essential? No. Some patients don’t have the money for these additional tests and trying to get these tests done would be problematic.
When someone is coming in for an induction, the assumption is that they are coming in with significant withdrawal. I don’t think they should be driving to the office if they’re that sick. So they’re at risk for that reason alone. People generally feel better by the 2nd or 3rd dose, but not everybody has the same reaction. Some people get energized from buprenorphine, some get sedated. So I think that it is a wise decision when you are giving an induction to require that they have someone drive them to and from the clinic.
The rule of thumb is that you’ll be able to wean 80% of patients off of buprenorphine after one year without too much difficulty. Of the remaining 20%, some(~10%) you will be able to wean off with more difficulty, i.e. requiring adjuvant medications, and some (~10%) you will not be able to wean off completely. Over the years, those “unweanable” patients will fill your buprenorphine slots.
I consider these based on the symptoms. I look at their patient/family history to see what has worked for them in the past. As an example, I may use mirtazepine for anxiety and sleep. It has a good sedating effect and if the patient has underlying anxiety it can to help. I may use clonidine if there are withdrawal symptoms. If they are on clonidine for over a week you should not discontinue abruptly but rather do a gradual taper mainly to avoid rebound increase in blood pressure.
Giving small doses of oral naltrexone at first is necessary, but it is a barrier since naltrexone is not commercially available in smaller doses. You can always order low dose oral from a compounding pharmacy in order to get the dose to use for oral induction.
The injectable naltrexone is usually better tolerated than comparable oral doses. There’s less GI distress and nausea, possibly because much lower doses are needed as parenteral formulation bypasses the first-pass metabolism. Bioavailability of injection naltrexone is approximately 4 times greater than bioavailability of oral formulation.
It’s true that in the short term patients transitioning from heroin to buprenorphine suffer very little physiological “adjustment” of their system, and immediately feel well. Some people definitely need that. With the transition from heroin (agonist) to naltrexone (antagonist), there is a profound change in the physiology of the opioid neurotransmitter system with associated physical discomfort lasting up to 2-3 weeks. However the neuroadaptations (and symptoms) resolve completely and the great majority of patients feel normal and stable with minimal craving and no daily cycles of subjective effects seen in some patients with the fluctuation of blood level of the agonist. Patients are no longer physically dependent on opioids and they certainly are acutely aware of it. More importantly, many patients feel a burst of energy and motivation to seek new rewarding experiences, such as exercise, and are able to regain a normal libido (usually suppressed during opioid use) therefore it does not seem that naltrexone is blocking other pleasurable activities. The exception is that some patients loose a desire for alcohol, cigarettes and “junk” food. However, these are all anecdotal data, there are no published studies comparing the effectiveness and side-effects/subjective experiences in patients randomly assigned to treatment with injection naltrexone or buprenorphine/methadone.
Buprenorphine is best tapered down to low dose before stopping it, to reduce the level of physiological dependence and to decrease time required for elimination. Usually taper to 2 mg is sufficient, most patients find it difficult to stabilize on lower doses. Alternatively one can use adjunctive medications to minimize symptoms of withdrawal. Adjunctive medications targeting emerging symptoms are also very useful during the washout period and during initiation of treatment with oral naltrexone. Washout period of 4-6 days is usually sufficient after which naltrexone can be started, first at the low oral dose (6-12mg) followed by an injection of XR-naltrexone. With the longer washout there is less risk of withdrawal following injection but higher risk of relapse. Adjunctive medications can be continued during the first 1-2 weeks following injections (see Sigmon, Bisaga et al., 2012 for the list of medications and doses). During this transition patients need to be supported, as it is an outpatient detoxification, preferably with daily medical checkup (in person or on the phone) and psychosocial support if available.
I don’t believe there is a maximum dose of methadone. You may have to get permission from the state opioid treatment authority for certain amounts. The largest dose I’ve seen is 1400mg a day. The patient was functioning well and it helped his pain. Most of overdose deaths with methadone occur in the pain sector. Methadone can be very tricky and careful monitoring is necessary.
It can take a while for urine tests to become negative. People have been suffering for many years so you can’t expect this problem to go away after a few treatments. Maybe it’s an indication that the patient should be placed on maintenance rather than tapering.
We have less experience with buprenorphine but my own experience is that people generally don’t require an increase in dose and will often go down in dose to see what happens. If they still feel good they’ll usually stay at that new dose. Generally tolerance does not create a problem for opioid agonist therapy.
QID Dosing (4 times a day) is sometimes beneficial for patients with chronic pain. I had a patient with neuropathic pain and chronic headaches. Had her on 8 mg TID but we switched her to 4 QID she had an improved benefit. The total daily dose was lower but the dosing schedule change seemed to provide additional analgesic benefit.
In our practice all of our patients have some history of addiction. My view is that those co-occurring problems are so intertwined that you’re always treating both problems. Any decrease in pain or distress decreases the chance for relapse so you’re still treating the addiction. So any time you’re adjusting the buprenorphine dose for analgesic benefit you should consider the benefit or risk to the relapse prevention as well.
Discussing naloxone and overdose prevention with family is sometimes a good mechanism for expressing your concern about how he is doing. It’s a good message with which to reach him.
I prefer to refer to the sample as either positive or negative. As professionals managing patients in a medical context we should avoid street slang when discussing these as it stigmatizes the disease.
Monitoring routinely conveys an expectation. If you only monitor when you suspect something, it may stigmatize the monitoring. Watching people take the medication can be important to ensure they are taking it the right way, as it testing them afterwards to determine a baseline for their levels. Pill counting is another important tool at your disposal. By establishing an expectation of monitoring, people tend to be more honest in their self reports. It should be a normal part of what you do with all patients.
The less people adhere to a program, the more structure they need. That means seeing them more often, more frequent monitoring and perhaps intensifying treatment. I believe monthly prescriptions are a privilege and if they need to earn that privilege by doing well. It’s important to document our actions very clearly because that’s what protects us and protects our patients.
If it’s for an emergency then you can do it. For example If a patient is suicidal or was admitted to the psychiatric floor for another reason other than drug addiction, and the patient is being maintained on buprenorphine, then any physician even if does not have the waiver to prescribe buprenorphine can continue the prescription to avoid the withdrawal. If you can see the patient that would be a better option but if it’s an emergency and the patient is at risk of relapse then at least perhaps speak with the patient on the phone and document that and give the patient a few days until the primary provider comes back. The good thing about buprenorphine is that it is Schedule III so you can order it over the phone which is good for cross-coverage issues.
During the induction phase they have to come a few days in a row. Then weekly. We don’t give more than a week’s prescription at a time. After the first month we can decide if they need more intensive treatment or not.
I have the same experience. It’s supported by the literature – a study showed that at the maintenance level relapse was about at 10% whereas at the taper it was 50%. It’s my clinical experience as well. I tell people that it’s their choice and I can’t force them to stay on suboxone but if they relapse it’s okay, they can come back in and we’ll start them again.
We rely on the norbuprenorphine to buprenorphine ratio. The norbuprenorphine should be double the buprenorphine. If the norbuprenorphine is low and the buprenorphine is high, then the patient may not have been taking it for several days and restarted before coming to the screening.
You don’t want to be the only provider treating these co-morbidities. You’ll want to collaborate with primary care, pain specialists, etc to combat these problems. My role is to determine if the patient meets the criteria for opioid use disorder. If not then I would refer them to another provider since it is not my area of expertise.