Nov 1, 2019
In this podcast, Dr. Greg Peterson, a emergency medicine physician with Ridgeview Medical Center, discusses opioid use disorder, treatments for opioid withdrawal, and the use of medical assisted therapy (MAT) for the ongoing opioid crisis.
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In this podcast, we are discussing opioid use disorder, treatment of opioid withdrawal, and medical assisted therapy for the current opioid crisis that is ongoing.
The CDC noted that in 2016, a little over 2 million Americans suffer with OUD (opioid use disorder). In that same year there are around 42,000 deaths related to the opioid misuse. Interestingly, about 135,000 new heroin users after misusing mediations in 2015. Essentially, over 100 deaths daily are related to this epidemic. The stats are staggering and unfortunate.
The direct medical costs in 2016 were $12.2 billion. Indirect societal costs $9.2 billion. Total societal costs area somewhere around $80 billion.
Interestingly, less than 5% of morphine equivalents come from the ED.
MAT is a longer-term strategy for treating patients along with counseling and psychosocial support to assist those for the propensity of misuse. Withdrawal is treatment of acute phase sxs (n/v/d/piloerection) along with some of the more prolonged phase sxs of withdrawal include: anhedonia, depression, insomnia, decreased appetite which can last months or longer.
COWS or Common Opioid Withdrawal Symptoms is a scoring tool that allows the clinician to better assess where the patient is within their withdrawal state. The scoring system is based on 0-4/5. 4 and 5 obviously being more concerning for severe withdrawal sxs. Common sxs include: HR, dilated pupils, diaphoresis, anxiety/irritability, restlessness, joint or bone pain, GI upset, tremors, runny nose, yawning, and gooseflesh skin. Usually less than 5 - no withdrawal. 5-12 your are starting to withdrawal; 13-24 moderate withdrawal; over 24 - badness.
The options for treatment of pt with withdrawal can include: opioid agonist - such as methadone or buprenorphine or non-opioid medications such as: alpha-adrenergic medications - including: clonidine, antiemetics (like Zofran). Studies show these treatment options are effective for treating the withdrawal.
The medications for typical MAT use and withdrawal are the opioid agonist Methadone and Buprenorphine. Buprenorphine is partial mu agonist and is thought of as a safer medical treatment option for withdrawal and MAT. The literature notes that their is "ceiling effect" for euphoria with the use of Buprenorphine. Typically dispensed as a tablet, sublingual film, depot injection, subcutaneous (sc patches) along with implantable.
Buprenorphrine is compounded with Naloxone (trade name Suboxone) with is thought to be safer and less prone to abuse. If given, a person is till using opioids Suboxone can precipitate withdrawal sxs. Withdrawal sxs are based on shorter vs longer acting opioids. Norco or Percocet are shorter time periods to withdrawal in comparison to Methadone which can take several weeks before pts experience sxs.
The Drug Addiction Treatment Act of 2000, or DATA 2000, requires clinicians to have a valid license, DEA#, and complete an 8-hour training course covering Buprenorphine and OUD treatment management.
"Warm Hand Off" is generally the PCP or ED physician and addiction specialist having a discussion directly with the patient about the next steps in their care management.
"Cold Hand Off" is streamlined referral system where social work is assisting the patient by providing resources or helping with the setup of next appointment.
Vivitrol comes in a 380mg dose of naltrexone that is given as an IM depot injection monthly for opioid medical assisted therapy.
The literature seems to report that MAT combined with psychosocial management is more effective than just the psychosocial therapy. The psychosocial model by itself has a low success rate, in comparison to combined therapy. Some studies have included that therapy + Suboxone vs solo therapy with Suboxone did not show a difference in the rates of success.
Dr. Peterson notes that proposing MAT to a medical group or hospital is complex. It requires close collaboration with addiction specialists, therapy, and social work for the continued coordination of care. Optimally, the thought is short follow-up 24-48 hrs after discharge from the clinic or Ed to addiction specialist.