UCLA Integrated Substance Abuse Programs



Continuing the Conversation:Co-Occurring Substance Use Disorder and MOUDwithVeronica Velasquez-Morfin, M.D.Tuesday, March 31, 2020Question: Please give us your thoughts on supplementing Sublocade with buprenorphine strips. Answer: I’ve had 2 patients in this situation. Our first few patients were started on a loading dose and didn’t require additional strips, but we’ve now had 2 recent situations where the patients didn’t make it the full 4 weeks, and we had to use strips to hold them over till their next injection. It seems to be working okay so far. We don’t really have any evidence or guidance on it – it’s all symptom-based. If patients are having hot flashes or sweats or other signs of withdrawal, they’ll tell you directly, and we try a dose of a strip and see if it makes them feel better. This might be an indication to continue the loading dose of Sublocade. Perhaps people on higher doses may need to supplement with strips, whereas people on lower doses don’t.Question: Do you think COVID-19 is impacting opioid availability and driving more people to outpatient programs?Answer: We have our own pharmacy, and our pharmacist came to us and said that with an increased focus on low-barrier care, it’s possible for the system to get overwhelmed. We can still give them 4-week prescription, but there are some signs of a buprenorphine shortage. I have also seen that there’s an increase in new patients calling us with a wide variety of needs. Alcohol abuse is another thing people are calling us for. COVID-19 is affecting people emotionally and mentally in many ways. Isolation is a big part of relapse, so trying to combat the isolation is huge for us. We’re trying to bring those groups back together into a virtual setting. Patients’ ability to get on Zoom is important. Patients are Zooming their AA meetings, and we’re trying to replicate that method. People who are just starting out in sobriety are at great risk for relapse, so we’re doing what we can to stay engaged with them, such as holding weekly check-ins. Question: What were Candace’s stated goals?Answer: When I first met her, she was in acute opioid withdrawal. She didn’t outright say she wanted to quit heroin. She was on opioids – including methadone – for injuries about 10 years prior to her addiction. The prescription pain meds were eventually discontinued, which is how she started using heroin. We started her on buprenorphine. So overall, that’s her goal – to stop using heroin. There’s been 3 relapses over the years, but within the last 6 months, she’s been consistent. In terms of the math, it’s very slow going. She worries about becoming manic depressive if she gets off meth. We have a psychiatrist on staff here that may be able to get her to take a helpful medication.Case Study: Ryan36-year-old male with regular use of cannabis and etoh while on buprenorphine for OUD. He works at a restaurant as a server and drinks to deal with the stress at work. He drinks after work either with his coworkers or goes to a bar. Feels alcohol helps with his social anxiety and is better able to interact with people.Question: I’ve heard other presenters say that when you’re weighing the risks associated with concurrent opioid and alcohol use, the risk that a patient is going to have a fatal event with opioids far outweighs the risk of a fatal event with alcohol. What is your opinion on this?Answer: I completely agree. You’re at higher risk of overdose with continued heroin or prescription opioids. Alcohol can kill you too, but unless it’s very severe, there’s much less of a chance. Question: When it comes to trauma in substance use disorder – how do you address that?Trauma is very common. All our patients receive A-scores, giving us a trauma baseline. All patients have mental health assessment to get that baseline of what’s there in terms of mental health and trauma. It’s then up to our team to decide how they want to move forward with that information and form a treatment plan. Many start on individual therapy, which has led to a lot of success. It’s a very common thing – lots of people start using due to trauma.Question: What is your recommendation if someone comes in for buprenorphine while simultaneously on a high dose of benzodiazepines?Answer: The use of benzos is similar to that of alcohol, so we actually approach it in a similar manner. You have to be cautious of dosing and be aware of the fact that patients could be buying on the street in addition to using prescriptions. It’s essential to develop trust and establish rapport, and we treat the OUD first. If you can stabilize the OUD first with buprenorphine, let them know that there’s risks involved, make sure they have Narcan available, and let them know you’re concerned and there for support, they may then find it easier to taper off the benzo. Sometimes it’s a behavior pattern that is ingrained, and that can be changed. It might happen in a month, several months, or a year. I give patients a choice between a taper or a transition to a longer-acting benzo. Comment: I’ve heard patients say they take benzos because they have anxiety, but we often forget that one of the symptoms of opioid withdrawal is anxiety. Once they’re stabilized on medicine for opioid use disorder, their anxiety often goes down.Reply: I agree with that. I’ve heard patients say that they never thought they could get off benzos, but that buprenorphine treatment made it easier. Comment: One participant says she works with a psychiatrist who put everyone coming in for OUD on a twice-daily benzodiazepine regimen by default. Any thoughts?Reply: Benzos are usually meant to be temporary. Using an SSRI is possible. I’m not sure what that psychiatrist’s rationale is. This wouldn’t be my go-to med for someone with generalized anxiety disorder because it’s not the best long-term option. Our psychiatrist doesn’t do that. We are very selective in terms of patients that receive benzos. Question: One person says that they do opioid prescription prevention and is curious about using medicines for OUD in adolescent populations. What age is too young for this kind of treatment?Answer: We have had perhaps two people under 18 in our program within the last 4 years. One moved away, and we lost touch with her. The other had severe trauma. My philosophy is that if patients are old enough to shoot heroin, they’re old enough to be on buprenorphine. I follow that motto and weigh risks vs benefits. One 16-year-old had OUD and we started her on buprenorphine, but she had a lot of other mental health issues that we struggled with. While she was on buprenorphine, we saw that she was also using cocaine, benzos and alcohol. We tried working with her, but she required a lot of our resources and we determined that she needed a higher level of care. We kept her as stable as possible. There’s not a lot of resources for teenagers, unfortunately. Question: Buprenorphine is FDA-approved down to age of 16?Answer: I believe so.Question: If someone younger than 16 were given buprenorphine, you’d have to exercise even more caution, because it would be considered an off-label use.Answer: Yes.Question: What are your thoughts on methadone dosing when patients are also using cocaine or methamphetamine? Is it safe to exceed 70mg of methadone in this patient population or is there some potential for heart damage?Answer: One question you have to ask is: are they trading buprenorphine or Suboxone to get other drugs? We sometimes test them for this to make sure there’s no exchange of drugs. In terms of the risk in providing a higher buprenorphine dose above 16mg while they’re on methamphetamine, it’s hard to assess that risk. We don’t prescribe methadone for OUD in our FQHC setting. Methadone clinics may approach this differently. I’m not sure why they cap dosing at 70mg. It’s best to stabilize the OUD and prevent relapse.Question: How do you handle patients on buprenorphine and kratom?Answer: We’ve had people come in seeking help for kratom addiction. If patients come in for buprenorphine because of a kratom addiction, it’s hard to test for kratom. We do try buprenorphine on them, though. Kratom is expensive, so it actually helps them from a financial standpoint too. I haven’t seen continued use of kratom while these patients are on buprenorphine. ................
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