Triage, Assessment & Treatment

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1 Triage, Assessment & Treatment Launette Rieb, MSc, MD, CCFP, FCFP, dip ABAM Clinical Associate Professor, Dept. Family Practice, UBC Physician Director, St. Paul's Hospital Goldcorp Addiction Medicine Fellowship

2 Triage Determine patient expectations Many ways to treat heroin dependence Not everyone qualifies for methadone Opioid History: Type, amount, route, frequency Establish diagnosis: Opioid dependence Other substances: Use, abuse, dependence Other history: Detoxification, recovery, abstinence

3 Triage (cont d) Past Medical History: HIV, HCV, pain, pregnancy Psych: Suicide attempts, psychosis, violence Current medications, allergies Problems with previous detoxes or methadone Motivation: Stage of change Signature for PharmaNet required

4 Triage Decision Tree Outpatient detox: Healthy, supports, 1 st go Inpatient detox: Phys, psych, social probs Naltrexone after detox +/- treatment centre Methadone taper: Smokers, youth Meth Maintenance: IDU x 1+ yrs, >18yrs Failed in/out-patient detox Social issues which preclude detox Pregnant, HIV+, HCV+, or other urgent medical

5 Triage to Methadone At the end of the triage visit: Provide a requisition for urine drug screen (UDS) Include any speciality drugs taken in the past or suspected List synthetic opioids, benzodiazepines other than lorazepam, and designer drugs +/- urine bhcg. Bloodwork: AST, ALT, GGT, HIV, Hep ABC, CBC, RPR, TSH +/- TB skin test

6 Assessment Fill in details of addiction history Each substance 1st use, amount, route, frequency, dx Community supports utilized NA, AA, Matrix, 1:1 Differentiate each addiction and if needed have them sign separate contracts Medical history: Include accidents & surg. Psych Hx: Dx, Tx, meds, symptoms Family Hx: Draw tree (drug and alcohol, psych issues) Social Hx: Legal, vocational/schooling, spouse, roommates/family

7 Assessment (cont d) Physical exam: vitals, pupils, autonomic signs, nasal septum, dentition, murmurs, liver, tracks, jaundice, tattoos, piercings, mini mental status exam Opioid use: Small pupils, somnolent, tracks Opioid withdrawal: Lacrimation, salivation, piloerection, temperature dysregulation, hyper-reflexic & agitated, pain all over, nausea, vomiting, diarrhoea Review lab work must have urine and liver enzyme results to prescribe methadone! Collateral: Family, other MDs, PharmaNet

8 Assessment (cont d) Review treatment agreement with patient and witness their signature Have them sign CPSBC release and fax Have them sign permission to communicate with other MDs/health care providers Once CPSBC approves you can write the first methadone prescription Warn of OD risks when initiating and stopping methadone, and drug interactions

9 Management of Ongoing Substance Use in the Context of Methadone Maintenance Concurrent Heroin use Other Opioids Alcohol Stimulants Benzodiazepines/Zopiclone THC

10 Concurrent Heroin Use During induction Adjust methadone Counselling Appropriate monitoring Episodic relapses Review dose Ensure daily supervised dispensing Counselling to address relevant issues Appropriate monitoring

11 Other Opioid Use Prescription vs. street use PharmaNet profile every visit! Beware Oxycontin and hydromorphone do not show up as an oipioid on the standard UDS done by labs So you will need to write the name of the medication or drug you are looking for on the lab requisition Or use point of care testing that includes these substances in the panel

12 Alcohol Use Screen for abuse/dependence Alcohol use is contraindicated Interaction with methadone Increased sedation and respiratory depression Treatment plan for alcohol abuse/dependence is mandatory if M.M. is to be continued Uncontrolled alcoholism is indication to withdraw from M.M. New BCMA Guideline: Office Based Management of Problem Drinking (www.bcguidelines.ca)

13 Stimulant Use Increasing incidence of cocaine and methamphetamine use Destabilizing with M.M. Treatment is cognitive/behavioural intervention Counselling Support services Relevant treatment contract Consider inpatient treatment for failure to maintain abstinence or if consequences escalating (remove from environment) Rule out stimulant as primary drug of abuse/dependence before initiating M.M.

14 Benzodiazepine and Zopiclone Use Chronic use contraindicated in substance-dependent individuals Outcome worse with M.M. when benzos are concurrently used Concern regarding alcohol and benzo use with M.M. Screen at assessment Treatment plan Refer to Ashton manual for withdrawal procedure Screen urinalysis and PharmaNet Urinalysis breakdown

15 Marijuana Use Screen for marijuana abuse/dependence at initial assessment Treatment plan Treatment contract Outline expectations

16 Improving Compliance If unable to document benefits after dose adjustment and appropriate psychosocial intervention, consider alternate treatment. Outpatient Detoxification Intensive outpatient treatment Residential/intensive inpatient treatment Support group (AA/NA/SMART/16 Steps etc.) Addiction medicine consult

17 Improving Compliance If patient transfers to alternate M.M. provider Communication between new and current physician required prior to transfer preferably by phone. Otherwise valuable information is lost and theapeutic interventions can be undermined. Records should then be transferred and reviewed prior to accepting the client long term.

18 Summary Consistent application of basic set of principles results in: Improved patient care Containment of overall risk

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