Triage, Assessment & Treatment Methadone 101/Hospitalist Workshop

Transcription

1 Triage, Assessment & Treatment Methadone 101/Hospitalist Workshop Launette Rieb, MSc, MD, CCFP, FCFP Clinical Associate Professor, Dept. Family Practice UBC American Board of Addiction Medicine Certified

2 Triage Determine patient expectations Many ways to treat opioid dependence Not everyone qualifies for methadone Opioid History: Type, amount, route, frequency Establish diagnosis: Opioid use disorder with physical dependence, rare exceptions (e.g. exiting incarceration) Other substances: Use, substance use disorders Other history: Detoxification, recovery, abstinence College of Physicians and Surgeons of British Columbia 2

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 College of Physicians and Surgeons of British Columbia 3

4 Triage Decision Tree Outpatient detox: Healthy, supports, 1st go Inpatient detox: Physical, psychological, social problems Put on naltrexone after detox +/- treatment centre Methadone taper: Short use of oral/smoked opioids, youth Meth Maintenance: IDU, generally age 18 years or older Failed in/out-patient detox Social issues which preclude detox Pregnant, HIV+, HCV+, or other urgent medical issue College of Physicians and Surgeons of British Columbia 4

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 diazepam (and lorazepam if Life Labs), designer drugs +/- urine bhcg Bloodwork: AST, ALT, GGT, HIV, Hep ABC, CBC, RPR, TSH +/- TB skin test College of Physicians and Surgeons of British Columbia 5

6 Assessment Fill in details of addiction history Each substance 1st use, amount, route, frequency, diagnosis Community supports utilized NA, AA, Matrix, 1:1 Differentiate each addiction and if needed have them sign separate contracts Medical history: Include accidents and surgeries Psychological history: Diagnosis, Treatment, medications, symptoms Family history: Draw tree (drug and alcohol, psychological issues) Social history: Legal, vocational/schooling, spouse, roommates/family College of Physicians and Surgeons of British Columbia 6

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 College of Physicians and Surgeons of British Columbia 7

8 Assessment (cont d) Review treatment agreement with patient and witness their signature Have them sign College of Physicians & Surgeons of BC Patient Registration or Patient Transfer forms and fax in to College Have them sign permission to communicate with other MDs/health-care providers College will register patient to you and fax back confirmation and you can write the first methadone prescription Warn of overdose risks when initiating and stopping methadone, and drug interactions College of Physicians and Surgeons of British Columbia 8

9 Management of Ongoing Substance Use in the Context of Methadone Maintenance Concurrent Heroin use Other Opioids Alcohol Stimulants Benzodiazepines/Zopiclone THC College of Physicians and Surgeons of British Columbia 9

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 College of Physicians and Surgeons of British Columbia 10

11 Other Opioid Use PharmaNet profile every visit! Beware fentanyl, oxycodone, tramadol, and sometimes hydromorphone do not show up as an opioid on the standard UDT 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 (POC) that includes these substances in the panel Point of care testing hydromorphone can show up as opioid and oxycodone BuTrans patch can give negative UDT even by GCMS ~20% opioid + UDT in lower mainland also have fentanyl College of Physicians and Surgeons of British Columbia 11

12 Alcohol Use Screen for an alcohol use disorder Alcohol use is contraindicated with methadone or buprenorphine Interaction with methadone/suboxone Increased sedation and respiratory depression Treatment plan for alcohol use disorders is mandatory if methadone maintenance is to be continued Uncontrolled alcoholism is indication to withdraw from methadone maintenance New BCMA Guideline: Office Based Management of Problem Drinking ( College of Physicians and Surgeons of British Columbia 12

13 Stimulant Use Increasing incidence of cocaine and methamphetamine use Destabilizing with methadone maintenance 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 methadone maintenance College of Physicians and Surgeons of British Columbia 13

14 Benzodiazepine and Zopiclone Use Chronic benzodiazepine use contraindicated in substance-dependent individuals Outcome worse with methadone maintenance when benzodiazepines are concurrently used Concern regarding alcohol and benzodiazepine use with methadone maintenance Screen at assessment Treatment plan Refer to Ashton manual for withdrawal procedure Screen urinalysis and PharmaNet Urinalysis breakdown College of Physicians and Surgeons of British Columbia 14

15 Marijuana Use Screen for marijuana use disorder at initial assessment Treatment plan Treatment contract Outline expectations College of Physicians and Surgeons of British Columbia 15

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 College of Physicians and Surgeons of British Columbia 16

17 Imagery Overall rate of sustained successful taper: 4.4% among all episodes initiating a taper and 2.5% among all completed episodes. Longer tapers had higher odds of success [12-52 weeks versus <12 weeks (OR: 3.58 ( ); >52 weeks versus <12 weeks: (6.68 ( )). A gradual, stepped tapering schedule, with dose decreases scheduled in only 25-50% of the weeks of the taper, provided the highest odds of sustained success (vs. <25%: (1.61 ( )). Nosyk et al, Addiction 2012; 107(9): College of Physicians and Surgeons of British Columbia 17

18 Patterns of Methadone Dose Tapering: Most Successful Patterns Checked College of Physicians and Surgeons of British Columbia Modified from Nosyk et al, Addiction 2012; 107(9):

19 Improving Compliance If patient transfers to alternate methadone maintenance provider Communication between new and current physician required prior to transfer preferably by phone. Otherwise valuable information is lost and therapeutic interventions can be undermined. Records should then be transferred and reviewed prior to accepting the client long term. College of Physicians and Surgeons of British Columbia 19

20 Summary Consistent application of basic set of principles results in: Improved patient care Containment of overall risk to patient Reduced conflict during visits Reduced risk of coroner s cases Well done! College of Physicians and Surgeons of British Columbia 20