4/13/15. Case 1. COWS = Clinical Opioid Withdrawal Scale. Special Populations

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1 Special Populations ACMT Addiction Academy Faculty Panelists 1 Case 1 The Toxicology service is consulted from the ED as the county jail has brought in a 21 year-old Hispanic woman who is 18 weeks pregnant. She was arrested on a warrant and has been incarcerated for just over 24 hours and during that time has developed nausea, irritability, began sweating, had increasing anxiety and was yawning continuously. She was noted to have stigmata of IVDU and told the intake officers that she was going into heroin withdrawal. Question: How do you approach this patient in the Emergency Department? 2 COWS = Clinical Opioid Withdrawal Scale What are your treatments in pregnant patients A.) Non-opioid agents? B.) Opioid agents? C.) Opioid (e.g. buprenorphine) And adjunctive agents? T 3 1

2 Case 1 continued They have brought her to the ED stating, medical says we need to get a Subutex prescription from someone here. What are your obligations in the ED? How soon are resources available for pregnant patients? What types of laws govern addiction and pregnancy? 4 Case 2 additional pregnancy questions A pregnant patient 36 weeks is admitted to labor and delivery for early contractions. She has been taking buprenorphine (Subutex ) for treatment of opioid use disorder. She has been able to maintain abstinence from other non-prescribed and illicit opioids. The pharmacy is calling you because the OB providers to not have a DATA 2000 waiver for office based treatment with buprenorphine and they only carry buprenorphine-naloxone on the formulary and want to know what to do about continuing her buprenorphine treatment. Pregnancy and use (efficacy and safety) for buprenorphine/naloxone vs methadone vs buprenorphine alone for treatment of opioid use disorder? Continuing buprenorphine in the hospital (do physicians need a DATA waiver?) Is buprenorphine safe in lactation? Can you continue buprenorphine or methadone during c section? How do you treat/approach the neonatal abstinence syndrome? 5 Discussion Points Case 1-2 Efficacy and safety for buprenorphine-naloxone vs buprenorphine vs methadone treatment of opioid use disorder in pregnant patients Effects of opiate withdrawal in pregnancy Methadone or buprenorphine safety in lactation Continuing buprenorphine or methadone during surgery (c section) Neonatal abstinence syndrome Severity with buprenorphine versus methadone (buprenorphine is much less severe NAS) and safe for use in nursing mothers. Recognition and treatment of opioid dependence in pregnant patients 6 2

3 Opioid dependence in pregnancy Maternal treatment with buprenorphine has comparable efficacy to methadone. Less NAS with buprenorphine. Less suppression of fetal heart rate and movements with buprenorphine. Possible induction issues with buprenorphine 7 Case 2 A 16 year-old boy is brought in to the Pediatric Emergency Department after his mother returned home and found him, slurring his speech and falling all over the kitchen! He opens his eyes, sighs loudly and Turns away from you during the exam (toxicology consultation/ed assessment) He had stayed home from school due to stomach cramps. Lives with his mother. 8 Case 2 continued The patient has been using marijuana and been caught drinking several times. The mother asks you what she can do about his drinking and drugging. What resources/options do you have? When the patient is more awake he and his mother have a loud and animated discussion about him snorting her Xanax again. 9 3

4 Case 3 A 17 year-old boy is brought to the Emergency Department because he has been, buying Suboxone again and I found it in his room! The father is demanding that he be admitted and, detoxified, and then referred to an inpatient treatment facility. He states he is not going to be bringing the boy home that he, is not able to have him around his younger brothers! Questions: What are your options for placement for teens (< 18) for alcohol/drug abuse? What are your treatment options? In an opioid dependent patient < 18 years-of-age where can you refer for detoxification? What if they showed up to the ED asking for help without a parent? Questions: A 17 year-old male presents to the ED with redness and swelling in the left antecubital fossa and he admits to injecting Suboxone. He states that he is going into withdrawal and that he needs some help. He has a fever and looks ill. How do you approach this patient? 10 Discussion points Case 2-3 Confidentiality for adolescents What screening is available for adolescents how to judge severity of alcohol use in adolescents and their risk for alcohol dependence Treatment options for adolescents primary care clinician, outpatient psychosocial addiction medicine treatment, pharmacological treatments This patient also smokes tobacco. Treatments for tobacco dependence in teens? 11 Confidentiality policies 12 4

5 Breaking confidentiality 13 CRAFFT Begin: I m going to ask you a few questions that I ask all my patients. Please be honest. I will keep your answers confidential. 14 CRAFFT- screen for alcohol and drug use disorders Part B: Each yes response scores 1 point. A total score of 2 or higher is a positive screen, indicating a need for additional assessment. 15 5

6 Case 4 An 66 year-old female presents to the emergency department somnolent and with myoclonus. Her sister found her laying on the bed and she couldn t wake her up. She had a bottle of Lyrica that was open with most of them spilled on the bed and some other pills on her dresser and around the room. She has CKD, DM, HTN, chronic pain, arthritis (bilateral TKA) which has been increasing over the past month. She is arousable to painful stimuli but confused and mumbling. She has myoclonus. RR is 8 breaths/minute. Her creatinine is elevated to 2.3 from baseline 1.4. She was in the ED the month before after nearly burning her house down with some smoke inhalation after, she fell asleep in a chair with her cigarette going. She is on multiple medications, including MS Contin 30mg PO BID. CKD (Cr ), HTN, arthritis, chronic pain, obesity, GERD Medication list: MS Contin, Lyrica, gabapentin (this and Lyrica listed) she has an old bottle of Flexeril and a bottle of tramadol with the name of her son on it that is empty she has a lot of non-pain meds as well (metformin, glyburide, lisinopril, several others her list is old 16 Case 4 Discussion Points What is the problem with this patient? What are your treatments and interventions? How to assess for medication toxicity in the elderly What changes should be made to her medication regimen? What if the patient is resistant? She will just go to another doctor and get the same pills! Alternate scenario: patient is using oxycodone for chronic pain and drinks 2 glasses wine daily. She comes to the ED with an alcohol level of 120 mg/dl after suffering a hip fracture from a fall. Her husband reports that she is taking extra Ambien as well. Assessment of drug or alcohol addiction in the elderly 17 Older and elderly What types of treatment options are there for elderly patients? How do you suggest that the medications they are taking are dangerous/ not indicated? What if their family is clueless about the addiction or very enabling? 18 6