A Helping Hand
Medication Assisted Therapy or MAT is a critical component of the care and treatment of patients with opiate use disorder. Over the course of the past several years, more and more ED providers, have been on the front line of initiating treatment of patients withdrawal symptoms and linking those patients to outpatient resources.
22 yo F who has a history of polysubstance abuse presenting after stopping use of ‘heroin’ for the past several days. She states her last use was 24 hours ago and that she had been cutting back her use for the several days preceding this period of abstinence. She has been using opiates for the past 6 years - initially pills and then moving on to heroin/fentanyl for the past 2 years. She occasionally uses marijuana and does not drink alcohol. She has used methamphetamine remotely in the past but has not done so for the past year. She used to snort the opiates but over the past year has been injecting. Her best friend overdosed and died last week and she has now decided that she wants to quit using. She states that she has previously stopped using for approximately 3 months last year but went back to using after losing her job.
Now that she has been free from opiates for the past 24 hours she has began to experience withdrawal and presents to the ED for your help.
She reports a sense of chills and sweating, severe aching in her joints, and multiple episodes of vomiting and diarrhea over the past 4 hours. She denies any abdominal pain with the exception of cramping that is associated with the episodes of vomiting and diarrhea.
Vital Signs - T - 98.2, P - 105, RR - 16, BP - 115/76, O2 sat - 99% RA
General - appears uncomfortable, is restless while lying on the stretcher with a sheet pulled over her head, she yawns once during exam
HEENT - pupils 6 mm bilaterally and equally reactive, mild amount of clear rhinorrhea, otherwise normal exam
Chest - clear to auscultation bilaterally
CVS - slightly tachycardic, regular rhythm, nl S1 and S2 without m, r, g. 2+ radial pulses bilaterally, no lower extremity swelling
Abd - normal
Skin - slightly moist though not frankly diaphoretic, no evidence of cellulitis/abscess, some track marks noted in the left AC, mild piloerection noted
Neuro - awake alert, oriented appropriately, no tremor noted, normal motor strength and tone, normal sensation
How do you Assess the Severity of the Patient’s Withdrawal Symptoms?
As with every patient, a thorough history is necessary in the patient presenting with signs/sx of opiate withdrawal. Providers should inquire about other substances abused, timing or recent use, previous attempts at abstinence, previous severity of withdrawal symptoms. A thorough social history that explores the social support network (or lack thereof) is also critical. Tenuous housing situations, difficulty obtaining transportation, lack of sober friends all can negatively impact the patient’s ability to be successfully linked with outpatient resources.
COWS - Clinical Opiate Withdrawal Score - This is a validated tool that can be used to assess the severity of the patient’s opiate withdrawal. (1) Similar to the CIWA scale used in alcohol withdrawal, this score is comprised of a mix of physiologic/objective findings (e.g vital sign abnormalities, presence of diaphoresis) and subjective symptoms relayed by the patient. A score less than 5 indicates no active withdrawal, scores between 5-12 indicate mild withdrawal, scores 13-24 indicate moderate withdrawal, and scores >25 indicate moderate-severe and severe withdrawal.
What Medications Are Used in Medication Assisted Treatment?
Methadone, Oral Naltrexone, and Buprenorphine are the medications used in MAT. Studies looking into the effectiveness of buprenorphine have shown equal to slightly decreased effectiveness as compared to treatment with methadone (depending on dosing strategy) and significant efficacy as compared to placebo. (2, 3). In addition, office-based and in-home initiation of buprenorphine based MAT has been shown to be effective (4)
Buprenorphine is a partial opiate agonist. Due to its partial agonist activity there is a possibility of precipitated withdrawal if the patient has recently used opiates. This reinforces the need for the patient to be in active withdrawal (as assessed by COWS) at the time of first administration. In the United States, writing a prescription for buprenorphine requires a special DEA license (X-waiver) and the completion of a training program.
Seize the Opportunity
You must talk to your patient’s about opiate use/abuse. For the patient presenting wanting help, that ED encounter may be the most important couple of hours of their life and may save them from a future overdose or from the myriad of infectious complications that come from opiate abuse. As an individual provider, we must do everything we can to alleviate that patients symptoms of withdrawal and link them to appropriate outpatient resources. We should also use that ED encounter to offer screening for HIV, HCV, and thoroughly examine the patient for any current medical complications from opiate use disorder. Healthcare systems should strive to set up channels to facilitate outpatient follow up and provide social work resources to address transportation/housing barriers.
For UCMC specifically, engaging social work and the Early-Intervention Program (EIP) counselors will help overcome many of the outpatient barriers to care. If the patient is in active withdrawal, you can calculate a COWS score and administer buprenorphine based on our established protocol. In some instances, admitting the patient to the hospital or ED Observation can help with both symptom control as well as linkage to care.
The patient is seen by EIP who connects her to outpatient resources. Based on her calculated COWS score she is found to be in moderate to moderate-severe withdrawal. She is initially given 8 mg of buprenorphine in the ED in keeping with the established practice guideline. After a period of observation, she still has some symptoms of withdrawal. She is given an additional 8 mg dose after which her symptoms of withdrawal are largely gone. She is able to be discharged from the ED and follows up with UC Addiction Services the following morning where she is linked in with an inpatient rehab facility.
Tompkins, D. A., Bigelow, G. E., Harrison, J. A., Johnson, R. E., Fudala, P. J., & Strain, E. C. (2009). Concurrent validation of the Clinical Opiate Withdrawal Scale (COWS) and single-item indices against the Clinical Institute Narcotic Assessment (CINA) opioid withdrawal instrument. Drug and alcohol dependence, 105(1-2), 154–159. doi:10.1016/j.drugalcdep.2009.07.001
Strain, E., Stitzer, M., Liebson, I., and Bigelow, G. (1994). Comparison of buprenorphine and methadone in the treatment of opioid dependence. American Journal of Psychiatry, 151 (7), 1025-30. 10.1176/ajp.151.7.1025.
Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD002207. DOI: 10.1002/14651858.CD002207.pub4.
Lee, J. D., Grossman, E., DiRocco, D., & Gourevitch, M. N. (2009). Home buprenorphine/naloxone induction in primary care. Journal of general internal medicine, 24(2), 226–232. doi:10.1007/s11606-008-0866-8
Written by Jeffery Hill, MD MEd