We are in the midst of an opioid epidemic. In 2017, 47,000 Americans died of opioid overdose; 35% of those from prescription opioids. (Scholl et al 2018.) There is now a growing recognition that healthcare providers need to do much better in their approaches to managing pain, as well as screening and managing opioid use disorders.
Opioids, including Morphine and Opium, became commercially available in the 1800’s. Since then, newer versions have been developed to last longer and/or be more potent. At first, these newer versions were marketed as being “safer” and having less risk of addiction and overdose. Around that same time, in the 1990’s, there was a new campaign in medicine to use pain as the “5th vital sign.” It is likely a combination of these two changes that dramatically increased the use of opioid medications in America. Unfortunately, the the safety statements were based on biased and poorly done studies. Also, our focus on pain didn’t increase patient satisfaction or improve patient morbidity or mortality. Instead, a growing population of patients became dependent on chronic opioids. Sadly, this has led to an epidemic of opioid use disorder (OUD) and staggering rates of overdose (Substance Abuse and Mental Health Services Administration, 2018; Centers for Disease Control and Prevention (CDC), 2011).
The medical community finally started to focus on the opioid epidemic in the last few years. New studies have been done to show the risk of addiction and overdose with use of opioids. Use of opioids for longer than a week substantially increases the chances of chronic use. Patients given more than a week of opiates after surgery or for treatment of acute back pain were 44% more likely to become chronic users (Alam, 2012). Also, chronic use of opioids does not seem to improve pain or quality of life. Newer research shows better pain management with other medications and treatment modalities (Chou et al, 2016; Dowell, 2016). These other treatments are explained in detail in Module 30 Part 3. There has also been an increase into research on methods to improve treatment for OUD (Substance Abuse and Mental Health Services Administration, 2018).
This module will briefly review the effects of opioid medications on the brain. You will learn to diagnose OUD and evidence-based techniques to help manage OUD. Lastly, you will learn a methodology for creating effective patient-provider relationships through motivational interviewing (MI) and trauma-informed care. By employing the information in this module, you will be able to join the forefront of the fight against the
The effect of opioids on the brain starts with binding at mu opioid receptors and leads to downstream effects on physiology and behavior. Opioids by definition, include endogenous opioids, opiates (i.e. Morphine, codeine), semisynthetic opioids (i.e. heroin, oxycodone), and fully synthetic opioids (i.e. Fentanyl) (National Institute on Drug Abuse (NIDA), 2018).
The effect of opioids on the body is attributed to the binding of their receptors. Although there are three types of receptors (mu, kappa, and delta) the main effects of opioids are attributed to their binding of mu receptors. These receptors are found mainly in the central nervous system, the gut, and afferent neurons in the peripheral nervous system. Binding causes activation of pain and reward pathways in the brain, slowing of the respiration center in the brainstem, decreased motility of the gut, and some blunting of stimulus from the periphery (NIDA, 2018).
In the central nervous system, mu receptors are distributed widely in the thalamus, prefrontal cortex (PFC), nucleus accumbens (NA), and ventral tegmental area (VTA). Activation in the thalamus causes the analgesic properties of opioid medications. The effect on the PFC is hypothesized to impact impulse control. Activation in the NA and VTA stimulates the feelings of euphoria associated with the medication (NIDA, 2018).
The overall effects of opioid medications include analgesia, euphoria, sedation, pupil constriction, respiratory depression, and decreased heart rate. There are also substantial rates of constipation, dry mucus membranes, nausea, insomnia, and depression. All these responses are achieved through the stimulation of dopamine release and inhibition of GABA release. Dopamine is associated with the reward pathway. Typically, it is released in response to food, sex, or other euphoria relatedactivities. GABA is responsible for inhibiting dopamine release. Thus, exogenous opioids overstimulate the reward pathway by both increasing dopamine release and decreasing its regulation by inhibiting release of GABA. These chemical changes also cause behavioral changes. The euphoria experienced with release of dopamine in the NA causes positive reinforcement. There is also negative feedback due to activation of the amygdala when the ligand dissociates from the mu receptor. Chronic use of exogenous opioids will lead to greater activation in the amygdala compared to an opiate naive brain. The amygdala is responsible for the experience of fear and anxiety. There is also an effect on the PFC which leads to impairment of judgement and attention. The combination of these effects creates a high risk for dependence and addiction (NIDA, 2018).
There are many risk factors for developing OUD including both physiologic and environmental components. Physiologically, the response to opioid medications varies from person to person. Some find the first experience with an opioid unpleasant, while others find it pleasurable. It appears that these responses are in part determined by the density of brain dopaminergic neurons. There is an increased risk in people who have a history of psychiatric disorders. There are important genetic factors born out by twin studies, and the significant increase in risk with patients who have family history of substance use disorder. Family history may also play a role in the environmental aspects. Patients with high numbers of adverse childhood events, such as physical, sexual and emotional abuse, including having a parent who has substance use disorder (SUD), have a greater risk of OUD. Other environmental factors play a role, including availability and high levels of use in the home and community
It is important to highlight any implicit bias you may have when diagnosing OUD. Historically, SUD has been viewed as a moral failing or lack of willpower on the part of the patient. Basically, that the only reason anyone has this issue is because they have made bad choices and used “hard drugs.” Now, scientific advances have established that SUD and OUD are brain diseases, akin to other chronic diseases. Addiction is preventable, treatable, changes biology, and if left untreated, can last a lifetime. People with SUD have excess morbidity and mortality, but with appropriate treatment, including inpatient rehabilitation and MAT, many, perhaps up to 30 – 40 percent, will achieve sobriety. It will often take multiple attempts at treatment, and since you can never know who will respond, it is important to be positive and hopeful, and patient, with your patients with SUD. An excellent review of the science of substance abuse can be found on the website of the National Institute on Drug Abuse (NIDA): https://www.drugabuse.gov/publications/teaching-addiction-science/understanding-drug-abuse-addiction-what-science-says. Thus, OUD management is guided by the same principles of the management of all chronic conditions that require attitude, behavior, diet, lifestyle changes and medication to achieve the best outcomes.
When diagnosing OUD, it is crucial to get a thorough history of the patient. The history should include identifying risk factors, comorbidities, the physiological effects of the opioids on the patient, and any negative impacts that the use of opioids has had on his or her life.
OUD is a loss of control of the use of opioids coupled with physiological evidence of dependence. The severity is associated with how many symptoms and consequences the patient has endured due to this loss of control. Diagnosing OUD requires use of the DSM 5 criteria as outlined below.
A patient must have 2 or more of the symptoms below. It is important to note that physiological dependence is not enough for diagnosis.
- Opioids are often taken in larger amounts or over a longer period than intended.
- There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
- A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
- Craving, or a strong desire to use opioids.
- Recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home.
- Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
- Important social, occupational or recreational activities are given up or reduced because of opioid use.
- Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids.
- Tolerance, as defined by either of the following:
- a need for markedly increased amounts of opioids to achieve intoxication or desired effect
- markedly diminished effect with continued use of the same amount of an opioid
- Withdrawal, as manifested by either of the following:
- the characteristic opioid withdrawal syndrome
- the same (or a closely related) substance are taken to relieve or avoid withdrawal symptoms
Patients are considered mild if they have 2-3 of the above symptoms, moderate if they have 4-5, and severe if they have more than 6 (American Psychiatric Association, 2013.) How would you diagnose our patient? Does he have Opioid Use Disorder? Is it mild, moderate, or severe?
Telling your patient a diagnosis of OUD is the same as telling a patient about any other diagnosis:
Creation of official techniques for management of OUD started in the Mid 1900s. The lead model was one of abstinence called the Minnesota model and started in the 1950s. The techniques employed in this 28-day inpatient intensive program were adopted from the Alcoholic anonymous (AA) groups. This doctrine preached that the only path to sobriety was through complete cessation of a substance and was taught by a combination of professional staff and those in recovery themselves. This model is the basis for 90% of today’s rehab programs (Clark, 2015; Baylor, 2020).
Then came Methadone. Starting in the 1960’s methadone was used to help patients refrain from illicit opioid use. In 1970 the FDA approved Methadone for detoxification and in 1972 it was approved for Medication Assisted Treatment (MAT). Methadone started to be included in opioid treatment programs (OTP) in 1974. These treatment programs combined daily dosing of the medication with group and individual counseling (Clark, 2015; Baylor, 2020).
In 1984, the FDA approved Naltrexone. The next big change in addiction treatment came in 2000. The DATA 2000 law allowed expansion of OUD treatment to outpatient offices. In 2002, Buprenorphine was approved for use. It was made available to doctors when they complete a training course and could be offered outside of the OTPs. Since then, long acting formulations of Naltrexone and buprenorphine have been approved. Access has also been improved by allowing advanced practice providers to get the waiver to provide. Now, the standard of care is a combination of MAT and counseling. In the next section we will dive deeper into each of these options (Clark 2015; Baylor, 2020).
Methadone, buprenorphine and naltrexone are now the foundation for management of OUD. Each works by a different interaction with the mu receptors and all three come with risks and benefits (Clark, 2015; Baylor, 2020).
Mechanism of Action
Methadone is a mu receptor full agonist. Like opioid medications (i.e. oxycodone, morphine, endogenous opioids) methadone fully binds and activates the mu receptor with a weak affinity. Unlike those opioids, it has a longer half-life of 15-60 hours. It produces both analgesia and sedation.
Methadone is metabolized in the liver by cytochrome P450 (CYP450): 2B6, 2C9, 2C19, 2 D6, and 34A. It is excreted in the biliary tract and urine (Clark, 2015).Effectiveness
Methadone maintenance programs are an effective way to increase rates of sobriety. It significantly reduces rates of injecting drugs, HIV transmission, criminal activity and mortality rates.Initiation of Treatment
Initiation of methadone can be tricky as it is important to treat craving symptoms without depressing the respiratory drive. Initiation should also be done slowly to consider the long half-life of methadone that can lead to a summation effect. Studies show that a dose over 60mg is needed to be effective. Many patients are stabilized on a dose between 80 and 100mg. Occasionally, patients will require higher doses. This module will not go into the specifics of initiation of methadone as it requires a provider to be working in an OTP. If a patient would benefit from initiation of methadone, referral to an addiction center or, if the patient is currently in the hospital, use of an addiction consult service is warranted (SAMHSA, 2018).Side Effects
Methadone has many side effects. Common symptoms include sedation, dry mouth, and constipation. It also produces significant QT prolongation and can lead to torsades de pointes. Its actions, like opioids induces respiratory depression and at high doses can cause respiratory arrest. The respiratory effects typically happen earlier than the analgesic effects making it important to titrate slowly and carefully to achieve necessary analgesia without causing respiratory depression (Isbister, 2017).
There are many medications that interact with methadone. Mainly it is important to stay away from medications that cause QT prolongation, sedation, or respiratory depression. There are also a few medication interactions due to its metabolism by CYP450 (Isbister, 2017; SAMHSA, 2018).
Mechanism of Action
Buprenorphine is a partial agonist of the mu receptor. This means that the receptor is only partially activated. The benefit of the partial binding is that there is a “ceiling” effect to the respiratory depression typically seen in mu receptor agonists. Buprenorphine has a long half-life of 24-36 hours and a high affinity for the receptor. This high affinity means that buprenorphine can displace opioid bound to the receptor. It will also block other opioids from binding to the receptor. However, the blockade is not 100% as the binding is a dynamic process. Buprenorphine has a slow dissociation from the receptor which means that it has a less intense withdrawal syndrome (Mendelson, 1997).
Buprenorphine is metabolized in the liver by CYP450 3A4 (CYP3A4). It has a less-active metabolite, norbuprenorphine. Most of the buprenorphine is excreted in the biliary tract but both buprenorphine and norbuprenorphine are also secreted in the urine.
Buprenorphine has a high first pass metabolism and so oral administration is not effective. Sublingual, intravascular, transdermal, depot injections and implants are all routes available for buprenorphine. Sublingual, depot injections and implants have all been approved for use in OUD. The most common formulation is the sublingual tablet or film (Mendelson, 2017; SAMHSA, 2018).Effectiveness
Management of OUD with buprenorphine is effective at decreasing mortality and increasing rates of sobriety. At doses of 7mg and above, it performed as well as methadone in retaining patients in treatment, decreasing illicit drug use, and improving mortality rates. At lower doses it worked better than placebo but was inferior to methadone (Hser, 2014).
Buprenorphine is now almost exclusively used as a combination drug with naloxone. The combination began due to patients crushing the medication and injecting the medicine intravenously. This method leads to more activation at the receptor and can lead to a euphoric sensation. It also increased the amount of medication that was being “diverted” or sold on the street. The addition of naloxone, a potent antagonist of the mu receptor, helps to prevent this. When taken sublingually, the naloxone is not absorbed, allowing the buprenorphine to bind to the receptors. If crushed and injected, the naloxone will be absorbed and not only block the buprenorphine from binding but also knock any other opioids off the receptors initiating withdrawal symptoms. Since combining the two medications the risk of diverting has significantly improved (Baylor, 2020).Initiation of Treatment
Buprenorphine can be initiated either in the office or at home. Both techniques are equally effective. The decision should be made based on the patients desires and what your office can handle. It is crucial that the patient has already started having symptoms of withdrawal before initiation. If not, there is a risk of precipitating withdrawal when the first dose of buprenorphine is given.
For an in-office induction, the patient must arrive in mild withdrawal. This means, the patient must abstain from opioids for 12-24 hours if using short acting opioids (like oxycodone or heroin), 24-36 hours if using longer acting opioids (like Morphine ER), or 72 hours if on methadone. The Clinical Opioid Withdrawal Scale (COWS) is a validated survey used to assess if a patient is at the appropriate level of withdrawal by assessing signs and symptoms. If the total is great than 8 (or 13 if patient is primarily using fentanyl) you can proceed with the induction. If the number is lower than that, you run the risk of precipitating withdrawal in the patient. The patient is then given a 2-4mg dose of buprenorphine-naloxone (Bup) and told not to speak or swallow for 5 mins. 20-60 minutes later you assess the patient with the COWS form again. If the patient scores a 0-2, they are sufficiently treated and can be sent home to continue on that dose. If the score is >2 then the patient should receive a second 2-4mg dose, wait 20-60minutes, and have a COWS administered again. This process should be repeated until the COWs score is <2 or the patient has taken a dose of 16mg. If a patient’s COWS score increased from the initial score it is likely that you have precipitated withdrawal in this patient. Quickly give them another dose of Bup and continue the titration process. Remember that studies show higher success rates in patients on 7mg or higher. Typically, patients are stabilized on either an 8 or 16 mg dose (Lee, 2008, Sohler, 2010).
At-home induction is very similar to in the office, but the patient doesn’t have to go through symptoms of withdrawal in the waiting room of an outpatient office. Patients are instructed to start the induction when they are having signs or symptoms of withdrawal. An easy way to educate patients on when the timing is right is to use a Subjective Opioid Withdrawal Scale (SOWS). The patient should be instructed to start the process 12-24 hours after their last use or longer if using medications as described above. The patient then takes 2-4mg and waits an hour before assessing. They repeat this process until they no longer have the symptoms of withdrawal. It is recommended patients do not use more than 12mg in the first day of an at-home induction. Then on day 2, they take the total dose that they took on day 1. If they still are feeling symptoms of withdrawal, they can add more medication to total 16 mg (Sohler, 2010).
Both methods are shown to be equally successful. No matter which method is chosen, it is important to make sure the patient has close follow-up to allow for any adjustments to the dose (Sohler, 2010).Side Effects
Buprenorphine has many of the same side effects as opioids but to a lesser degree. Symptoms include dry mouth, constipation, headache, and nausea. Many times, the nausea can be improved by having the patient expel any remaining sputum after the initial 5 minutes instead of swallowing it. The main benefit of buprenorphine is that the respiratory depressive effects have a “ceiling effect” and so it has a significantly reduced risk of overdose. Things that increase the risk of overdose is the combination of Bup and injected benzodiazepines. There is also an increase in sedation if taken with alcohol (Hakkinen, 2012; SAMHSA, 2018).
Mechanism of Action
Naltrexone is an antagonist of the mu receptor. It has a relatively short half-life of 4 hours when taking orally. The intramuscular (IM) version has a half-life of 5-10 days. It has a very high affinity for the receptor and will displace all bound opioids. Also, at levels >2mg/ml, naltrexone will block all opioids from binding. It has an active metabolite that also blocks the receptor called 6-beta-naltrexol.
It is also thought to have a behavioral effect as it blocks the positive feedback of euphoria if a patient uses while taking the medication (Baylor 2020).Effectiveness
When compared to placebo, IM Naltrexone has high rates of abstaining from drugs. It also performed on par with buprenorphine and methadone. Some studies have shown that it may improve rates of abstinence from other substances (Comer, 2006; Comer 2010; Tanum, 2017).Initiation of Treatment
Naltrexone dosing is standardized so there is no need to titrate up. The key to initiation is that a patient must have abstained from opioid use for 7-10 days or they risk precipitating withdrawal. Once initiated, the IM version is preferable to the oral medication as it has better rates of compliance (SAMHSA, 2018).Side Effects
There are minimal side effects with Naltrexone. Side effects are typically seen in the first week of use and is termed a “naltrexone flu” as it mimics flu symptoms with rhinorrhea, diarrhea, body aches, and fatigue. Likely, it is a milder form of withdrawal as the naltrexone blocks even endogenous opioids (SAMHSA, 2018).
In this 6 minute video clip, Dr. Bass explains these medication options to the patient.
Helping patients decide on the next steps in their treatment plans can be tricky. It’s important to let the patient drive the conversation while offering salient evidence-based techniques. Also, making that decision is just the first step on what will likely be a difficult path.
OUD is a chronic illness with hills and valleys. Patients may be very motivated in the beginning and able to have long stretches of abstinence. Or, conversely, it may take many visits before a patient is able to consistently abstain. Whatever the path, it is critical as the provider to offer support and guidance. Most importantly, the provider should continue to prescribe the MAT that the patient is on as this improves rates of abstinence and decreases the rate of overdose.
To better understand OUD as a chronic condition compare it to a Type 2 Diabetic patient. Imagine that you have a diabetic patient who is coming in for a regular checkup. The patient reports that he is taking his metformin, but has been slipping back into an old habit of eating a donut for breakfast. You check the A1c and find that it is increasing. What is your next step? Your first thoughts are probably to counsel the patient on a diabetic diet, refer to a nutritionist, and/or, if the A1c is high enough, add a second agent. The option of stopping the metformin because the patient is not following the treatment plan probably never came to mind. Sadly, taking away the medication is exactly what some doctors will do if a patient on Buprenorphine comes to the office and has returned to use. When patients are struggling and return to opioid use, they need more support, not to have the drug that is helping them taken away. That is why a harm reduction chronic disease model is the most successful with this patient population.
Making lifestyle changes is hard, changes that require stopping an addictive substance. Think of your patients who struggle to stop smoking despite mountains of evidence about the negative health effects. With OUD patients it is important to have techniques available to help support them (Schuckit, 2016). It is particularly important to continue to support your patients who relapse, and explain that relapses are common. Praise them for continuing to come to their appointments and for their efforts to improve their situation. Be a source of hope and encouragement for whatever goal the patient decides is best for their recovery. If you react with judgement, anger, or even disappointment, it can damage the relationship you have built with your patient. Your understanding of the ups and downs of OUD treatment, and your nonjudgemental words of encouragemnt can make all the difference for your patients.
Miller and Rollnick described clinical approaches using MI in 1991 (Miller, 1991), and since then many studies have proven its efficacy in more than 25,000 clinical trials. MI is a technique that will help patients successfully change their lifestyles. Whether a patient is trying to stop eating sugary foods, quit smoking, or stop using heroin, this is a technique that can help. There are many ways to teach MI. However, all technique encourages the creation of a trusting patient-provider relationship, a patient-directed focus on change, patient-centered reflection and a detailed action plan. Overall, MI is a collaborative conversation based on open-ended questions that help to strength a patient’s motivation.
Motivational interviewing is based on the following assumptions:
- Ambivalence about substance use (and change) is normal and constitutes an important motivational obstacle in recovery.
- Ambivalence can be resolved by working with your client's intrinsic motivations and values.
- The alliance between you and your client is a collaborative partnership to which you each bring important expertise.
- An empathic, supportive, yet directive, counseling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase client defensiveness and reduce the likelihood of behavioral change.)
- Express empathy through reflective listening.
- Develop discrepancy between clients' goals or values and their current behavior.
- Avoid argument and direct confrontation.
- Adjust to client resistance rather than opposing it directly
- Support self-efficacy and optimism.
We distill these assumptions and principles in the following steps:Engage
First, create the relationship with the patient by engaging their trust. Ask questions that allow you to see the patient as a complete human being with a history and desires for the future.Focus
Next, ask the patient questions to help them focus on one area of their lifestyle that they both want and can change. This can be done by asking a patient “If you could change one this about your life, what would it be?” Let the patient guide the conversation. Reflect what you hear from the patient.Evoke
It is crucial to help a patient develop a deeper “why” for what is driving them to change. This will help the patient when they are struggling to make the healthier choice. Ask the patient “What is important to you?” “What do you want to be able to do?” “What identity do you want to have?” or “What motivates you?” Once a patient answers, ask them “why” until you get to a deeper understanding of what is driving their desire to change. This is illustrated in the video clip below.
Negotiate a Plan
Once the patient has picked an area to focus on for change and evoked a reason to make that change, it is time to iron out the details of “how.” Patients may make a vague statement of “I want to be healthier.” It is important for the provider to help them develop a “SMART” plan. “SMART” is an acronym that stands for: Specific, measurable, attainable, realistic, and time bound. These goals allow the patient to focus on how to make a goal achievable. For example, instead of saying “I want to be healthier” a “SMART” goal would be, “Instead of eating cupcakes or donuts, I will substitute nut mixes for my mid-afternoon snack.” Instead of “I want to abstain from heroin” say, “I will not use heroin during the week until our next follow up visit.” It is important for these goals to be attainable so that the patient feels the positive reinforcement of the sense of success at their follow up visit.
A plan should also include a discussion about barriers to success. When a person goes on a difficult hike, they make sure they are prepared for a variety of things. The hiker will bring water, a jacket, a map, a phone, and will go through the hike to make sure they have contingency plans should something go wrong. A patient with OUD is about to go on the hardest hike they have been on, and they need to be prepared. Ask the patient “what barriers do you see for your success with your plan?” Once they have identified them, ask the patient to come up with contingency plans. They can even create statements. “If I feel a craving, I will go for a 15-minute walk.” To help them feel prepared to achieve their goal.
Occasionally, a patient will struggle to identify any barriers. At that time, you can offer common barriers to sobriety. For example “What would you do if you were offered your drug of choice?” It is important for the patient to be the source of plan to overcome the barrier in order to ensure success.
Overcoming barriers can be hard to do alone. Patients should also receive the offer of counseling services and support groups in addition to medications. Still, although counseling tends to improve the chances of retention in a recovery program, a patients lack of accessing counseling services should never stop that patient from continuing to receive their medication. Narcotics anonymous and rehabilitation program are also an option for further support. It is important to note that not all programs promote use of MAT so educate your patient to advocate for themselves or not use programs that will make them feel bad due to their use of medication assisted treatment.
The provider should help guide this discussion using questions to help the patient create a plan to change their lifestyle. At the end of the discussion, the provider can summarize what they have heard. This process does not have to be very lengthy. It can be done within the confines of a 15-minute office visit. As a patient becomes familiar with it, the discussions will become easier and more efficient. (Glynn, 2010).
Trauma is any physically or emotionally damaging event in a person’s life. Many people by the age of 18 will have experienced trauma. The number increases when you do not give an age cut off. This is true across ethnicities, races, and socioeconomic classes. Given the prevalence of trauma, it is likely that many patients seen every day are survivors of traumas. Having survived trauma puts people at risk for being “triggered” in which an event, word, or action activates their amygdala (the fear center of the brain) and causes them to become reactive. This can put strain on the provider-patient relationship. It can also cause these patients to become secluded and not access the care that they need. To better serve these patients we need to practice Trauma-Informed Care (TIC). (Purkey, 2018)
Practicing TIC means recognizing that many patients, staff, and providers have experienced trauma at some point in their lives. This realization encourages providers to be mindful of their language, offer understanding and support, and resist the urge to be reactive.
Many patients suffering from OUD have experienced trauma in their lives. They also will likely have experienced stigma due to their condition from family, friends, and the medical community. It is important to recognize this and modify behavior to build a trusting, non-judgmental environment during interactions with these patients.
It can often be helpful to gain an understanding of the nature of patients’ trauma histories. If you ask in a non-judgmental and curious way, and give your patients the space to answer, they will often reveal their difficult and still painful experiences. Say, “I get the feeling you have suffered a great deal in your life. Can you bear to tell me about it?” Or, “Has anything really bad happened to you, like physical or sexual abuse?” Sometimes people will tell you things they haven’t told anyone else. It is important to know that you don’t have to “fix” their problems in the moment, and in fact you cannot. But if you don’t have the counselling skills necessary to address their emotional pain, you can refer them to psychiatrists and/or counselors who can work with them over time.
Language is a critical area to TIC. Words have power. Providers should really choose language that keeps the patient first, for example, referring to your patient as a patient with OUD, not an addict. It also means asking permission before any exam or intimate line of questions. “Is it okay if I listen to your heart?” These simple acts empower the patient to guide the visit.
It is also important to connect with the patient by offering them words of support and understanding. Do not judge them by using phrases like “You should have known better” or “why would you put yourself in that position?” Instead, offer kind words like “that must have been hard/scary/intimidating” or “I am sorry that you experienced that.”
Hurt people hurt people. People who have experienced trauma will become triggered and many may lash out. Becoming defensive will only escalate the problem. To best serve the patient, practice nonreactivity. When a patient becomes aggressive, simply remain calm and encourage the patient to breath or separate themselves from the trigger. Create space for a pause. Once the patients have calmed down, debrief the moment to figure out what triggered the patient. This may require the patient returning for another visit or having an extended time alone in the room.
It is also important to recognize that as providers, we too have experience trauma and can be triggered. It may be experienced as frustration or even anger towards a patient. When you notice this, pause. Separate yourself from the situation and take a breath. See if you can figure out what has triggered you so that you are aware of it for future interactions. It can be a simple thing such as a patient not taking medication that you have prescribed. This may not be the first time that patient has ever done that but perhaps you have a history of a patient who never took the medication you prescribed and then had a bad outcome that the patient blamed you for. Now, when a patient acts in a similar way, you are triggered to assume that history is going to repeat itself. You may feel frustrated or agitated. It is important to recognize your own triggers and trauma to be able to practice TIC.
OUD is currently an epidemic in America. It is crucial to recognize the signs and symptoms of OUD. OUD is a chronic condition that requires a harm reduction model for successful treatment. Once a patient is diagnosed, they should be offered management options. Evidence has shown that abstinence only programs are only successful for 5-10% of patients. Use of MAT, especially when coupled with counseling, is successful at increasing periods of abstinence from drugs. MAT consists of the use of methadone, BUP, or naltrexone. Each of these medications comes with pros and cons and the decision on which treatment should be decided using a patient directed conversation.
Along with MAT, it is important to offer counseling techniques to patient to help them successfully make lifestyle changes. One of these techniques is called MI. MI involves an open-ended patient driven discussion that gets a patient to engage in treatment, focus on an area for change, evoke a reason for that change, and negotiate a plan to achieve the change.
TIC allows us to focus on ways to create a safe and supportive relationship for our patients that have experienced trauma. It encourages mindful word choices, being supportive, and deescalating moments when a patient, staff, or provider may be triggered.
By utilizing this knowledge, a provider will be able to offer the best tools to help patients with OUD abstain from use and work towards creating the quality of life for which the patient is striving.
You have seen parts of our interview as we went through the module. Now, feel free to watch the entire interview to solidify the use of these frameworks in managing patients with OUD.
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Maya A. Bass, MD, MA FAAFP
Drexel University College of Medicine
Barbara A. Schindler, MD, DFAPA
Drexel University College of Medicine
Dennis H. Novack, MD
Drexel University College of Medicine
Video Camera, Light
George Zeiset B.A.