Opiate Abuse Paper
The patient is a 58-year-old woman with chronic pain due to inflammatory arthritis. She presents for her first appointment with you in a primary care office. She states that she is aware that she is asking for an early refill of her Oxycontin however, she is traveling out of state, and she is concerned that she may have a flare-up on her trip.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) as a screening tool is authentic and can be accomplished within minutes (Shonesy et al., 2019). A vast majority of patients screened annually neither require additional work up nor referral (Shonesy et al., 2019). However, the prognosis of drug and substance use is directly proportional to the time of detection and intervention.
The patient presenting for her first appointment has inflammatory arthritis. Inflammatory arthritis is a chronic debilitating condition (Poudel et al., 2022). There are several kinds of inflammatory arthritis, although this is beyond the scope of this paper. A vast majority of patients with this chronic condition are ordinarily on opioids under the control of pain management specialists (Poudel et al., 2022).
Consequently, her early refill request of oxycontin in this initial appointment is a little concerning. Additionally, much of the information about this client is unknown since no history, physical examination, or review of the previous consultation has been done. This information is critical to the course of management and treatment. Subsequently, the patient must be assessed comprehensively before further actions.
SBIRT, although reliable, will likely be inconclusive due to less information to review. A National Institute of Drug Abuse (NIDA) quick screen can be used to assess her. The result will most probably be positive. Consequently, a NIDA lifetime use scan will be required to determine the use of one or more substances. Opioid addiction has devastating consequences (Foli et al., 2021).
Alternatives such as transitioning to non-opioid medication. Patient collaboration, as well as involvement in decision-making, are crucial, which necessitates a good rapport. Currently, I will not fill her oxycontin for various reasons. Firstly, the narcotic prescribing laws in Florida do not allow chronic noncancer pain treatment unless done by a pain management specialist. Similarly, her pain is chronic as opposed to the ordinary 3-day script used for acute pain (Foli et al., 2021).
Finally, inadequate information basis regarding the patient and being an initial visit makes it difficult to sufficiently manage this patient or aid in transitioning to a non-opioid analgesic.
Application of SBIRT steps to this scenario
S-screening
How long have you been using oxycontin?
In the last three months, how frequently have you used oxycontin?
Does it interrupt your activities of daily living
Have you had any difficulties with social, health, financial or legal problems while taking oxycontin?
Has a friend or family member shown any concern regarding your use of oxycontin?
Have you had any challenges with fulfilling obligations at school, work, or home?
Have you ever tried to stop or decrease your use of oxycontin?
Each of the queries is scored, providing a method to quantify the severity and risk NIDA-Modified ASSIST screening. This score will also direct her further care.
BI-Brief Intervention
Assess her screening score and the use of opiates
Elaborate on the consequences of addiction and possible concerns.
Evaluate other treatment options
Evaluate if she needs assistance or transition to something else.
Referral and Treatment
Based on her risk assessment score, a decision regarding the appropriate referral would make.
Analysis of her motivation and comprehension of concerns about opiate use.
Identify additional questions for this patient.
Are you on any other prescription drugs aside from oxycontin?
Do you know about your diagnosis and who made it?
How many pain tablets do you take daily?
Who do you see presently for chronic pain management?
What was the initial dosage, and what is the current dosage?
Are there any other medications you have utilized for pain control?
Have you discussed with the prescribing physician the need for an early refill?
How is your medication prescribed?
Have you altered your medication or increased its dosing recently?
How frequently is it refilled?
Develop a Treatment Plan
An extensive and comprehensive history and physical examination.
Diagnostic labs.
Solicit her medical records from other healthcare providers.
Review the use of E-forced or electronic controlled medication.
Discuss alternative treatment options.
Arrange for a discussion with her prescribing physician.
Discuss the state laws regarding the prescription of narcotics and other controlled substances.
Arrange for a follow-up to finalize the physical.
The patient is a 24-year-old man brought to your clinic by his family for an evaluation. The patient states that he is struggling with prescription pain pills and wants help. He appears to be in opioid withdrawal; he describes anorexia and diarrhea, and he is yawning and sweating upon examination. He scores 15 on the Clinical Opioid Withdrawal Scale (COWS), indicating moderate withdrawal.
Commence office-based buprenorphine/naloxone (suboxone) with an observation plan
According to Velander (2018), the ratio of buprenorphine to naloxone is 4:1. This facilitates better compliance whilst diminishing the misuse potential. However, this drug is strictly regulated, and its prescription necessitates specialist treatment services and licensing. For instance, a healthcare provider ought to submit a waiver and complete continuing education to prescribe this medication (Toce et al., 2018).
Initiating Suboxone
Individualized induction dosing 2/0.5mg-4mg/1mg x’s 1. May titrate in increments by 2mg/0.5mg-4mg/1mg q2h up to and 8/2-mg sublingual tablets on day 1 (Toce et al., 2018). Day 2 dose may be increased up to 16mg/4mg (Toce et al., 2018). Starting at a low dose and slowly titrating ensures optimal effect in diminishing withdrawal symptoms. Finally, this approach ensures that the patient tolerates the medication and hence minimizing the side effects.
Develop a treatment plan for this patient that includes ongoing MAT and psychosocial treatment interventions
The treatment plan will consist of a comprehensive evaluation of his dependence and the necessity for inpatient addiction services. Similarly, the presence of a positive family support system must be confirmed. In designing the plan, a comprehensive discussion including all treatment options available and collaboration with the patient to select the best treatment option to meet his target goals is mandatory. Psychosocial treatment intervention includes multidimensional cognitive and behavioral therapy.
Construct a safe taper schedule for a patient taking alprazolam (Xanax) 2 mg TID. Include a brief narrative explaining the evidence for tapering a patient who has been on benzodiazepine for an extended amount of time.
It is essential to determine the underlying rationale for alprazolam used to treat this patient appropriately. According to Baandrup et al. (2018), mood stabilizers or antidepressants may be considered during benzodiazepine withdrawal. Benzodiazepines must not be stopped abruptly as there is a significant risk of withdrawal syndrome (Baandrup et al., 2018).
Alprazolam should be tapered off over 6 to 10 weeks with a 50% reduction in the dosage every 1-2 weeks.
1st two weeks
1 mg thrice daily while monitoring for withdrawal symptoms
2nd two weeks
0.5 mg thrice daily while monitoring for withdrawal symptoms
3rd two weeks
0.25 mg thrice daily while assessing for withdrawal symptoms
4th two weeks
O.25 mg twice daily while assessing for withdrawal symptoms
5th two weeks
0.25 mg once daily while assessing for withdrawal symptoms.
(Baandrup et al., 2018).
References
Baandrup, L., Ebdrup, B. H., Rasmussen, J. Ø., Lindschou, J., Gluud, C., & Glenthøj, B. Y. (2018). Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users. The Cochrane Library, 2018(3). https://doi.org/10.1002/14651858.cd011481.pub2
Foli, K. J., Huang, W., Adams, N., Kersey, S., Good, B., Ott, C., & Duha, M. S. (2021). Nurses’ Substance Use Education Through a Massive Open Online Course.
Poudel, P., Goyal, A., & Lappin, S. L. (2022). Inflammatory Arthritis. https://pubmed.ncbi.nlm.nih.gov/29939526/
Shonesy, B. C., Williams, D., Simmons, D., Dorval, E., Gitlow, S., & Gustin, R. M. (2019). Screening, Brief Intervention, and Referral to Treatment in a retail pharmacy setting: The pharmacist’s role in identifying and addressing the risk of substance use disorder. Journal of Addiction Medicine, 13(5), 403–407. https://doi.org/10.1097/ADM.0000000000000525
Toce, M. S., Chai, P. R., Burns, M. M., & Boyer, E. W. (2018). Pharmacologic treatment of opioid use disorder: A review of pharmacotherapy, adjuncts, and toxicity. Journal of Medical Toxicology: Official Journal of the American College of Medical Toxicology, 14(4), 306–322. https://doi.org/10.1007/s13181-018-0685-1
Velander, J. R. (2018). Suboxone: Rationale, science, misconceptions. The Ochsner Journal, 18(1), 23–29. https://www.ncbi.nlm.nih.gov/pubmed/29559865
Opiate Abuse Paper Instructions
Complete the following case studies:
1. The patient is a 58-year-old woman with chronic pain due to inflammatory arthritis. She presents for her first appointment with you in a primary care office. She states that she is aware that she is asking for an early refill of her Oxycontin however she is traveling out of state and she is concerned that she may have a flare up on her trip.
Apply the steps in SBIRT to this scenario
Identify additional questions for this patient
Develop a treatment plan for this patient
2.The patient is a 24-year-old man brought to your clinic by his family for an evaluation. The patient states that he is struggling with prescription pain pills and wants help. He appears to be in opioid withdrawal; he describes anorexia and diarrhea, he is yawning and sweating upon examination. He scores 15 on the Clinical Opioid Withdrawal Scale (COWS), indicating moderate withdrawal.
Initiate office-based buprenorphine/naloxone (Suboxone) with a plan for observation.
Include your rationale for each treatment decision
Develop a treatment plan for this patient that includes ongoing MAT and psychosocial treatment interventions.
Construct a safe taper schedule for a patient taking alprazolam (Xanax) 2mg TID. Include a brief narrative explaining the evidence for tapering a patient who has been on a benzodiazepine for an extended amount of time.
Foli, K. J., Huang, W., Adams, N., Kersey, S., Good, B., Ott, C., & Duha, M. S. (2021). Nurses’ Substance Use Education Through a Massive Open Online Course (NSUE-MOOC). Purdue University, School of Nursing, West Lafayette, Indiana.
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