Category: substance use

Treatment of Adults with Opioid Use Disorder

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Do you have patients who are misusing opiates? Do you wonder if you can manage prescribing medications for opioid use disorder (MOUD) or have questions about what to prescribe? Drug overdose deaths in the United States are at an all-time high, with most caused by opioid use, namely fentanyl. The good news is that effective medication treatments for opioid use are available, and in case you didn’t know, Washington providers can call the Psychiatry Consultation Line at 877-927-7924 to consult with our psychiatrists about using these treatments with your adult patients.

It’s critical for more clinicians to explore whether they can prescribe MOUD; in 2019, only 18% of people with opioid use disorder (OUD) received MOUD in the prior year. What are the MOUD options for your patients living with OUD?

Methadone 

The three FDA-approved MOUD options are methadone, buprenorphine and naltrexone. Methadone is a full mu-opioid agonist that has been exhaustively studied and shown to be safe and effective for patients with OUD, particularly when dosed above 60 mg per day. Because of the time involved in titration, achieving a dose of methadone that alleviates cravings and protects patients from overdose can take weeks. Despite the efficacy data, methadone is the most tightly regulated MOUD, and it is only accessible through DEA-approved treatment facilities. Many counties in Washington have no methadone clinics, leaving those with OUD only two MOUD options: naltrexone and buprenorphine.

Naltrexone

Naltrexone, particularly in the form of the 380 mg per month, long-acting injectable is another option for patients. As a full mu opioid blocker, initiation of naltrexone requires full withdrawal from opioids. Starting naltrexone prior to completion of opioid withdrawal can result in precipitated withdrawal. Many patients are unable to achieve full cessation and thus studies have shown higher dropout rates with naltrexone for OUD compared to buprenorphine.

Buprenorphine

Buprenorphine is the third FDA-approved MOUD with evidence similar to methadone in terms of treatment outcomes. In years past, prescribing buprenorphine required at least 8 hours of training and an x-waiver. As of January 2023, this requirement was dropped and anyone with a standard DEA registration number can prescribe buprenorphine. Unlike methadone, buprenorphine can be prescribed in an office-based setting, making it more accessible for patients.

As a partial agonist with a high binding affinity for the mu-opioid receptor, buprenorphine is a very safe option for OUD. Even at maximum doses, patients do not experience respiratory depression with the medication alone. Further, doses of buprenorphine, which protect patients from overdose, can be achieved quickly in one or two days. Given the pharmacologic properties of buprenorphine, patients must be in some degree of opioid withdrawal prior to initiating buprenorphine, as it can otherwise precipitate opioid withdrawal. Typically, it is recommended for patients to achieve a clinical opioid withdrawal scale (COWS) score of 8 or more prior to initiating buprenorphine. Though precipitated withdrawal is not necessarily dangerous, patients feel extremely uncomfortable and can have negative connotations with buprenorphine, reducing their likelihood of continuing the medication in the future.

Thankfully this outcome is a relatively rare occurrence. In one recent study less than 1% of patients experienced precipitated withdrawal when dosed with buprenorphine after achieving a COWS score greater than 8. Techniques for initiating buprenorphine varies significantly, ranging from “low dose induction,” the practice of giving small doses of buprenorphine with gradual increases over time to “standard induction,” giving 4 mg -12 mg of buprenorphine in the first day, to “high dose inductions” initiating higher doses of buprenorphine, 16 mg to 32 mg quickly following emergence of withdrawal symptoms.

Buprenorphine Treatment Guidelines

Regardless of the initiating dose, the goal of treatment is to achieve a dose of buprenorphine that eliminates opioid withdrawal, significantly reduces or eliminates craving to use opioids, and blocks the effects of illicit opioids to the degree that the patient has significantly reduced, or better yet, stopped use of illicit opioids all together. If patients have cravings to use, evidence of withdrawal from opioids, or continue using illicit opioids, increasing the dose of buprenorphine should be considered. The current maximum dose is 32mg daily.

Previous guidelines have suggested that doses of buprenorphine beyond 24 mg may not be necessary, but these recommendations were based primarily on data associated with patients using heroin. In the current era where the illicit opioid market is dominated by fentanyl, patients may well require higher doses of buprenorphine. Typically, buprenorphine has been dosed once daily, but for some, 2-4 doses spread throughout the day are preferred. Buprenorphine has multiple formulations for the treatment of OUD which include sublingual, buccal, implantable, and long-acting subcutaneous injectable versions.

There are no clear data on the length of time patients with OUD should remain on MOUD. However, after cessation of medications, rates of return to use of opioids is high, so most experts recommend ongoing maintenance therapy with buprenorphine or methadone. For more information on treatment of patients with MOUD, please see the resources below. And please call the PCL at 877-927-7924 if you are a Washington provider who would like to consult about your adult patients with mental health and/or substance use care needs.

Author

Jonathan Buchholz, MD
Director, Addictions Psychiatry Fellowship; Medical Director of Inpatient Psychiatry, VA Puget Sound

Dr. Buchholz specializes in working with individuals experiencing co-occurring mental health and substance use disorders, a process that reminds him of the amazing resiliency that lies within us all.

Related Resources

Practice-Based Guidelines: Buprenorphine in the Age of Fentanyl
Provides practical clinical practice-based guidance, based on available research combined with emerging clinical experience, on the use of buprenorphine in the treatment of individuals using fentanyl and other highly potent synthetic opioids.

Linking People with Opioid Use Disorder to Medication Treatment
This prevention resource presents strategies that can help state, local, and tribal leaders and healthcare professionals link persons living with OUD to evidence-based care. Strategies are based on the best available evidence.

Medications for Opioid Use Disorder
The Executive Summary of this Treatment Improvement Protocol provides an overview on the use of the three Food and Drug Administration-approved medications used to treat opioid use disorder—methadone, naltrexone, and buprenorphine—and the other strategies and services
needed to support recovery.

Providers Clinical Support System-Medications for Opioid Use Disorders
A program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and created in response to the opioid overdose epidemic. PCSS-MOUD’s goal is to provide evidence-based practices to improve healthcare and outcomes in the prevention of those at risk and treatment for individuals with an opioid use disorder (OUD).

10 Tips for Prescribing in the Perinatal Period

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Perinatal person with baby

Psychiatric disorders are common during pregnancy and postpartum. For example, rates of perinatal depression and anxiety are 15-20%. Twenty percent of people with postpartum depression have a bipolar spectrum disorder. In addition, many people have pre-existing psychiatric conditions and are already taking psychotropic medications when they become, or are planning to become, pregnant. The overall goal of treatment during pregnancy is to use the lowest number and dosages of medications possible, while effectively treating the underlying psychiatric disorder(s).

Although the Perinatal PCL receives questions about diagnoses, non-medication treatments, and resources and referrals, many calls are about prescribing and the effects of medications during pregnancy and lactation. Here, we provide some general guidelines about prescribing during the perinatal period and some resources to find information about risks of specific medications.

What are some general guidelines about prescribing during the perinatal period?

1. Consider risks during pregnancy whenever prescribing medication for someone of childbearing potential.
About 50% of pregnancies are unplanned. Considering, and informing people of childbearing potential about, risks of their medication(s) during pregnancy helps to maximize prescribing of safer medications and avoid patients’ suddenly discontinuing needed medication if they find out they are pregnant.

2. Make any medication changes before pregnancy if possible.
This minimizes the number of exposures for the baby and maximizes stability for the parent. Changing a newer medication with less data regarding safety in pregnancy to an older medication with more safety data can be done before pregnancy, if desired. Making this change once the patient is already pregnant involves exposing the baby to two medications instead of one and potentially causing worsening of the parent’s psychiatric condition during pregnancy.

3. Ideally, the patient should be psychiatrically stable for at least 3 months before trying to conceive.
Although this is not always possible, it decreases the risk of relapse and exposure of the baby to risks of untreated/undertreated psychiatric illness.

4. Avoid polypharmacy whenever possible.
Prescribing the fewest medications possible to effectively treat the patient’s psychiatric disorder reduces exposures for the baby. Reviewing the need for each medication is especially important when someone is taking multiple medications and/or more than one medication in a class (e.g., two or more antidepressants, two or more antipsychotics, multiple antianxiety/hypnotic medications, etc.).

5. Avoid Depakote.
Depakote (valproic acid) is a commonly prescribed mood stabilizer for patients with bipolar disorder. Depakote is a known teratogen (rate of malformations elevated in all dosage ranges and 25% at doses above 1450 mg/day) and is associated with significantly decreased IQ in children exposed in utero.

6. Optimize non-medication treatments.
At all times, and especially during the perinatal period, we want to maximize the use of evidence-based non-medication treatments such as psychotherapy. Even if someone requires medication for effective treatment of their condition, non-medication treatments can help minimize numbers and dosages of medications and increase effectiveness of treatment.

7. Remember that an untreated/undertreated psychiatric disorder also poses risks to the parent and the baby.
Untreated/undertreated psychiatric disorders pose significant risks for parents and babies. For example, perinatal depression is associated with higher rates of preterm birth, low birth weight, problems with attachment and bonding, and increased rates of psychiatric disorders in childhood and adolescence. For this reason, it is important to treat psychiatric disorders effectively during the perinatal period.

8. If you are thinking of stopping your patient’s psychotropic medications because they are pregnant, please call us first.
Discontinuing medications abruptly can precipitate relapse (another exposure for the baby and risk for the parent). Also, stopping some medications can cause withdrawal symptoms that are potentially dangerous (e.g., benzodiazepines) or unpleasant (e.g., antidepressants). We would be happy to help you sort out which medications to discontinue and safe tapering schedules.

9. Prescribing during the perinatal period requires a risk-risk discussion.
Informed consent during the perinatal period involves collaborating with the patient in discussing and weighing risks of medication for the fetus/baby, risks of the psychiatric disorder, and possible alternative treatments.      

10. Use a patient-centered and team approach.
In addition to collaborative decision-making with, and support of, the patient, this includes involving family members and communicating with other care providers. It is important to educate the partner and/or family members about the risks and benefits of treatment as well as warning symptoms of relapse. Communication with obstetric and pediatric providers minimizes the patient’s hearing conflicting opinions and being confused and concerned.   

The Perinatal PCL is a free, state-funded, provider-to-provider consultation line like the Psychiatry Consultation Line (PCL) but focused on behavioral health disorders and symptoms during the perinatal period (pregnancy and the first 12 months postpartum). We are available at 877-725-4666 or by email at ppcl@uw.edu, weekdays 9-5. Like PCL, we also offer scheduled consultations.

Any healthcare provider in Washington State can call us with any behavioral health-related questions about a patient/client who is pregnant, planning pregnancy, postpartum, or who has pregnancy-related complications (e.g., infertility, pregnancy loss). Perinatal PCL is staffed by University of Washington perinatal psychiatrists, an addiction psychiatrist with expertise in the perinatal period, and our program coordinator, who is trained in social work. We offer psychiatric consultation and local perinatal mental health resources. For more information about Perinatal PCL, and to access our online Perinatal Mental Health Care Guide, please visit our website.

Author

Deb Cowley, MD
Board-certified psychiatrist at UWMC-Roosevelt
UW professor of Psychiatry and Behavioral Sciences
Medical director, Perinatal PCL

Dr. Cowley has expertise evaluating and treating women who have mental health issues during pregnancy and postpartum, and throughout their life cycle, including premenstrual and menopause-related psychiatric symptoms. Her clinical interests include anxiety disorders, depressive disorders, obsessive compulsive and related disorders, panic disorder, postpartum depression, evidence-based medicine, maternal mental health and women’s health.

Related Resource

Management of Psychotropic Drugs During Pregnancy
Psychiatric conditions (including substance misuse disorders) are serious, potentially life threatening illnesses that can be successfully treated by psychotropic drugs, even during pregnancy. This review presents an up to date and careful examination of the most rigorous scientific studies on the effects of psychotropic drugs in pregnancy.

Other Resources

InfantRisk for Healthcare Providers
This collection of apps is for healthcare providers and parents about the safety of medications during pregnancy and breastfeeding. 

LactMed
This database of drugs and other chemicals provides information about the safety of exposure during breastfeeding.

Reprotox
This database of medications highlights their effects during pregnancy, breastfeeding, and development. (Requires subscription.)

MotherToBaby
These fact sheets are for parents regarding risks of drugs (including non-prescribed drugs) during pregnancy and breastfeeding. 

Perinatal Support Washington
This non-profit organization provides a warm line, support groups, peer support, resources, and therapy referrals to support emotional wellbeing for new parents. 

Treating Generalized Anxiety Disorder with buspirone

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A common question to the Psychiatry Consultation Line is around treatment of Generalized Anxiety Disorder (GAD) in patients with a history of substance use disorders and for whom a Selective Serotonin Reuptake Inhibitor has not been effective. First-line treatments for Generalized Anxiety Disorder include Cognitive Behavioral Therapy (CBT), Serotonin Reuptake Inhibitors (SRI), or a combination of both. In cases where adjunctive CBT and multiple trials of SRIs have failed, buspirone can be given some consideration.

In 1980s-era, double-blind studies of GAD, buspirone’s efficacy was shown to be similar to benzodiazepines. An important difference between benzodiazepines and buspirone is that it takes buspirone longer to start working. Buspirone requires a multi-week or multi-month trial to assess efficacy. Compared to benzodiazepines, buspirone is less likely to cause sedation and, importantly, is not associated with the development of tolerance or dependence. Common side effects of buspirone include dizziness, nausea, and headache.

The FDA max dosing is 60mg/day and while some patients require a high dose, average therapeutic doses are in the range of 20 to 45 mg/day. Buspirone has a short half-life and some patients benefit from TID dosing.

Please refer to your own reference material for full prescribing information regarding medication dosing, risks, benefits, side effects, monitoring requirements, and drug interactions. We most often use Micromedex, UpToDate, or Epocrates. Additionally, there are free databases available to Washington State providers at https://heal-wa.org/professions/.

Author
Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatric Consultation Line

Learn more
How do I address emerging anxiety during substance use recovery?  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) discuss characteristics between a substance induced anxiety disorder and a primary anxiety disorder, and 2) to talk through different treatment options for anxiety symptoms.

CBT for Anxiety (CBT-A): What can I do with my patient instead of giving them a PRN benzodiazepine?  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Patrick Raue, PhD
The objectives of this presentation are to 1) understand the CBT model of anxiety symptoms, 2) describe how to give the “treatment pitch” to patients, and discuss the difference between treatment with exposure vs. anxiety management strategies, 3) understand how to develop and work on an exposure hierarchy with patients and 4) describe anxiety management strategies that use physical and cognitive approaches.

Anxiety: fast facts and skills for the primary care physician  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Ryan Kimmel, MD
A brief overview of diagnosing and treating anxiety in primary care.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

How to ask about substance use

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If you struggle with asking patients about their alcohol and/or drugs use, you are not alone. Asking sensitive questions in a way that makes it more likely a patient will respond honestly can be challenging, and defensiveness or resistance to answering are not uncommon. Complicating this is the need to build a connection with your patient, and fear that a negative response to being asked will alter your rapport. For some, the challenge lies in asking the question; for others, it is what to do if you suspect a patient has a substance use issue.

Why, then, should providers ask about substance use? The pandemic has fueled escalating rates of both mental health and substance overuse, with one in 10 people reporting they started or increased their substance use during the. Suicide rates are up, as are overdose rates in our state. Before the pandemic, The National Institute on Drug Abuse estimated that there were over 20 million adults in the US with a substance use disorder. Of those, 38% of them also had mental illness.  Substance use disorder has a significant impact to personal health, and early intervention is key to preserving patient health and lowering health care costs. And, primary care is the de facto setting where many patients access mental health and substance use care.

There are over a dozen evidence-based screening tools for substance use, including the DAST, AUDIT-C, and CAGE. While the screening tools set a clear framework for what to ask, it’s important to know how to ask — how to set the stage — so the patient’s answers are more likely to be reliable and valid. Setting the stage includes managing our own anxiety, mitigating the patient’s anxiety, and being mindful of the wording, order and form of the questions you are asking.

To begin, be aware of your own anxiety and fears about asking sensitive questions. What’s driving them? What feels uncomfortable about asking these questions? To quell their own anxieties, some people find it helpful to practice and to ground themselves in the reasons why the answers are so important. Asking sensitive questions eventually becomes more natural, but until then, take a minute to check in with yourself and what you need to feel confident.

The words you use to ask sensitive questions, and how you set up the structure of asking, is key. Where does asking about drug and alcohol use fall in your assessment? Your psychosocial assessment should have flow, and it can be helpful to ask less loaded habit questions before asking about drug/ETOH use. For example, consider asking about diet and exercise before asking about other habits around smoking, alcohol and drugs. Starting off with questions about more socially acceptable substances like caffeine, tobacco, and then alcohol can be helpful in normalizing this line of questions.

As you head into the more sensitive questions, it can be helpful to start off with close-ended or fixed choice questions. “Have you ever drank alcohol?” or “Have you ever used any drugs or Cannabis?” This can then be followed up by asking “How often do you use?”, “How much do you use?”, and “How do you use?” if appropriate.  Asking additional questions to identify potential harms associated with their use can identify potential areas of intervention and education. “How often do you use a fresh needle when you inject…never, sometimes, almost always, always?” Asking about access to Narcan is important if the patient is using opioids or methamphetamine which may have opioids like fentanyl mixed in.

Be careful to use words that are less loaded—don’t use the term “illegal” when referring to drugs, for example, and try to ask about each drug specifically. “Have you ever used cocaine” is better than “have you ever used street drugs.” When talking with patients, be careful too about terms that are defined by each of us individually, like “drunk,” “high,” “frequently,” etc. Ask specific, quantifiable questions.

After you have a thorough substance use history from your patient and it turns out they have some concerning use patterns, what do you do now? Behavioral interventions have shown effectiveness in reducing substance use in those who are at risk for developing dependence. Commonly used elements for engaging in behavioral interventions are described in the FRAMES acronym—Feedback of risk, encouraging Responsibility for change, Advice, a Menu of options, therapeutic Empathy and enhancing Self Efficacy. Motivational interviewing can help you engage with patients who have more problematic use, but who are not yet expressing interest in change, or are contemplating change but not stating a readiness to change.

Remember, you can always call the PCL for advice on what to do once you have determined a patient does have some concerning substance use habits. Many providers feel ill-equipped to treat substance use and mental health conditions and the PCL adult psychiatrists and addiction psychiatrists are there to support you in the care of your patient. Call us anytime – we are a part of your team!

Author
Jennifer Magnani, MSW, LICSW, is the Assistant Program Director of the Psychiatry Consultation Line.

Learn more
Screening, Diagnosis, and Medication Assisted Treatment for Alcohol Use Disorders (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) identify the current screening tools and recommendations for alcohol use disorders, 2) discuss what to consider in diagnosing alcohol use disorders, and 3) review the current medications used for alcohol use disorders.

What Are Some Behavioral Strategies to Help My Patient Stay Sober? (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) review the importance of behavioral strategies for relapse prevention, 2) describe which behavioral strategies can be incorporated, and 3) learn when to use these strategies in a clinical situation.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.