#27- Recap: ACAAM Lightning Round

August 1, 2024 | By Carolyn Chan

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Transcript available via YouTube

Spark your learning

We cover clinical pearls from graduating addiction medicine fellows by covering ACAAM’s annual lighting round presentation.  Learn about tianeptine, buprenorphine starts in patients with acute hepatitis, vaccinations for persons who inject drugs, and more! 

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Production Partner: ACAAM

The Curbsiders Addiction Medicine are proud to partner with  The American College of Addiction Medicine (ACAAM) to bring you this mini-series.  ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Visit their website at acaam.org to learn more about their organization.

Show Segments

• 00:00 Intro, disclaimer
• 03:00 Picks of the week
• 07:00 Buprenorphine and hepatitis
• 16:30 Ketamine for withdrawal
• 24:00 Hepatitis B
• 28:20 Tianeptine
• 35:30 Hepatitis C treatment
• 39:00 PETH
• 47:40 Unintended phenobarbital consequences
• 53:40 TBI and overdose risk
• 58:00 Outro

Recap: ACAAM Lighting Round Pearls

1. If available, use the buprenorphine monoproduct for buprenorphine initiations in patients with moderate to severe liver impairment (Child-Pugh class B and C). Naloxone is metabolized by the liver, and using the combination product (buprenorphine-naloxone) in an individual with significant liver impairment may be associated with precipitated withdrawal. 
2. Ketamine can be considered as an adjunct to help patients with symptoms of precipitated opioid withdrawal. 
3. Hepatitis B is more prevalent among individuals with a history of injection drug use compared to the general population.
4. As of 2023, the CDC recommends screening all adults for hepatitis B. The Advisory Committee on Immunization Practices recommended hepatitis B vaccination for infants, children not vaccinated, and adults ages 19-59. Adults age 60 or older with risk factors (including injection drug use) should also receive hepatitis B vaccinations.
5. Recent blood transfusions can cause a false positive phosphatidylethanol (PEth) test due to the transfer of PEth from donors who have consumed alcohol.
6. Tianeptine, an atypical tricyclic antidepressant, also acts as a mu-opioid receptor agonist, and regular use can place an individual at risk of opioid withdrawal symptoms with abrupt cessation.
7. Phenobarbital is a CYP450 enzyme inducer that can decrease methadone levels. Be cautious when using phenobarbital for alcohol withdrawal in individuals treated with methadone. 

ACAAM Lighting Round – Notes

Buprenorphine and Acute Hepatitis

Presentation by: Dr. Ruchi Shah, DO from Boston Medical Center

Case Summary: A patient with opioid use disorder presents with acute hepatitis A with transaminase levels >1,000 and wants to start buprenorphine. They are in opioid withdrawal and given buprenorphine-naloxone via a high-dose protocol. They develop precipitated withdrawal despite repeated dosing of buprenorphine/naloxone and experience persistent symptoms of nausea and withdrawal. When they are switched to the buprenorphine mono-product, their symptoms of nausea and withdrawal resolve.

Clinical Pearl: Dr. Shah reminds us that buprenorphine and naloxone are both metabolized by the liver. In patients with healthy liver function (and even mildly impaired liver function: Child-Pugh Class A), sublingually administered naloxone has very poor bioavailability. Moderate to severe liver impairment (Child-Pugh class B and C) can increase the bioavailability of sublingually-dosed naloxone, and to a lesser extent, buprenorphine. (Nasser, 2015). Higher plasma concentrations of naloxone can then lead to precipitated withdrawal. For patients with Child-Pugh scores of 7-15 (class B and C) who need to start buprenorphine, the combination product of buprenorphine-naloxone is not recommended as it may cause precipitated withdrawal (SAMHSA TIPS 63). Instead, clinicians should prescribe the buprenorphine mono-product. 

Ketamine for Precipitated Withdrawal

Presentation by: Dr. Parmis Rad, MD, from Kaiser Permanente Northern California

Case Summary: A patient with opioid use disorder in withdrawal was started on buprenorphine and experienced precipitated withdrawal. Despite multiple doses of buprenorphine, their withdrawal worsened. To help manage the precipitated withdrawal, they were given ketamine, which resulted in an improvement in withdrawal symptoms. 

Clinical Pearl: Ketamine is an NMDA antagonist that is also thought to potentiate the effectiveness of buprenorphine mu-opioid receptor signaling and resensitize fentanyl-induced mu-opioid receptor desensitization (Hailozian, 2022). Although evidence is limited, ketamine can be considered as an adjunct to help patients with symptoms of precipitated opioid withdrawal. 

Hepatitis B Vaccination 

Presentation by: Dr. Lindsay Perusek, DO from MetroHealth Hospital

Project Summary: Dr. Perusek presented a retrospective chart review of hepatitis B screening and vaccination rates among patients receiving care in a substance use disorder treatment clinic. Screening rates were <50% and documented vaccination or evidence of serologic immunity was 30%. This suggests an opportunity to improve screening and vaccination among individuals seeking SUD treatment. 

Clinical Pearl: Hepatitis B is more prevalent among individuals with a history of injection drug use, compared to the general population (Shing, 2020). In a sample of hepatitis B cases, injection drug use was reported in 36% (CDC). Primary prevention is important, and vaccination rates in the country remain low. 

Dr. Presuek reminds us of the CDC recommendations, which were updated in 2023:

• Universal hepatitis B screening (surface antigen, core antibody, and surface antibody) for all adults to identify hepatitis B infection, and those without immunity who might benefit from vaccination
•  Hepatitis B vaccinations for anyone less than 60, or anyone 60 years and older with risk factors (e.g., current or recent injection drug use)

For a deeper dive into the updated Hepatitis B screening and vaccination guidelines, check out The Curbsiders Internal Medicine Podcast show #440 (Hepatitis B with Arthur Kim.) 

Tianeptine 

Presentation by: Dr. Alman Khalid, MD from HMH Jersey Shore University Medical Center

Case Summary: A patient with daily tianeptine use presented to the emergency department with symptoms of anxiety, restlessness, palpitations, and hypertension after discontinuing the substance. They were started on buprenorphine 8mg qday and gabapentin. They returned days later to follow up in a clinic with continued anxiety, restlessness, and tachycardia. Their buprenorphine was increased to 20mg a day, gabapentin was continued, and fluoxetine 20mg was started. At a follow-up encounter two weeks later, the patient’s withdrawal had resolved.

Clinical Pearl: Tianeptine is an atypical tricyclic antidepressant that is not FDA-approved in the U.S. but is utilized in some countries as an antidepressant. In the U.S. it can be found in gas stations, smoke shops, and online. It has a unique mechanism of action involving serotonin and glutamate. It is also a full agonist at the mu-opioid receptor and a weak agonist at the delta opioid receptor. Patients who use tianeptine regularly may experience opioid withdrawal symptoms if they suddenly discontinue their use (Eidnoff, 2023).

Hepatitis C Treatment in the Hospital

Presentation by: Dr. TaReva Warrick-Stone, DO from Thomas Jefferson University Hospital

Project Summary: Dr. Warwick-Stone describes a quality improvement project to initiate treatment for chronic hepatitis C in the hospital setting and continue follow-up in a Bridge Clinic. On the inpatient addiction consult service, they started to recommend screening patients for viral hepatitis, HIV, and syphilis. For those interested in hepatitis C treatment and planning to follow up in an outpatient addiction bridge clinic, medications were ordered and started during hospital treatment. A number of patients were able to successfully connect to the outpatient bridge clinic to continue their hep C treatment. 

Clinical Pearl: Per Infectious Disease Society of America Guidelines, active drug use or a concern for reinfection are not contraindications to hepatitis C treatment. Evidence supports that sustained virologic response can be achieved among individuals with intravenous drug use(Heo, 2024; Hellard, 2009).

False Positive PEth

Presentation by: Dr. Giovani V. Cruz Cruz MD and Dr. Jessica AS Want MD MPH from the University of California Las Angeles

Case Summary: A patient with decompensated cirrhosis is admitted to the hospital and has undetectable phosphatidyl ethanol (PEth). During their stay, they require a blood transfusion and afterward, their PEth is elevated at a cut-off suggesting moderate alcohol use. 

Clinical Pearl: Serum phosphatidyl ethanol (PEth) is a biomarker for alcohol exposure and can assess alcohol consumption (Mazhar, 2024). PEth tests for phospholipids (most commonly PO PEth and PLP PEth) on the surface of red blood cells induced by alcohol use (Mazhar, 2024).  It is correlated to the amount of alcohol consumed over the past 30 days.  A level of > 200ng suggests heavy alcohol use (4 or more standard drinks a day). If the donor of the red blood cells used alcohol recently, it can cause a false positive PEth in the recipient that would suggest alcohol consumption. 

Unintended Phenobarbital Consequences

Presentation by: Dr. Stuart MacKay from Penn State Milton S. Hershey Medical Center

Case Summary: A patient presented with alcohol withdrawal with seizures, and they were treated with phenobarbital. The patient had multiple similar admissions and developed an iatrogenic sedative-hypnotic use disorder. 

Clinical Pearl: Sedative-hypnotics (i.e., benzodiazepines and barbiturates) are first-line treatments for severe alcohol withdrawal. Iatrogenic sedative-hypnotic use disorder can occur, and judicious prescribing (especially upon hospital discharge) is advised. 

Phenobarbital is an inducer of multiple cytochrome P450 enzymes and can increase the metabolism of buprenorphine and methadone, leading to decreased serum levels. Clinicians treating patients with co-occurring alcohol withdrawal and opioid use disorder should be aware of this medication interaction and consider other treatment options for alcohol withdrawal (Tersaki, 2023.) 

Overdose Risk and Traumatic Brain Injury

Presentation by: Dr. Gabriella Reed, MD from Boston University – Boston Medical Center

Colleagues: Alex Walle, Miriam Harris, Janet Mok, Eugenia Socias

Summary of research: A prospective longitudinal cohort asked individuals to self-report if they had a traumatic brain injury (TBI), and self-report if they had an overdose. They found individuals who reported prior TBI had higher odds of experiencing a subsequent non-fatal overdose, even after controlling for confounders. Stay on the lookout for this exciting research to be published!

Clinical Pearl: An emerging literature suggests an important relationship between TBI and opioid overdose. The relationship is bidirectional in that TBI is a risk factor for opioid overdose and opioid overdose can lead to TBI. Additional research is needed to inform guidelines on screening and prevention. (Martin, 2024). 

Links

1. Join the American College of Addiction Medicine

Goal

Listeners will be served delicious knowledge food from a recap of the ACAAM’s 2024 Lightning Round. 

Learning objectives

After listening to this episode listeners will…  

1. Describe a clinical scenario that can cause a false positive phosphatidylethanol (PEth) test.
2. Describe current guidelines on hepatitis B screening and vaccination.
3. Recognize the potential of opioid withdrawal for patients who use tianeptine regularly. 
4. Describe the mechanism by which ketamine can treat precipitated opioid withdrawal. 

Disclosures

Dr. Chan, Cohen, Morford, and Stahl report no relevant financial disclosures, and the Curbsiders report no relevant financial disclosures. 

Citation

Chan, CA. Cohen S. Morford KM, Stahl N, Leyde S, “#27 Recap ACAAM Lightning Round”. The Curbsiders Addiction Medicine Podcast.https://thecurbsiders.com/addiction  August 1st, 2024