Listen as we recap some of our favorite addiction medicine episodes! We cover the treatment of alcohol use disorder, opioid use disorder, and discuss strategies surrounding the management of long-term opioid therapy. Share with us your favorite addiction medicine pearls that we may have forgotten in the comments, or by tagging us on Twitter @thecurbsiders.
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Patients at low risk of developing a severe alcohol withdrawal syndrome can be managed with an ambulatory detox protocol. In Dr. Chan’s experience, she has used diazepam for ambulatory alcohol detox and recommends the patient completes a fixed taper of diazepam 10mg Q6H on day 1, diazepam 10mg Q8H on day 2, diazepam 10mg Q12H on day 3, and diazepam 10mg QD. (4 pills – 3 pills – 2 pills – 1 pill) (ASAM Alcohol Withdrawal Pocket Guide)
Gabapentin can also be used for the ambulatory management of alcohol withdrawal (ASAM Alcohol Withdrawal Pocket Guide). Dr. Suzuki recommends utilizing gabapentin 1800-2400mg a day and then tapering the dose for patients who are at low risk of developing severe alcohol withdrawal. For patients who are at low risk for severe alcohol withdrawal, Dr. Chan recommends consider utilizing gabapentin 300mg Q6H on day 1, gabapentin 300mg Q8H day 2, gabapentin 300mg Q12H on day 3, and gabapentin 300mg QD (Uptodate Ambulatory Management of Alcohol Withdrawal).
Patients at high risk of developing a severe alcohol withdrawal syndrome–such as individuals who have a history of alcohol-related seizures, or delirium tremens–should be managed inpatient. For patients with a history of seizures, delirium tremens, or with baseline high benzo requirement, consider starting a fixed taper of long-acting benzodiazepines, with additional PRNs as needed for breakthrough symptoms. Dr. Suzuki reports that the first two days of withdrawal are the golden period. If you can minimize symptoms in those two days, you will likely avoid any of the severe withdrawal complications later on. Symptom-driven protocols are preferred for most individuals to prevent overmedication (ASAM Alcohol Withdrawal Pocket Guide). Phenobarbital can also be utilized to treat alcohol withdrawal, the benefits include that it is long-acting and can self-taper.
There are 3-FDA approved medications for the treatment of alcohol use disorder: naltrexone, acamprosate, and disulfiram (Winslow, 2016). Naltrexone is often used as first-line therapy, but is contraindicated in patients currently on opioids, and for individuals with severe liver disease (e.g., decompensated cirrhosis, acute hepatitis). For naltrexone, the number needed to treat (NNT) is 12 for return to heavy drinking, 20 for return to any drinking (Jonas, 2014). Acamprosate is often used if naltrexone is contraindicated (e.g. patients on oxycodone, or buprenorphine), and can be used in patients with liver disease. The starting dose is 666mg TID. Disulfiram is not commonly used, as it causes an unpleasant reaction if an individual has a return to alcohol consumption.
Counsel patients on the risks and benefits of long-term opioid therapy. For patients with continued pain, or aberrant behavior, assess the patient for opioid use disorder using the DSM-V criteria. For patients presenting to your office on opioids, options include continuing the medication, tapering opioids, or switching to buprenorphine. If a patient opts to taper their opioids do it very slowly, and offer to go down on the frequency of dose or dose level. Dr. Azari’s recommendation: go down 2-10% of total MME (morphine milligram equivalents) per month. Dr. Kertesz discusses more on the ethics of non-consensual taper of opioids in this editorial (Kertesz, 2020).
For individuals switching from full opioid agonists to buprenorphine for chronic pain, consider the use of a microdosing strategy (Becker, 2020). Microdosing is the process of giving small doses of buprenorphine to individuals on a full agonist opioid to minimize the risk of precipitated withdrawal (Microdosing- Shawn Cohen, MD Tweetorial).
There are 3 medications used for the treatment of opioid use disorder: methadone, buprenorphine, and extended-release naltrexone (Coffer, 2019). To start buprenorphine, patients should have symptoms of opioid withdrawal before receiving their first dose in order to minimize the risk of precipitated withdrawal.
For individuals who have exposure to fentanyl, consider utilizing a revised buprenorphine induction protocol (Antoine, 2020). Fentanyl is lipophilic, and repeated use can cause it to accumulate in peripheral tissues, thus causing it to mimic the profile of a longer-acting opioid (Antoine, 2020). For the revised induction protocol, wait until the individual has a COWS score > 13, and then give 2mg of buprenorphine every 60-90 minutes until the withdrawal symptoms have improved (Antoine, 2020, Bisaga 2019). For individuals who are unable to tolerate a standard-revised buprenorphine protocol, or have a preference for a microdosing strategy, there are a number of microdosing protocols to slowly introduce buprenorphine (Ghosh, 2019, Weimer, 2020).
Non-Prescribed Buprenorphine Use
Persons with a higher frequency of reported non-prescribed buprenorphine use are less likely to experience an opioid overdose (Carlson, 2020). Individual motivations for taking non-prescribed buprenorphine have been described such as avoiding waiting for treatment, desire for autonomy, and avoiding requirements of formal treatment (Silverstein, 2020).
Perioperative management of opioid use disorder
For patients already on buprenorphine make sure to discuss strategies around pain management. For many patients, they should be continued on buprenorphine through the peri and post-op period. (Lembke, et al, 2019).
Fixed tapers are the standard for treating individuals with benzodiazepine use disorders (Longo, Treatment of Benzodiazepine Dependence). Duration of the taper is based both on the dose the patient was previously taking and the time available to treat the patient, oftentimes these tapers should be slow and occur over a period of weeks.
Listeners will be able to diagnose, manage substance withdrawal syndromes, and treat common substance use disorders.
After listening to this episode listeners will…
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Chan C, Taranto N, Berk J, Williams PN, Brigham SK, Watto MF. “#259 Addiction Medicine Triple Distilled”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date March 1, 2021.
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