#259 Addiction Medicine Triple Distilled

March 1, 2021 | By Carolyn Chan

Alcohol Use Disorder, Opioid Use Disorder, and more!

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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Credits

• Producers: Carolyn Chan MD; Nora Taranto MD
• Infographics: Hannah R Abrams; Justin Berk MD, MPH, MBA; Carolyn Chan MD; Nora Taranto MD
• Writer and Cover Art: Carolyn Chan, MD
• Hosts: Carolyn Chan MD; Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Editor: Justin Berk MD (written materials); Clair Morgan of nodderly.com

Sponsor: Panacea Financial 

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CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Time Stamps

• Intro, disclaimer 00:00
• Alcohol Use disorder (inpatient and outpatient management) 03:50 
• Sponsor -Panacea Finanicial 24:00
• Partner -The Cribsiders Pediatric Medicine Podcast
• Chronic Pain and  Opioid Therapy (prescribing buprenorphine; microdosing) 25:30
• Benzo Tapers 46:11
• Outro

Addiction Medicine Triple Distilled Pearls

1. The first two days of alcohol withdrawal are the “golden period”. If you can manage to maintain the patient with minimal symptoms during that time, you will likely avoid any of the severe withdrawal complications later on. 
2. Naltrexone is often 1st line therapy for the treatment of alcohol use disorder, but is contraindicated in patients currently on opioids, or with severe liver disease (e.g., decompensated cirrhosis, acute hepatitis). For naltrexone, the NNT is 12 to prevent a return to heavy drinking.
3. Counsel patients on the risks and benefits of long-term opioid therapy for chronic pain.  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 per month.
4. There are 3-FDA approved medications for the treatment of opioid use disorder: methadone, buprenorphine, and extended-release naltrexone. To start buprenorphine, patients should have symptoms of opioid withdrawal before receiving their first dose to minimize the risk of precipitated withdrawal.
5. Individuals on buprenorphine who have a surgery planned often should stay on this medication through the peri- and post-op period without discontinuation. 

Addiction Medicine Triple Distilled Notes 

Curbsiders Episodes Covered:

#212: Sober Talk: Managing Inpatient Alcohol Withdrawal with Dr. Joji Suzuki  Air date: May 7, 2020

#194: Alcohol Use Disorder Treatment with Dr. Marlene Martin  Air date: February 10th, 2020

#156: Chronic Pain, Opioids, Tapers with Dr. Soraya Azari and Phoebe Cushman Air date: June 24, 2019

#187: Buprenorphine Master Class: Managing Opioid Use Disorder for the Generalist with Dr. Michael Fingerhood Air date: June 24, 2019

#224: Hospital Addiction Medicine with Dr. Melissa Weimer Air date: July 13th, 2020

Alcohol Use Disorder

Ambulatory Management of Alcohol Withdrawal

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).

Inpatient Alcohol Withdrawal: Symptom Driven or Fixed-Dose Benzo Protocol? 

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. 

Treatment of Alcohol Use Disorder

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. 

Chronic Pain and Opioids

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).

Opioid Use Disorder

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).

Benzodiazepine Use Disorders

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. 

Goal

Listeners will be able to diagnose, manage substance withdrawal syndromes, and treat common substance use disorders. 

Learning objectives

After listening to this episode listeners will…  

1. Develop a treatment plan to manage alcohol and opioid withdrawal.
2. Counsel a patient on pharmacotherapy options for opioid use disorder.
3. Perform a buprenorphine induction for an individual with opioid use disorder.
4. Describe strategies to manage patients on long-term opioid therapy (LTOT): taper, switch to buprenorphine or maintain.
5. Counsel a patient on medications for AUD.

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

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.