#336 Updates in Addiction Medicine: Live From SGIM 

May 23, 2022 | By Nora Taranto

Video

Credits

• Written and Produced by: Nora Taranto MD
• Hosted by: Nora Taranto MD; Matthew Watto MD, FACP; Paul Williams MD, FACP  
• Guests: Stefan Kertesz MD MSc; Ximena Levander MD MCR FACP; Kenneth Morford MD FASAM; Katherine Mullins MD 
• Show Notes, Cover Art, Infographics: Nora Taranto MD 
• Reviewer: Molly Heublein MD 
• Production team: Pod Paste

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Show Segments

• Intro
• Tapering long-term opioids
• Perioperative buprenorphine management
• Defining recovery in alcohol use disorder
• The Fourth Wave
• Treatment for methamphetamine use disorder
• E-cigarettes for smoking cessation
• Disparities in substance use disorder prevalence and treatment 
• Advocacy opportunities
• Outro

Addiction Medicine Pearls

1. Tapering long term stable, high dose opioids may increase the risk of overdose and mental health crisis. 
2. Engage in shared-decision making with your patient (and regularly screen for opioid use disorder) when you first meet a patient on long-term opioids, before deciding whether and how to taper.  If you and your patient do decide to taper opioids, go slow. 
3. Continue buprenorphine perioperatively, per the latest society consensus guidelines. You can divide the dose over the day to achieve better pain control.
4. You should give short-acting full opioid agonists on top of a patient’s home baseline buprenorphine to manage acute pain.
5. Abstinence is not the only way to maintain recovery in alcohol use disorder.  Consider a harm-reduction approach, basing your guidance primarily on a patient’s functioning rather than focusing entirely on abstinence.  
6. The fourth wave refers to the increase in psychostimulant-related overdoses in the last decade, either alone or in combination with opioids.  
7. To treat methamphetamine use disorder, consider mirtazapine for individuals with sleep disruption, bupropion for those with depression or low energy, and potentially extended-release injectable naltrexone to reduce cravings.
8. E-cigarettes may help with smoking cessation, though it remains unclear how to taper off of the e-cigarettes themselves.     
9. The opioid overdose rate in black individuals is now higher than in white individuals. There are disparities in the location of buprenorphine prescribers (more in white neighborhoods) and in the manner of MOUD prescribed. We need ongoing advocacy to address these disparities.  

Updates in Addiction Medicine Show Notes

Tapering Opioids

Consider whether you actually need to taper long-term, stable opioids, and if you decide to taper, go slow (less than 10% from baseline, per month).  A 2021 retrospective study of commercial and Medicare Advantage plans in over 100,000 patients on stably high doses of opioids (> 50 morphine milligram equivalents per day) found that with tapering, individuals experienced higher overdose rates (6.3/100pt years vs 4.9 in the tapered group) and higher rates of mental health crisis with depression/anxiety/suicide attempts.  More rapid tapers (exceeding 10% per month) were associated with more complications (Angoli 2021).  

This risk comes in part from changes in the drug supply over the last decade. Specifically, the amount of fentanyl contaminating other substances has increased over time (Palamar 2022). This can lead to fatal overdoses after just one use of  a non-medically prescribed opioid (fentanyl can lace heroin, cocaine, and methamphetamine, to name a few).    

Engage in shared decision-making with your patients on long-term opioids, and reflect on the reason for which you are considering tapering.  Routinely screen your patients for opioid use disorder, and also screen for adverse effects from the medications they are taking.  If they have clinical stability on their long-term opioid dose without adverse outcomes, then you may not need to taper them.  If you come to a decision alongside your patient to taper, maintain close contact with them as you taper and let them guide how quickly and how low you ultimately go.   

Perioperative Buprenorphine Management

For a long time, there was uncertainty about what to do with buprenorphine (which is a partial opioid agonist) during surgery, in which patients may require other opioids for pain management.  There is a risk that buprenorphine won’t be re-started in patients after it is held for surgery, and these patients will subsequently experience adverse outcomes. The latest society consensus guidelines recommend continuing buprenorphine in the perioperative setting (Kohan 2021) based on data from the last two decades.  

But we have to get everyone up to speed on this recommendation to continue buprenorphine perioperatively (even the day of surgery).  A 2021 retrospective study (Wyse 2021) looked at holding habits and found that ⅔ of patients experienced perioperative buprenorphine dose holds, and only ⅔ of patients were retained on buprenorphine in the 12-month period following surgery, with 5.5% experiencing an overdose. 

Think about the buprenorphine-naloxone as their basal pain medication, and add onto it as needed to manage acute pain.  There are also ways to use the buprenorphine-naloxone to manage acute pain, such as splitting the dose of buprenorphine and spreading it out over the course of the day to maximize its analgesic properties. But you can and should give short-acting, full opioid agonists (such as oxycodone) to manage acute pain on top of the baseline buprenorphine.  Surgeons don’t have a ton of experience adjusting or managing buprenorphine, so remember to explicitly  give them recommendations to continue. 

Alcohol Use Disorder: Defining Recovery 

Does recovery from alcohol use disorder require complete abstinence from alcohol? Recovery from a psychiatric disorder is normally thought about in terms of the definition of the disorder itself–which typically involves functional improvement.  But for many, recovery from alcohol use disorder in the public view means complete abstinence (e.g. 12-step programs), and occasional use symbolizes a failure of recovery. But what should we consider recovery? 

A 2021 study in the Journal of Addiction Medicine (Witkiewitz 2021) found that individuals who were high-functioning at 3 years maintained their high-functioning at 10 years, regardless of abstinence or alcohol use during this period, suggesting that non-abstinent recovery is possible and sustainable. This fits well within a harm-reduction approach to alcohol use, in which you focus on realistic goals and improving functioning in important life domains rather than only abstinence as the most important measure of recovery.  Occasional alcohol use should not be viewed as a failure–and abstinence may not be the ultimate goal to strive for, if functioning has improved in a patient’s life. 

This evolving definition of recovery may also factor into discussions about liver transplant. A retrospective study out of Johns Hopkins (Herrick-Reynolds 2021) found that there was no difference in overall survival or relapse-free survival between patients transplanted before 6 months of abstinence versus after waiting for the typical 6 months of abstinence (the so-called “6 month rule” for liver transplant).  Multidisciplinary assessment of a patient’s ability to enter and sustain recovery may be the key tool to identifying appropriate transplant candidates instead of the traditional and strict time-trial of abstinence.  

The Fourth Wave

The fourth wave refers to the increase in psychostimulant use and overdose deaths since 2012, following three waves of the opioid overdose epidemic.  Overdoses related to methamphetamines and other stimulants can occur both in combination with opioids and also independent of opioid use, as stimulants can cause cardiac complications and strokes. The rate of stimulant-related overdoses  among US Veterans tripled from 2012 to 2018 (Coughlin 2021).  In recent years, American Indian and Alaska Native individuals suffered from the highest rates of methamphetamine-involved deaths (Han 2021).  Rates of depression and anxiety, as well as other psychiatric disorders, are higher in individuals using methamphetamine, and women in particular may treat their mood symptoms with methamphetamine, per Dr. Levander, so screen for co-occurring mood disorders in your patients.   Depending on your geographical location, individuals may use methamphetamine alone or they may use it in combination with opioids (Ellis 2018).  

Recently, there have been several trials looking at treatment of methamphetamine use disorder.  A placebo-controlled RCT in 2020 found that mirtazapine reduced the use of methamphetamine and high-risk sexual behaviors in cisgender men and transgender women who have sex with men (Coffin 2020).  Trivedi et al. subsequently  found a decrease in methamphetamine use with naltrexone plus bupropion compared to placebo (injectable naltrexone 380 mg every three weeks and 450 mg bupropion daily).  But remember, naltrexone is typically dosed every 4 weeks, so this dosing strategy–done to increase the steady state level at the end of the dosing period–may run into some insurance coverage issues (though the VA apparently does currently cover IM naltrexone for methamphetamine use disorder!). The other challenge with using naltrexone is that many patients have co-occurring opioid use disorder and are quite hesitant to use naltrexone.  

Dr. Levander’s expert advice: Consider using mirtazapine (you can try low dose for maximal sleep effect) if you have patients who have poor sleep quality when they go through methamphetamine withdrawal, or bupropion if you have a patient with substantial depression without the sleep disruption. 

E-Cigarettes

A recent RCT looked at e-cigarettes versus other nicotine replacement therapy in the UK, where e-cigarettes are more widely available as a harm-reduction tool (Myers Smith 2021). The authors found that there was a significant reduction in smoking at 6 months among those using e-cigarettes–but that individuals didn’t necessarily stop using the e-cigarettes. One tip: you can control how much nicotine is in the e-cigarette cartridges, so you can advise your patients to decrease nicotine contents over time and taper off the e-cigarettes.   

Disparities, and Advocacy

Overdose rates have evolved in the last decade, and though they have always been the highest in American Indian and Alaska Native individuals, overdose rates in Black individuals have increased and are now higher than in White individuals, for the first time since 1999–with a rate that has tripled for black men since 2015 (Friedman 2022). This may be because of increasing fentanyl contamination in heroin and other substances (The Washington Post covered this change and the possible reasons for it in 2018).  

There is also a disparity in who receives the medications for opioid use disorder (MOUD) such as buprenorphine or methadone. Black individuals are less likely to be initiated on MOUD (Hollander 2021), in part because of where buprenorphine prescribers are located–more frequently in predominantly white neighborhoods (Lagisetty 2019). 

There are changes coming down the pipeline, and changes that have occurred during the pandemic that have increased accessibility to methadone by increasing take-home flexibility and the length of take-home prescriptions (SAMHSA 2021).  Clinics that increase availability and shorten outpatient wait times can improve follow-up rates and initiation of MOUD in the outpatient setting (Roy 2021). And from an ACGME perspective, as of July 2022, all internal medicine programs will newly be required to have didactic and clinical experiences in addiction medicine (keep an eye out for the launch for our Addiction Medicine Series in early July, 2022, to help with this!). Hopefully this is the start of a wave of focus.  

But there’s still a far distance to cover before our patients have what they need. We need to advocate for easier, more accessible MOUD for our patients, including by thinking about credentialing requirements to enable easy methadone and buprenorphine prescribing. 

Goal

Listeners will be served delicious knowledge food on addiction medicine, live from SGIM 2022.

Learning objectives

After listening to this episode, listeners will…

1. Define recovery in alcohol use disorder
2. Recognize the concerning data on tapering opioids in patients on long-term opioids.
3. Recognize the importance of continuing buprenorphine in the perioperative period and ensuring re-start if it is held. 
4. Describe the possible treatment options for methamphetamine use disorder. 
5. Identify disparities in substance use disorder prevalence, and opportunities for advocacy.

Disclosures

The Curbsiders report no relevant financial disclosures. 

Doctors Stefan Kertesz, Ximena Levander, Kenny Morford, and Katherine Mullins report no relevant disclosures.

Citation

Taranto NP, Kertesz S, Levander XA, Morford K, Mullins K, Williams PN, Watto MF. “#336 Updates in Addiction Medicine”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date: May 23, 2022