1 of 22

Treating Substance Use Disorders in HCA

Preceptor Pre-Practice Conference

April 1-5,2024

Julia Lindenberg MD

2 of 22

Goals

Review (briefly) medications for opioid use disorder (MOUD)

Review (briefly) medications for alcohol use disorder

Describe harm reduction philosophy

Consider some (real life) cases

2

3 of 22

Medications for Opioid Use Disorder: 3 options

1. Methadone: a full agonist that activates

the mu-receptor

2. Buprenorphine: a partial agonist that

activates the mu-receptor at lower levels

3. Naltrexone: An antagonist that occupies

the mu-receptor without activating it

3

4 of 22

Important pharmacologic features of buprenorphine

4

Partial agonist at mu receptor

Comparatively minimal respiratory suppression and no respiratory arrest when used as prescribed

Long acting

Half-life ~ 24-36 Hours

High affinity for mu receptor

Blocks other opioids**
Displaces other opioids

Can precipitate withdrawal

Ceiling effect doses of buprenorphine above 24 mg do not significant decrease respiratory or cardiovascular function

full agonist

(e.g. morphine,

methadone)

partial agonist

(buprenorphine)

antagonist

(naloxone,

naltrexone)

dose

mu opioid effects

ceiling effect

---------------------------------------------

5 of 22

FDA approved since 2017

First injection given in HCA May 2023

Designed for patients on doses from 8-24 mg buprenorphine

SQ depot injection Q26-28 days

Rare risk – intradermal injection

Consider for patients stable on buprenorphine – can refer to OBAT clinic

Injectable Buprenorphine

6 of 22

Convenience

Taste of films/tablets

For some, decreases risk of use (patients often hold SL buprenorphine if actively using)

Dental concerns with films

Pharmacy issues - stigma

Tapering

Can be detected in urine for up to 12 months!

Why Injectable Buprenorphine?

7 of 22

Medications for Alcohol Use Disorder: Two main options

Oral and injectable naltrexone

Best evidence for this drug; cannot be rxed if patient on opioids
50 mg once daily (can start ½ tab, some trials go up to 100 mg)
SEs: nausea, headache, dizziness
Some trials demonstrate superiority with injectable naltrexone
Contraindicated with hepatic failure, active hepatitis, monitor LFTs

Acamprosate

333 mg; usual dosing is 666 mg (2 tabs) TID (can do 666 mg BID)
Contraindicated in severe CKD (CrCl<30)

Second line options

Disulfiram (particularly if supervised)
Topiramate (start 25 mg, titrate up to 300 mg)
Gabapentin (higher doses studied 900-3600mg)

8 of 22

FDA approved for OUD and AUD
Any provider in HCA can prescribe injectable naltrexone for AUD
You can refer to OBAT if desired or patient has OUD
Can start PO naltrexone 50 mg first (optional)
380 mg IM q 28 days

Process: Email HCA LPNs who will assist with checking insurance coverage; once verified, they will help get patient scheduled

Injectable Naltrexone

8

9 of 22

Case

Mr. F Is a 42 yo M who presents for post-discharge follow up after a recent hospitalization for respiratory failure secondary to an opioid overdose.
He describes taking "percocets" on the street that he thinks were laced with fentanyl, which led to his recent overdose. He is highly motivated to stop using opioids.
He was offered buprenorphine during his hospitalization but did not want to stay inpatient an additional night for induction
He has not used opioids since his recent discharge.
His PCP refers him to OBAT clinic.
The OBAT clinic is full for the following Tuesday so he is offered an appointment in 10 days.
He later cancels that appointment and a rescheduled appointment
He is found down 3 weeks after his last discharge and later passes away from an opioid overdose.

10 of 22

OBAT Response

Access slots added to Maelys' and Julia's schedule

Faculty Development Talk – June 2023

HCA Portal (needs updating – will be updated by end of this week)

11 of 22

Harm Reduction

Set of practical strategies aimed at reducing negative consequences of drug use

Guiding Principles:

People use drugs -their reasons are complex and dynamic
Meet them where they are
Helping people avoid adverse consequences of use helps them survive until they are ready to enter treatment
Encouraging sobriety alone is insufficient

12 of 22

Harm Reduction

13 of 22

Prescribe naloxone (offer every visit!)

Nasal naloxone is now OTC
Rx is usually cheaper
Standing prescriptions remain

2. Offer HIV/Hepatitis testing, PREP

3. Prescribe needles for patients who inject drugs and/or refer to needle exchange programs (Boston – AHOPE)

4. Talk to patients about the MA Never Use Alone Hotline

5. Offer fentanyl test strips (in Atrium Suite

Harm Reduction: 5 simple things you can do

14 of 22

15 of 22

Case 1 for group discussion

45M with h/o tobacco use, chronic neck pain, OUD on buprenorphine 12 mg for > 10 years, followed with OBAT since its founding
All recent UDS negative except for buprenorphine and metabolites
Keeping q3 month visits with OBAT
Has not had a PCP since Dr. Aronson retired!
Referred back to PCP for health maintenance (i.e. CRC screening), addressing neck pain

Would you prescribe his buprenorphine?
What kind of visit frequency and monitoring is reasonable?

16 of 22

Case 2 for Group Discussion

40 F with h/o OUD (intranasal fentanyl), on buprenorphine 24 mg for 3-4 years
Moves to NYC for work for several years
Now back in Boston, reestablishing care in HCA, asking about OBAT clinic referral

Questions to ask him?
Would you prescribe buprenorphine on this visit?
Does he need to see OBAT clinic?

17 of 22

Sample Follow-up OUD Visit

How are they doing with their buprenorphine? Any side effects? Managing constipation?
Have they used any drugs at all?
Any cravings to use? Close calls? (How did they manage?)
?Utox if indicated
Check MassPAT
Set up follow-up

18 of 22

Case 3 for Group Discussion

68 M patient, Spanish speaking, with h/o chronic diarrhea, htn, CAD, DM2, OUD on stable buprenorphine 16 mg for > 15 years.
He misses several OBAT appointments
On an epi visit, he notes missing his appointment and running out of buprenorphine 1-2 days ago, noticing early withdrawal symptom.

Would you prescribe buprenorphine this visit?

19 of 22

Case 4 for group discussion

56 M with HIV (stable, on ARVs, undetectabl CD4), tobacco use, anxiety, OUD on buprenorphine 32 mg, cocaine use disorder, followed by OBAT clinic regularly
Calls on a weekend; he lost his buprenorphine on a bus to Fall River where his family lives, requesting early refill, took his last dose this AM
Recent UDS

Would you prescribe buprenorphine?
Any alternative options?
Faster Paths

7 days a week; 8-4:30 PM

20 of 22

Case 5 for group discussion

34F with h/o anxiety, depression, PTSD, OUD, tobacco use disorder
Brought to ED last week with overdose, UDS + for fentanyl
You have known her many years; she declines referral to OBAT
When asked, she wants to start buprenorphine

Would you start her on buprenoprhine?
What options are there for starting her?
Traditional induction vs. microdosing
HCA Portal Resources (to be updated by end of this week)

21 of 22

HCA OBAT Clinic

Other key team members:

Verona White – Administrative Assistant in Addiction Psychiatry
Edna Henry and Avanel Lockhart – Medical Assistants
Primary Care Residents
HCA LPNs – give injections

Maelys Amat – OBAT Physician

Leslie Bosworth – Social Worker

Julia Lindenberg – Medical Director

Marissa McCann – Pharmacist

HCA OBAT (Office Based Addiction Treatment)Team

HCAOBAT@bidmc.harvard.edu

22 of 22

Summary

Buprenorphine can be a life-sustaining treatment for OUD and any MD/NP can now prescribe it
There is little to no risk prescribing this for a patient who is already taking it actively
There is a lot of risk to not prescribing for that same patient
OBAT is here to help and support you; reach out to us anytime by page, email