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Stimulant Use Disorder

Mitchel Wagner, DO

5 Minutes

Learning Objectives:

Demonstrate verbal de-escalation skills and early administration of voluntary medication in order to decrease potentially avoidable physical and chemical restraints in patients with mental health disorder
Recognize disparities in access to care for patients with mental health and substance use disorders
Identify interpersonal, institutional, and system-related factors possibly related to reported racial disparities in physical restraint use
Implement knowledge of the interplay between social determinants of health and mental health disorders into bedside care
Implement best practices for care for psychiatric patients boarding in the emergency department to ameliorate the effects of difficulty with access to care
Implement trauma-informed-care practices in the care of emergency department patient, particularly those violently injured and with mental health disorders
Identify evidence-based screening and referral practices for substance use disorders and implement effective SBIRT programs based in the ED
Develop a harm-reduction framework for assisting patients with substance use disorders in the ED
Implement evidence-based and society-endorsed best practices for patients seeking treatment or at risk of complications for substance use disorders, including ED initiation/provision of medications for opioid use disorder in appropriate patients and effective connection to longitudinal treatment
Identify unique needs among special populations with substance use disorder, including pediatrics, obstetrics, patients involved with the criminal justice system, and patients experiencing homelessness

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Disclosures/Interests

None

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Learning Objectives

Understand definition of stimulant use disorder, epidemiology, and its impact on ED care
Recognize and treat chronic and acute complications of stimulant use disorder
Understand importance of verbal de-escalation techniques and when to utilize medications
Develop a harm-reduction framework for assisting patients with substance use disorders in the ED
Implement evidence-based and society-endorsed best practices for patients seeking treatment or who are at risk of complications of stimulant use disorders

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Stimulant Use Disorder Overview

The continued use of a stimulant despite known harm to the user
Stimulants include illicit drugs like cocaine, amphetamine, methamphetamine, Ecstasy (MDMA) and prescription medications like Adderall and Ritalin
Stimulant use disorder has continued to increase after the stimulant epidemics of the 1980s and 1990s
When assessing for presence of stimulant use disorder always ask about concurrent drug use

https://www.drugtargetreview.com/news/101934/findings-reveal-possible-connection-to-substance-use-disorders-and-metabolic-dysfunctions/

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Stimulant Use Disorder Overview cont.

Overdose deaths have increased along with opioid deaths in the 21st century, with increasing prevalence within the african american community
In 2019 54% of overdose deaths from stimulants also involved an opioid
From 2003-2015 annual hospital costs from amphetamines increased nearly 500% from $436 million- $2.17 billion

https://www.cdc.gov/nchs/data/databriefs/db406-H.pdf

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Chronic Complications of Use

Hypertension
Pulmonary hypertension
Cardiomyopathy
If injecting, skin abscesses, endocarditis, blood borne pathogen exposures
Psychotic symptoms can persist for months or even years after stopping the drugs
Chronic deficits in cognition with decrease in ability to focus, memory, and decision making
Weight loss, nutritional deficiencies, erectile dysfunction
Depression, Insomnia

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Chronic Management Options

There is no FDA-approved medication for management of stimulant use disorder.
Ensure they have clean needles if using IV, counsel on the importance of not sharing or reusing
Encourage patients to snort when able to reduce risk of infection, transmission of HIV, hepatitis
Psychosocial treatment with cognitive behavioral therapy and contingency management (providing meaningful rewards for meeting treatment goals)
Ensure they have access to Fentanyl strips and Naloxone at home, encourage testing of their drugs prior to use

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Acute Complications of Use

Heart Attack
Overdose/Death
Psychosis
Hallucinations
Irregular Heart Rhythms
Hyperthermia
Severe Agitation

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Management of acute intoxication/agitation in the ED

Priority must be the safety of yourself, your staff, and the patient
If patient is agitated, begin with verbal de-escalation paying close attention to tone of voice and body language while empathizing with the patient, setting limits, and providing choices when able
Drugs for sedation can be considered if patient is a harm to themselves or others
Avoid physical restraints whenever possible

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FOAMed Resource

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Post-Module Questions

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Which of the following are known complications of chronic stimulant use?

Weight loss
Weight Gain
COPD
Bradycardia

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Which of the following are known, acute, complications of stimulant use?

Small Bowel Obstruction
Incontinence
Heart attack
Respiratory Depression

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Which of the following is commonly involved in cases of overdoses related to stimulant use?

Ketamine
Opioids
Aspirin
Tylenol

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Which of the following is not an extremely important question to ask when obtaining a history from a patient with known stimulant use?

Route of administration?
Concomitant drug/alcohol use?
Availability of Fentanyl strips or Narcan?
Do you like the way it makes you feel?

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Special Populations

Mitchel Wagner, DO

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Disclosures/Interests

None

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Learning Objectives

Develop a harm-reduction framework for assisting patients with substance use disorders in the ED
Implement evidence-based and society-endorsed best practices for patients seeking treatment or at risk of complications for substance use disorders, including ED initiation/provision of medications for opioid use disorder in appropriate patients and effective connection to longitudinal treatment
Identify unique needs among special populations with mental health and substance use disorders, including pediatrics, obstetrics, patients involved with the criminal justice system, and patients experiencing homelessness

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Pediatric and Adolescent Patient Considerations

Treatment Paradigms are similar to adults
When pursuing medication for addiction treatment care must be taken to consider local laws in terms of confidentiality and consent
It is extremely important to allow the patients as much autonomy as possible to increase patient engagement in treatment
Overdose education, including administration of Naloxone, is most efficient when family-based

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Harm Reduction Treatments in Pediatric and Adolescent Patients

Syringes services are typically not available to those who are <18 y/o

It is important to discuss clearly and openly with patients in this age group way to keep alcohol use as safe as possible

Buprenorphine and methadone medication treatments for opioid use disorder are possible but require special care to be taken in terms of dosing, observation, and patient assistance

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Pregnant Patient Considerations

Treatment for opioid use disorder with methadone or buprenorphine is still recommended and is most effective when initiated early
Treatment for opioid use disorder should include medication as well as withdrawal management or psychosocial treatment
Care for pregnant women undergoing treatment should be managed by physicians with experience in the treatment of obstetrics and substance use

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Pregnant Patient Considerations

Utilizing medications for opioid use disorder (MOUD) has been shown to improve patient, obstetric and neonatal outcomes.
Pregnant patients still have a right to determine their treatment plan, MOUD alone is not justification to contact child protective services
Concern of child protective services involvement and the potential loss of custody of their unborn child is a large area of concern for many

Good support and counseling is needed to reassure them that engagement in treatment will increase the likelihood they will be able to retain custody

ACOG position statement and ASAM both recommend use of MOUD with evidence showing significant improvement in outcomes.

In cases where Child protective services is contacted:

Key point and area of concern for pregnant people w/ a use disorder is concern about involvement of DCYF/child services/etc. This is a very real concern but people need support and counseling that medication will improve child outcomes, engagement in treatment will increase likelihood they will be able to retain custody.

https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy

https://www.acog.org/-/media/project/acog/acogorg/files/pdfs/brochures-flyers/dii-oud-practice-approach.pdf

https://bridgetotreatment.org/resource/buprenorphine-quick-start-in-pregnancy/

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Justice-Involved Patient Considerations

Justice-Involved patients are at a much higher risk for substance use disorder

Jail-based substance use disorder treatment programs are available and effective, but severely underused.

Most US correctional facilities do not continue or initiate medical therapy for substance use disorder, MOUD may not be as effective an option

https://www.illinoistimes.com/news-opinion/prison-health-care-still-bad-12787400

Their increased risk is due to multiple societal, economic, and psychosocial components
The majority of Justice-involved patients receive minimal withdrawal support and long term treatment programs
Medication-assisted treatment is still the best option but unfortunately unavailable to most patient’s
Resources should still be provided for the patient and the jail contacted to inquire about substance abuse programs available to the patient at the facility
The medical provider must advocate for continuation of therapy while incarcerated

FDA recently approved a 7d injectable buprenorphine which will be useful for these patients and those who are homeless

Can also give a high doe bupe in the ED to provide a longer half life

https://bridgetotreatment.org/resource/care-for-patients-with-opioid-use-disorder-who-are-in-custody/

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Justice-Involved Patient Considerations cont.

Recent pushes to continue MOUD while incarcerated have been successful in reducing the number of overdose deaths after incarceration

Buprenorphine is a great option for initial treatment, if your local jail is unlikely to continue treatment one time dose of 24mg or 32 mg total initial daily dose can be effective in reducing cravings and protecting against overdose over the next 2 or more days. (https://bridgetotreatment.org/resource/care-for-patients-with-opioid-use-disorder-who-are-in-custody/)
Continuing this treatment after release is imperative for their continued success and reduction in all-cause overdose mortality
Risk for relapse and overdose is exceptionally heightened in the weeks immediately after release from prison or jail

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Homeless Population Considerations

Homelessness and substance use disorder often co-exist
Homeless patients are at an increased risk for morbidity and mortality from substance use
It is extremely important to address social determinants of health (SDOH) while also providing treatment for SUD
Street outreach and community health worker/peer outreach programs are often helpful ways to assist with SDOH

https://www.cdc.gov/about/sdoh/index.html

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Homeless Population Considerations cont.

Qualified physicians are able to prescribe methadone in one time doses for up to 72 hours while trying to establish outpatient follow-up (repeat dosing in the ED)

Be aware that they may not have the ability to pay for or store medications prescribed like buprenorphine

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FOAmedResources

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Post-Module Questions

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True or False, MOUD in Pregnant Patients Has Been Shown to Improve Both Obstetric and Neonatal Outcomes

True
False

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When Are Justice-Involved Patients At Highest Risk For Mortality Associated With Substance Use Disorder?

The immediate 24 hours after incarceration
The transition period after release for more than 24 hours
Prior to incarceration

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Which of The Following are Essential Components of the Management of Pregnant Patients with Opioid Use Disorder?

Care and management provided by an OBGYN alone
Pure psychosocial therapy
Management of withdrawal, use of medications as well as psychosocial therapy
Pure medical management

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What Must Be a Foundational Aspect of Treatment of Adolescent Patients With Opioid Use Disorder?

Close Parent Involvement and Discipline in The Home
As Much Patient Autonomy as Possible
Threat of Jail Time
Pure Psychotherapy management

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A 14 y/o Male Arrives In Your ED With An Acute Opioid Overdose, He Stabilizes after Naloxone and Observation. When Discussing His New Prescription of Naloxone and the Proper Administration Upon Discharge What Is The Most Effective?

Giving the prescription to the patient when parents are out of the room so he feels comfortable to keep it on him
Discussion of the medication and its proper uses and storage with the patient, his parents, and any other available family members together
Giving the prescription to the parents away from the patient so he is unaware.

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References

Medication-Assisted Treatment of Adolescents With Opioid Use Disorders. Policy statement from the AAP https://publications.aap.org/pediatrics/article/138/3/e20161893/52715/Medication-Assisted-Treatment-of-Adolescents-With

Medications for Maintenance Treatment of Opioid Use Disorder in Adolescents:A Narrative Review and Assessment of Clinical Benefits and Potential Risks. Carmenga et al

Medications for Maintenance Treatment of Opioid Use Disorder in Adolescents: A Narrative Review and Assessment of Clinical Benefits and Potential Risks: Journal of Studies on Alcohol and Drug

The ASAM (American Society of Addiction Medicine) National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update https://sitefinitystorage.blob.core.windows.net/sitefinity-production-blobs/docs/default-source/guidelines/npg-jam-supplement.pdf?sfvrsn=a00a52c2_2

DrugFree.org - Resource for parents, able to connect to parent-recovery coaches to support families with children w/ SUD. https://drugfree.org/

Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. https://jamanetwork.com/journals/jama/article-abstract/183842

Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis.https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.94.4.651

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References

Substance use and homelessness among emergency department patients. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6478031

Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial.

https://jamanetwork.com/journals/jama/article-abstract/183842

Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis.

https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.94.4.651

The ASAM (American Society of Addiction Medicine) National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update https://sitefinitystorage.blob.core.windows.net/sitefinity-production-blobs/docs/default-source/guidelines/npg-jam-supplement.pdf?sfvrsn=a00a52c2_2

Evidence-based treatment and supervision practices for co-occurring mental and substance use disorders in the criminal justice system.

https://www.tandfonline.com/doi/abs/10.1080/00952990.2017.130383

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References

https://www.cdc.gov/about/sdoh/index.htm

https://www.illinoistimes.com/news-opinion/prison-health-care-still-bad-12787400

How to Use the DEA 72-Hour Emergency Rule for Methadone and Buprenorphine in Jails https://www.rsat-tta.com/Files/HMA-Issue-Brief-DEA-72-Hour-RuleFinal

Care for Patients with Opioid Use Disorder Who Are in Custody https://bridgetotreatment.org/resource/care-for-patients-with-opioid-use-disorder-who-are-in-custody/

Opioid Use and Opioid Use Disorder in Pregnancy, ACOG https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy

ACOG District II Practice Approach Algorithm: Managing OUD in Pregnancy https://www.acog.org/-/media/project/acog/acogorg/files/pdfs/brochures-flyers/dii-oud-practice-approach.pdf

Buprenorphine Quick Start in Pregnancy- Bridge to Treatment https://bridgetotreatment.org/resource/buprenorphine-quick-start-in-pregnany/

Equity in Emergency Department Care for Opioid Use Disorder https://www.acep.org/administration/quality/equal/emergency-quality-network-e-qual/e-qual-opioid-initiative/equal-opioids---webinars/opioids-webinars/equity-in-emergency-department-care-for-opioid-use-disorder---dr.-elizabeth-samuels-and-dr.-utsha-khatri

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References

Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System. https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2671411

Substance use and homelessness among emergency department patients. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6478031

Equity in Emergency Department Care for Opioid Use Disorder https://www.acep.org/administration/quality/equal/emergency-quality-network-e-qual/e-qual-opioid-initiative/equal-opioids---webinars/opioids-webinars/equity-in-emergency-department-care-for-opioid-use-disorder---dr.-elizabeth-samuels-and-dr.-utsha-khatri

Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012 Feb;13(1):17-25. doi: 10.5811/westjem.2011.9.6864. PMID: 22461917; PMCID: PMC3298202.