Triage, Assessment and Treatment Planning Methadone/Buprenorphine 101 Workshop December 10, 2016 Oliver, BC Prepared by Todd Sakakibara MD, CCFP, FCFP Clinical Assistant Professor, Dept. Family Practice UBC Diplomate of the American Board of Addiction Medicine
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Triage, Assessment and Treatment Planning · • Methadone or Suboxone taper: the longer the better • Methadone or Suboxone maintenance: – May have previously trialed in-patient/outpatient
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Triage, Assessment and Treatment Planning Methadone/Buprenorphine 101 Workshop December 10, 2016 Oliver, BC Prepared by Todd Sakakibara MD, CCFP, FCFP Clinical Assistant Professor, Dept. Family Practice UBC Diplomate of the American Board of Addiction Medicine
College of Physicians and Surgeons of British Columbia 2
Triage • A thorough workup will allow you to recommend the best treatment
options
• Determine patient expectations/goals
• Multiple ways to treat an opioid use disorder (informed consent)
• Methadone may not necessarily be the best option
• Opioid history: Type, amount, route, frequency, last use
• Establish diagnosis for OAT: Opioid use disorder with physical dependence, rare exceptions (e.g. exiting incarceration, detox)
• Other substances: Use vs. substance use disorders
• Other history: Detoxification, recovery, abstinence
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Triage • Consider – age of the patient and duration of opioid use, parents, consent
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Stimulant use Increasing incidence of cocaine and methamphetamine use • Destabilizing with methadone maintenance
• Treatment is cognitive/behavioural intervention
– Counselling
– Support services
– Relevant treatment contract
• Consider in-patient treatment
• Consider contingency management
• Determine if stimulant is the primary drug of abuse/dependence before initiating methadone maintenance
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Benzodiazepine and zopiclone use • Chronic benzodiazepine use is a concern in substance-dependent
individuals
• Outcome worse with methadone maintenance when benzodiazepines are concurrently used
• Overdose risk significant • Screen at assessment
– Treatment plan
– Refer to Ashton manual for withdrawal procedure
– Urine drug test and PharmaNet
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Marijuana use Screen for marijuana use disorder at initial assessment • Treatment plan
• Treatment contract
• Outline expectations
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Improving outcomes If unable to document benefits after dose adjustment and appropriate psychosocial intervention, consider alternate treatment • Switch OAT
• Taper off OAT
• Intensive outpatient treatment
• Residential/intensive in-patient treatment
• Support group (AA/NA/SMART/16 Steps etc.)
• Addiction medicine consult
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Imagery
• Overall rate of sustained successful taper: 4.4% among all episodes initiating a taper and 2.5% among all completed episodes.
• Longer tapers had higher odds of success [12-52 weeks versus <12 weeks (OR: 3.58 (2.76-4.65); >52 weeks versus <12 weeks: (6.68 (5.13-8.70)).
• A gradual, stepped tapering schedule, with dose decreases scheduled in only 25-50% of the weeks of the taper, provided the highest odds of sustained success (vs. <25%: (1.61 (1.22-2.14)).
Nosyk et al, Addiction 2012; 107(9):1621-9.
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Most successful patterns of MMP taper: patient-guided
Modified from Nosyk et al, Addiction 2012; 107(9):1621-9.
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Transfers/cessation of treatment If patient transfers to alternate OAT provider • Communication between new and current physician required prior to
transfer – preferably by phone; otherwise valuable information is lost and therapeutic interventions can be undermined
• Records should then be transferred and reviewed when accepting the client long term
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Summary Consistent application of basic set of principles results in: • improved patient care