Understanding OUD: The Treatment
PURPOSE: To understand the intricacies of treating opioid use disorder (OUD) is crucial for optimizing patient outcomes and minimizing risks.
WHY: The treatment landscape encompasses various factors, including the duration of treatment, concurrent use with other medications, and its role in managing pain. Understanding a patient's history guides tailored treatment plans, accounting for substance use, mental health, and preferences. Vigilant monitoring and diversion control are vital to mitigate risks. Dosage adjustments demand a delicate balance between effectiveness and misuse. Skillfully navigating these complexities enables patient-centered care, fostering recovery and enhancing quality of life.
Duration of Treatment
• Duration will depend on the individual patient and psychosocial changes made.
•The evidence supports that Medication-Assisted Treatment (MAT) is the most effective approach for treating Opioid Use Disorder (OUD), while also respecting patient autonomy.
• While some brains have the capacity to regain the ability to produce dopamine, this isn't universal for all individuals.
• It is best to slowly wean a patient from MAT without stimulating withdrawal which creates cravings and significantly increases the risk of relapse.
• Decisions about dosing and tapering of MAT are clinical and should not be dictated by the criminal justice system
• NOTE: OUD relapse after being on MAT is exceptionally deadly.
What About Other Substances?
MAT is being used for OUD, not other substances.
Patients frequently use multiple substances.
Multiple studies show treatment of OUD with MAT reduces or eliminates other substance use over time.
The greatest concern is the use of benzodiazepines with MAT.
Recommendation: Do NOT stop MAT because of benzo use.
Relapse is expected in the chronic disease of addiction.
What about using opioids on top?
This could indicate a potential diversion of MAT medications or inadequate control of opioid cravings, suggesting the need for reassessment and adjustment of the treatment approach.
Consider an inadequate dose of MAT.
Patients may be diverting MAT and using other drugs.
It may be necessary to switch to a different MAT drug.
Increase psychosocial treatments as needed.
Relapse is expected in the chronic disease of addiction.
OUD and Treatment of Pain
• In the realm of opioid use disorder (OUD) and the treatment of pain, understanding the nuances between acute and chronic pain is paramount. Acute pain, typically short-term and often associated with injury or surgery, necessitates immediate relief to enhance patient comfort and facilitate recovery.
• Conversely, chronic pain, enduring over extended periods, demands a comprehensive approach aimed at enhancing functionality and quality of life. The goals of care in managing pain, irrespective of its nature, should prioritize not only symptom alleviation but also functional improvement and psychological well-being.
• Undoubtedly, it's crucial not to undertreat pain, as inadequate management not only compromises patient comfort but may also exacerbate the risk of opioid misuse or addiction. Balancing effective pain relief with prudent opioid prescribing practices is essential for optimizing patient outcomes and mitigating the risks associated with opioid use disorder.
Opioid deficit “Withdrawal”
Pain Relief
Approach to treatment: first visit
What history should I gather?
Substance use history
Last substance use
Most recent amount
Previous treatment
Treatment successes!
Recovery plan
Support network
Goals of treatment
Approach to Dose Adjustment
When a patient requests a dose increase, a systematic approach to dose adjustment is vital for ensuring safe and effective pain management.
• First and foremost, it's essential to assess the reasons behind the request. Asking the patient about their symptoms and how the current dose is affecting their pain levels and daily functioning can provide valuable insights.
• Additionally, considering somatic symptoms as potential manifestations of underlying anxiety or psychological distress is crucial, as addressing these factors may influence the patient's perceived need for higher doses.
• Furthermore, evaluating whether the patient is nearing the threshold of tolerance or experiencing medication-related side effects is important.
•Finally, ensuring that the patient feels comfortable discussing their concerns and that the dialogue remains open can foster a collaborative approach to dose adjustment while mitigating the risk of inappropriate opioid escalation.
Diversion
When addressing opioid use disorder (OUD) and its treatment, managing the risk of diversion is paramount.
Firstly, healthcare providers must remain vigilant and implement strategies to minimize diversion, such as carefully monitoring prescription refills, employing prescription drug monitoring programs, and utilizing abuse-deterrent formulations when appropriate.
Additionally, patient education regarding the safe storage and disposal of medications can help reduce the likelihood of diversion. Importantly, it's essential to adopt a compassionate approach that acknowledges OUD as a chronic medical condition rather than a moral failing. Punitive measures such as "kicking people out" of treatment programs for manifestations of their disease can be counterproductive, exacerbating feelings of shame and hindering patients' access to necessary care. Instead, focusing on providing comprehensive support, including access to evidence-based treatments like medication-assisted therapy and counseling, can facilitate long-term recovery while minimizing the risk of diversion.
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