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Faisal

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  1. This sounds more of a case of Opioid Dependence. If the patient is stable, there is no escalation of his opioiduse, no safety concerns, no compulsive use, no aberrant behaviors and no other use disorder, switching to Suboxone would not really make sense. You could also contact his other provider to see if they have had any concerns. Looks like you have already made the case. However tapering off of any opioid is a whole another issue. As an aside, Suboxone can be used for pain management. You will need to mention this as an off label use on your prescription and change diagnosis to Opioid Dependence (or mild OUD).
  2. Agree with full agonist dosing. Keep the patient comfortable!
  3. Hope you don't mind me asking, but If you do switch to Buprenorphine (I am assuming you are referring to the combined product with Naloxone), there is no guarantee the problematic behaviors will resolve. Also, methadone is a more potent analgesic than Buprenorphine so the patient may repeatedly ask for his Bupe dose to be increased and this will further obscure the treatment goals (pain control vs OUD). And since you feel opioids in general have been an issue for this patients, why continue with them? Thanks.
  4. Getting the patient off the benzos should be the priority. Going up on the methadone dose under the circumstances would not be feasible and in fact dangerous. A couple of thoughts and a few suggestions which may or may not help: Firstly, make sure this patient has Narcan with him. I'm sure your OTP would have done this already. Are you following the Fentanyl levels? Since fentanyl metabolites are multiple and have varied half lives, following the levels could help determine if the patient continues to use. Regarding the benzodiazepines, are these prescribed or illicitly obtained? If the former, it is imperative to contact the provider and request that these be tapered off. In the latter situation, would you consider prescribing the benzodiazepine as a harm reduction maneuver with the goal of weaning it off completely? Is the patient even agreeable with the benzos being weaned off in the first place? Again, BZD levels would need to be monitored during treatment. Referring this patient for residential level treatment is a sound idea, but spots seldom open up when we need them to and there is no guarantee he would be accepted. Switching this patient to Buprenorphine is a better idea, since it is a safer alternative to methadone. Have you spoken to the patient about the possibility of discharge from the OTP? this sounds harsh and controversial but fear is a great motivator for change. I have seen patients in our program cease their alcohol consumption or decrease it dramatically when all else failed and they were given a deadline. Good luck. Hope you will keep us posted.
  5. I would recommend initiating an induction first. The risk of a negative outcome is higher if he continues to abuse opioids.
  6. I'm sorry to chime in. But currently there is no FDA approved pharmacotherapy for the treatment of Cannabis Use Disorder. There have been a few positive studies regarding certain pharmacological agents e.g N-AC, Naltrexone, Gabapentin, CB-1 receptor antagonists, etc, that have shown some decrease in cravings associated with THC use. Regards. http://us.psychiatryonline.org/doi/pdf/10.1176/appi.focus.20180038
  7. ASAM recommends observed UDS whenever possible. You could substitute with oral swabs too. It's more labor intensive and the results take several days which can affect treatment planning. Confirmation testing to include specimen validity can be used as well. Results again take longer. No use if they are bringing in someone else's urine We made the switch to observed urine screens a couple of months ago for all our OBOT patients regardless of the therapeutic alliance. Results were quite revealing. Those who were usually negative started coming up positive for various other substances. Also, there were a few who would bring in external samples regularly in case of random testing and would would beat the test.. even the temperature felt warm! I guess where there is a will there is a way! Good Luck!
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