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Medical Student 8 Hour Buprenorphine Training
Session 5: Specialty Topics
Session 5: Specialty Topics
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Video Transcription
Hello. I'm Dr. Jim Finch. Today we will explore appropriate management of MAT in a variety of special populations. We will discuss renal and hepatic diseases and also refer you to some resources for emerging research on racial disparities and the LGBTQ population. Before we start, remember the three types of medications used in MAT? How much do you remember about them? The first special population we will address is the group of individuals that demonstrate the co-occurrence of psychiatric disorders along with substance use problems. Like so many other common medical problems that tend to coexist, like diabetes and renal vascular disease, when one of the conditions is present, it is useful to have an index of suspicion for the other. You saw this slide in the first module, but it is important to reaffirm the significant overlay between these two areas. As seen here, over a third of patients with a substance use disorder will have a diagnosable psychiatric disorder, while just shy of a quarter of those with a mental health disorder have co-occurring substance use problems. So consider our patient Jose, a 45-year-old man of Latino descent who lives on a ranch in northern California with his wife and three children, working as a ranch foreman, and has recently presented for substance use treatment. Jose also suffers from depression and anxiety, which are the most common behavioral symptoms reported by patients as they enter treatment for substance-related problems. This does not necessarily mean that the patient requires specific treatment for these symptoms. The urgency of the need for treatment will depend upon a number of factors, of course, but it can be reassuring for patients to know that there will often be a fair amount of resolution of these symptoms, even at times complete resolution, with abstinence from their substance use. Of course, it may be difficult for individuals to accept that much of their symptoms are secondary to the direct or indirect effects of the drugs they are using. There is no specific period of time associated with resolution of these symptoms, but generally, unless there is a genuine urgency for treatment, it is judicious to watch, reassure, and provide supportive counseling without initiating medication. However, symptoms that do persist beyond acute intoxication, withdrawal, or prolonged abstinence may be targets for treatment. Sometimes they will be identified as co-occurring psychiatric disorders, sometimes by careful history found to predate the individual substance use or developing independently. If medication is needed in those cases, patients with an opioid use disorder being treated with MAT, such as buprenorphine, can still respond quite well, even synergistically, to concurrent psychotropic medication administration for their depression and anxiety. In treating Jose's anxiety and depression, it is of primary importance to first establish a diagnosis before considering treatment. This may sound obvious, but remember, depressed mood or anxiety are symptoms, not diagnoses, and as we've just discussed, they may be entirely expected as a direct or indirect result of drug use or its consequences. Establishing a diagnosis then guides the selection of antidepressant or mood-stabilizing medication that may be indicated. In this setting, it is strongly recommended to avoid using benzodiazepines, as it is true with most, if not all, patients with these symptoms. There is significant risk for misuse of these medications in individuals with a substance use disorder, and interactions with buprenorphine can result in respiratory difficulty if not taken as prescribed. Serotonin reuptake inhibitors, or SSRIs, are considered first-line medication options for a number of diagnosed anxiety disorders. Psychotherapy can also be effective, and one effective methodology in this setting is cognitive behavioral therapy. Combining medication and psychotherapy has often been shown to be the most effective, and we'll talk more about this in Module 7. Another common substance use mental health disorder issue regards patients who present stating that they have attention deficit disorder, ADD, or attention deficit hyperactivity disorder, ADHD, and requesting treatment with stimulants. This can be confusing to sort through. On the one hand, substance use problems will often result in the patient's inability to focus, secondary to their drug use, and the behaviors or lifestyle associated with it. And inattention is associated with a variety of emotional problems, including anxiety, depression, and sleep disorders. On the other hand, there is an established association between childhood ADHD and substance use disorders, particularly if the ADHD was left untreated in childhood. Again, a good evaluation of the patient, including a review of childhood history, should take place prior to consideration of initiating a psychostimulant. The use of psychostimulants in this population can be problematic, and the prescription monitoring system should also be checked for prior or current medication misuse. If it is determined that the patient has a legitimate diagnosis of attention deficit disorder, non-stimulant treatment should be considered first. But if a stimulant is warranted, it can be safely and effectively used in the setting of medication-assisted treatment of an opioid use disorder. It just requires proper monitoring. As we discussed previously, genetics and early childhood experiences, such as lack of nurturing and other adverse childhood events, are the precursors to the development of substance use-related problems, including opioid use disorders. In many ways, these are pediatric illnesses, and they often begin to manifest in early to late adolescence. Here we see how the rate of new-onset opioid use disorders has been increasing over the last 20 years in association with the increased availability of pharmaceutical opioids during the same period. As you can see, this increase appears as early as 16 to 17, but shows a marked increase in 18 to 20-year-olds and an alarming more than five-fold increase in young adults 21 to 25. This reinforces not only the need for attention to screening and earlier intervention, but also, unfortunately, means that these problems will be with us in the health care system for many years to come. Unfortunately, participation in treatment for adolescents, particularly in terms of access to medication-assisted treatment, has seriously lagged this identified need. As seen in this graphic, since FDA approval of buprenorphine naloxone and later extended release naltrexone, the proportion of youth with opioid use disorders accessing these treatments has remained low at only 20 to 30 percent. Consider Anika, 17 and a half years old, an only child who had started smoking cannabis at 13. She was able to reasonably continue to do reasonably well in school until she started snorting heroin a little over a year ago. Her deterioration in function has now brought her drug use to others' attention. The Data 2000 authorizes treatment of individuals 16 years or older with an opioid use disorder with medication-assisted treatment with buprenorphine. Methadone is also available for individuals 18 years or older, but only at a licensed opioid treatment program. An exception to the regulations regarding methadone do allow adolescents as young as 16 years old to be treated if they have a history of at least two prior unsuccessful attempts at treatment. It's also important to understand the age of consent in the state in which you practice and whether parents will need to be involved in the consent of treatment. As an important aside, it is recommended to assess all female adolescents for pregnancy prior to starting medication. The American Academy of Pediatrics recommends that all those seeing adolescents and young adults must be aware of the value of medication-assisted treatment and know the avenues for treatment in their community if they are not wavered themselves. All of the currently FDA-approved medications for opioid use disorder are approved for adolescents. As stated, buprenorphine is approved for patients 16 years and older and is often considered to be the treatment of first choice. It has been shown to significantly decrease the use of opioids and often other drugs like cocaine, and it has been shown to increase retention in treatment compared to non-drug treatment options. It has been shown to lower the risks associated with injection drug use, and there can be a reduction in the need for more intensive additional treatment while the patient is taking buprenorphine. As stated previously, methadone is approved for patients 18 years older and under certain circumstances younger. Extended-release naltrexone is also approved for patients 18 years and older, though it has been used effectively in younger adolescents. Both of these FDA-approved medications have shown clear treatment effectiveness. Psychosocial treatments have shown efficacy as well, although typically best when combined with medication therapy. Involving the family can be extremely helpful, as are programs that increase educational and vocational supports. Providing behavioral interventions that are associated with improvement in coping skills and reduction in cravings are often a focus of psychosocial treatment. Problems associated with pregnancy and opioid use disorders have grown significantly in the last 20 years. Epidemiologic evidence indicates that approximately 21,000 pregnant women between the ages of 15 and 44 years old have misused opioids in any given preceding month. Our patient, Natalia, falls into this group. She's a 24-year-old hairdresser married to a man who is incarcerated, and she is having their first child. The American College of OBGYN, along with the American Society of Addiction Medicine, recommends screening for substance use as a part of any comprehensive obstetric assessment, preferably beginning at the first prenatal visit. Screening, brief intervention, and referral to treatment, so-called SBIRT, is recommended for all pregnant patients, and we'll talk more about SBIRT later. Established screening instruments, like the National Institutes of Drug Abuse QuickScreen or the CRAFT, can be routinely incorporated into history gathering, or clinical prompts can be used, like asking the four Ps, parent and partner history of substance abuse, and patient's present and past use history. If opioid use disorder, moderate to severe, is diagnosed, particularly with evidence of physical dependence, substitution agonist therapy is generally the recommended treatment. Buprenorphine and methadone have both been used effectively in this regard. In terms of relative strengths of these two alternatives, methadone has a much longer history associated with treatment and pregnancy, and does offer more structure during treatment than most office-based treatment programs. In some cases, there are opioid methadone treatment programs with specific treatment modalities for the pregnant woman. One should strongly consider referral to these programs when they are available. Buprenorphine, on the other hand, has shown to be equally effective in terms of treatment during pregnancy, and is considered to have less risk for overdose and drug-to-drug interactions. In addition, there is now significant evidence that buprenorphine results in milder neonatal opiate withdrawal symptoms, associated with a decreased need for morphine treatment, shorter hospital stays, and overall shorter duration of treatment. As with methadone, there are some model OB programs prescribing buprenorphine in combination with prenatal care. This has been shown to increase the compliance of patients with opioid use disorder treatment and prenatal care with improved outcomes. For many years, methadone was considered the first-line treatment in the opioid-dependent pregnant patient. It is still commonly used, and still an effective alternative. Doses need to be adequate to maintain stability, avoid withdrawal, and minimize craving. This requires ongoing monitoring. There can be increases in metabolism and circulating blood volume during pregnancy that will result in the need to increase methadone doses as pregnancy progresses. Some patients also may need to split their daily methadone dose, particularly in the third trimester, to maintain consistent blood levels. The consistency of methadone blood levels has been identified with a reduction in neonatal withdrawal symptoms. These graphs were taken from a New England Journal of Medicine article published in 2010. This was a multi-site study, now referred to as the MOTHER study. The results shown here relate to its findings regarding neonatal abstinence syndrome. They show a nearly 10 times reduction in total morphine administration in the buprenorphine-exposed infant compared to those whose moms were taking methadone. It also shows a significant decrease in the length of hospital stay and the overall duration of treatment for neonatal abstinence. These are some of the findings supporting buprenorphine becoming the first-line treatment for the opioid use disorder during pregnancy. But there are other reasons driving this shift beyond the information from the MOTHER study. First of all, women often maintain their stability without a need for significant dose adjustment, and there's seldom a need to increase the dose of buprenorphine during pregnancy, as there often is with methadone. Splitting the dose during the third trimester may be done, but is rarely needed. A more subtle factor for many women is that office-based buprenorphine treatment is considered less intrusive and more life-normative than the more structured nature of a methadone treatment program. Traditionally, women in treatment with the buprenorphine naloxone combination product have been switched to the monoproduct if they become pregnant so as to not expose the fetus to an additional medication, naloxone. In the postpartum period, the patient would then be transitioned back to the combination product. This is still the current recommendation, but it is evolving. Naloxone is FDA-labeled Category B, but the combination buprenorphine naloxone product is Category C. This means there is no known iatrogenic effect in animals, but women are still regularly placed on a buprenorphine monoproduct during pregnancy. There is growing evidence, however, that the combination product is safe during pregnancy, and this may become standard treatment in the future. This is in part due to the risk of injection of the monoproduct by women when the monoproduct is being used. It should also be noted that there is little transfer of buprenorphine to breast milk, and if present in breast milk, its availability is further reduced by its first pass through the liver after being swallowed. Therefore, it is recommended that women on buprenorphine continue to breastfeed. Neonatal opioid withdrawal syndrome, or what was previously referred to as neonatal abstinence syndrome, are seen to some extent in 70 to 95 percent of infants born to untreated opioid-dependent pregnant women. Approximately 50 percent of these infants will need treatment. Symptoms associated with neonatal withdrawal include irritability, fever, diarrhea, hyperreflexia, and potential seizure. The symptoms begin approximately 24 to 72 hours after birth and will peak within three or four days and may continue up to a week. There are, of course, other potentially serious complications to a healthy delivery that are associated with untreated opioid dependence during pregnancy. There's an increased risk of placental abruption, preterm labor, and potential fetal death. It is also important to recognize that a mother continuing to use tobacco products during pregnancy can also result in an increased incidence of neonatal withdrawal syndrome in the mother currently being treated with either methadone or buprenorphine. This is one more reason to work with patients to reduce and discontinue their use of tobacco products. There have been significant advancements in the treatment of neonatal withdrawal. Medications used during this period of time include various opioids and or clonidine, but the real advancements have taken place in the non-pharmacologic approaches, which include rooming in with the infant and mother, maintaining a quiet, more relaxed atmosphere while continuing to screen for withdrawal symptoms while the infant is with its mother. To reconfirm, breastfeeding is not contraindicated when the mother is currently receiving medication for opioid use disorder. Since, as has been stated, neither methadone nor buprenorphine is transferred in clinically significant amounts. However, for the same reason, there is also not enough to prevent or treat withdrawal symptoms in the neonate. If symptoms of withdrawal are present, they require treatment per established protocols. In this section, we're going to consider the management of pain in patients currently maintained on buprenorphine for their opioid use disorder. To begin with, it's important to consider that there is often an overlap between opioid use disorders and pain. Patients with substance use disorders have an increased incidence of trauma and other injury, and poorly managed preexisting pain conditions can also lead to opioid-related problems. Consider Ernest, a 54-year-old man who worked in a car manufacturing plant. Twenty-two years ago, a piece of heavy equipment malfunctioned and fell on top of him, causing a severe back injury. He has been on regular daily opioids since then. Ten years ago, he was found to be overusing his medications and they were discontinued. Attempts were made to manage his pain without opioids, but with little relief, and he began buying them on the street, eventually transitioning to heroin. Eventually, he did seek treatment, and for two years has been maintained on buprenorphine, which has stabilized his opioid use disorder. However, he still suffers from intermittent worsening of his back pain. The mix of pain and addiction can at times be difficult to sort through for patients and their clinicians. Patient concerns about pain or requests for analgesics can be interpreted as drug-seeking, that is, manipulative attempts to gain opioids for non-medical uses. As a result, clinicians may dismiss the person's concerns, leaving them with untreated pain that can itself be a trigger for misuse, as it was in the case of Ernest. In addition, pain, as well as addiction, elicits a great deal of suffering and can lead to emotional encounters, anger, frustration, anxiety, for clinicians as well as for patients. Appropriate monitoring and intervening with the at-risk behaviors are necessary, but so is openness and curiosity about the patient, their behavior, and their stated concerns. When approached in this collaborative way, particularly with a patient like Ernest who is actively working on his recovery and wants to minimize any exposure to full agonist opioids, it moves the patient towards managing his or her pain in a way that does not put them at added risk. Acute pain, in many ways, is the most straightforward management issue for someone on buprenorphine maintenance. It may be appropriate to simply add non-opioid medications, such as nonsteroidal anti-inflammatories, while continuing their current maintenance dose of buprenorphine, but on a split-dose schedule. More frequent dosing of buprenorphine increases the analgesic effectiveness of this medication. The buprenorphine can also be increased while maintaining three or four times a day dosing, adding small supplemental doses as needed. Buprenorphine is a potent analgesic with a greater than 10 to 1 morphine milligram equivalent for acute pain. Alternatively, patients can continue buprenorphine and a full opioid agonist medication can be added. This was not thought possible a number of years ago, but we now know that further analgesia can occur by adding an opioid to maintenance buprenorphine in the setting of ongoing pain. Lastly, there may be reason to stop the buprenorphine and initiate full agonist therapy temporarily. Obviously, both of the last options add significant potential risk and must be discussed and monitored carefully. So, Ernest needs to have some minor surgery. In considering the need for perioperative pain management, he feels anxious over the fear of being undertreated or mistreated because of stigma or misunderstanding. At the same time, the surgeon or anesthesiologist may have a fear of being deceived or manipulated. This has become less common as clinicians have become more familiar with managing patients currently maintained on buprenorphine. But it is often important for the prescriber managing the opioid use disorder to collaborate with the surgeon and be involved in the discussion of the patient's pain management, including a discussion of likely opioid tolerance that may require higher doses than the surgeon's usual practice. Getting a multi-party consent and coordinating care can help to ease the concerns of both the patient, like Ernest, and the surgeon. Patients who will be treated with full opioid agonist during surgery typically take the last dose of buprenorphine 24 hours before an elective procedure. Post-op, the surgeon may elect to keep the patient on opioid pain medications if hospitalized, but often the patient will immediately be put back on buprenorphine in a split dose, and a full opioid agonist can be added if needed. Of course, regional anesthetics that are sometimes used for orthopedic procedures and pain management following the procedure can be very helpful while the patient is maintained on buprenorphine. Other multimodal pain management is suggested. This table reviews two post-operative care options for patients who, like Ernest, are on buprenorphine prior to surgery. In the patient who has been taken off buprenorphine and treated with full opioid agonist during the procedure and continued during hospitalization, then we would transition back to buprenorphine split dose prior to discharge. When patients are exposed to full opioid agonist, it is important to discuss with them the risk of relapse. An alternative to starting full opioid agonist is to continue buprenorphine. This may mean continuing their maintenance dose but splitting it through the day. Again, there will be times when increasing the dose is warranted, but this will be in a split dose schedule. Most importantly, the physician should discuss and detail these alternatives with Ernest and help him recognize that you will be available to him and to his surgeon if problems arise. Relieving Ernest's distress is one step towards better pain management. Now we will look at management of pain for the patient currently taking naltrexone, an opioid antagonist. This table shows three different scenarios, a patient with mild acute pain, a patient needing elective surgery, and a patient in more severe acute pain or needing emergency surgery. For the patient in mild pain, the use of non-opioid medications is fully available as an analgesic option. This may include non-steroidal anti-inflammatories, acetaminophen, and other non-opioid or non-pharmacologic modalities. If the patient is going to have elective surgery and they are on an oral naltrexone, typically taken daily, then they would be instructed to discontinue their medication 72 hours prior to surgery. If the patient is receiving injectable extended-release naltrexone, then the surgery would be planned for four weeks after the injection, which is the usual duration of the shot's effect. In the case of a patient on naltrexone having severe pain from a physical illness or acute trauma, their pain will need to be managed in the hospital. In the case of pain from severe trauma or non-elective emergency surgery or physical illness, high-potency opioids, for example the fentanyl products, can override the blockade, but the patient will need to be monitored closely. Although emergent pain management was a significant concern when this medication was first introduced, it has turned out to be more of a theoretical than actual problem. It has not turned out to be a major complication to the use of long-acting injectable naltrexone. Patients currently receiving methadone for their opioid disorder that have acute pain should be able to take either a higher dose of methadone or be placed on a supplemental dose of an alternative full opioid agonist during the period of pain. Ideally, the methadone dose should also be split, usually three times per day, for optimal analgesic effect, but it should be noted that patients on methadone for opioid use disorder are treated through licensed opioid treatment programs, and as a rule, these programs have patients on a single daily dose administered each morning. So there may need to be a discussion between the program physician and the surgeon or other treating clinician. It should also be noted that, like those on buprenorphine, these patients will likely require higher doses than non-opioid-dependent patients because of tolerance. Patients with chronic pain in the setting of active or past opioid use disorders are best managed using a multimodal team approach, particularly if there is consideration of full agonist opioid therapy. On the other hand, chronic pain is very common in this population, and it has become increasingly clear that in many cases buprenorphine, through office-based settings or methadone and opioid treatment settings, can provide opioid analgesia that is entirely adequate for many, sometimes most patients, providing a relatively safe, low-abuse potential opioid for their pain management. In more complex pain syndromes, there should be consideration for consulting a pain management specialist and utilization of a multidisciplinary pain management plan. This would allow for either non-opioid or adjuvant analgesics to be used or other non-pharmacologic therapies. As you think of the populations we have talked about so far, what questions do you have that you can seek answers for later? In considering the treatment of older adults, it is important to recognize that this demographic of the population is growing rapidly both here in the United States and globally. Remember our patient Gwen? While we are treating her, it's also important to recognize that she and her peers are not immune to alcohol and other drug-use disorders, and in fact, this has been one of the fastest-growing demographics in the United States. As you can see, alcohol-use disorders are the most common SUDs in this group, as it is in the population at large, but non-medical use of opioids is not inconsequential, particularly in the setting of age-related changes. At the same time, there has been a lack of high-quality research surrounding the treatment of older adults with substance-use problems. This includes the problems that this segment of the population can get into to prescribe various controlled substances, most prominently opioids and benzodiazepines. As illustrated by the patient Gwen that we met in Module 4, there are unique features of the older adult population, including physiologic changes that result in decreased metabolism and increased elimination time of medications, polypharmacy, which is much more common in older adults, complicating their management, multiple comorbidities, which may include cognitive decline and which may limit their ability to manage their medications safely, a higher incidence of pain in the older population. 25% to 50% of a community cohort will have some element of pain on a monthly basis, which increases to as high as 70% to 80% of patients in nursing homes and other long-term care facilities. Significant risk of depression and suicide associated with decreased mobility, declining physical health, isolation, and pain. Given this information, it is important that you conduct a thorough screening for alcohol and other drug use disorders on all older adult patients. Keep in mind the importance of attending to medication management due to the possibility of cognitive impairment. At the same time, stay attentive to the possibility or potential for depression and suicidality. On the other hand, also stay on guard against ageism. So what if she takes too many of her pain pills or benzos? What else does she got? Oh, let him zone out. At least he's comfortable. The creeping assumption that simply because of advancing age there should not be an effort to maximize the individual's quality of life or a chance for a return to functionality. In the case of opioid use disorders with or without comorbid chronic pain, buprenorphine may be a good choice for treatment, particularly over methadone. There will be less chance for respiratory compromise, including sleep apnea, less drug-drug interaction, and less potential for cardiac dysrhythmia, including QT prolongation. Considerations in the management of patients with co-occurring opiate use disorder and HIV, like our patient Jennifer, are important to understand in part because this is a high-risk population. It's not uncommon to see HIV-positive patients with a history of an opioid use disorder. Consequently, things to keep in mind are both buprenorphine and methadone are metabolized by the cytochrome P453A4 hepatic enzyme. This is the same hepatic enzyme involved in the metabolism of a variety of antivirals, most prominently the protease inhibitors. However, methadone is more acutely affected. Due to the induction of this hepatic enzyme, methadone levels can drop to a clinically identifiable level, putting patients into mild withdrawal. It can also have an effect on the efficacy of the antiviral. Many HIV clinics are now providing opioid treatment in the form of buprenorphine. This ability to treat these patients in a multidisciplinary, co-management setting is one of the genuine successes of office-based opioid treatment, allowing for the improvement of management of both the substance use disorder and the HIV disease, improving medical, behavioral, and overall social health. Renal disease does not significantly interfere with the use of buprenorphine. There is no significant difference in the kinetics of buprenorphine in patients with renal failure versus healthy controls. This is in part because of the very small amount of buprenorphine that's filtered and excreted by the kidney. Patients on hemodialysis with an opioid use disorder can be managed with either buprenorphine or methadone effectively. In consideration of the management of patients with compromised hepatic function, clinicians should keep in mind that buprenorphine undergoes hepatic metabolism by the cytochrome 3A4 system. Consequently, patients with compromised hepatic function may have reduced metabolism of buprenorphine. This should be considered when managing clinical dosing. There is no specific hepatic toxicity associated with the administration of either methadone or buprenorphine. At the same time, patients with impaired hepatic function need to be monitored closely. Hepatitis C is endemic in this population. When the patient has both hepatitis and impaired hepatic function, it is important to see that the patient is getting appropriate care, and one should be communicating closely with the hepatologist or infectious disease specialist in considering co-management. Due to their hepatic metabolism, both buprenorphine and methadone may be contraindicated in a patient with acute hepatitis. However, it is important to not rule this out without consulting the treating hepatologist. Not infrequently, it will be suggested to go ahead and start medication-assisted treatment due to the considerable risk that the patient would have from the continued use of opioids, including the potential for continuing injection drug use. Patients with mild elevation of the liver enzymes to moderate elevation at three times normal may be initiated or continued on their buprenorphine or methadone, but it should be monitored closely. The etiology of this abnormal liver function should be determined and treated. Behavioral health equity is the right to access quality health care for all populations, regardless of the individual's race, ethnicity, gender, socioeconomic status, sexual orientation, geographical location, and social conditions through prevention and treatment of mental health and substance use conditions and disorders. To date, there is a limited amount of research concerning how opioid addiction and subsequent use affect the LGBTQ population. In a 2009 study in Chicago, researchers found that men who have sex with men are more likely than the general male population to experience substance use problems with prescription opioid pain relievers. Similarly, studies on how the brain disease of addiction impacts people from different races and backgrounds are only just now emerging. Before we summarize, spend a few moments considering what your major learnings were from this module. What thoughts do you have as we leave this topic and set of topics?
Video Summary
In this video, Dr. Jim Finch discusses the appropriate management of medication-assisted treatment (MAT) in various special populations. Dr. Finch begins by emphasizing the importance of understanding the co-occurrence of psychiatric disorders and substance use problems. He explains that over a third of patients with a substance use disorder have a diagnosable psychiatric disorder, and nearly a quarter of those with a mental health disorder have co-occurring substance use problems. Dr. Finch then goes on to discuss specific examples of special populations, such as individuals with psychiatric disorders, attention deficit disorders, adolescents, pregnant women, patients with pain, older adults, individuals with HIV, and patients with renal and hepatic diseases. He provides recommendations for the management of these populations and highlights considerations such as medication selection, dosing adjustments, and the need for multidisciplinary approaches. Dr. Finch also mentions the importance of addressing health equity and researching the impact of opioid addiction on different populations, including the LGBTQ community and people from different racial backgrounds. In summary, Dr. Finch provides valuable insights and recommendations for the appropriate management of MAT in various special populations, highlighting the need for individualized and comprehensive care.
Keywords
medication-assisted treatment
special populations
psychiatric disorders
substance use problems
co-occurring disorders
MAT management
multidisciplinary approaches
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