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Medical Student 8 Hour Buprenorphine Training
Session 6: MAT and Urine Drug Testing
Session 6: MAT and Urine Drug Testing
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Video Transcription
Hello again. I'm Dr. Kelly Fedorio. Welcome to Module 6, where we will discuss buprenorphine induction, other medication options, and urine drug testing. Take a minute to look over these objectives. As we begin, keep in the back of your mind what we discussed in Module 4 on patient evaluation, particularly about the importance of building a therapeutic alliance with your patient, so that you can learn this new information through that lens. Buprenorphine induction refers to the initiation of the medication in a patient who is currently opioid dependent. The overall goal is to assist the patient in stopping full agonist opioids and initiate the partial agonist buprenorphine. In establishing the stabilization on buprenorphine, the specific goals are to discontinue the use of other opioids, significantly reduce any withdrawal symptoms, do this with minimal to no side effects, and ultimately decrease further cravings for the use of opioids. Prior to the initiation of buprenorphine, we should establish that the patient meets criteria for an opioid use disorder. We also want to make sure that they have a way to pay for their treatment and their medication. They will also need to understand that there will be ongoing urine drug testing. You'll also establish how you're going to approach the initiation of medication. Buprenorphine induction is done in two different ways. It can be done in the office where the patient takes your prescription, has it filled at the pharmacy, and then returns to your office in mild to moderate withdrawal, prepared for the first dose of the medication. This can also be done at home. In that case, your patient would once again take your prescription to the pharmacy and get it filled, but have instructions on how to initiate the medication at home. This is most commonly done with patients that already have prior experience with the use of buprenorphine. Keep in mind, many patients that have been buying their opioids on the street will have had some exposure to the use of buprenorphine. It will still be important that you review clearly with the patient how to initiate the medication. There are a variety of buprenorphine-naloxone combination products that are FDA approved for treating patients with opioid use disorder, or OUD. The important thing is that you understand the dosing equivalents so you can treat the patient appropriately no matter which product is used. They're all in a ratio of 4 to 1 buprenorphine to naloxone product. Choosing the specific product depends on patient and provider preference, and equally important is what insurance and cost factors need to be considered. When doing inductions in the office, we typically try to do these earlier in the week. That way, your office will be open to respond to the patient having difficulty. They're also often done early in the day. I typically do inductions as my first scheduled patient. That way, patients will be able to take their last dose of an opioid in the evening and spend most of the time without medication while they're sleeping. We use the Clinical Opioid Withdrawal Scale to determine the level of withdrawal and the appropriateness for starting the medication. Patients only need to be in mild to moderate withdrawal at the time of induction. The first dose is typically 2 to 4 milligrams of buprenorphine. This lower dose allows for the medication to start to take over the receptors because of its high affinity to the opioid receptor. Subsequent doses result in complete dominance of the receptors by buprenorphine. By doing this slowly, patients will have less potential for having withdrawal symptoms as they move from the higher intrinsic activity stimulated by a full opioid agonist to a partial agonist. After giving the patient their prescription in the office, they would return home with the following instructions. If they're taking or using short-acting opioids like oxycodone, hydrocodone, or heroin, then they need to wait about 12 to 16 hours before starting the buprenorphine. On the other hand, if they're taking sustained-release medicine like OxyContin, they need to wait 24 hours. Methadone is a tricky one. They would need to wait at least 36 hours if they're taking 30 milligrams a day or less. Higher doses may take 48 hours or longer before the patient will be in withdrawal. I would not advise that your first patient be discontinuing methadone. Get a little experience before you try that one. The important point is that the patient is in mild to moderate withdrawal no matter what they were taking prior to the initiation of the medication. Fentanyl, because of its high potency, competes with buprenorphine. Therefore, you want to make sure the patient is in more moderate withdrawal before administering buprenorphine. These are the signs and symptoms of opioid withdrawal. We pointed out some previously that some of them are subjective symptoms while others are objective signs. I encourage you to always establish some objective signs, in particular, pupillary dilation, sweaty palms, and or pyloreaction or goose bumps. This ensures that the patient is in mild to moderate withdrawal. You're looking for a score of at least greater than 8 and typically around 11. It'll be important to educate the patient about the proper administration of buprenorphine. This should be done for both office and home inductions and is one advantage to doing an office induction because the patient is sitting right in front of you. Sublingual tablets and film are held under the tongue until the patient no longer feels any film or pill particle. Then, we advise patients to allow the saliva to remain under the tongue for another two minutes. At that point, all the medication that is going to be absorbed will have been absorbed. The buccal film instructions are much the same. So, the patient needs to start with a moist mouth. They can just have taken a drink of water prior to taking the medication, but they shouldn't have a pool of water in their mouth. They shouldn't drink acidic juice or coffee within 15 minutes of administration. The reason is, and the reason why they should not have smoked a cigarette within 15 minutes, is because all of these substances will result in vasoconstriction of the vasculature of the mouth. That will reduce the absorption of the medication. I also encourage patients not to talk after they start taking their medicine. I'll often tell them that this is a few minutes to consider their recovery and what steps they might take that day to move it further along. At the point that the medication has been well absorbed, the patient has a choice to either swallow the saliva or spit it out. They will not get an appreciable amount of any more medicine by swallowing it. And, some patients experience nausea and headache from swallowing, so I typically recommend spitting it out. If the patient arrives at your office on the day of induction and does not appear to be in withdrawal, confirm with them what time they last took their last opioid. If for some reason they state they could not wait and they took another opioid within a few hours of coming to your office, then consider having them return home and come the following day or, if possible, have them wait in the office until more objective signs of withdrawal appear. Typically, if the patient is in mild withdrawal, they'll be able to start with 2 mg of buprenorphine and the patient will have little to no problems. The important point is to start with a low dose and then move up as the patient builds tolerance. So now, we have a patient that is dependent on short-acting opioids, let's just say heroin. You tell them that you'll see them at 8 a.m. in the morning to start the induction to buprenorphine. That means you want them to take their last dose of heroin at 6 p.m. the day before. That way it gives them 14 hours prior to the potential administration of the buprenorphine. These patients have all been in mild to moderate withdrawal in the past, so they often know what symptoms to watch for. When the patient arrives in the office, you assess them using the clinical opiate withdrawal scale. You document the severity of their withdrawal, which will typically be in the 8 to 11 range. You then review the instructions for administration and allow them to take their first dose. This is if the patient is transferring from methadone. Typically, patients will need to be tapered down to 30 mg or less for at least a week or two prior to the transfer. If possible, they could take at least one day at 15 mg and then the next day at no medication, then the following day start the buprenorphine. This would mean approximately 48 hours after the last dose of methadone. They should be in mild to moderate withdrawal when arriving at your office. If that's the case, you would administer the medication just like we talked about previously. Initially, have the patient place the first dose of 2 to 4 mg tablet or film under the tongue. We typically have them stay in the office for the next hour or two. They usually will have gotten significant relief from their withdrawal symptoms within 30 to 45 minutes of the first dose. You can have them stay an hour and a half to two hours. They most often will report being comfortable but still experiencing mild withdrawal symptoms. If that's the case, I would go ahead and have them take another 2 to 4 mg and at that point they can return home. Over time, you'll be able to estimate what they will probably need for stabilization. I specifically will try to have them stabilize on 8-2 mg to 12-3 mg. This gives you an opportunity to have room to move up if they're still experiencing cravings but still not necessarily going up above 16 mg of buprenorphine. I also tell the patient the mild withdrawal symptoms they may have the 2nd or 3rd day will continue to get better as they reach a steady state by the 5th day. Again, the primary reason to go up on the dose is craving. Over time, patients will stabilize withdrawal symptoms on buprenorphine at lower doses but this might not result in craving reduction to the point that they stop using opioids. Remember, that is our goal. Most of the time, 16-4 mg will result in adequate reduction in craving. If during the induction, opiate withdrawal symptoms start to appear after the administration of buprenorphine, you may have precipitated withdrawal. This is a very rare event and this is the reason we want people to be in mild to moderate withdrawal prior to initiating their first dose and why we give a first dose of only 2-4 mg. Typically, precipitated withdrawal will subside in the next 1-4 hours. If it does occur, what's happening is that the buprenorphine is competing with a full opiate agonist and if you remember back on the graph we looked at with intrinsic activity on the y-axis and dose on the x, when full opioid agonists are on board above the 40% intrinsic activity level, they will be providing more intrinsic activity than buprenorphine can. Buprenorphine intrinsic activity levels off at the 40% level, but it has a higher affinity to the receptor, higher than most other full opioid agonists, and consequently will drop that intrinsic activity down to the 40% level very quickly. Again, this is a very uncommon occurrence, but if it were to happen, just hold at the current dose, allow the patient to stabilize, and then within an hour, if there's still withdrawal symptoms, go ahead and give another 2-4 mg. This allows the system to equilibrate. There may be a reason to add something like clonidine, an alpha-2 agonist, to reduce some of the agitation associated with withdrawal, but again, it's very uncommon. Reassurance to the patient is probably as important as anything. They will stabilize nicely within a relatively short period of time. Your reassurance will go a long way in helping them transition and move towards recovery. Your reassurance will go a long way in helping them transition and move towards more positive engagement in their treatment. Home induction is used widely. As far back as 2007, 42% of primary care physicians were utilizing home inductions. There's strong reason to believe that this has grown since then. It has similar safety and efficacy outcomes as office induction. Many patients coming into treatment will have already tried buprenorphine. Many patients are appropriate for home induction, but those who are not appropriate are those patients who are taking opioids for pain and have started to lose control of their medication management. These patients may be more naive to buprenorphine. The process for home induction is essentially teaching them the same protocol of discontinuing short-acting opioids for 12-16 hours and long-acting for 24 hours. I would only recommend the initiation of buprenorphine following methadone in a home setting if the patient has significant past experience taking buprenorphine. We give the patient the clinical opiate withdrawal scales, signs, and symptom criteria, which they should have before taking the first dose of buprenorphine. Once mild to moderate withdrawal has been established, the patient would self-administer 2 mg of the medication. They can then self-assess 1-3 hours later, and if still feeling withdrawal symptoms, take another 2 mg. Typically, we would give the patient enough 2 mg tablets to be able to self-administer between 8 and 12 mg the first day. You'll want to have contact with the patient the day after initiation. This can either be in person by having the patient return to your office, which I would recommend a couple of times. This will give you a clearer understanding of the patient's experience in that first day so that when you start to follow up by a phone call on the second day, you'll have a much better understanding of what the experience has been like. Then, you may feel more comfortable reviewing that first 24 hours with the patient over the phone. Also, this gives you a chance to deepen your alliance with the patient by asking open-ended questions and listening carefully to the answers. You'll want to assess how they tolerated the medicine. You'll want to ask things like, how much did they take on that first day? How are they feeling today? Are there continued signs or symptoms of withdrawal? By obtaining this information, you will have a better sense of dosing recommendations for the medication. If the patient is experiencing either lethargy or sedation, they may have taken too much of the medicine, and you would recommend coming down by 2 to 4 mg. You can often reassure the patient if they are experiencing mild withdrawal symptoms that this will dissipate over the next few days as they reach a steady state. I do typically try to hold them at their current dose if they seem to be having a reduction in their cravings. Again, this allows you to stay below 16-4 mg daily, so that if you do need to go up because of cravings or continued opioid use, you have room to move. The average dose across the country is 12-3 mg daily. As described, most patients will not need more than 16-4 mg daily. Though there is FDA approval to go to 32 mg daily, this is pretty rare. Most insurance companies will not approve the medication above 24 mg. There is evidence that these higher doses will stabilize the patient more rapidly. However, typically in the first few days of starting the medication, the patient is hopeful, so this can be an important time to make a connection with them, engage them in behavioral changes that will help reduce their cravings, and help them understand that they will stabilize on a lower dose, and this can have equal efficacy if given some time to stabilize. Going to higher doses means that once stabilization takes place, the patient may begin to recognize that they do not need as much medicine as they did, and you are potentially setting them up for giving or selling some of their dose to others. If you suspect this, you may want to initiate more intensive monitoring by establishing more frequent urine toxicology testing, shorter prescription durations, or pill counts. These can be contingencies that can also be used for greater stabilization and potentially coming down off higher doses. That brings us to stabilization and maintenance. First of all, I would encourage you on a regular basis to talk with a patient about how they are administering their medication. A few times I've neglected this and brought it up a couple of months after the patient has started on buprenorphine, only to find that they're swallowing it or doing something else that's interfering with their getting the full dose. It's advised that patients do not take more than two film strips or tablets at any one time. This is not dose dependent. It's because only two strips or tablets can be effectively absorbed at one time. The package insert does refer to either once a day dosing or twice a day. Twice a day dosing is not a problem, however, eventually you would want to move the patient towards taking it once a day. The goal is that they would take it either in the morning or at night, and then not be thinking about taking further medication throughout the day. This gets the patient away from the idea that the medication is somehow going to be making them feel better, and instead gets the patient into a state where they are moving forward in other ways in their recovery. During stabilization period, you will want to continually reassess the patient, all the while deepening your alliance with them. During this time, review how they're taking their medication and encourage once a day dosing. Again, this is to help move them away from the association that taking their medication is like taking the drugs that they used to use. Remember, patients should not try to dissolve more than two tabs or strips in their mouth at one time. If there's continued opioid use or significant craving, you'll want to raise the dose at two to four milligram increments and not more frequently than once over a five day period. This brings us to that difficult question of how long the patient should be taking one of these medications. You've seen the evidence that even after 16 weeks of regular administration, patients are at high risk of relapse on discontinuing the medication. As a general rule, you'll want to continue prescribing it as long as the patient is benefiting from the treatment and you're not observing problems. Patients will often initially come into the office saying, I don't want to be on this medicine forever. I'll sometimes use that kind of statement in talking to patients about why we want to stabilize on a dose at 16 milligrams or below. The goal is to have them on the lowest stabilizing dose, which they also, if it's their desire, will help them come off of it most easily. Once patients have stabilized on a dose and their lives are stabilizing, work, home, interpersonal interactions, then it's not uncommon to talk to the patient about reducing the dose but coming off of the medication is completely up to the patient. When they feel comfortable that they can move forward in their lives without medicine, that is when we start to come off. It's recommended that they do not come off in less than six months and usually it's closer to or longer than one year before patients are ready to come off. Remember, whether the patient is on medication or not, they will be able to move forward in their lives very successfully. A scenario that you may be confronted with is a family member or partner wanting the patient to come off the medication. They may ask, how long do they need to be on this? I don't want them to be taking this medicine forever. When I meet with these family members, I'll often ask them how they see the patient doing compared to when they were misusing opioids. They're often in full agreement that there have been very positive changes. I'll then ask, what do you see in the patient now that you think they need to be on? What do you think will change in terms of their appearance or behavior once they're off the medicine? They don't typically have a response to this. I then tell them to let their loved one continue the medication as long as they feel that they need it. We continue to work on behavioral changes that will help reduce any potential that they would relapse once they do come off the medication. The medicine is not somehow controlling the positive behavior changes that they make. It's only helping them gain greater control for a period of time. This period of time is different for everyone. The disease of opioid dependence is complex. It starts in a variety of ways and gets worse for many different reasons. This variety will result in the patients also recovering differently. Remember, this is a disease of the brain with variations in a patient's neurobiology and the environment in which they've been in or are in while they're recovering. Some will have an easier time in controlling their cravings than others. I usually tell the partner, let the medication management and behavioral change be something that the patient and I can continue to work on together. Maybe someday they'll come off the medicine and maybe a month later they'll let you know about it. Usually, you won't be able to tell the difference. This graph is used to display an observational study in which some patients were continued on buprenorphine throughout the year and all others were tapered off at various intervals. Overall, it shows that those who were maintained on buprenorphine had 14% fewer emergency department visits and 18% fewer admissions to the hospital. This study demonstrated that tapering is less efficacious than ongoing maintenance treatment in patients with an opioid use disorder involving prescription opioids who receive buprenorphine therapy in a primary care setting. The primary outcome was retention in treatment. What you see is that those patients that were maintained on buprenorphine had a significantly higher likelihood to be retained in treatment compared to the tapered condition. This same study identified the percentage of urine samples negative for opioids and showed that there was greater opioid use in the taper group at 35.2% compared with the maintenance group at 53.2%. There were also more days of illicit opiate use and fewer maximum consecutive weeks of opioid abstinence in the tapered group. We have already talked about naltrexone as a medication which has been found to be effective in treating opioid use disorder. This slide reiterates that naltrexone is an opioid receptor antagonist, so it blocks the opioid receptor entirely with high affinity. So it literally will displace other opiates. Consequently, naltrexone can only be initiated in patients who are completely opioid-free. It is recommended that naltrexone be started after a seven to 10 day washout period between the last dose of an opioid and the initiation of naltrexone. This can be a barrier to get patients started on naltrexone. Many patients relapse during this opioid-free period before they can initiate the medication. If naltrexone is given to a patient physically dependent on opioids prior to full withdrawal, the patient will go into precipitated withdrawal. This is different than a spontaneous withdrawal which has a slower onset and more natural progression. In preparation for administration of the extended release naltrexone injection, you need to do a few things. First of all, it's a rather expensive once a month injection. The out-of-pocket expense typically runs over $1,000 per injection. It's usually obtained through a specialty pharmacy and then shipped directly to the provider. It needs to be kept refrigerated and then taken out of the refrigerator at least 45 minutes prior to the time it's going to be administered. It can be out of the refrigerator for up to three days prior to injection. Prior to the injection, it is important that you check the opioid status of the patient and verify by self-report and drug screen that they are opioid-free. You can give a naloxone challenge before the first dose and we'll talk about that in an upcoming slide. The most common side effect is pain at the injection site. This happens less if the injection is given as a deep intramuscular into the gluteus muscle. Other side effects such as headache, nausea, and a general flu-like illness are most common with the first injection but not subsequent injections. Clearly and most importantly, the patient should understand that this opioid blockade will interfere with acute and chronic pain opioid management. A naloxone challenge is when the patient is administered a low dose of naloxone to see if there are withdrawal symptoms indicative of patients still being physiologically dependent on opioids. A positive test will occur within five to 10 minutes of the administration of the medicine and will typically dissipate within 30 minutes. The severity of the withdrawal is proportional to the patient's level of physical dependence. The procedure entails an intramuscular injection of 0.8 to 1.2 milligrams of naloxone using an insulin syringe. Administering a naloxone challenge will not produce any withdrawal in a patient that is no longer physiologically dependent but will save the patient from a more severe protracted withdrawal if a full dose of naltrexone were administered while they were still dependent. There are a couple of ways to complete a medically supervised withdrawal. You can treat the patient purely symptomatically trying to help them with any withdrawal symptoms they may experience. You can try to decrease the period of time they're under supervised withdrawal by administering naltrexone at a low dose, three to six milligrams, and titrating up. You would start this typically three to four days after a patient has taken their last dose of a short-acting opioid. All the while you help them with their emerging withdrawal symptoms. An alternative way to medically supervise withdrawing a patient from opioids is using buprenorphine. This protocol utilizes the high affinity and slow dissociation of buprenorphine. Here you would typically give enough buprenorphine to suppress opioid withdrawal after the patient had started into withdrawal, just like the induction protocol we talked about before. Then gradually taper down on the dose of buprenorphine over the next few days. This withdrawal protocol can be as short as four days or extended out to literally any period of time. When using this protocol for a patient coming off a full opioid agonist, they have little to no withdrawal feelings on discontinuing the buprenorphine. If they do, then the symptoms can be managed symptomatically. It's important to understand that the only time patients with opioid use disorder should be acutely withdrawn is either when they are entering a controlled setting like incarceration or prior to the initiation of naltrexone. There are a variety of regimens that can be used based on one's clinical practice and the patient needs. Here you see an example of a three-day withdrawal. The patient is loaded on the first day with buprenorphine naloxone, 8-2 milligrams or 12-3 milligrams sublingually. Then tapered by two to four milligrams a day. This of course can be adjusted clinically depending on the patient. The patient may experience mild withdrawal symptoms for two to three days after discontinuation. This protocol is typically well tolerated. Offering reassurance that the symptoms are not going to be severe and potentially treat emerging insomnia, anxiety and myalgias will increase retention and improve engagement. There are a variety of adjunctive medications commonly used to assist in helping the patient be more comfortable during medication-managed withdrawal. These include alpha-2 agonists such as clonidine and lefexidine, a more recently approved medication. Lefexidine is associated with less potential of lowering the patient's blood pressure and potential falls. However, at this time it's also much more expensive. On the next slide we'll review alpha-2 agonists more thoroughly. Patients may also have difficulty initiating sleep which can be nicely treated with trazodone or diphenhydramine. Musculoskeletal discomfort can be treated with acetaminophen or ibuprofen and GI distress can often be resolved just with increasing oral hydration. However, sometimes an anti-emetic may also be helpful. It's also not uncommon that the patient may have diarrhea and this can be alleviated with lopiramide. Clonidine, again, is an alpha-2 adrenergic agonist. This is a presynaptic agonist that works by inhibiting the release of norepinephrine which is the primary stimulant causing the severe agitation the patient often experiences. But this can also result in lowering the patient's blood pressure. In fact, it has a long history of being prescribed for hypertension. This can result in postural hypotension putting the patient at risk for falling. Consequently, patients are typically monitored before each dose to make sure the blood pressure is still greater than a systolic of 100 and a diastolic greater than 60. Patients can also become bradycardic and the medication is held for a heart rate less than 60. The dose of clonidine can be titrated between 0.1 and 0.2 milligrams given every four to six hours as needed for anxiety or agitation. But it's not recommended that more than 1.2 milligrams per day. If the patient is vomiting or having severe diarrhea and becoming dehydrated then you wanna be careful in using clonidine. Maintaining good hydration is very important. It's also important to remember that clonidine only reduces the physical withdrawal symptoms and not cravings for opioids. Patients can be somewhat more comfortable taking clonidine because it does help them stay relaxed and they can become mildly sedated. At the same time, if they're experiencing dizziness, fainting or headache, this is more indicative of volume depletion and hypotension. Predictors of a more severe withdrawal include patients that have been taking regular high doses of opioids over a longer period of time which often includes patients that have been injecting heroin also patients that have abruptly discontinued high dose opioids. Patients that have experienced severe withdrawal in the past have greater expectancy of these withdrawal symptoms and their anxiety about anticipation of symptoms can make their experience even worse. In summary, the initiation of injectable naltrexone will be more successful in the patient that has been fully withdrawn from other opioids. When administered correctly, deep IM in the gluteus muscle, there will be less discomfort and induration. This will contribute to the patient's compliance with subsequent injections. When the medical team is aware and available to support the patient with emerging withdrawal symptoms, they will feel supported which can reduce anxiety and improve their engagement in their treatment. This is reflected as we've talked about before in the staff's positive engagement with the patient and reduction in both negative judgment of the patient. Both anticipatory guidance and provision of a motivational attitude with the patient on the part of the treatment team will improve long-term adherence to treatment and often a better outcome for the patient. We're now going to talk about drug testing, a very important part of treatment. You should view urine testing as a way to help patients move forward in their recovery. It is not meant to be used to catch patients. I tell them that directly. A positive test should be used to help patients reflect on their behavior and actions and consider what changes they can make in order to manage their recovery more effectively. Testing results in a more even playing field and encourages honesty between the patient and the provider. We've talked about the language used with patients and staff. Remember that words matter. That means that we don't call urine or patients clean or dirty. In other areas of medicine, dirty urines can refer to contaminated urine, but in addiction medicine, it refers to the patient and their disease. So we're careful to use the terms positive and negative urine drug screens. Laboratory testing for evidence of substance use should be done at the time of initial assessment. The results of the test will contribute to treatment planning. Drug testing is not just to see what non-prescribed medications or drugs the patient may be taking, but also to see that they are taking the medications that have been prescribed. Over time, drug testing is one more way in assisting us to identify the efficacy of treatment and therefore ongoing treatment planning. Ideally, laboratory testing should be random, although this can be difficult. Due to the patient's transportation problems, other obligations, work, childcare, the validity of the test can be increased when urine drug testing is observed. However, this also has complications and it's not frequently done. The testing needs to be somewhat convenient for the patient. Also, having timely results of their drug testing will contribute to having more impact on the patient when the results are reviewed in real time with them. Maintaining high quality drug testing is of course important, and you should have good working knowledge of the general principles of your local laboratory. Urine testing is the most common form of clinical drug testing. This is because urine is easily available and testing, and the testing has reasonable sensitivity and specificity. We typically use urine drug testing to evaluate substance use over a longer period of time, which then contributes to the ongoing treatment plan. This graph shows the longer period of time that urine will allow for detection of various drugs, compared to a breathalyzer, blood, or oral fluids. These other tests do have utility, but they're not as easily obtained in the window of time needed when we're working with the patient. Hair evaluation is most frequently used in forensics. It's more expensive, and the results are not quickly available. There are no strict guidelines that establish the frequency of urine drug testing. It's typically determined by a variety of factors. In the early stages of treatment, you may be getting weekly specimens. This is done until you establish the patient is either remaining absent, or at least moving in the right direction, and then you start to extend the testing out. Urine drug testing can be used to better identify potential diversion of the patient's medication. In that case, they may have aberrant levels, or none of the medication you're prescribing in their urine. The frequency can also be adjusted as per the stability of the patient and their adherence to treatment protocols. You may also want to see the patient within a short period of time, depending on the half-life of the drug that you're trying to monitor. This, for example, might be cocaine, which has a tendency to not stay in the urine as long as other drugs, like cannabinoids or benzodiazepines. Lastly, urine drug testing frequency can be associated with the setting in which treatment is taking place. There are some settings, like an opioid treatment program, where federal law mandates a minimum of eight drug tests per year per patient, whereas office-based treatment typically doesn't have specific mandates. There may be either private insurance or Medicaid stipulations on the number of confirmatory urine drug screens that can be done per year. Random drug testing and or observed urines can be helpful in your attempt to get more clear representative samples of the patient's drug use. So, we talked about some of the screening tests and confirmatory tests. Screening tests are immunoassay tests that are rapid and inexpensive. Typically, the sample's collected in a cup in the office with strips on the side of the cup that can be easily read positive or negative for various substances. They're typically described as point-of-care testing. They can be done readily on-site. However, these samples need to be considered as presumptive because of the lack of specificity in this form of testing. Confirmatory testing, on the other hand, is more expensive and time-consuming. It involves either liquid chromatography or gas chromatography with mass spec. It is typically done in a certified laboratory and, consequently, the results are not available the same day. They are, however, more specific and precise than the screening test. The results are considered definitive. This form of testing can also help differentiate specific opioids or benzodiazepines the patient may be using. So, commonly, we will do a screening test in the office and compare the results with the patient's presentation and their description of whether or not they are currently using. If there are positive results on the screening test, particularly if it's an opioid or benzodiazepine that was not suspected or admitted to by the patient, then we would typically send the sample on for confirmation. Screening tests are done much more frequently than confirmatory testing. Common point-of-care screening tests include opiates, either precursors of or breakdown products to morphine, cannabinoids, certain benzodiazepines, amphetamines, and cocaine. There are point-of-care testing cups or strips that will identify buprenorphine, but nor-buprenorphine, or fentanyl, oxycodone, methadone, or alcohol metabolites. Often, you can design your point-of-care testing based on your setting or drug treatment program. There are also tests for designer drugs, but this has been limited by the rapid development of variations on the drugs. You can learn a lot about how patients are taking their buprenorphine by understanding drug testing. First of all, be clear that buprenorphine is not detected by a general screening test for an opiate. It has its own immunoassay test, or it can be determined by confirmatory testing. When confirmatory testing is done, we'll get both the buprenorphine level and nor-buprenorphine, which is the active metabolite. Typically, nor-buprenorphine will be two to three times the concentration of buprenorphine. We talked about this a little bit earlier in the training. If you don't see this ratio, then look for other aspects of the result that can indicate aberrant use of buprenorphine. For example, if there's no buprenorphine in a tox screen, or very little, then the patient probably has not taken buprenorphine in the last couple of days. If, on the other hand, there's only buprenorphine and no metabolite, then the patient put the buprenorphine directly into the urine. Remember, buprenorphine is rapidly broken down by the liver and then excreted by the bowel or kidney. Consequently, it is impossible for there to be buprenorphine but no nor-buprenorphine in a tox screen if the patient actually took it. It is also important to remember that the amount of buprenorphine or nor-buprenorphine is not necessarily dose-dependent between patients. On the other hand, the patient's levels of buprenorphine and nor-buprenorphine, if they are maintained on the same dose, will typically be quite consistent over time. It's possible for patients to alter their urine specimens. They can add a substance directly to the urine without ingesting it. They can dilute their specimen with water, decreasing the concentration below the level of detection of your lab or the point-of-care test. They may also provide a sample that they took prior to using an illicit drug, or one that they obtained from another person. Adulteration of the specimen can often be detected by checking for an appropriate temperature or specific gravity. If the patient has brought in an older sample, it typically will not be at body temperature. And if they add water to the specimen, it'll often be below normal physiologic specific gravity. A specific gravity below 1.002 would typically indicate that water has been added. You want to have consistent clinic policies that have been reviewed with the patient so that when you come across this situation, the patient knows what will be expected of them if they have surprising test results. This might include consequences for testing positive for illicit drugs, or alcohol, or the lack of a prescribed medication. This is where it will be helpful to have a signed treatment agreement that you can refer back to. I would have you consider again that these drug tests are not designed to catch the patient's aberrant behaviors. They're to help you and the patient reach the patient's goal of sobriety. So you may want to review the buprenorphine dose that may be inadequate. It may not be helping the patient control their cravings. Or review the psychosocial interventions that you're currently providing. Maybe they need to be increased in frequency or intensity. Lastly, address whether this particular level of care is the level most likely to help the patient reach their goal. You'll probably want to increase the frequency of testing until the patient is stabilized. This is where treatment team meetings can be very helpful. You can review with the team what they're seeing, what weaknesses and assets might be addressed, and what changes in therapy could be helpful for the patient. The general plan would then be meeting with the patient to discuss why you are doing this testing and how it can support their recovery. Review the results with the patient and tell them how you interpret the results. And always stay open to the patient's description. You'll want to keep in mind the potential for false positives. This may mean that you call the laboratory to help review the lab results. This would also be a reason that you would go ahead and get confirmatory testing. Not infrequently, when you clearly review the results with the patient, you'll be able to have an open discussion addressing potential treatment plan adjustments. At that time, you may also review with the patient the potential inability for you to continue to help them and the need to move to a higher level of care if the drug use continues. I always try to go back to both the patient's description of why they're entering treatment in the first place, of what they wanted to accomplish, and also my intention that this treatment will result in them moving forward in their life in a healthy way. If you're not accomplishing these goals, then you need to make changes. I let the patient know that moving to a higher level of care doesn't mean that they can't come back after they're stabilized. In summary, buprenorphine is best initiated when the patient has been in mild to moderate withdrawal that is typically between a score of eight and 10 on the clinical opiate withdrawal scale. Scores below this may mean that the patient still has enough opioid on board that they may experience precipitated withdrawal symptoms when they first take the buprenorphine. Buprenorphine is used to manage cravings. Patients will stabilize on a specific dose of buprenorphine and no longer have withdrawal symptoms. So withdrawal symptoms are not what we are trying to manage over time. It's the cravings that will determine whether we need to go up on the medication, remain at the same dose, or potentially start to taper down. It's also important to remember that continuing treatment over an extended period of time will mean that the patient will have fewer emergency department visits and fewer hospitalizations associated with their opioid use. Extended release injectable naltrexone is a good non-opioid alternative to using either a full or partial opioid agonist for the treatment of an opioid use disorder. It has both well-demonstrated efficacy and tolerability. Drug testing is an important component in office-based opioid treatment. It can assist the patient in maintaining treatment recommendations. It will also assist the provider in establishing appropriate treatment planning, dosing of medication, and the appropriate level of care.
Video Summary
The video is module 6 of a training course on buprenorphine induction, other medication options, and urine drug testing. Dr. Kelly Fedorio leads the module, discussing various topics related to buprenorphine induction. She explains that buprenorphine induction is the initiation of the medication in an opioid-dependent patient, with the goal of discontinuing full agonist opioids and starting buprenorphine. The specific goals of stabilization on buprenorphine include discontinuing other opioids, reducing withdrawal symptoms, minimizing side effects, and decreasing cravings. Patients must meet criteria for opioid use disorder, have a way to pay for treatment, and understand that urine drug testing will be conducted.<br /><br />Dr. Fedorio explains the two ways buprenorphine induction can be done: in-office or at home. For both methods, patients must be in mild to moderate withdrawal. She discusses the recommended doses and administration methods for buprenorphine and emphasizes the importance of patient education. She also mentions the various buprenorphine-naloxone combination products available and the considerations for choosing a specific product.<br /><br />The video then transitions to a discussion on medication options and urine drug testing. Dr. Fedorio explains the importance of urine drug testing for evaluating substance use, medication adherence, and treatment efficacy. She discusses the differences between screening tests and confirmatory tests, highlighting the limitations and benefits of each. The video concludes with a discussion on interpreting drug test results and potential interventions based on the results.<br /><br />No specific credits are mentioned in the video transcript.
Keywords
buprenorphine induction
medication options
urine drug testing
opioid-dependent patient
stabilization on buprenorphine
patient education
buprenorphine-naloxone combination products
urine drug testing importance
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