Triage, Assessment and Treatment Planning 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 • 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 ORT: Opioid use disorder with physical dependence, rare exceptions (e.g. exiting incarceration)

• 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

• Past medical history: HIV, HCV, pain, pregnancy

• Psych: Suicide attempts, psychosis, violence

• Current medications, allergies

• Problems with previous detoxes or ORT

• Motivation: Stage of change

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Triage decision tree • Outpatient detox: Healthy, supports, low risk for complications

• In-patient detox: Physical, psychological, social problems

• Offer naltrexone after detox +/- treatment centre

• Warn of OD risk post detox

• Methadone or Suboxone taper: the longer the better

• Methadone or Suboxone maintenance:

– May have previously trialed in-patient/outpatient detox

– Social issues which preclude detox

– Pregnant, HIV+, HCV+, or other urgent medical issue

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Triage to opioid replacement therapy (ORT) At the end of the triage: • Order a urine drug screen (UDS) or do a point of care (POC) UDS

• Include any speciality drugs taken in the past or suspected

• +/- urine bHCG

• Bloodwork:

– AST, ALT, GGT, HIV, Hep ABC, CBC, RPR, etc…

– +/- TB skin test

• Consider an ECG

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Assessment • Fill in details of addiction history

– Each substance first use, amount, route, frequency, diagnosis

– Community supports utilized – NA, AA, Matrix, 1:1

– Flesh out the recovery and treatment history

• Medical history: Include accidents and surgeries

• Mental health history: Diagnosis, treatment, medications, symptoms

• Family history: Draw tree (drug and alcohol, psychiatric issues)

• Social history:

– Legal, vocational/schooling, partner, roommates/family

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Assessment Physical exam: • vitals, pupils, autonomic signs, nasal septum, dentition, murmurs, liver,

tracks, jaundice, tattoos, piercings, mental status exam

– Opioid use: Small pupils, somnolent, tracks, RR

– Opioid withdrawal: Lacrimation, salivation, piloerection, temperature dysregulation, hyper-reflexic and agitated, pain all over, nausea, vomiting, diarrhoea

• Review lab work

• Collateral: Family, other MDs, PharmaNet, pharmacist

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Assessment • Review treatment agreement with patient and witness their signature

• Have them sign permission to communicate with the other MDs/health-care providers involved

• Warn of overdose risks when initiating and stopping methadone, and drug interactions

• Offer Narcan kit

• After the complete workup you may write the first methadone or Suboxone prescription

• Document everything you have covered

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Management of ongoing substance use in the context of methadone/Suboxone® maintenance • Concurrent heroin and other opioid use

• Alcohol

• Stimulants

• Benzodiazepines/zopiclone

• THC

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Concurrent heroin and other opioid use • During induction

– Adjust methadone/Suboxone

– Counselling

– Appropriate monitoring

• Episodic relapses

– Review dose

– Re-evaluate daily supervised dispensing

– Counselling to address relevant issues

– Appropriate monitoring

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Alcohol use • Screen for an alcohol use disorder

• Alcohol use is a concern with ORT

– Interaction with methadone/Suboxone

– Increased sedation and respiratory depression

• Treatment plan for alcohol use disorders is mandatory if ORT maintenance is to be continued

• Uncontrolled alcoholism may be an indication to withdraw from methadone maintenance

• BCMA Guideline: Office Based Management of Problem Drinking (www.bcguidelines.ca)

• Consider acamprosate, gabapentin

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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

– Screen 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 ORT

• Taper ORT

• 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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Patterns of methadone dose tapering: most successful patterns checked

Modified from Nosyk et al, Addiction 2012; 107(9):1621-9.

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Transfers/cessation of treatment If patient transfers to alternate ORT 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

• Containment of overall risk to patient/public

• Reduced conflict during visits

• Reduced risk of coroner’s cases

Well done!