“Brief” protocols. Recent studies of Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs have found that the simple, time-limited interventions they offer (visit http://www.samhsa.gov/prevention/sbirt/SBIRTwhitepaper.pdf to learn more) lead to a reduction in self-reported illicit opioid use.17,18 Family physicians can readily incorporate SBIRT protocols into routine practice, as an evidence-based and often reimbursable approach to substance abuse.17
Suspect opioid dependence in a patient who:
- describes pain resulting from back or orthopedic injuries without corresponding documentation or imaging
- requests a specific opioid for pain management
- shows little interest in a physical exam, diagnostic testing, or nonpharmacological remedies
- talks about changes in work or relationship status
- ceases to participate in activities or hobbies that previously occupied a considerable amount of his or her time. This may signal social isolation or indicate that the patient is spending a great deal of time in pursuit of opioids.
Additional steps before initiating treatment
After screening and diagnostic evaluation provide evidence that a patient is opioid dependent, you can take several steps to guide him or her to the appropriate treatment.
A thorough biopsychosocial assessment covering co-occurring psychiatric illnesses, pain, psychosocial stressors contributing to opioid use, and infectious disease screening is required to gain a clear picture of the patient’s situation. In every case, acute emergencies such as suicidal ideation require immediate intervention, which may involve hospitalization.19
Assess the patient’s desire for help. After the initial assessment, it is often helpful to categorize the patient’s “stage of change” (precontemplation, contemplation, preparation, action, or maintenance),20 and to tailor your next step accordingly. A patient who denies that opioid use is a problem or is clearly ambivalent about seeking treatment may require a conversation that uses principles of motivational interviewing—a collaborative approach that aims to evoke and strengthen personal motivation for change.21 Consider a question that encourages him or her to express reasons for change, such as: “How would you like your current situation to be different?” As almost everyone abusing opioids has thoughts about stopping, such a question may help the patient focus on specific changes.
CASE When you question Sam about his interest in oxycodone, he breaks down. He’s been unable to find work or to lose the excess weight he gained during the many months he cared for his wife. He tells you that soon after his wife stopped taking the pain pills, he started taking them. At first, he took one occasionally. Then he started taking the opioids every day, and finally, whenever he awakened at night. Now, Sam says, he has no more pills, and he’s nauseous, depressed, and unable to sleep—and looking to you for help.
Sam fits the criteria for opioid withdrawal as a result of physiological dependence; further questioning reveals that he also suffers from opioid dependence, and that he is receptive to treatment.
Recommending treatment and following up
Several options are available for patients who, like Sam, have signs and symptoms of opioid withdrawal as a result of physiological dependence. You can provide a referral to a physician specializing in addiction, recommend detoxification and/or treatment in an inpatient facility, or initiate pharmacological treatment and provide a referral to a behavioral therapist. Whatever the initial approach, most patients will ultimately be treated as outpatients, with a combination of pharmacotherapy and behavioral therapy—often, with monitoring and oversight by a primary care physician. Which approach to pursue should be guided by evidence-based recommendations (TABLE)17,22-27 and jointly decided by physician and patient.
Treating opioid dependence: Key clinical recommendations
|Screen all patients for substance use, including opioids. Brief interventions and referral to treatment when appropriate may reduce opioid use17,22||Consistent findings from RCTs; evidence-based guideline (A)||SBIRT reduces self-reported opioid use; efforts to replicate such reports with objective evidence (eg, toxicology screens) are underway|
|Recommend maintenance medication (ie, buprenorphine, naltrexone, methadone) for all patients entering treatment for opioid dependence with physiological dependence; methadone is the safest for pregnant women23-25||Consistent findings from RCTs; evidence-based guideline (A)||Methadone is the gold standard for pregnant women; further studies are needed to determine the safety of in utero exposure to buprenorphine and naltrexone|
|Keep patients on maintenance medication for ≥3 months; higher relapse rates are noted when medication is discontinued in <3 months23,24||Consistent findings from RCTs (A)||Relapse rates are higher when maintenance medication is discontinued in <3 months|
|Caution patients with opioid dependence of the risk for accidental overdose and death with relapse and take action—eg, offering naloxone rescue kits to patients and families, as appropriate26||Consistent findings from RCTs and prospective cohort studies; evidence-based guideline (A)|
|Take steps to prevent diversion and accidental ingestion of agonist therapies, using tools such as frequent toxicology screens, random pill counts, and designated pharmacies, and monitoring adherence to psychosocial treatment26,27||Practice guideline (consensus) (C)|
|RCTs, randomized clinical trials; SBIRT, Screening, Brief Intervention, and Referral to Treatment; SOR, strength of recommendation.|