NUR 7642 Module 3 Opioid Use Disorder Case: Buprenorphine Start, Overdose Risk and Retention in Treatment Example

Revived With Naloxone on a Job Site: Starting Buprenorphine for a 33-Year-Old Roofer After a Fentanyl Overdose

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7642: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Adult Population, Part B

Mentor Name

Month Day, Year

Revived With Naloxone on a Job Site: Starting Buprenorphine for a 33-Year-Old Roofer After a Fentanyl Overdose

The Overdose

Jason, an invented patient, is 33 and works on a roofing crew in Elizabeth. At 25 he injured his back in a fall and was prescribed oxycodone for months. Once the prescriptions ended he found pills through a coworker's cousin, and within a year heroin had replaced them because it cost less. For the past two years what he buys has mostly been fentanyl. He uses four to six times a day, sniffing rather than injecting, to avoid withdrawal and get through work. Last week a coworker found him unresponsive in a truck and sprayed naloxone twice and kept him breathing until paramedics took over.

In the emergency department he is in early withdrawal: yawning, sweating, with dilated pupils, runny nose, stomach cramps and gooseflesh. He says he is tired of living this way and wants to stop, but he has tried twice before and failed within days because the withdrawal was unbearable. He has no other drug use except cannabis and no history of psychiatric illness. He lives with his girlfriend and their two-year-old son. His hepatitis C antibody test is positive.

His girlfriend arrives and is frightened and angry. She has found him using twice before and says she cannot keep living this way with a toddler in the house. The paper records that she is invited into the plan with his consent: she is trained in naloxone, told what buprenorphine does and does not do, and handed the details of a group for families of people in recovery. Her safety and the child's are part of the case, and the plan does not ask her to supervise his recovery.

The Diagnosis

Jason meets the criteria at the severe level: he takes more than he means to, has tried and failed to stop, spends much of his day getting and using opioids, craves them, has kept using despite the danger to his job and family, uses in physically hazardous situations on roofs and has tolerance and withdrawal. A clinical opiate withdrawal scale score of 14 confirms moderate withdrawal, which matters for starting buprenorphine safely.

Starting in the Emergency Department

D'Onofrio et al. (2015) randomly assigned 329 opioid-dependent patients in an urban emergency department to referral to treatment, a brief motivational interview with referral, or a brief interview with buprenorphine started in the department and continued in primary care. At 30 days, 78 percent of the buprenorphine group were engaged in addiction treatment compared with 37 percent of the referral group and 45 percent of the brief interview group. The buprenorphine group also cut their days of illicit opioid use from 5.4 a week to 0.9, a larger drop than the other groups.

Because Jason is already in moderate withdrawal, buprenorphine with naloxone is given in the department. A first dose is followed by a second an hour later when his withdrawal eases but does not disappear. He leaves with a bridge prescription to his clinic appointment three days later, a naloxone kit and his girlfriend trained in its use.

Finding the Right Dose

Mattick et al. (2014) reviewed 31 randomized trials with 5,430 participants comparing buprenorphine with placebo or methadone. Retention beat placebo at every buprenorphine dose studied, and at high doses of 16 mg or more it also reduced illicit opioid use measured by urine tests. Compared with flexibly dosed methadone, buprenorphine held on to slightly fewer patients, though both cut opioid use about equally.

At his clinic visit, Jason still has afternoon cravings at 16 mg a day. Because fentanyl's potency can leave people underdosed at older standard amounts, his dose is raised to 24 mg, and his cravings ease. Urine tests are used to guide care and are not a reason to discharge him. Methadone in an opioid treatment program is discussed as an option if buprenorphine does not hold.

Because he works on roofs, the question of whether buprenorphine affects his safety at height is raised directly. Once his dose is stable, buprenorphine does not usually impair coordination or alertness in people who are tolerant to opioids, and active fentanyl use is far more dangerous on a roof than a steady dose of medicine. He is told not to work at height during the first days of dose changes and to report any drowsiness. With Jason's permission, his foreman learns just that he has weekly medical appointments.

Why Medicine Saves Lives

Larochelle et al. (2018) linked seven state agency data sets covering 17,568 overdose survivors in Massachusetts from 2012 through 2014. Over the next twelve months, most received no medicine at all; roughly one in nine started methadone, one in six buprenorphine and one in seventeen naltrexone. Compared with no medicine, methadone was linked with a 47 percent lower rate of death from any cause and buprenorphine with a 37 percent lower rate, while naltrexone showed no clear link. The study was observational, which the paper notes, but its size and the consistency with trials make it a strong reason not to treat withdrawal alone.

For Jason, this is explained simply: staying on buprenorphine lowers his chance of dying in the next year, and stopping it, especially in the first months, raises it again.

Beyond the Prescription

His hepatitis C is referred for treatment, which now cures most people in two to three months. He is offered counseling but told that medicine is not conditional on attending it. His back pain is addressed with physical therapy and anti-inflammatory medicine. He is advised never to use alone, to keep naloxone in the truck and at home, and to use fentanyl test strips if he does use. A note for work, with his consent, covers his clinic visits. He is seen weekly through the first month and fortnightly after that.

Conclusion

Jason has severe opioid use disorder after an overdose, at the start of the year when his risk of death is highest. Buprenorphine, started in the emergency department as a trial showed raises engagement, is dosed to 24 mg to control cravings with fentanyl in the supply. A review of 31 trials supports buprenorphine for keeping people in care, and a large cohort of overdose survivors shows lower death rates with medicine. Naloxone, hepatitis C treatment, pain care and harm reduction surround the prescription, and retention in treatment is the measure that matters most.

References

D'Onofrio, G., O'Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., Bernstein, S. L., & Fiellin, D. A. (2015). Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA, 313(16), 1636-1644. https://doi.org/10.1001/jama.2015.3474

Larochelle, M. R., Bernson, D., Land, T., Stopka, T. J., Wang, N., Xuan, Z., Bagley, S. M., Liebschutz, J. M., & Walley, A. Y. (2018). Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Annals of Internal Medicine, 169(3), 137-145. https://doi.org/10.7326/M17-3107

Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, (2), Article CD002207. https://doi.org/10.1002/14651858.CD002207.pub4