Today’s post is my response to a brief case vignette of a psychiatry oral board exam patient. Today I address the drug abuse issues. I will leave the issue related to when and how to give an Axis II diagnosis for the follow up post. Let’s start.
Patient On Methadone Using Lorazepam
“Dear Jack, I want to share this ABPN II live patient case with you which I failed this year in June and will appreciate your feedback or comments. Here is the case very briefly:
“Patient was a 60+ hispanic male on methadone 60 mg/day for the last 25 years and was being f/u in the clinic to receive his medication. He also reported h/o heroin addiction since age 18 and still using ativan off the streets once in a while. Married for a short period of time and divorced and has 2 adult sons who he does not get along with. No h/o depression or any other psychiatric problems. He does not work but has a house which he shares with his son. Receives disability benefits. H/O diabetes only.
“I think I got nailed down on both psychotherapy and pharmacotherapy issues. They asked me if I would continue methadone or consider changes to his medication. I said…I would continue with the medication but later after the exam I realized that considering his age I should have considered non opioids such as naltrexone….Any thoughts on this?”
“They also asked me if I would consider anything on Axis II. I answered no…but later I realized may be I should have considered atleast borderline personality d/o considering key features in the history. Any thoughts on this?”
Issue 1: Start With An Adequate Assessment
The writer of this case states that he recommended that methadone be continued but has had second thoughts. My advice is that when presenting a case, consider whether the particular problem in your treatment plan that you are discussing first requires further assessment before any change in managment is made.
In relation to this patient’s heroin addiction and treatment with methadone, state first that you would assess for continued drug abuse. The patient already endorses use of lorazepam. The combination of a benzo and an opioid can be dangerous and in larger doses lead to respiratory suppression and death. So state that you would carefully assess the scope of the problem with the patient’s use of lorazepam.
Second, the abuse of one drug makes the abuse of others much more likely. So state that you would carefully assess for the possible use of other opioids, other drugs of abuse, and even of methadone itself. Your assessment should include a further interview of the patient, interview of collateral sources, and, of course, obtaining a secure urine drug screen.
As a review of the different drugs that can be screened for, here is a list.
The basic drug test is called a “Five-Screen” (or “NIDA-5” or “SAMHSA-5”) which tests for the following five categories of drugs:
1. Cannabinoids (Marijuana, Hashish)
2. Cocaine (Cocaine, Crack, Benzoylecognine)
3. Opiates (Heroin, Opium, Codeine, Morphine)
4. Amphetamines (Amphetamines, Methamphetamines)
5. Phencyclidine
However, you can also order a “Ten-Screen” which includes these five additional drugs (often for no additional cost):
6. Barbituates (Phenobarbital, Secobarbitol, Pentobarbital, Butalbital, Amobarbital)
7. Methaqualone (Qualuudes)
8. Benzodiazepines
9. Methadone
10. Propoxyphene (Darvon compounds)
In addition, you can include the following drugs too:
11. LSD
12. Hallucinogens (Psilocybin, Mescaline, MDMA, MDA, MDE)
13. Inhalents (Toluene, Xylene, Benzene)
14. Etoh as a blood test
In the above list note that methadone and propoxyphene are opioids that are screened for separately from the opiates listed in #3. (Note that opioids are opiate-like chemicals that are not derived from opium.)
Given this, we can discover whether this patient is using opiates such as heroin in addition to receiving his long-term treatment with methadone.
Issue #2: How to Treat
The writer questions whether he should have considered switch of the methadone to naltrexone. Naltrexone is certainly used in the treatment of heroin addiction although it is NOT FDA approved for such use. In order to use naltrexone effectively (and safely!) the recovering patient currently must be and must stay free of heroin and all other opiate-like drugs. Since naltrexone is a powerful opioid antagonist, its consumption will lead to immediate and dramatic opiate withdrawal if there is any opiate on board. This fact leads us back to Issue #1: we remain unsure whether the patient is actually free of opiate use. We would have to ascertain that first. And second, we would have to receive the patient’s assurance that he will remain free of opiates.
I believe that naltrexone would be a tough sell for this patient even if he is not using heroin. Naltrexone is a completely different treatment than is methadone. Methadone is an opioid agonist and provides some of the same pleasant sensations that use of any other opioid would in addition to preventing opiate withdrawal. Conversely, naltrexone is used when the patient is NOT on opioid replacement treatment, and is living free of all opioids. Naltrexone functions as a deterant to opioid and opiate use.
Given this patient’s 25 year history of methadone use, the much more amenable intervention would be treatment with buprenorphine. In short, buprenorphine is a mu-opioid partial agonist (as well as kappa-opioid antagonist). It can be used for long term replacement opioid treatment, giving enough agonist effect to stave off withdrawal, but enough antagonist effect that it is harder (although not impossible) to achieve a high.
Suboxone is a formulation of buprenorphine and naloxone combined and is the formulation usually prescribed in the outpatient setting. Naloxone is included so that if Suboxone is abused and injected IV or taken IM, the naloxone causes opioid antagonist effects, and thus precipitates opioid withdrawal.
If you have experience treating patient on long-term methadone, please share your insights with us regarding the challenges both you face as the clinician and that your patients face. Thanks much. Next time I’ll address Axis 2 diagnosis.
