The patient is a 58-year-old woman with chronic pain due to inflammatory arthritis. She presents for her first appointment with you in a primary care office. She states that she is aware that she is asking for an early refill of her Oxycontin however she is traveling out of state, and she is concerned that she may have a flare up on her trip.
· Apply the steps in SBIRT to this scenario:
Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based method that detects individuals that may be abusing alcohol or drugs. SBIRT was developed to prevent or decrease health-related injuries, disease, accidents, or negative outcomes (SAMHSA, 2020).
Screening: A pre-screening questionnaire would be provided to this individual to determine how often they use recreational/prescription drugs and/or alcohol. In this case, the individual is using a prescription drug. Once this is determined, they will be provided a Drug Abuse Screening Test (DAST) that asks specific questions in relation to use of the drug being used (UKMC/SBIRT, n.d.) or they can be provided. The score tallied from the DAST questionnaire will determine the individual’s level of risk. If the score is O, they’re considered a level 1/low risk. In level 1, the provider would encourage positive preferences and inform the individual concerning the risks of drug use. If the score is 1 or 2, they’re consider level 2/risky. In level 2, the provider will discuss brief intervention to refrain or decrease the use of drugs. If the score of the DAST questionnaire was 3-5, they’re considered a level 3/harmful. In this instance the individual will be given a brief intervention to decrease use along with a follow-up appointment. If the score is 6-10, they’re considered level 4/severe. In this case, the individual will be asked to accept referral for specialty treatment UKMC/SBIRT, n.d.).
Brief Intervention: Depending on the severity of determined addiction, brief intervention will consist of patient-centered conversation that uses motivational interviewing ideas, which helps to raise awareness of the individuals drug use and stimulate them to alter their behaviors (UKMC/SBIRT, n.d.). Brief intervention should last approximately 5-15 minutes on the same day of the first screening. It will be recommended the individual changes their behavior to abstain or decrease their use of the drug, then continued follow-up will be necessary (UKMC/SBIRT, n.d.). Individuals with more serious concerns from their abuse of drugs or those who refuse specialized treatment, will have more intense interventions with follow-up. Severe cases the focus is to inspire the individual to accept a referral for specialized treatment (UKMC/SBIRT, n.d.).
Referral to Treatment: Individuals identified as needing specialized substance abuse treatment.
· Identify additional questions for this patient:
It would be important to make the individual feel as comfortable as possible. This can be an embarrassing subject for the person being questioned. The provider must convey that they will not be reporting their answers to law enforcement and that the information they provide will be kept confidential. The provider must be careful of how questions are worded and not to come across as judgmental. Showing the individual respect by asking permission is an important method of communication. The individual will likely want to know why they are being asked questions and the provider should be open and honest, while showing concern toward their situation. The individual must know that answering your questions is an option. I would want to ask this individual how long they have been taking opioids, how often are they taking it, who prescribed them the medication, and whether anything else has helped their chronic pain. I would also want to know about any other stressors or concerns they may be having in their life, and whether they have a support system. This would be to assess other concerns that may be lending itself to their addiction (McBride, 2010).
· Develop a treatment plan for this patient:
This individual may benefit from buprenorphine, an opiod partial agonist, as part of a medication assisted treatment (MAT) (SAMHSA, 2021). This can only be prescribed from a provider with a DEA license, and specific training. In conjunction with buprenorphine, the individual should receive counseling and behavioral therapy. They must be monitored closely throughout treatment (SAMHSA, 2021).
The patient is a 24-year-old man brought to your clinic by his family for an evaluation. The patient states that he is struggling with prescription pain pills and wants help. He appears to be in opioid withdrawal; he describes anorexia and diarrhea, he is yawning and sweating upon examination. He scores 15 on the Clinical Opioid Withdrawal Scale (COWS), indicating moderate withdrawal.
· Initiate office-based buprenorphine/naloxone (Suboxone) with a plan for observation.
It is recommended that Suboxone be provided 12-14 hours after the last dose of an opioid to manage withdrawals symptoms. The dose should be strong enough to suppress symptoms. This is usually anywhere from 4-16 mg per day, 2-4 mg to start, and increase in 2-4mg increments. The dose will slowly be tapered over as little as 3-5 days, or 30 days or more (ASAM, 2015). The patient will be observed in the office after the initial induction of Suboxone. Individual may need behavioral therapy along with referral to suboxone treatment center, if warranted
· Include your rationale for each treatment decision
Suboxone has been tried and true, and providers with a DEA license and special training are able to prescribe this medication safely (ASAM, 2015). If a drug like Methadone is prescribed, it requires closer monitoring due to common misuse.
· Develop a treatment plan for this patient that includes ongoing MAT and psychosocial treatment interventions.
Psychosocial treatment is necessary when combined with MAT, there should be frequent office visits, and frequent blood monitoring to test for drugs (ASAM, 2015).
· Construct a safe taper schedule for a patient taking alprazolam (Xanax) 2mg TID. Include a brief narrative explaining the evidence for tapering a patient who has been on a benzodiazepine for an extended amount of time.
It takes approximately 8 weeks to wean from Xanax. The dose is typically decreased by 25% every quarter of the determined withdrawal period. In this given case, the dose of Xanax would decrease to 4.5mg in two weeks, then decrease to 3mg for two weeks, then 0.75mg for two weeks, so forth (AAC, 2021).