Dialogue Volume 13 Issue 4 2017 - Page 53

PRACTICE PARTNER R ates of overdose and addiction are increasing rapidly in Ontario. Buprenorphine, a medication used to treat opioid use disorder, is an important tool for combatting this crisis. Physicians working in ED, hospital, and primary care settings are encouraged to know how to prescribe buprenorphine. Buprenorphine is a sublingual partial opioid agonist with a slow onset and long duration of action. In the appropriate dose, it relieves cravings and withdrawal symptoms for 24 hours without causing sedation or euphoria. It is combined in a 4:1 ratio with naloxone as an abuse deterrent. Buprenorphine is far more effec- tive than abstinence-based treatment at retaining pa- tients in treatment, reducing opioid use and prevent- ing overdose and other harms of illicit opioid use (1) . Buprenorphine has a ceiling effect and therefore has a much lower risk of overdose than other potent opioids such as morphine, oxycodone or hydromorphone (2, 3) . Unlike methadone, the CPSO does not audit bu- prenorphine prescribing. This reflects the vastly differ- ent safety profiles of methadone and buprenorphine. The CPSO recommends that physicians have an appropriate level of knowledge when prescribing bu- prenorphine, as they should with any medication. The CPSO also recommends physicians be familiar with the expectations articulated in its Prescribing Drugs policy. Buprenorphine in the ED and Hospital CASE: A 35-year-old man has an overdose after injecting heroin laced with fentanyl; he is resuscitated in the ED. On discharge, he states he needs something for withdrawal or he will start using again. The ED doctor calls the psychia- trist on call, who recommends transfer to the withdrawal management service. The patient refuses. A month later, he dies of an overdose. Patients in the ED or hospital with an opioid-related problem, such as overdose or sepsis, should be offe red a buprenorphine prescription prior to discharge (4) . Without this intervention, they are at high risk of relapse; those who have been abstinent while in hospital are at especially high risk for acciden- tal overdose due to loss of tolerance. The prescription should last for at least 3–5 days, or long enough for the patient to be seen in an addiction medicine clinic that provides urgent assessment and treatment. Patients should also be advised to get a naloxone kit for overdose prevention, which can be obtained without a prescrip- tion and free of charge at most Ontario pharmacies. Buprenorphine in Primary Care CASE: You have been prescribing oxycocet 10/day to a 40-year-old woman with fibromyalgia. She has requested early refills of her prescription several times in the last year. Her husband tells you she is buying medications from the street, and her health is deteriorating; she is depressed and unwell. When you confront her, she states she has to buy from the street because the oxycocet no longer con- trols her pain. Family physicians are encouraged to become comfort- able with prescribing buprenorphine. There are not enough addiction specialists in Ontario to provide opioid substitution treatment to all who would benefit from it, and smaller communities often lack special- ized methadone clinics. While the drug itself is safe and easy to prescribe, it is recommended that family physicians take an online course or workshop (see resources at end of article) in order to become familiar with the components of opioid agonist treatment (eg, take-home doses, regular urine drug screens). Diagnosing Opioid Use Disorder in a Pain Patient It can be very challenging to discern the features of an opioid use disorder in patients who also have chronic pain. Opioids have both analgesic and psychoactive effects. Tolerance to the analgesic effects develops slowly, and patients without an opioid use disorder can often remain on the same low to moderate dose  rivastava A, Kahan M, Nader M. Primary care management of opioid use disorders: Abstinence, methadone, or buprenorphine-naloxone? Canadian family S physician Medecin de famille canadien. 2017;63:200-5. 2. Kahan M, Srivastava A, Ordean A, Cirone S. Buprenorphine: new treatment of opioid addiction in primary care. Canadian family physician Medecin de famille canadien. 2011;57(3):281-9. 3. Ducharme S, Fraser R, Gill K. Update on the clinical use of buprenorphine in opioid-related disorders. Canadian family physician Medecin de famille cana- dien. 2012;58(1):37-41. 4. D'Onofrio G, O'Connor PG, Pantalon MV, Chawarski M, Busch SH, Owens PH, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. Jama. 2015;313(16):1636-44. 1. ISSUE 4, 2017 DIALOGUE 53