Case 1 – 17 yo white female 2 year history of using opioids – prescription post minor surgery, continued use post prescription (non-medical sources) – escalated over time, difficult to afford Attempting to stop; severe withdrawal symptoms led her to use again Approx. 3 months before starting treatment she started using heroin intranasally – prompted her to seek treatment Doing well on buprenorphine - stopped using opioids almost immediately; no significant side effects She was hesitant to engage in outpatient treatment but states she is involved in self- help Initially toxicologies were negative for all substances except buprenorphine and its metabolites. Recent toxicologies were positive for cannabis. When this is discussed with the patient she denies use. Thoughts at this point?

Thoughts? Case 1 – continued Repeat toxicology showed the same results. Now she admits to using cannabis for anxiety. She states that her use is not a problem and that she feels better using cannabis. She also states that the cannabis use is not why she entered treatment. Thoughts?

Case 1 – continued Discussion Points: OUD was motivating factor in seeking treatment – seems improved on MAT, no diversion OUD vs. other drug use – ambivalence towards other drug use, what’s impacting life Are there opportunities to engage the patient in conversation regarding the cannabis use? Are they really involved in any other recovery related activities? What other mental health treatments if any have been tried? Is the patient aware of the potential risks of other drug use in the setting of another SUD dx? How can the prescription of buprenorphine be continued safely in the face of a new clinical concern? Try to engage the patient in formal SUD and or MH tx. More frequent visits? Harm reduction mindset and documentation thereof. Patients OUD was the motivating factor that led her to seek treatment. Her OUD does appear to be improved on MAT. There does not appear to be any diversion Patients often have some level of ambivalence regarding other drug use. In reality the untreated OUD is often much more negatively impactful on their life than other drug use. Are there opportunities to engage the patient in conversation regarding the cannabis use? Are they really involved in any other recovery related activities? What other mental health treatments if any have been tried? Is the patient aware of the potential risks of other drug use in the setting of another SUD dx? How can the prescription of buprenorphine be continued safely in the face of a new clinical concern? Try to engage the patient in formal SUD and or MH tx. More frequent visits? Harm reduction mindset and documentation thereof.

Case 2 – 24 yo white female 3 year history of using opioids. Has had several unsuccessful treatment attempts including inpatient treatment. She is using about 4 or 5 bags of heroin intranasally a day Recently found out she was pregnant, now approximately 18 weeks. She has not had any prenatal care. This is her first pregnancy She is referred to treatment but she is unsure what to do. She is afraid her baby “will be taken” if anyone finds out she is using and is pregnant. Her mother has told her to “just stop”. Initial thoughts?

Discussion points What are the recommendations regarding MAT and pregnancy What can we say to a patient like this? Can the pregnancy motivate a change in behavior?

Case 2 continued After some discussion she agrees to start buprenorphine. Patient is induced with no issues and stops using opioids She is linked with prenatal care and is compliant throughout her pregnancy. She is compliant with all MAT appointments. She had been using cannabis sporadically but this stops as well. She has a healthy full term baby boy who has some symptoms consistent with NAS. CPS is called. She is not allowed to breastfeed.

Discussion points What is the role of CPS in the care of women with OUD? Are we obliged to call them? How does the affect a patient? Is breastfeeding appropriate for a patient on MAT? Can it be encouraged? What should we do about NAS?

Case 2 continued The baby is treated primarily non pharmacologically for mild NAS with emphasis on breast feeding and maternal contact. The CPS evaluation identifies no concerns in regards to the safety of the baby. She is released home. When the home care team goes out for a prenatal visit the baby’s father is in the home. They are not living together but she is considering letting him back in to the house. He appears to “nod off” at times during the visit. She admits he uses opioids. What should we do now?

Case 3- 25 yo AAF 3 year history of opioid use. Opioid use began with recreational prescription opioids and progressed over time. Started using heroin within one year. Initially started with nasal use and progressed to IV use within a few months; She is also using intranasal cocaine on a regular basis What does the natural history of OUD look like?

Case 3 continued The patient has had multiple treatment attempts including several detox admissions and 3 long term inpatient treatments. She has had periods of abstinence but never longer than a few months. She has currently been using approximately 1 gram of heroin daily for 1 year. She is currently homeless and working in the sex trade. She has a child but does not currently have custody. She presents to the emergency department with an acute opioid overdose. She is given several doses of Narran. She is discharged from the ED with a number for outpatient evaluation.

Discussion points How do we prioritize the needs of a patient like this? Is there a role for MAT? For abstinence based treatments? What is the role of harm reduction strategies and what exactly would those be? When the health care system has an interaction with a patient like this how does that look? Does bias play a role?

Case 3 continued The patient presents to the hospital a month later with weight loss, fevers and chills and SOB. She is diagnosed with acute endocarditis and admitted to the hospital for IV antibiotics. She is also diagnosed with Hepatitis C She begins having withdrawal symptoms within 24 hours of the admission. She begins to become somewhat aggressive and starts to threaten to leave AMA. Security is called to monitor the patient. Social work is call as well.

Discussion points How do we feel about a patient like this? What do we think about behavioral issues that might arise and how are they best managed? What is the best way to manage a patient like this long term? What are the complications of OUD?

Further discussion points What is the optimal duration of MAT? What is the best paradigm to think about SUD? Is it a disease? What does the optimal treatment look like? What are the complications of MAT?