Suboxone and the Emergency Physician: Get Waivered Training

suboxone

Clinical scenario: A 56-year-old male with a past medical history of opioid use disorder presents to the emergency department with acute on chronic right lower flank pain. The patient states the pain was exacerbated while shoveling snow over the weekend and worsens with movement. He feels nauseous but denies any chest pain, shortness of breath, vomiting, abdominal pain, or pain with urination. He denies any history of kidney stones, recent surgeries, and recent injuries. He does not smoke cigarettes, but does drink alcohol almost daily.

His pain actually first started 2 months ago due to a work incident, for which he was prescribed a 1-month supply of hydrocodone for the pain. Although his severe pain reduced in intensity over the first 3 days, he states that he was unable to resist his urge for the painkillers and finished the supply over the next month. The patient was seen in another emergency department one week ago.

On physical exam, the patient seems restless and anxious appearing, but is alert and oriented x 3. His pupils are dilated and reactive to light. His skin is warm and flushed. The patient is tender in the right lower flank region and grimaces upon palpation. The remainder of his exam and vital signs are normal, except for being slightly tachycardic.

Diagnostic testing revealed a normal complete blood count, comprehensive metabolic panel, and non-contrast abdomen/pelvis CT study. His urine toxicology report shows the presence of hydrocodone.

A Tale of 2 Possibilities in Management

Let us assume for a moment that 2 different providers are treating this patient.

  • Physician A treats the patient’s flank pain and nausea in the emergency department, while monitoring him for several hours. Afterwards, the patient is discharged home and instructed to follow up with his primary care physician. After a few days, however, the patient returns with similar symptoms and again with normal lab results and imaging studies.
  • Physician B treats the patient’s flank pain while also recognizing the patient’s opioid dependence by starting the patient on a suboxone treatment plan along with behavioral therapies to curb symptoms of withdrawal and cravings [1]. After a few days, his primary care physician notes that the patient drastically has reduced his dependence on opioids and was on the road to recovery.

Physician B’s approach illustrates the need for physicians to recognize themselves as opioid use disorder (OUD) providers. Part of this role involves understanding and recommending suboxone treatment plans to aid patients in their recovery from opioid addiction.

What is suboxone and why is it important?

Suboxone is a prescription medication that is used to treat opioid addiction in individuals and is composed of buprenorphine and naloxone. Buprenorphine is a drug that blocks opioid receptors and reduces a person’s urges by acting as a partial opioid agonist, while naloxone reverses opioid overdoses. Both components work in conjunction to prevent withdrawal symptoms and thereby helping individuals on the road to recovery. The treatment plan using suboxone is supplemented with a behavioral counseling program to help individuals affected by opioid addiction by targeting the underlying reason for their opioid use and discovering new coping mechanisms [1].

Get X-Waivered to Prescribe Buprenorphine

Based on the Drug Addiction Treatment Act of 2000 (DATA 2000), the DEA-X waiver is a federal regulation that requires physicians to complete training followed by an administrative process in order to have the legal authority to prescribe buprenorphine [2]. Although the research that shows that buprenorphine is effective, only 5% of physicians nationwide are waivered, which limits access to life-saving medications and treatment for patients struggling with opioid addiction [3]. In a 2018 study, researchers demonstrated that 30% of rural Americans are without a buprenorphine provider, compared to the 2% of non-rural Americans [4]. Along with geographical disparities, other health disparities also exist. According to a study published by The Substance Abuse and Mental Health Services Administration (SAMHSA), among minority communities, African American and Latinx populations continue to have significantly lower access to substance-use treatment services [5]. In the wake of the COVID-19 pandemic, it has become increasingly urgent to find innovative ways to help healthcare providers obtain their X-waiver.

2021 Policy Changes

New policy changes under the Biden administration have allowed for expansion of buprenorphine treatment programs for patients with opioid use disorder [6]. As of April 2021, clinicians are now able to complete an exemption form to opt-out of the 8-hour training requirement to obtain the X waiver [2, 6]. Instead, clinicians can now submit a notice of intent form among other documents to SAMHSA that allows clinicians to treat up to 30 patients. When caring for more than 30 patients, X-waiver training is required [2]. Although this a promising start, emergency physicians should continue plans to obtain a DEA-X waiver in order to obtain more formal education, to adjust to any future policy changes, and to treat more than 30 patients. The Get Waivered program offers FREE training courses for healthcare providers to obtain a DEA-X waiver remotely.

Challenges for the Emergency Physician in Managing Opioid Use Disorder

In an emergency department, physicians are often met with several challenges when treating patients with opioid use disorder. These challenges include, but not limited to [7]:

  1. Absent Social Norms (Lack of norms around treating OUD may decrease motivation to obtain the waiver)
  2. Increased Hassle Bias (Irrelevant details make task of completing waiver process more difficult and challenging)
  3. Lack of Salience (Are there any success stories associated with treating patients with OUD with buprenorphine?)

Nudging Physician Behavior

Patients affected by opioid addiction can also be helped by making key changes to physician behaviors. As an example, behavioral researchers at the Nudge Unit at Massachusetts General Hospital recommend using principles of social norming and increasing salience in order to increase the number of physicians that can prescribe buprenorphine [8]. Below are examples that can have lasting effects on how clinicians perceive and approach the opioid epidemic moving forward.

  1. Implement a Get Waivered month at their clinical setting. This establishes a social norm and increases the possibility of more providers obtaining an X-waiver.
  2. Create presentations about the Get Waivered program with detailed instruction on the steps involved in obtaining an X-waiver to minimize hassle bias.
  3. Recruit patients with opioid use disorder to discuss their stories of recovery using buprenorphine during a training session to improve salience [7].

What’s next?

Please register for upcoming FREE training sessions at getwaivered.com/remote to obtain your DEA X-waiver.

RegionDateTime
Get Waivered Southeast10/21/202212 PM EST
Get Waivered Northwest11/18/202212 PM EST

Note: The above dates/times are tentative and may be subject to change in the near future.

References

  1. Suboxone.” Addiction Center, 20 Nov. 2020. Accessed May 26, 2022.
  2. Buprenorphine.” SAMHSA. Accessed May 26, 2022.
  3. Berk, Justin. To Help Providers Fight The Opioid Epidemic, ‘X The X Waiver’: Health Affairs Blog. Health Affairs, 5 Mar. 2019. Accessed May 26, 2022.
  4. Andrilla C, Holly A, et al. Geographic Distribution of Providers With a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5‐Year Update. Wiley Online Library, John Wiley & Sons, Ltd, 20 June 2018. Accessed May 26, 2022.
  5. Double Jeopardy: COVID-19 and Behavioral Health Disparities for Black and Latino Communities in the U.S. (Submitted by OBHE) (samhsa.gov). PDF file. Accessed May 26, 2022.
  6. Cornish A. Why new guidelines for opioid treatment are a ‘big deal’. NPR. Published April 27, 2021. Accessed May 26, 2022.
  7. Bruno M and GetWaivered. “Implementation Archives.” Get Waivered.. Accessed May 26, 2022.
  8. Nakagawa J. Nudging ER Doctors To Prevent Opioid Overdoses. Cognoscenti, WBUR, 30 Jan. 2018. Accessed May 26, 2022.
By |2022-08-07T21:56:02-07:00Aug 12, 2022|Public Policy, Tox & Medications|

EM Pharm Pearls: Estimated rise in blood glucose concentration with dextrose administration

A common question is how much should we expect the blood glucose concentration to increase after dextrose 50% (D50) administration. Fortunately, there is an answer from 3 studies.

  1. Balentine JR, Gaeta TJ, Kessler D, Bagiella E, Lee T. Effect of 50 milliliters of 50% dextrose in water administration on the blood sugar of euglycemic volunteers. Acad Emerg Med. 1998;5(7):691-694. doi:10.1111/j.1553-2712.1998.tb02487.x PMID 9678393
    • Population: Healthy volunteers in the ED
    • Intervention: 25 gm (1 ampule of D50)
    • Result: Mean increase of 162 mg/dL at 5 min. Glucose concentrations returned to baseline by 30 minutes.
  1. Murthy MS, Duby JJ, Parker PL, Durbin-Johnson BP, Roach DM, Louie EL. Blood glucose response to rescue dextrose in hypoglycemic, critically ill patients receiving an insulin infusion. Ann Pharmacother. 2015;49(8):892-896. doi:10.1177/1060028015585574. PMID 25986006
    • Population: Critically ill patients experiencing hypoglycemia while on insulin infusions
    • Intervention: D50
    • Result: Median increase of 4 mg/dL per gm of D50 administered
  1. Adler PM. Serum glucose changes after administration of 50% dextrose solution: pre- and in-hospital calculationsAm J Emerg Med. 1986;4(6):504-506. doi:10.1016/S0735-6757(86)80004-3. PMID 3778594
    • Population: ED patients with altered mental status (23 with diabetes, 28 without diabetes)
    • Intervention: 25 gm (50 mL of D50)
    • Result: Mean increase of 166 mg/dL

Take Home Points

  • Glucose concentrations increase 4-6 mg/dL per gm of dextrose administered
    • 50 mL of D50 = 25 gm = expected 100-150 mg/dL glucose rise
  • D50 rescue glucose is short-lived (30 minutes)
  • If the blood glucose does not respond as anticipated, investigate further (e.g., IV decannulation)

 


Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

Interpretation and Limitations of Opiate Urine Drug Tests

Background

Urine drug tests are commonly sent for patients in the emergency department, however care should be taken when interpreting the results of these tests given their limitations. The American College of Medical Toxicology published a position statement on the interpretation of urine opiate and opioid tests [1]. In this publication, they outline many of the limitations of opioid urine drug tests and explain why they exist.

Evidence

  • Though often used interchangeably, the terms opiate and opioid are not the same. ‘Opioid’ is the broad category name while ‘opiate’ simply refers to the naturally occurring opioids. The term ‘opioid’ encompasses opiates (e.g., morphine, codeine, opium), semi-synthetic agents (eg, heroin, hydrocodone, hydromorphone, oxycodone), and synthetic agents (eg, methadone, fentanyl, tramadol). Notice the name of the urine drug test next time you order one, it is likely specific for opiates (not opioids). This is because many tests are designed to identify morphine, though they will also detect codeine and heroin as they are both ultimately metabolized to morphine.
  • The standard urine drug tests do not specifically look for oxycodone, hydrocodone, etc. However, they can trigger a positive result due to their structural similarities, but not in every case. Therefore, a negative result doesn’t rule out use of these common drugs.
  • Similarly, synthetic opioids will not reliably cross-react with the opiate urine drug test as they are quite structurally dissimilar. In order to detect some of these agents, a test specific for the compound in question should be used.
  • As there are numerous different manufacturers of urine drug tests, hospitals may not utilize the same tests. In order to further understand the methods and cross-reactivity of a hospital’s specific urine drug test, the hospital’s laboratory should be contacted to request the package insert. Below is an example of the cross reactivity between various opioids with a opiate urine drug test [2].
Cross-reactivity of Various Opioids with Morphine Urine Drug Test [2]
CompoundEquivalent to 300 ng/mL Morphine (ng/mL)Cross-reactivity (%)
Codeine224134
Heroin36682
Hydrocodone1,08628
Hydromorphone1,42521
Oxycodone>75,000<0.4
Meperidine>100,000<0.3

 

Previous ALiEM posts discuss further limitations of urine drug tests, specifically for benzodiazepines and opiates.

Bottom Line

  • The term ‘opioid’ is the broad class of substances, while ‘opiate’ refers to the naturally occurring opioids (e.g., morphine, codeine)
  • Many urine drug tests are designed to identify morphine and will also detect codeine and heroin, as they are ultimately metabolized to morphine
  • Due to structural similarity, some semi-synthetic opioids may cross-react but fully synthetic opioids are unlikely to cross-react

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

  1. Stolbach A, Connors N, Nelson L, Kulig K. Acmt position statement: interpretation of urine opiate and opioid tests. J Med Toxicol. 2022;18(2):176-179. doi: 10.1007/s13181-021-00864-1. PMID: 34780053.
  2. Opiates II [package insert]. Indianapolis, IN: Roche Diagnostics; 2006.

Should Diphenhydramine be included in an Acute Agitation Regimen?

Background

Acute agitation in the emergency department is a common issue that frequently requires the use of chemical sedation to preserve safety for patients and healthcare workers. A commonly employed treatment regimen is the combination of haloperidol 5 mg + lorazepam 2 mg + diphenhydramine 50 mg (B-52). Diphenhydramine is included in this treatment regimen primarily to prevent extrapyramidal symptoms [1,2]. However, the incidence of extrapyramidal symptoms (EPS) with haloperidol is quite low when treating agitation in the emergency department (ED) [3,4]. Therefore, the excessive and prolonged sedation from adding prophylactic diphenhydramine may outweigh the intended benefit and should be reserved for treatment of EPS if symptoms occur.

Evidence

Jeffers et al. conducted a multicenter, retrospective, cohort study which compared the efficacy and safety of haloperidol, lorazepam, and diphenhydramine (B-52) (n=200) vs. haloperidol and lorazepam (52) (n=200) in treating patients >18 years old with acute agitation in the ED [5]. Their primary outcome was the administration of additional agitation medication(s) within 2 hours.

Outcomes52 (n=200)B52 (n=200)p-Value
Administration of additional sedative within 2 h, n (%)40 (20)28 (14)0.11
Median ED LOS (hours)13.8170.03
Use of restraints, n (%)53 (26.5)86 (43)0.001
Hypotension, n (%)7 (3.5)32 (16)<0.001
Administration of anticholinergic within 2 days, n (%)15 (7.5%)6 (3%)0.04
    Itching/allergies, n (%)1 (0.5)1 (0.5)1.00
    Home benztropine, n (%)2 (1)4 (2)0.41
    Insomnia, n (%)4 (2)0 (0)0.06
    Unknown, n (%)8 (4)1 (0.5)0.02

 

Overall, the B-52 combination resulted in more oxygen desaturation, hypotension, physical restraint use, and longer length of stay. However, the conclusions from this study may be limited as it was a relatively small study and  it used surrogate markers to assess clinical endpoints.

Further discussion regarding the onset and duration of IM medications for acute agitation may be found in this blog post.

Bottom Line

  • The risk of extrapyramidal symptoms following haloperidol for agitation in the ED is relatively low
  • Diphenhydramine may not be necessary when using haloperidol + lorazepam to treat agitation in the ED
  • ED length of stay is increased with the addition of diphenhydramine to haloperidol + lorazepam

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

  1. Mokhtari A, Yip O, Alain J, Berthelot S. Prophylactic administration of diphenhydramine to reduce neuroleptic side effects in the acute care setting: a systematic review and meta-analysis. J Emerg Med. 2021 Feb;60(2):165–74. doi: 10.1016/j.jemermed.2020.09.031. PMID: 33131965.
  2. Vinson DR, Drotts DL. Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial. Ann Emerg Med. 2001 Feb;37(2):125–31. doi: 10.1067/mem.2001.113032. PMID: 11174228. 
  3. Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, et al. Intramuscular midazolam, olanzapine, ziprasidone, or haloperidol for treating acute agitation in the emergency department. Ann Emerg Med. 2018 Oct;72(4):374–85. doi: 10.1016/j.annemergmed.2018.04.027. PMID: 29885904.
  4. Schneider A, Mullinax S, Hall N, Acheson A, Oliveto AH, Wilson MP. Intramuscular medication for treatment of agitation in the emergency department: A systematic review of controlled trials. Am J Emerg Med. 2021 Aug;46:193–9. doi: 10.1016/j.ajem.2020.07.013. PMID: 33071100.
  5. Jeffers T, Darling B, Edwards C, Vadiei N. Efficacy of combination haloperidol, lorazepam, and diphenhydramine vs. Combination haloperidol and lorazepam in the treatment of acute agitation: a multicenter retrospective cohort study. J Emerg Med. 2022 Mar 11;S0736-4679(22)00057-9. doi: 10.1016/j.jemermed.2022.01.009. PMID: 35287982.

ACMT Toxicology Visual Pearl: Hypertension and Rash

mercury poisoning toxicity

Which toxic exposure can present with the pictured rash along with hypertension and tachycardia mimicking pheochromocytoma?

  1. Arsenic
  2. Lead
  3. Mercury
  4. Silver
  5. Thallium

(more…)

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