By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
After about one week working in Vancouver's Downtown Eastside I have almost entirely run out of prescriptions on my duplicate and methadone prescribing pads. It is the real deal. I have quickly learned and begun to feel comfortable prescribing opioid agonist treatment for opioid use disorder, and the evidence backs up its effectiveness as a treatment strategy*. I have spent a lot of time getting familiar with the ins and outs of prescribing such medications as buprenorphine/naloxone, methadone, slow-release oral morphine, and injectable hydromorphone. As a family doctor in the general community, I see myself prescribing buprenorphine/naloxone and then methadone most frequently, currently the first and second line opioid agonist therapies at this instant in time. Things are changing rapidly in the world of addictions medicine however, and I wouldn't be surprised if the recommended approaches change by the time I graduate from my residency program.
There is so much I could get into about appropriate use of pharmacologic agents in the management of substance use disorders. Here I will briefly touch on the pharmacological agents I will need to be most familiar with prescribing for the most common substance use disorders: tobacco, alcohol, and opioid.
Pharmacological treatment for tobacco use disorder
Medication options for the treatment of tobacco use disorder include nicotine replacement therapy, varenicline, bupropion, nortriptyline, and clonidine. Choice of the specific agent will depend on how an individual wants to approach smoking cessation and their individual comorbidities and history of response to therapies if smoking cessation was previously attempted. The best resource I am aware of for managing and referring patients for information and resources for smoking cessation is Quit Now.
Pharmacological treatment for alcohol use disorder
Something I've seen become more and more commonly used to help patients with alcohol use disorder is gabapentin, typically prescribed as a medication for neuropathic pain. Increasing the dose gradually and as tolerated can significantly help some patients reduce their craving for alcohol and make a significant difference in their ability to recover from this disorder.
Pharmacological treatment for opioid use disorder
The first-line recommendation for treating opioid use disorder is treatment with buprenorphine/naloxone, recently stealing the lead from methadone. While methadone is an easier medication to start, buprenorphine/naloxone is better in pretty much every other way, not the least of which is its safety profile, with almost no potential for overdose. Buprenorphine is a partial opioid agonist, which means it partially acts on the opioid receptors to decrease withdrawal symptoms and reduce cravings, while providing less euphoria as well. It is taken sublingually, well absorbed this way, and contains naloxone, which is poorly absorbed this way. As such, the naloxone is simply there to act as a deterrent to abuse, because if buprenorphine/naloxone is instead injected, the naloxone is highly available and antagonises the agonist effect of buprenorphine or other opioids in the blood stream. Because of its safety profile, it means patients can also get this medication as "carries" to take home, unlike the highly restricted nature of methadone that requires that patient show significant prolonged stability on it before reducing the frequency at which they must have it given by daily witnessed ingestion at their pharmacy. (Methadone also just has a lot of negative things about it that buprenorphine does not, such as a significant number of drug interactions and increased risk of a heart arrhythmia.) Many patients end up selecting methadone over buprenorphine/naloxone despite the benefits of the latter because it requires patients to experience a not-insignificant degree of withdrawal symptoms on starting the medication for the first time (otherwise the partial agonist properties of buprenorphine competes with the full agonist profile of illicit opioids in the patient's bloodstream and causes a precipitated withdrawal). Common to the treatment of both treatments is the requirement for regular and random medication counts and urine drug testing, and the need to practice harm reduction education.
A point I want to mention in the practical application of substance use disorders is the need to adopt a flexible but firm approach, particularly when it comes to the prescribing of methadone and other opioid agonists. While there is a lot of evidence to support their benefit in treating opioid use disorder, they are not without significant risk. There are well published guidelines, such as the one by the British Columbia Centre on Substance Use called, "A Guideline for the Clinical Management of Opioid Use Disorder," and these recommend when to proceed and when to refrain from proceeding with advancing treatment, or withholding it all together. However, in a patient fraught with trauma and deep-rooted lack of trust toward people in positions of authority - much as the physician is in the setting of being a gatekeeper to opioid agonist therapy - it is important to be sensible and non-absolutist in your application of the therapy. Building and maintaining patient rapport is one of the most important relationship goals of any family physician, and this can be particularly challenging in the setting of patients with substance use disorder, who often start from a position of poor trust in relationships of care. Nevertheless, it is equally important to be cognizant of the harm that can be done with careless prescribing of these controlled substances (and many other non-controlled substances as well), and it is always important to "first do no harm." I learned just how challenging the application of treatments for substance use disorder is in reality compared to on paper guidelines when completing my elective with the Portland Hotel Society (PHS). In an evaluation form I did learn that I was able to demonstrate "Firm and caring boundaries" while also "Rapport building" and providing "Compassionate care." At the same time, these skills are always a work in progress, always require shifting where exactly you draw the line in the sand as the patient in front of you changes the frame of reference.
As I mature in my career, my hope is that with more experience I will become more and more equipped to feel confident about where in the sand the line ought be drawn to best balance the risk of doing harm and the potential for benefit for future patients. Recognising that past experiences influence my future decisions, I also hope that I can continue to be optimistic with every patient and continue to focus on building trust as a guiding principle in my approach to providing medical care. There are certainly times even during my 2 week PHS elective where I encountered particularly challenging cases that I felt seemed hopelessly refractory to medical care. Thanks to the UBC Faculty of Medicine Behavioural Medicine Curriculum and my own personal goals to develop my capacity for mindfulness when I feel strong emotional reactions, I think I was usually able to perceive when my own visceral reactions may have been impacting my judgment. My approach to this was to recognize my ability to do harm, and to make not doing this my first priority in these interactions. Providing good patient-centered care is not something that will realistically be able to occur before rapport is built, and in patients who have difficulty with trust based on previous experiences being unable to do so, this is ever important to keep in mind. When providing care to patients with a history of trauma in relationships of care, it is imperative to not further corrode their lack of trust in caregivers in order to help them heal from the outside and the inside.
*There are many differing views on how society ought to stand in relation to substance use. It is a subject that is fraught with complexities and that pinches nerves for a lot of people. But no matter what stance you adopt, the evidence is clear that harm reduction improves health and economic outcomes on the grand scale, and is, based on my own values, the humane way to approach substance use in our communities. If you aren't convinced, consider checking out this website that gives the lowdown of the harm reduction philosophy. It also touches on intimately related social, political, and judicial realities.