Use of a primary care and pharmacy-based model for the delivery of injectable opioid agonist treatment for severe opioid use disorder: a case report.

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Date: Feb. 3, 2020
Publisher: CMA Impact Inc.
Document Type: Article
Length: 1,977 words
Lexile Measure: 1870L

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A 48-year-old man presented to his primary care clinic, requesting treatment for severe opioid use disorder (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). He reported using intravenous (IV) heroin for the past 20 years and was currently injecting one-quarter of a gram daily. His lifetime overdose history was unknown, but the patient reported 9 overdoses in the few months preceding presentation to the clinic. The patient also reported injecting crystal methamphetamine with heroin twice per week for the past 8 years. He had active nicotine use disorder and an alcohol use disorder in sustained remission. The patient's medical history included posttraumatic stress disorder from childhood trauma, and depression. His daily medications included venlafaxine 75 mg, mirtazapine 15 mg and prazosin 3 mg (with which he was intermittently compliant). He had no allergies, was homeless and relied on criminal activities to support his addiction. He had used methadone twice (maximum daily dose of 110 mg, maximum duration 6 years) as well as buprenorphine-naloxone (maximum daily dose of 16 mg, 3 months' duration) and slowrelease oral morphine (maximum daily dose of 140 mg, 2 months' duration). The patient had also previously been offered counselling but did not engage with this.

On physical examination, the patient was seated comfortably in the outpatient clinic and was alert, with no overt signs of intoxication or withdrawal. Investigations showed a normal complete blood count and renal and liver profile. A urine drug test completed 6 weeks previously was positive for fentanyl, opiates and amphetamines.

Given the patient's previous unsuccessful attempts with oral pharmacotherapy and high overdose risk, injectable opioid agonist therapy with hydromorphone was started. The patient's primary care physician (who has experience in addiction medicine) prescribed induction, which was completed in clinic (under nursing supervision), with subsequent transition to a community pharmacy for ongoing witnessed administration. For details of the induction protocol, see Box 1. After day 4, the patient's dose was titrated by 10 mg IV daily to control cravings and withdrawal.

Subsequently, he was transitioned to injectable opioid agonist therapy at a designated community pharmacy, where a pharmacist completed a pre- and post-dose assessment, and witnessed administration. However, the patient continued to engage with his primary care clinic for regular assessments, education on harm reduction and ongoing primary care needs. Stabilization occurred about 1 month after induction on hydromorphone 210 mg IV twice daily and 300 mg slow-release oral morphine in the evening. After stabilization, the patient reported that he had no illicit opioid use. Urine drug tests, although consistently positive for crystal methamphetamine, were negative for fentanyl (and all other substances) 2 weeks after induction of injectable opioid agonist therapy, and for 6 months thereafter. The patient also adhered to his antidepressant medications, reported improved mental health, ceased survival crime, transitioned into stable housing and started working in a low-barrier employment program.

Three months after induction, the patient decided (without medical support) to discontinue his second dose of IV hydromorphone...

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Gale Document Number: GALE|A613049224