Primary care for people who use drugs

Primary care for people who use drugs

OPIOID USE DISORDER IN SPECIAL POPULATIONS Daniel Warren, MD Assistant Professor, Department of Family and Community Medicine University of Kansas School of Medicine-Wichita DISCLOSURE Medical director, Wichita Treatment Center (methadone clinic)

Buprenorphine clinic prescriber, HealthCore Clinic (federally-qualified health center) Board member, Substance Abuse Center of Kansas OBJECTIVE 1. Describe the commonalities and differences of treating opioid use disorder (OUD) in special populations such as those who are

pregnant, hospitalized, or in chronic pain SPECIAL POPULATIONS IN OUD TREATMENT Living with chronic pain Living with serious mental illness

Hospitalized Living with HIV Pregnant and newly delivered Unstably housed Healthcare

professionals Older adults Adolescents Criminal justice involvement Awaiting transplant SPECIAL POPULATIONS IN OUD TREATMENTSOCIAL FACTORS

Living with chronic pain Living with serious mental illness Hospitalized Living with HIV

Pregnant and newly delivered Unstably housed Healthcare professionals Older adults Adolescents

Criminal justice involvement Awaiting transplant SPECIAL POPULATIONS IN OUD TREATMENTMEDICAL CONDITIONS Living with chronic pain Living with serious

mental illness Hospitalized Living with HIV Pregnant and newly delivered Unstably housed

Healthcare professionals Older adults Adolescents Criminal justice involvement Awaiting transplant

SPECIAL POPULATIONS IN OUD TREATMENT Living with chronic pain Living with serious mental illness Hospitalized

Living with HIV Pregnant and newly delivered Unstably housed Healthcare professionals Older adults

Adolescents Criminal justice involvement Awaiting transplant CHRONIC PAIN CHRONIC PAIN: THEN WHAT?

Unique fears Unique shame Unique stigma Typical responses: lie, minimize, suffer in silence, go to the street CHRONIC PAIN AND OUD They are related But how?

COMPETING HYPOTHESES (1) Pain as risk for OUD (2) OUD as risk for pain COMPETING HYPOTHESES (1) Pain as risk for

OUD YES (2) OUD as risk for pain YES CHRONIC PAIN

Good news Bad news NATURE OF THE PROBLEM Barriers to adequate pain treatment in context of opioid use disorder Providers fear triggering relapse Rx interactions with methadone/buprenorphine

Patients see adjuncts as weaker than opioid agonists Pain patients may not want MAT due to perceived effect of buprenorphine or methadone on pain HOW NOT TO RESPOND TO ABERRANCY: DISMISSING THE PATIENT 78% of practices dismissed patients for violated pain agreements in the last 2 years Perverse incentive Possible consequences

Withdrawal Disenfranchisement Escalation OPIOIDS AND MAT If prescribing opioids for pain in the setting of OUD, monitor more closely Drug screens Shorter duration prescriptions Random pill counts

Have an exit strategy Contact MAT clinic to share in treatment plan PSEUDOADDICTION Seeking more opioids for pain relief is pseudoaddiction; seeking for euphoria is addiction Old view: pain protected against addiction in opioid use

Based on single case report HOSPITALIZED ADMITTED: THEN WHAT? Unique fears Unique shame Unique stigma Typical responses: leave AMA, get kicked out,

spread unmanageability, suffer in silence HOSPITALIZED Another way Screen Detox Treat HOSPITALIZED

Expand differential diagnosis Treating pain Illicit opioid use Communication Connection to treatment HOSPITALIZED Medication-assisted treatment: why?

Options Initiation Continuation Discharge PREGNANCY TWO LINES: THEN WHAT? Unique fears

Unique shame Unique stigma Typical responses: avoid, adopt, abort, abstain PREGNANCY Another way Screen Detox? Treat

STATE LAWS ABOUT SUBSTANCE USE IN PREGNANCY 23 states + D.C.: substance use during pregnancy is child abuse 3 states: substance use in pregnancy is grounds for civil commitment 25 states + D.C.: mandated reporters must report suspected prenatal drug use 8 states: must test for prenatal drug exposure if suspected

17 states + D.C.: pregnant women have priority access to state-funded drug treatment programs 10 states: publicly funded drug treatment programs cannot discriminate against pregnant women https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy PREGNANCY: MAT Initiation challenges

Payment challenges Side effects Benefits DELIVERY AND IMMEDIATE POSTPARTUM Pain management Contraception Neonatal abstinence syndrome Breast feeding

Discharge prescribing POSTPARTUM: MAT Benefits Complications Reevaluate goals PROGRESS

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