of the undesirable effects associated with opioids, including respiratory depression, thereby making it necessary to be managed by a trained health professional. Currently, methadone is typically dosed daily and through an approved clinic. In limited cases Buprenorphine Buprenorphine is an increasingly popular treatment for OUD. It was approved in 2002 for the treatment of OUD and differs from methadone in that buprenorphine is only a partial agonist and has less potential for side effects and overdose injury as compared to methadone. One of the most important advantages of buprenorphine is its ceiling effect on respiratory depression. As described earlier, respiratory depression frequently leads to hypoxia and arrest in many opioid overdoses. Buprenorphine has very little risk for respiratory depression, and this has made it increasingly favored and more suitable for its initiation in the outpatient arena. Unlike methadone, the lack of required daily visits to a treatment center can also be an advantage. Another advantage of buprenorphine is the availability of long- acting injectable or implantable formulations that carry a low risk of diversion and can be managed as a monthly visit. Some patients still prefer methadone over buprenorphine. Both methadone and buprenorphine are first line agents for the treatment of OUD in pregnancy. 62 Buprenorphine can only be prescribed and dispensed by a certified provider who has a Drug Enforcement Agency license and has undergone training and/or qualifies for a Drug Addiction Treatment Act of 2000 Naltrexone Different in mechanism from methadone or buprenorphine, naltrexone is an opioid antagonist medication available in both PO and IM formulation. It can be prescribed by any licensed provider without the need for special requirements linked to buprenorphine or methadone. There is no abuse potential. It is currently approved for the treatment
patients may be allowed to take methadone at home between program visits. The length of methadone treatment should be a minimum of 12 months with some patients requiring long-term maintenance. 61
(DATA 2000) waiver. This list includes physicians, nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists (CNSs), certified registered nurse anesthetist (CRNAs) and certified nurse- midwifes (CNMs). This license is commonly referred to an "x-waiver" as, after a successful application is submitted, a new DEA card is provided with an "x" before the number, designating the provider as approved to prescribe buprenorphine. Important to note that any DEA licensed practitioner can order Buprenorphine during treatment of OUD during inpatient hospitalization, as the x-waiver is only necessary for prescription authority. Practitioners can apply for a buprenorphine waiver through the SAMHSA website at: https://www.samhsa. gov/medication-assisted-treatment/become- buprenorphine-waivered-practitioner. In an attempt to recruit more practitioners to treat OUD with MOUD, SAMHSA has recently allowed acquisition of an x-waiver license without the traditional training course. The submission of a Notice of Intent (NOI) to treat using buprenorphine is required and is limited to the care of 30 patients at a time. Treatment of more than 30 patients concurrently requires additional training and approval. of both OUD and for the treatment of alcohol abuse. As opposed to methadone and buprenorphine, naltrexone is not a controlled substance, so it can be prescribed by any healthcare provider who is licensed to prescribe medications. However, as an opioid antagonist, use of Naltrexone must be monitored closely to prevent serious acute withdrawal symptoms.
ACUTE TREATMENT OF OVERDOSE: NALOXONE (NARCAN)
Overdose involving opioids continues to be common and acute treatment of opioid overdose typically utilizes naloxone (Narcan) to reverse the dangerous respiratory depression and sedation associated with severe toxicity. Scientists looking to treat constipation caused by chronic opioid use first patented naloxone in New York in 1961. In 1971, the Food and Drug Administration approved naloxone for treating opioid overdoses by intravenous or intramuscular injection. In 1996, piloted use of take- home naloxone kits started in 15 states. Naloxone is a strong opioid antagonist. Dosing of naloxone in medical settings should start low to reverse severe respiratory depression but with the intent of avoiding full withdrawal. Acute withdrawal results in dysphoria, insomnia, pupillary dilation, piloerection, yawning, muscle aches, lacrimation, rhinorrhea, nausea, fever, sweating, vomiting and diarrhea. 63 Currently, intranasal (IN) naloxone kits are widely distributed
throughout the United States and can be used by laypersons to revive individuals that are unresponsive due to opioid overdose. Naloxone is combined with oral buprenorphine in some formulations like Suboxone (buprenorphine + naloxone) to discourage intravenous injection. When a combination medication like Suboxone is ingested, the buprenorphine gets absorbed in the stomach while the naloxone is inactivated by stomach acid and does not result in opiate withdrawal. Administration of naloxone in the setting of overdose or suspected overdose presents little to no risk to the patient if the overdose or alteration in mental status is not from opiates. It is important to communicate this to families or friends and the public to encourage the use of naloxone. Naloxone distribution campaigns vary between states with some states providing free naloxone kits from pharmacies, distribution events and even vending machines.
Book Code: CT24CME
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