Opioid withdrawal Successful treatment of opioid overdose frequently results in withdrawal symptoms for the patient habituated to opioids. Treatment of opioid withdrawal symptoms can be complex. In the acute care setting the withdrawal can be abrupt and severe following the use of naloxone or due to precipitated withdrawal related to the inappropriate use of buprenorphine. Clinical evaluation of withdrawal should utilize the Clinical Opiate Withdrawal Scale COWS score to assist in decisions related to treatment. This 11-item scale can be used in both inpatient and outpatient settings to reproducibly rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time. A template of this scale can be found at this site: (https://www.asam.org/docs/default- source/education- docs/cows_induction_flow_sheet. pdf) Some adjunct medications can serve to lessen the symptoms and bridge the patient to more definitive
therapy, or past the duration of action of the naloxone. It is important to note that the duration of action of naloxone is typically less than one hour, while the duration of action of the opioid agent that was responsible for the overdose initially may be multiple hours. This is important when creating a treatment plan for those that are treated in the ED or on the street and refuse to be monitored or evaluated after they wake from their sedation. Opioid medications and drugs continually impact society. The pain-relieving effects are useful in the setting of acute pain, but the risks associated with prolonged use are well documented. The modern practitioner would be advised to continue to educate themselves about the risks and benefits of these agents and seek counsel from experts when appropriate to assist in the care of patients with conditions that are associated with opioid use. Please complete case studies 1 & 2.
Case study 1 Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Mrs. Smith brings in her 18-year-old son, Bobby, for evaluation of his substance use disorder (SUD). He has been using unprescribed oxycodone and buying pills off the street. She asks for help getting assistance. Questions What are some of resources and options available for treatment of Bobby’s OUD? 1. Referral to a peer support work. 2. Referral to social worker. As the practitioner, this is not the first time you are asked to assist with treatment of OUD. You have APPs in your practice that are interested in helping patients with OUD. Which qualified practitioners are eligible to obtain an x-waiver? ○ Physicians. ○ Nurse Practitioners (NPs) ○ Physician Assistants (PAs). ○ Clinical Nurse Specialists (CNSs). ○ Certified Registered Nurse Anesthetist (CRNAs) ○ Certified Nurse-Midwifes (CNMs). One of the physician partners want to assist in this treatment but is concerned about the cost and time commitment of becoming x- waivered. What could you tell them regarding these concerns? _______________________________________________________________________________________________ _______________________________________________________________________________________________ Recent Practice Guidelines have allowed for an alternative NOI for those seeking to treat up to 30 patients : The customary NOI requires eligible providers to undertake required training activities prior to their application to prescribe buprenorphine; the alternative type of NOI allows those providers who wish to treat up to 30 patients to forego the training requirement, as well as certification to counseling and other ancillary services (i.e., psychosocial services). Practitioners utilizing this training exemption are limited to treating no more than 30 patients at any one time (time spent practicing under this exemption will not qualify the practitioner for a higher patient limit). This exemption applies only to the prescription of Schedule III, IV, and V drugs or combinations of such drugs, covered under the CSA, such as buprenorphine. 3. Referral to local recovery center. 4. Referral to Emergency Department. 5. Do a COWS score and consider initiating.
Case study continued on next page ►
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Book Code: CT24CME
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