Office-Based Treatment for Opioid Dependence: Reaching New Patient Populations
Office-Based Treatment
Case Report
Mr. A was a 34-year-old Caucasian man who began “chipping” intranasal heroin (less than daily use) about 5 years ago. He had used cocaine for 5 years before that and went from intranasal use on weekends to steadily increasing binges of smoking cocaine over a 3-year period. He used alcohol extensively to control the paranoia and withdrawal that he experienced during these binges, although he did not become dependent on it and never required medical detoxification. He stopped most of his alcohol abuse when others noted the frequency of alcohol on his breath as well as his frank intoxication. Instead, he began using heroin and cocaine together because the combination of smoked cocaine and snorted heroin provided relatively long-lasting euphoria, with a markedly attenuated crash after he stopped a cocaine binge. These reasons for adding heroin to cocaine abuse are relatively common among those who abuse both drugs and particularly among those who begin by using cocaine. He did not initially seek treatment on his own, but his family had become increasingly concerned about him.Mr. A had inherited the family business, a food marketing chain, after his father died when he was 28 years old, about 1 year before he sought treatment. This job required frequent travel for periods of 1 or 2 days on business. Both his older brother, an attorney, and his mother were increasingly concerned that he was not successfully managing the daily operations of the business and was falling into debt. They met with his wife, who was herself concerned about his temper outbursts at home with their two young children, as well as about his inability to get the funds for building an addition on their house; she was beginning to consider filing for divorce. As a result of a family confrontation, Mr. A resolved to change his “high-pressure” work life and appeared to slow down. He resisted getting professional help for his substance use, but his family felt that he had responded to their concerns by changing his behavior.Lack of money, however, still appeared to be a major problem, and one of his store managers reported to his brother that Mr. A appeared to spend several hours locked in his office and unavailable. When this brother asked whether Mr. A had been like this at work in the past, the manager stated that the situation seemed more serious. In the past Mr. A had become irritable and would sometimes disappear for several hours, but he usually came back full of energy. Now Mr. A was appearing sleepy and uninterested. This sedation was a sign of opioid intoxication at work, whereas the irritability probably reflected both opioid withdrawal as well as cocaine-induced paranoia, which appeared when he used cocaine alone, without either heroin or substantial amounts of alcohol.The family insisted that Mr. A seek professional medical help and threatened that his mother would take over control of the family business if he did not. They indicated that his lawyer brother had drawn up the required documents. Mr. A resisted but finally agreed to see the family’s primary care physician. He reported fatigue, occasional insomnia, weight loss, and occasional palpitations. The physician noted an unremarkable physical examination and proceeded to rule out thyroid disorders, HIV, and hepatitis as the cause of Mr. A’s complaints. The results of routine screening tests for these disorders were normal, and the physician ascribed Mr. A’s complaints to stress and a possible anxiety disorder and recommended counseling, which Mr. A resisted. Mr. A then had a serious auto accident that appeared to be related to a seizure. In the emergency room, a urine toxicology screen was positive for cocaine and opioids. After this crisis he agreed to seek psychiatric help. The precipitant for seeking treatment was an emergency room screening for illicit drugs, emphasizing the importance of screenings after serious accidents.In the initial assessment interviews, at age 29, Mr. A appeared concerned and open. He acknowledged that his father’s death the previous year had been a great loss to him and that his cocaine use had escalated during his father’s illness and death from lung cancer. Both Mr. A and his father were tobacco smokers. Mr. A had stopped smoking briefly after his father’s illness was diagnosed, but he soon relapsed and continued to smoke. Mr. A admitted using heroin with cocaine and stated that he snorted and smoked these drugs. He never used intravenous opioids, he claimed, and was aware of the risk of AIDS with intravenous drug use. Because his heroin use was intermittent, he had no signs of opioid withdrawal, and he had clear problems with alcohol, we agreed that in addition to weekly individual psychotherapy he would begin taking naltrexone twice weekly at 150 mg. At this dose he would be blocked from the use of heroin, and naltrexone would also reduce the potential for relapse to alcohol abuse.In therapy it appeared that Mr. A’s grieving for his father had been seriously aborted by his drug use, and therapy was intended to focus, in part, on this aborted grief in addition to tracking his substance use with breathalyzers for alcohol use and regular urine monitoring for heroin and cocaine. In addition, his sister and brother were seen monthly by a different therapist, while Mr. A went to couples counseling weekly with his spouse. Finally, he was to attend at least weekly Alcoholics Anonymous meetings. The weekly therapy lasted for 4 months, and Mr. A was compliant; he was observed taking naltrexone twice weekly: once at the individual sessions when a urine toxicology screen was also obtained and once at the weekly couples therapy session. After 4 months he declared himself “cured” and left the couple’s therapy and agreed to monthly individual contact but no further medication. After 2 monthly contacts, he terminated his visits.Six months later, almost on the 1-year anniversary of our initial contact, he returned to the emergency room with a heroin overdose. The overdose was sufficient to require naloxone reversal but was not serious enough to require hospital admission. Mr. A had no suicidal intent and refused hospitalization. Since he did not meet utilization review criteria for emergency hospitalization and because his insurance carrier was also denying coverage, he was referred to substance abuse day treatment starting the next morning, and he was held overnight in the emergency room. During that night he did not sleep and experienced the opioid withdrawal symptoms of sweating, rhinorrhea, and abdominal cramping. His initial response to naloxone was a clear sign of opioid overdose but not necessarily opioid dependence. His persistent withdrawal symptoms, well beyond the 30–45 minutes that naloxone would last, were consistent with opioid dependence.When he was interviewed, Mr. A indicated that he had stopped most of his cocaine use but that he was smoking or using heroin intranasally daily. When confronted in the emergency room about the heroin dependence he had developed, he stated that he believed that as long as he did not “shoot” heroin he could not become dependent on it. Nevertheless, it was clear that Mr. A needed some treatment for withdrawal symptoms; clonidine therapy was discussed. A day program was available that used clonidine plus naltrexone to complete detoxification during a 5-day program. Mr. A agreed to participate in this day program for a week, followed by an intensive evening outpatient program for a month. During this evening program, he intended to return to work part-time during the day.The day program began with a rapid 3-day clonidine-naltrexone detoxification that was more difficult than Mr. A had anticipated. Participants were to arrive before 9:00 a.m.; he came directly from the emergency room accompanied by his mother. During the next 3 days, he underwent rapid detoxification with clonidine and naltrexone. Although he medically tolerated it well, he complained of sleeplessness and anxiety that lasted for a week. After 6 days he was stable while taking naltrexone and having no detectable opioid withdrawal symptoms, although he continued to complain of disrupted sleep lasting about 6 hours per night. His daytime sedation had subsided, however. We considered this a successful medical detoxification and resumed giving him naltrexone, 150 mg twice a week.After this difficult period of outpatient detoxification, standard outpatient care with urine monitoring, weekly individual and couples treatment, and weekly Alcoholics Anonymous group visits were reinstituted. Mr. A participated for 6 months with good compliance in using naltrexone and had no positive illicit drug urine screens, but he again left treatment, resisting continued follow-up. During the next 3 years, he had two inpatient detoxifications for heroin use but would not enter a methadone maintenance program. He remained working at his family business and was successful in many areas. His heroin use was daily, and he sought inpatient detoxification when his intranasal habit became too expensive and interfered with his work schedule. This is an example of failed outpatient drug-free treatment that is frequently seen in this chronic, relapsing disorder and emphasizes the need to consider sustained opioid maintenance treatment.Mr. A again was seen for treatment and again had been heroin dependent for several months, having been using heroin in the year since his most recent inpatient detoxification. He specifically came to the research program that used buprenorphine in office-based treatment in a psychiatric setting. This type of care was quite appealing to him in contrast to methadone maintenance, with its many rules and restrictions.Mr. A had mild abdominal cramping and insomnia on his first day of induction to buprenorphine therapy, but overall he felt much better by the second dose. He continued his heroin use but discontinued it after 1 week of treatment. His induction involved a starting dose of 4 mg of sublingual buprenorphine on days 1 (Monday) and 2, 8 mg on days 3 and 4, and 16 mg on day 5 to last until Monday (day 8). All the buprenorphine doses were given under direct observation and were moved to a regular schedule of Monday (12 mg), Wednesday (12 mg), and Friday (20 mg). Mr. A reported that the reduced requirements for clinic attendance with buprenorphine allowed him to continue to perform his usual job without interruptions. In addition to weekly brief counseling sessions, he attended three Narcotics Anonymous meetings in the first week and continued with these meetings at least once a week throughout treatment. His weekly counseling visits focused on job- and family-related issues, while once-weekly urine toxicology screens verified his abstinence. These urine screens were obtained on a random schedule each week on one of the three days that Mr. A was medicated. His abstinence was interrupted by abuse of prescription drugs for 1 week, causing mild euphoria, but he continued to pursue treatment and became abstinent after reinduction of buprenorphine. At the end of the 12-week maintenance period, Mr. A attempted to transfer to opioid-antagonist therapy with naltrexone but was unable to remain abstinent from opioids for the required 4 days after his last dose of buprenorphine. He ultimately returned for continued maintenance with buprenorphine.
Discussion
Footnote
References
Information & Authors
Information
Published In
History
Authors
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/ePub
View PDF/ePubGet Access
Login options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).