Addiction Medicine Physicians Research Articles

Protocol for the development of a consensus practice guideline To address clinical and regulatory barriers to buprenorphine dispensing in community pharmacy

BackgroundLess than half of community pharmacies in the United States stock buprenorphine products indicated for the treatment of opioid use disorder. This lack of access to buprenorphine in community pharmacies is a significant barrier to care. To address this issue, this protocol outlines a comprehensive approach to develop a practice guideline aimed at improving access to safe and effective opioid use disorder treatment in community pharmacies.MethodsThe guideline development process will proceed in three phases, following a technique closely aligned with the Institute of Medicine’s guidance on guideline development. The first phase will involve conducting qualitative interviews with pharmacists in three states to identify their beliefs toward buprenorphine dispensing. As limitations on buprenorphine supply are related to constraints at all levels of the drug supply and regulatory system, the second phase, we will recruit representatives from regulatory agencies, pharmacy organizations, the Drug Enforcement Administration, pharmaceutical wholesalers as well as addiction medicine physicians and psychiatric pharmacists to develop consensus recommendations through a modified Delphi design. This will be followed by a public comment period and external expert review of the recommendations led by the National Association of Boards of Pharmacy. Finally, in the third phase, a national, mixed media dissemination campaign will be led by the National Community Pharmacists Association (NCPA) to convey recommendations to practicing pharmacists.DiscussionThe guideline development process aims to incorporate the perspectives of multiple stakeholders and emphasize the importance of addressing the regulatory and pharmacy-specific aspects of care in addition to clinical evidence and guidance. The development of this guideline will provide targeted, multidisciplinary guidance for pharmacists, improving access to safe and effective opioid use disorder treatment in the community setting.PreregistrationThis protocol was registered with the Open Science Framework in March of 2023. Registration may be found at: https://doi.org/10.17605/OSF.IO/6S9DY.

Multimodal Acute Pain Management in the Parturient with Opioid Use Disorder: A Review.

The opioid epidemic in the United States has led to an increasing number of pregnant patients with opioid use disorder (OUD) presenting to obstetric units. Caring for this complex patient population requires an interdisciplinary approach involving obstetricians, anesthesiologists, addiction medicine physicians, psychiatrists, and social workers. The management of acute pain in the parturient with OUD can be challenging due to several factors, including respiratory depression, opioid tolerance, and opioid-induced hyperalgesia. Patients with a history of OUD can present in one of three categories: 1) those with untreated OUD; 2) those who are currently abstinent from opioids; 3) those being treated with medications to prevent withdrawal. A patient-centered, multimodal approach is essential for optimal peripartum pain relief and prevention of adverse maternal and neonatal outcomes. Medications for opioid use disorder (MOUD), previously referred to as medication-assisted therapy (MAT), include opioids like methadone, buprenorphine, and naltrexone. These are prescribed for pregnant patients with OUD, but appropriate dosing and administration of these medications are critical to avoid withdrawal in the mother. Non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in a stepwise approach, and regional techniques like neuraxial anesthesia and truncal blocks offer opioid-sparing options. Other medications like ketamine, clonidine, dexmedetomidine, nitrous oxide, and gabapentinoids show promise for pain management but require further research. Overall, a comprehensive pain management strategy is essential to ensure the well-being of both the mother and the fetus in pregnant patients with OUD.

Addiction Medicine Physicians and Medicinal Cannabinoids

This Viewpoint communicates the importance of clinicians, particularly addiction clinicians, to be educated about both harmful and beneficial effects of cannabis and related products before making therapeutic recommendations.

Risk mitigation guidance and safer supply prescribing among young people who use drugs in the context of COVID-19 and overdose emergencies

Across North America, overlapping overdose and COVID-19 emergencies have had a substantial impact on young people who use drugs (YPWUD). New risk mitigation guidance (RMG) prescribing practices were introduced in British Columbia, Canada, in 2020 to allow people to decrease risk of overdose and withdrawal and better self-isolate. We examined how the prescribing of hydromorphone tablets specifically impacted YPWUD's substance use and care trajectories. Between April 2020 and July 2021, we conducted virtual interviews with 30 YPWUD who had accessed an RMG prescription of hydromorphone in the previous six months and 10 addiction medicine physicians working in Vancouver. A thematic analysis was conducted. YPWUD participants highlighted a disjuncture between RMG prescriptions and the safe supply of unadulterated substances such as fentanyl, underscoring that having access to the latter is critical to reducing their reliance on street-based drug markets and overdose-related risks. They described re-appropriating these prescriptions to meet their needs, stockpiling hydromorphone so that it could be used as an "emergency backup" when they were unable to procure unregulated, illicit opioids. In the context of entrenched poverty, hydromorphone was also used to generate income for the purchase of drugs and various necessities. For some YPWUD, hydromorphone prescriptions could be used alongside opioid agonist therapy (OAT) to reduce withdrawal and cravings and improve adherence to OAT. However, some physicians were wary of prescribing hydromorphone due to the lack of evidence for this new approach. Our findings underscore the importance of providing YPWUD with a safe supply of the substances they are actively using alongside a continuum of substance use treatment and care, and the need for both medical and community-based safe and safer supply models.

ASAM calls for addiction medicine physicians in insurance networks

The proposed Patient Protection and Affordable Care Act rule by the Center for Medicare & Medicaid Services (CMS) should include a requirement that addiction medicine physicians be included in health care networks, according to the American Society of Addiction Medicine (ASAM). In submitting a comment letter to the proposed rule Jan. 23, ASAM wrote that there should be a separate, individual provider specialty type specific to “Addiction Specialist Physicians” to be included as part of network adequacy. These specialists need to be available to patients in terms of specific time and distance standards, and should include physicians who receive subspecialty board certification in addiction medicine by the American Board of Preventive Medicine, subspecialty board certification in addiction psychiatry by the American Board of Psychiatry and Neurology, subspecialty board certification in addiction medicine by the American Osteopathic Association or certification by the American Board of Addiction Medicine. Along the same lines, on Jan. 27, ASAM released a new public policy statement that describes the role of addiction specialist physicians in U.S. health care. For the Jan. 23 letter to the CMS, go to https://sitefinitystorage.blob.core.windows.net/sitefinity‐production‐blobs/docs/default‐source/advocacy/letters‐and‐comments/22.01.23‐asam‐comments‐re‐2023‐notice‐of‐benefit‐and‐payment‐parameters‐rule.pdf. For the Jan. 27 public policy statement, go to https://www.asam.org/advocacy/public‐policy‐statements/details/public‐policy‐statements/2022/01/28/public‐policy‐statement‐on‐the‐recognition‐and‐role‐of‐addiction‐specialist‐physicians‐in‐health‐care‐in‐the‐united‐states.

A Novel Online Curriculum and Coaching Strategy to Expand the Addiction Medicine Workforce: The Michigan Collaborative Addiction Resources and Education System.

There is a shortage of addiction medicine (AM) physicians and a 9-year period (2017-2025) in which to build the workforce via a practice pathway enabling physicians to combine experiential hours with passing a board exam to become board-certified AM physicians. Afterward, AM specialists will need to complete the traditional fellowship pathway, requiring additional training. The Michigan Collaborative Addiction Resources and Education System (MI CARES) was developed from February to June 2019 to support physicians in obtaining AM certification via the practice pathway. This program was originally planned for Michigan physicians but was quickly expanded nationally. This novel, asynchronous, self-directed online curriculum follows the knowledge blueprint for the board exam, including continuing medical education credits. The program also provides 1:1 coaching support to educate physicians on how to properly document their experiential hours on the application for the AM board exam. The first module, which describes the practice pathway, was released in January 2020, and 7 substance-specific content modules were released monthly from February to August 2020. As of October 31, 2020, 231 physicians from 13 American Board of Medical Specialties in 37 U.S. states were enrolled in MI CARES. The longer a module was available, the more participants visited the module. Three early program adopters were approved to sit for the 2019 board exam, and 51 participants passed the board exam in 2020. Of these 51, 5 had previously been denied approval before participating in MI CARES. It will be important to replicate preliminary evidence of feasibility for this novel model for expanding the workforce in a newly approved and underrepresented specialty to see if it holds promise for replication as other subspecialties are identified. The curriculum is being expanded to include modules on additional topics and adapted for graduate and undergraduate medical education students.

Management of Hydrocarbon Burns: Considering Mental Health and Biochemical Abnormalities.

Volatile substance misuse, particularly the inhalation of hydrocarbons, is a growing issue globally. Consequences of volatile substance misuse, both acute and chronic cause cardiovascular, respiratory, renal, metabolic, and central nervous system damage. Whilst the effects of hydrocarbon abuse have been reported, the combination of intoxication with hydrocarbon and burns sustained has not yet been presented. A retrospective case series of patients who presented in the last 5 years to the Royal Adelaide Hospital with hydrocarbon-related burns in the context of illicit use was undertaken. Our aims are to present to the wider scientific community the high morbidity and mortality of hydrocarbon burn injuries and why this tertiary Burns Unit feel it most appropriate to medically stabilize these patients prior to definitive surgery for their burn. All patients that presented with acute hydrocarbon intoxication and sustained concomitant burns had significant psychiatric disorder and substance abuse history and three of five had either not eaten in several days resulting in acute malnourishment, refeeding syndrome or had evidence of chronic malnourishment with deranged electrolytes and hypoalbuminemia. Their definitive burns surgery was delayed where appropriate in order to facilitate medical stabilization as they were too high risk of cardiac membrane instability, electrolyte derangement, and/or respiratory compromise to undergo safe general anesthetic and burns debridement. We propose a multidisciplinary team approach, utilizing not only our Burns Unit care model of physiotherapists, psychologists, social work, and burns trained nurses and surgeons but also Intensive Care, Toxicology, Addiction medicine and General Medical physicians in the management of these patients.

Civil Commitment for Substance Use Disorders: A National Survey of Addiction Medicine Physicians.

Civil commitment (CC) for substance use disorders (SUDs) is a legal mechanism, initiated by family members, healthcare professionals, or others, that compels individuals with substance use problems into involuntary treatment. With the recent rise of US overdose deaths, more states are considering these laws. Yet little is known about physicians' perspectives regarding CC in treating patients with SUDs. We conducted a web-based survey of American Society of Addiction Medicine (ASAM) physician members regarding their awareness of, attitudes towards, and experiences with CC for adults with SUDs. One hundred sixty-five addiction physicians completed the survey; 60.7% favored, 21.5% opposed, and 17.8% were unsure regarding CC for SUDs. More than a third (38.4%) were unfamiliar with these laws and more than a quarter (28.8%) were unsure if CC for SUDs was permitted in their state. Support for CC was strongest for SUDs involving heroin (79.0%), alcohol (74.7%), and nonheroin opioids (74.7%). Those opposing CC were more likely to believe it would jeopardize patient rapport (P < 0.001), would be ineffective for unmotivated individuals (P < 0.001), and should only be permitted for certain substances (P = 0.007). A majority of respondents endorsed the need for more clinician education (91.5%) and research (87.1%) on this topic. Although most addiction physicians in this study approve of CC for SUDs, enthusiasm for this compulsory intervention is mixed with strongest support for patients with opioid and alcohol use disorders. At the same time, many respondents are unfamiliar with these laws and most believe more education and research are needed.

Addiction Medicine After COVID-19: The Imperative of a Trained Workforce

Addiction Medicine After COVID-19: The Imperative of a Trained Workforce

Cardiac and vascular changes in the patho- and morphogenesis of alcohol use disorder

Aim. To reveal the patho- and morphogenesis of microvascular injury, cardiac and vascular changes in individuals with alcohol use disorder (AUD) and the role of cardiovascular pathology in the thanatogenesis of patients with chronic alcohol intoxication.Material and methods. The study was carried out using the data of 1118 autopsies of patients with AUD. We used histological, immuno-histochemical, electron microscopic and biochemical methods, as well as morphometrics with statistical processing of the results.Results. Most patients with binge drinking developed alcoholic cardiomyopathy, cardiac hypertrophy, myocardial fatty degeneration, microvascular arteriolosclerosis and hyalinosis, diffuse focal sclerosis, as well as mitochondrial swelling and fragmentation of cristae in cardio-myocytes (CMC). The proportion of damaged CMC was 30,9±0,6%. Sclerosis affected 20,1±0,9% of the stroma. If alcohol was abandoned or consumed within the basal metabolic rate, these changes were reversible. With alcoholism, alcoholic cardiomyopathy, arteriosclerosis and arteriolosclerosis progressed. Compared with the binge drinking, the proportion of damaged CMC (44,8±1,1%) and the cardiosclerosis area (28,1±0,5%) significantly increased. Mallory bodies with autoantigen properties were detected. Morphological changes became irreversible.Conclusion. The data obtained identified the need for AUD isolation as an independent nosological entity with stage-by-stage pathogenesis. In the stage of binge drinking, the compensatory and adaptive capabilities of the body are preserved. With appropriate treatment, this stage of AUD is treatable. In the stage of alcoholism, changes in organs and tissues are irreversible, and it is more advisable for addiction medicine physicians to deal with palliative treatment of such patients.

Ranking the Harm of Psychoactive Drugs Including Prescription Analgesics to Users and Others-A Perspective of German Addiction Medicine Experts.

Background: Over the past 15 years, comparative assessments of psychoactive substance harms to both users and others have been compiled by addiction experts. None of these rankings however have included synthetic cannabinoids or non-opioid prescription analgesics (NOAs, e.g., gabapentinoids) despite evidence of increasing recreational use. We present here an updated assessment by German addiction medicine experts, considering changing Western consumption trends–including those of NOAs.Methods: In an initial survey, 101 German addiction medicine physicians evaluated both physical and psychosocial harms (in 5 dimensions) of 33 psychoactive substances including opioids and NOAs, to both users and others. In a second survey, 36 addiction medicine physicians estimated the relative weight of each health and social harm dimension to determine the overall harm rank of an individual substance. We compared our ranking with the most recent European assessment from 2014.Results: Illicit drugs such as methamphetamine, heroin, cocaine and also alcohol were judged particularly harmful, and new psychoactive drugs (cathinones, synthetic cannabinoids) were ranked among the most harmful substances. Cannabis was ranked in the midrange, on par with benzodiazepines and ketamine—somewhat more favorable compared to the last European survey. Prescribed drugs including opioids (in contrast to the USA, Canada, and Australia) were judged less harmful. NOAs were at the bottom end of the ranking.Conclusion: In Germany, alcohol and illicit drugs (including new psychoactive substances) continue to rank among the most harmful addictive substances in contrast to prescribed agents including opioid analgesics and NOAs. Current laws are incongruent with these harm rankings. This study is the first of its kind to include comparative harm rankings of several novel abused substances, both licit/prescribed and illicit.

Pandemic Creates Challenges, New Opportunities for Treating Patients With Substance Use Disorder

Pandemic Creates Challenges, New Opportunities for Treating Patients With Substance Use Disorder

In Case You Haven't Heard…

We attended day 1 of a lively New York Society of Addiction Medicine (NYSAM) meeting Feb. 7 and came away with the clear impression that addiction medicine physicians in New York are split when it comes to cannabis to treat substance use disorder, but wholeheartedly in favor of harm‐reduction techniques such as teaching patients how to use illegal drugs safely. But one thing is clear: They hate the buprenorphine waiver and want buprenorphine mainstreamed. In a surprise appearance, Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, spoke instead of Rep. Paul Tonko (D‐N.Y.), who could not be there. Rep. Tonko is sponsoring a bill that would deregulate buprenorphine. Parrino is on the other side of the argument. Thanks to NYSAM for hosting all views. (Look for more coverage of the meeting in next week's issue.)

Making the business case for an addiction medicine consult service: a qualitative analysis

BackgroundAs the drug poisoning crisis worsens in North America and opioid use disorder (OUD)-related hospital admissions increase, policymakers and hospital administrators are beginning to recognize the important role of hospitals in the OUD care continuum. This study explores and describes how U.S. addiction medicine physicians created and presented business propositions to hospital administrators to support the development of addiction medicine consult (AMC) services.MethodsFifteen qualitative interviews were completed with board-certified or board-eligible addiction medicine physicians from 14 U.S. hospitals. The interviews occurred as part of a broader mixed methods study exploring hospital service delivery for patients admitted with OUD. Using a directed content analysis, the transcribed interviews were coded, analyzed, and final themes consolidated.ResultsSemi-structured interviews completed with addiction medicine physicians from established (n = 9) and developing (n = 5) AMC services at 14 U.S. hospitals explored how clinical champions persuaded hospital administrators to support AMC service development. Four elements were foundational to making the “business case”: 1) describing the prevalence of substance use disorder (SUD) or OUD in the hospital; 2) identifying the negative financial impacts of not treating SUDs during hospitalization; 3) highlighting the ongoing care quality and treatment gap for hospitalized patients with SUDs; and 4) noting the success of other institutional AMC services. Study findings informed the creation of tools to support AMC service development: 1) an AMC service business case template, and 2) an AMC service design and operations resource list.ConclusionsOUD-related hospital admissions are unlikely to abate. Hospital administrators should consider innovative care delivery mechanisms to improve care for persons with OUD. AMC services may be a promising delivery mechanism to achieve this aim. For clinical and administrative champions, understanding how to communicate the potential effectiveness of this intervention to hospital leaders is an essential first step to AMC service creation.

Patient and Physician Perspectives on Treating Tobacco Dependence in Hospitalized Smokers With Substance Use Disorders: A Mixed Methods Study.

Individuals with substance use disorders have a high prevalence of smoking cigarettes. Hospitalization represents an opportunity to deliver concurrent treatment for tobacco and other substances. Using a sequential explanatory mixed methods design, we characterized practices and perspectives of patients and physicians about smoking cessation counseling during inpatient addiction medicine consultations. We abstracted data from 694 consecutive inpatient addiction consult notes to quantify how often physicians addressed tobacco dependence using the guideline-recommended 5As framework. We conducted semi-structured interviews with 9 addiction medicine physicians and 20 hospitalized smokers with substance use disorders. We analyzed transcripts to explore physicians' and patients' perspectives on smoking cessation conversations during inpatient addiction consultations, physician-perceived barriers and facilitators to engaging inpatients in tobacco treatment, and strategies to improve tobacco treatment in this context. 75.5% (522/694) of hospitalized substance use disorder patients were current smokers. Among smokers, 20.9% (109/522) were offered nicotine replacement while hospitalized, but only 5.4% (28/522) received the full guideline-recommended 5As. Patients and physicians reported minimal discussion about tobacco addiction during hospitalization. Physicians cited tobacco not being an immediate health threat and the perception that quitting tobacco is not a priority to patients as barriers, often limiting thorough counseling to patients with smoking-related admissions. Physicians and patients offered strategies to integrate treatment of tobacco dependence and other substances. Inpatient addiction consultations represent a missed opportunity to counsel patients with substance use disorders to quit smoking. System-level changes are needed to coordinate treatment of tobacco and other drug dependence in hospitalized smokers.

Inpatient Addiction Medicine Consultation and Post-Hospital Substance Use Disorder Treatment Engagement: a Propensity-Matched Analysis.

Hospitalizations due to medical and surgical complications of substance use disorder (SUD) are rising. Most hospitals lack systems to treat SUD, and most people with SUD do not engage in treatment after discharge. Determine the effect of a hospital-based addiction medicine consult service, the Improving Addiction Care Team (IMPACT), on post-hospital SUD treatment engagement. Cohort study using multivariable analysis of Oregon Medicaid claims comparing IMPACT patients with propensity-matched controls. 18-64-year-old Oregon Medicaid beneficiaries with SUD, hospitalized at an Oregon hospital between July 1, 2015, and September 30, 2016. IMPACT patients (n = 208) were matched to controls (n = 416) using a propensity score that accounted for SUD, gender, age, race, residence region, and diagnoses. IMPACT included hospital-based consultation care from an interdisciplinary team of addiction medicine physicians, social workers, and peers with lived experience in recovery. IMPACT met patients during hospitalization; offered pharmacotherapy, behavioral treatments, and harm reduction services; and supported linkages to SUD treatment after discharge. Healthcare Effectiveness Data and Information Set (HEDIS) measure of SUD treatment engagement, defined as two or more claims on two separate days for SUD care within 34days of discharge. Only 17.2% of all patients were engaged in SUD treatment before hospitalization. IMPACT patients engaged in SUD treatment following discharge more frequently than controls (38.9% vs. 23.3%, p < 0.01; aOR 2.15, 95% confidence interval [CI] 1.29-3.58). IMPACT participation remained associated with SUD treatment engagement when limiting the sample to people who were not engaged in treatment prior to hospitalization (aOR 2.63; 95% CI 1.46-4.72). Hospital-based addiction medicine consultation can improve SUD treatment engagement, which is associated with reduced substance use, mortality, and other important clinical outcomes. National expansion of such models represents an opportunity to address an enduring gap in the SUD treatment continuum.

Role of the Hospital in the 21st Century Opioid Overdose Epidemic: The Addiction Medicine Consult Service.

The aim of the study was to explore and describe the structure and design elements of addiction medicine consult (AMC) services within selected US hospitals. As part of a larger mixed methods study, 10 qualitative semi-structured telephone interviews were completed with board-certified addiction medicine physicians affiliated with the Addiction Medicine Foundation's Addiction Medicine Fellowship Programs at 9 US hospitals. Interviews were transcribed, coded, and analyzed using a directed content analysis. Interviews completed with established AMC services in 9 hospitals probed AMC structure and design commonalities and differences across 4 domains: (1) availability and coverage, (2) team composition, (3) scope and responsibility, and (4) financing. Only 1 service provided weekend consults and most services did not provide coverage in the emergency department. Interprofessional teams were common with a variety of discipline combinations. AMC service scope and responsibility, generally, included 3 types of activities: (1) education and culture change, (2) the delivery of psychosocial and medical services, and (3) hospital guidance document development. Finally, most AMC services existed within a fragile financial environment with idiosyncratic arrangements. As opioid use disorder (OUD)-related hospitalizations increase stakeholders look to innovative care delivery mechanisms to improve care and outcomes for persons with OUD. The implementation of an AMC service may be an organizational intervention for achieving these aims. Understanding the shared and different approaches to AMC service structure and design is an important first step for delivery systems interested in implementing or expanding these services.

Vermont Hub-and-Spoke Model of Care for Opioid Use Disorder: Development, Implementation, and Impact.

Opioid use disorders (OUDs) are reaching epidemic proportions in the United States, and many geographic areas struggle with a persistent shortage in availability of opioid agonist treatment. Over the past 5 years, Vermont addiction medicine physicians and public health leaders have responded to these challenges by developing an integrated hub-and-spoke opioid treatment network. In the present report, we review the development, implementation, and impact of this novel hub-and-spoke model for expanding OUD treatment in Vermont. Vermont's hub-and-spoke system has been implemented state-wide and well-received by providers and patients alike. Adoption of this model has been associated with substantial increases in the state's OUD treatment capacity, with Vermont now having the highest capacity for treating OUD in the United States with 10.56 people in treatment per 1000. There has been a 64% increase in physicians waivered to prescribe buprenorphine, a 50% increase in patients served per waivered physician, and a robust bidirectional transfer of patients between hubs and spokes based upon clinical need. Challenges to system implementation and important future directions are discussed. Development and implementation of a hub-and-spoke system of care has contributed substantially to improvements in opioid agonist treatment capacity in Vermont. This system may serve as a model for other states grappling with the current opioid use epidemic.

SY03-1-1 * ISAM FELLOWSHIP THE OPIOID PANDEMIC IN CHILDREN: EQUIPPING OURSELVES FOR SUCCESS

Opioid overdoses kill more young adults in the world than overdoses of any other drug. With the proliferation of prescription opioids (oxycontin, hydromorphone, etc), there has been a tremendous increase in opioid use disorders among all humans, specifically children and young adults. While statistics regarding youth opioid disorders are alarming, there has not been a concurrent increase in formalized medical education for pediatricians, family physicians or addiction medicine physicians regarding children and adolescents. Because drug abusers are often highly stigmatized in society, their healthcare utilization tends to be fragmented and sporadic. Pediatricians, family physicians, and addiction medicine physicians need to equip themselves with a cohesive skill-set to provide optimal care to such a high-risk patient population. This oral presentation will begin with a brief lecture-based review of the opioid epidemic among world children. We will then discuss the various screening and diagnostic tools available to clinicians and provide a referenced bibliography for further reading. Next, we will define evidence-based medical and non-medical treatment strategies employed in the treatment of youth opioid use disorders. The workshop will then transition to small group learning exercises where participants will practice learned objectives through case-based clinical vignettes. After the small group sessions, each group will present their particular conclusions to the group-at-large, and the workshop leader will highlight the learning objectives. The workshop will conclude with a question and answer session.

OR15-3 * 50 SHADES OF GRAY: ETHICAL CHOICES IN ADDICTION MEDICINE

Objectives. Recognize the roles of addiction medicine professionals regarding supply reduction. Handle patients with prescriptions that seems dubious or fraudulent. Feel comfortable navigating a patient dynamic when the patient is lying. The oral presentation will be focused around a challenging clinical vignette that presents a variety of potential choices, each with specific ethical consequences for the patient and physician. After discussing the vignette, there will be a structured discussion among presentation attendees. The moderator, Dr. Brennan, will use a common discussion technique in ethical discourse called anchoring, whereby the discussion is begun from a rigid viewpoint, and through discourse a consensus is gradually reached. The vignette discussed will be an adult male with a history of severe opioid use disorder who presented to an ER in New York City requesting admission for opioid detoxification and rehabilitation. The patient was very well known to the physician, having completed a 4 week inpatient stay for opioid use disorder several weeks prior to seeking readmission. In the interval weeks since discharge the patient had relapsed on opioids by finding several physicians in New York City to write him prescriptions for his drug of choice. Upon readmission to the inpatient unit his belongings were searched and recorded, and one of his prescriptions for opioids was mistakenly placed in his chart, rather than in his locker with the rest of his supplies. The physician happened to find this prescription and suspects that it was written at a pill mill, or perhaps written by a physician who didn't know that the patient had an addiction to opioids. Should the prescription, which represented the very crux of this patient's problem, be returned to the patient since it is their legal property? Or should the physician throw it away? What role should addiction medicine physicians have in patrolling other physicians with dubious prescribing habits?