1.38: A stigma that undermines care- opioid use disorder and treatment considerations
At the end of this case, students will be able to:
- Describe the public health impact of opioid use disorder in the United States
- Explain the role of social determinants of health in substance use disorders
- Describe FDA-approved medications for treatment of opioid use disorder
- Identify stigma as a major barrier to opioid use disorder treatment
Introduction
The opioid epidemic and opioid use disorder (OUD) are issues of critical importance to pharmacists of all areas of practice. In the United States, two-thirds of drug overdose deaths (47,600) in 2017 involved opioids. 1 Fentanyl and fentanyl analog (FA)-related deaths have increased dramatically in the last several years, with much of the fentanyl identified consisting of illicitly manufactured fentanyl (IMF). 2,3 Furthermore, the COVID-19 pandemic resulted in an acceleration of overdose deaths. 4 Synthetic opioids are thought to be the primary driver of this increase, discovered as contaminants in non-opioid drugs of misuse such as cocaine and methamphetamine in addition to opioids such as heroin, although it is known that lack of access to prevention, treatment, recovery and harm reduction services also played a role. 4 The intersection of race and geography compound opioid-related disparities, 5 and lack of access to treatment and recovery programming has been a long-standing issue in rural and tribal communities and urban neighborhoods characterized by high rates of poverty. 6
Stigma is defined as an attribute, behavior, circumstance, or condition that is socially discrediting, and is known to be a major barrier to seeking help for a substance use disorder (SUD). Of the more than 23 million Americans who meet criteria for a SUD each year, it is estimated that only 10% access treatment. 7 Two main factors that influence stigma are cause and controllability: stigma decreases when people perceive that the individual is not responsible for causing his/her problem and when he or she is unable to control it. 8 Research shows that one critical contributory factor to the perpetuation of stigma is the language used to describe SUD; use of medically and scientifically accurate terms such as substance use disorder and opioid use disorder is consistent with a public health approach that acknowledges the physiological component of addiction. 8 Healthcare professionals can reduce stigma by using non-punitive and medically accurate terminology by removing the terms “abuse,” “abuser,” “junkie,” “dirty,” and “clean” from our vocabulary.
Opioid use disorder (OUD) is a diagnosis introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 9 Although OUD is a generic term given in the DSM-5, the guidelines indicate that the diagnosis should include the actual opioid drug being used by the individual (e.g., heroin use disorder for individuals who use the opioid heroin). 9 The diagnosis of OUD can be applied to someone who uses opioid drugs and has at least two of a list of symptoms provided by DSM-5 within a 12-month period. 9 While behavioral interventions have been the foundation of treatment of OUD for many years, abstinence-based programs have been shown to be inferior to medication. 10 Medications for opioid use disorder (MOUD), also sometimes known as medication-assisted treatment (MAT), is an approach to treating OUD that combines the use of FDA-approved drugs with counseling and behavioral therapies. 11
Methadone and buprenorphine have been shown to reduce opioid cravings, increase treatment retention, reduce illicit opioid use, and increase overall survival. 10,12,13,14 Some research has shown that treatment with buprenorphine may be successful even without counseling and behavioral therapies. 11 Buprenorphine is also combined with naloxone, an opioid antagonist, to deter abuse of the formulation. This combination drug is available in tablet form (Zubsolv; Orexo US, Inc.) and as a sublingual film or tablet (Suboxone; Invidior). Naltrexone is a competitive opioid antagonist that is FDA approved for both alcohol and opioid use disorders and is available as an extended-release injection of naltrexone base (Vivitrol, Alkermes) and as a 50-mg oral tablet of naltrexone hydrochloride. Harm reduction, a set of strategies and ideas aimed at reducing the negative consequences associated with substance use, is another approach used in caring for individuals with SUD. These strategies support increasing the safety of drug use, meeting people “where they are at,” and addressing specific conditions of drug use. Examples of harm reduction tools/models used in opioid use disorder management include naloxone for prevention of opioid overdose, access to sterile syringes to prevent infection, fentanyl testing, and supervised consumption services. 15
Case
You are a clinical pharmacist working at a primary care clinic in a homeless shelter. You work as part of the primary care team that provides MOUD to people with OUD.
CC: “My urine is going to be dirty.”
Patient: DS is a 41-year-old male (67.7 in, 89 kg) who presents to the clinic today to start treatment for OUD.
HPI: DS has been on buprenorphine-naloxone in the past for OUD. He notes that this was helpful, but he relapsed and ran out of medication refills. Until recently, he was experiencing street homelessness but was able to find a bed in the shelter (where you are seeing him). He reports use of heroin and cocaine in the past two days to manage cravings and withdrawal symptoms.
PMH: OUD; allergic rhinitis; HTN; T2DM
FH:
- Father deceased (54 years old, heart disease); cannabis/EtOH/cocaine use
- Mother alive; s/p CVA, cannabis/EtOH/cocaine use
-
Three sisters
- HTN
- HTN, tobacco/ETOH use
- HTN, DM, tobacco/cannabis use
SH:
- Use of IV and IN heroin since age 16
- History of cocaine, oxycodone, and benzodiazepine use
- Drinks alcohol socially
- Uses tobacco (½ pack per day x 25 years)
Medications:
- Loratadine 10 mg once daily
- Lisinopril 20 mg once daily
- Metformin 1000 mg twice daily
Allergies: NKDA
Vitals:
- BP 135/83 mmHg
- HR 91 bpm
- RR 16/min
- Temp 98.4°F
- Pulse ox 98% on RA
Labs:
| Parameter | Value | Parameter | Value |
|---|---|---|---|
| Na | 135 mmol/L | HgbA1c | 6.8% |
| K | 5.0 mmol/L | Glu | 100 mg/dL |
| Cl | 97 mmol/L | Ca | 9.5 mg/dL |
| CO 2 | 25 mEq/L | AST | 23 IU/L |
| BUN | 19 mg/dL | ALT | 27 IU/L |
| SCr | 0.78 mg/dL |
- STI screening negative
-
Urine drug screen
- Amphetamines negative
- Benzodiazepines positive
- Cannabinoid negative
- Cocaine positive
- Opiates positive
- Methadone negative
- Fentanyl positive
- Buprenorphine negative
- Norbuprenorphine negative
ROS:
- Alert and oriented x3, comfortable
- Psych appropriate mood and affect
Surgical history/hospitalizations:
- ER visit one year ago for opioid overdose
- Left knee replacement two years ago
SDH: DS reports that his heroin use has prevented him from keeping stable housing. He has been experiencing homelessness for the past two years. He left the shelter during the height of the COVID-19 pandemic due to overcrowding and concern about getting infected. He was experiencing street homelessness for the past six months, but he has now returned to the shelter and reports it is less crowded. DS is currently unemployed with no income. In the past, he worked for a moving company but had to stop due to pain in both knees, despite a left knee replacement. He wants to renew his license to become a cab driver. He does not have health insurance, and receives medical care, including medications, free of charge through this clinic. DS keeps in touch with one of his sisters, but their relationship has been strained since he started treatment for OUD. His sister was not supportive of his decision and told him that he was “substituting one drug for another – what’s the difference?”
Additional context: DS reports that he grew up in a home with alcohol and drug use and was abused as a child. He believes that this has impacted his mental health and coping strategies as an adult.
Case Questions
- What components of the DS’s history may have put him at risk for OUD? What risk factors does he have for opioid overdose death?
- What are the FDA-approved treatment options for DS and his OUD? Compare and contrast their pharmacology, administration, and prescribing/accessibility.
- How would you discuss today’s urine drug screen results with DS?
- After further discussion with you, DS says that he would like to seek treatment with buprenorphine again since he reports it had been helpful in the past and it is easily accessible through his primary care physician’s office and local pharmacy. When would it be appropriate to initiate treatment with buprenorphine for OUD?
- What other healthcare professionals can we pull in to help address DS’s OUD and optimize treatment?
- What are the goals of therapy for treating DS’s OUD with buprenorphine?
- What harm reduction interventions can you recommend for DS?
- What would you tell the patient regarding his sister’s perception that he is “substituting” his substance use by starting treatment for OUD, and that it is “no different” from heroin?
- Knowing about this patient’s substance use history, are there any drug interactions you might want to warn him about?
Author Commentary
Pharmacists continue to play significant and expanding roles in addressing the opioid epidemic. For example, pharmacists can prevent opioid misuse by identifying risk factors for OUD and overdose through utilizing prescription drug monitoring programs (PDMPs) and facilitating safe disposal of medications by hosting “drug take back days.” Pharmacists can also educate patients, caregivers, and members of the care team about the safe and effective use of treatments for opioid use disorder and for prescription opioids. Another role for pharmacists in opioid use disorder management is monitoring drug therapy for treatment of opioid use disorder or management of pain for efficacy and safety. Pharmacists are involved in practicing harm reduction, including improving access to naloxone and sterile syringes for people who use drugs. Pharmacists may address and prevent substance use stigma in both patient interactions and training of health care staff. In these roles, pharmacists collaborate with other healthcare professionals to optimize treatment outcomes for patients. 16
Patient Approaches and Opportunities
Pharmacists have numerous opportunities for interventions to improve outcomes or lesson harm in people with OUD. Social determinants of health play a critical and under-addressed role in substance use. It is imperative to recognize that homelessness, lack of health insurance, and unemployment can affect how people with OUD can access treatment services.
It is important for pharmacists to avoid stigmatizing language and utilize harm reduction tools and approaches when working with patients with OUD. Stigma is a barrier that prevents many individuals with substance use disorders from seeking treatment. Further, for those who do seek treatment, stigma can negatively impact the care that is provided by some healthcare professionals who fail to address underlying causes OUD. 17
Harm reduction tools can limit negative consequences associated with drug use while maintaining respect for the rights of people who use drugs. 18 Additionally, it is common for an individual with a OUD to use more than one drug, and it is also common for opioids purchased on the street to be laced with other drugs, including fentanyl analogues. 2,3 Offering naloxone to patients for opioid overdose reversal and prevention of fatal overdose is a significant and potentially life-saving intervention that pharmacists can make in a variety of pharmacy practice settings. Also, pharmacists can identify and educate patients about drug interactions between opioids and other sedatives such as alcohol and benzodiazepines. Concurrent tobacco use is also common among people with OUD; pharmacists are well-poised to support these individuals in tobacco cessation.
Related chapters of interest:
- Safe opioid use in the community setting: reverse the curse?
- Smoke in the mirrors: the continuing problem of tobacco use
- Harm reduction for people who use drugs: A life-saving opportunity
- PrEPare yourself: let’s talk about sex
External resources:
-
Websites:
- National Institute on Drug Abuse. Opioid overdose crisis. https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis
- Treatment guidelines
- Substance Abuse and Mental Health Services Administration. Medications for opioid use disorder. Treatment Improvement Protocol (TIP) Series 63, Full Document. HHS Publication No. (SMA) 18- 5063FULLDOC. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.
-
Journal articles:
- Webster LR. Risk factors for opioid use disorder and overdose. Anesthesia & Analgesia 2017;125(5):1741-8.
- Dasgupta N, Beletsky L, Ciccarone D. Opioid crisis: no easy fix to its social and economic determinants. Am J Public Health 2018;108(2):182-6.
References
- Wilson N, Kariisa M, Seth P, Smith H, Davis NL. Drug and opioid-involved overdose deaths – United States, 2017-2018. MMWR Morb Mortal Wkly Rep 2020 ; 69(11):290-297.
- Centers for Disease Control and Prevention. Health Alert Network (HAN) 00413. Rising numbers of deaths involving fentanyl and fentanyl analogs, including carfentanil, and increased usage and mixing with non-opioids. 2018. https://emergency.cdc.gov/han/han00413.asp . Accessed December 21, 2020.
- Dai Z, Abate MA, Smith GS, Kraner JC, and Mock AR. Fentanyl and fentanyl-analog involvement in drug-related deaths. Drug Alcohol Depend 2019;196:1-8.
- Centers for Disease Control and Prevention. Overdose deaths accelerating during COVID-19: expanded prevention efforts needed. 2020. https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html . Accessed December 21, 2020.
- James CV, Moonesinghe R, Wilson-Frederick SM, Hall JE, Penman-Aguilar A, Bouye K. 2017. Racial/ethnic health disparities among rural adults – United States, 2012-2015. MMWR Surveill Summ 2017;66(23):1-9.
- Johnston KJ, Wen H, Joynt Maddox KE. Lack of access to specialists associated with mortality and preventable hospitalizations of rural Medicare beneficiaries. Health Aff (Millwood) 2019;38(12):1993-2002.
- Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.
- Kelly JF, Wakeman SE, Saitz R. Stop talking ‘dirty’: clinicians, language, and quality of care for the leading cause of preventable death in the United States. Am J Med 2015; 128(1):8-9.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5.™ 5th ed. Arlington, VA: American Psychiatric Publishing, Inc.
- Koehl JL, Zimmerman DE, Bridgeman PJ. Medications for management of opioid use disorder. Am J Health Syst Pharm 2019;76(15):1097-1103.
- Martin SA, Chiodo LM, Bosse JD, Wilson A. The next stage of buprenorphine care for opioid use disorder. Ann Intern Med 2018;169:628-35.
- Mattick RP, Breen C, Kimber J et al . Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2009; 3:CD002209.
- Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014; 2: CD002207.
- D’Onofrio G, O’Connor PG, Pantalon MV et al . Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA 2015; 313(16):1636-44.
- Harm Reduction Coalition. Principles of harm reduction. https://harmreduction.org/about-us/principles-of-harm-reduction/ . Accessed January 4, 2021.
- Centers for Disease Control and Prevention. Pharmacists on the front lines: addressing prescription opioid abuse and overdose. https://www.cdc.gov/drugoverdose/pdf/pharmacists_brochure-a.pdf . Accessed February 22, 2021.
- National Institute on Drug Abuse. Words matter: terms to use and avoid when talking about addiction. https://www.drugabuse.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-terms-to-use-avoid-when-talking-about-addiction . Accessed January 4, 2021.
- Harm Reduction Coalition. Principles of harm reduction. https://harmreduction.org/about-us/principles-of-harm-reduction/ . Accessed January 4, 2021.