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Difficulty: MediumSubstance-Related and Addictive Disorders

A 34-year-old man comes to the outpatient clinic requesting assistance with substance use cessation. He has been crushing and snorting prescription oxycodone daily for the past two years and recently transitioned to intravenous heroin use. He states, 'I want to get clean, but the withdrawals are unbearable.' His last opioid use was approximately 16 hours ago. His medical history is significant for a major depressive episode at age 25, for which he was prescribed fluoxetine 20 mg daily, which he continues to take. Upon further psychiatric history, he recalls a distinct three-week period during college when he slept only two hours a night, aggressively day-traded stocks leading to bankruptcy, and felt 'invincible.' He also notes occasional paranoia that undercover police are tracking his phone, but this only occurs when he is actively attempting to purchase illicit drugs. He is employed as a financial analyst and mentions, 'My manager is getting suspicious of my erratic hours, but I haven't told anyone at work about my problem.' Vital signs are temperature 37.1°C (98.8°F), blood pressure 142/88 mmHg, pulse 110/min, and respirations 18/min. Physical examination reveals mydriasis, frequent yawning, rhinorrhea, and prominent piloerection. Which of the following is the most appropriate next step in the management of this patient?

  1. Administer sublingual buprenorphine-naloxoneAnswer
  2. B
    Administer long-acting intramuscular naltrexone
  3. C
    Increase the daily dosage of fluoxetine
  4. D
    Initiate treatment with oral risperidone
  5. E
    Notify the patient's employer to coordinate a medical leave of absence

Answer

Administer sublingual buprenorphine-naloxone
The correct next step is to administer sublingual buprenorphine-naloxone. This patient has Opioid Use Disorder and is presenting in active, mild-to-moderate opioid withdrawal (evidenced by mydriasis, yawning, rhinorrhea, piloerection, and tachycardia 16 hours after his last heroin use). Buprenorphine is a partial mu-opioid receptor agonist with a high receptor affinity. It is a first-line medication for the treatment of Opioid Use Disorder. Because of its high affinity, it can displace full agonists (like heroin or oxycodone) from the receptor. Therefore, it must be initiated only after a patient is exhibiting objective signs of withdrawal; otherwise, it can precipitate acute withdrawal. Since this patient is already in withdrawal, buprenorphine induction is appropriate and will safely relieve his symptoms while providing maintenance therapy. Naloxone is included in the formulation to deter intravenous misuse, as it is poorly absorbed sublingually but active if injected.

Step-by-Step Solution

1
Identify the primary clinical syndrome.
The patient is presenting with Opioid Use Disorder and is currently experiencing acute opioid withdrawal.
Vital signs show tachycardia and mild hypertension, alongside physical findings of mydriasis, yawning, rhinorrhea, and piloerection, which are classic for opioid withdrawal following cessation 16 hours ago.
2
Determine the most appropriate pharmacotherapy for the current state.
Sublingual buprenorphine-naloxone is the best choice.
Buprenorphine, a partial opioid agonist, is indicated for maintenance therapy in Opioid Use Disorder. It must be initiated when the patient is in active mild-to-moderate withdrawal (as seen here) to avoid precipitating withdrawal.
3
Rule out alternative interventions.
Naltrexone is contraindicated currently, SSRIs are risky given the bipolar history, antipsychotics are not indicated for situational paranoia, and breaching confidentiality is unethical.
Each alternative violates a pharmacological principle, psychiatric diagnostic timeline, or ethical guideline.

Key Concept

Buprenorphine is a partial opioid agonist used for medication-assisted treatment of Opioid Use Disorder and should be initiated when a patient exhibits objective signs of active opioid withdrawal.
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Topics

Substance-Related and Addictive Disorders

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