August 23, 2023
The statistics regarding substance use disorders are frightening. On a special AMDA On-The-Go podcast, Sabine von Preyss-Friedman, MD, FACP, CMD, said, “In 2022 alone, the U.S. saw 109,000 deaths from drug overdoses, and Washington state has seen a 20% increase.” The good news, she said, is that effective treatments, particularly for opioid use disorders (OUDs), are available. She and her guest, Jennifer Azen, MD, discussed buprenorphine and substance use disorder in post-acute and long-term care (PALTC) settings.
Buprenorphine is a Food and Drug Administration (FDA)-approved medication to treat OUD. It is the first medication for this indication that can be prescribed or dispensed in a physician’s office or facility. “Buprenorphine is becoming fairly common in the U.S. Many patients are stable on this for their OUD for up to a decade,” Dr. Azen said. She noted that it will be more common in PALTC as facilities see more patients admitted on this medication. She observed, “Facilities that see a lot of trauma patients also often see a higher incidence of people with substance use disorders.”
While physicians practicing in settings such as PALTC can prescribe buprenorphine, the U.S. Drug Enforcement Administration (DEA) requires eight hours of CME to prevent and treat OUD and other substance use disorders. This requirement applies to most clinicians prescribing controlled substances under a DEA registration. This, Dr. Azen suggested, presents an opportunity for practitioners to learn how buprenorphine works, its mechanisms, and how it can be used in PALTC so patients aren’t destabilized and can get appropriate care.
It is essential for practitioners and clinical teams in PALTC to understand the use of this drug and be prepared to treat patients with OUD. Dr. Azen noted, “Patients being treated for substance use disorders—including OUD—are protected under the Americans with Disabilities Act. When they are referred to nursing facilities and denied admission based on their disorder, they have a claim for discrimination. The Justice Department is interested in this and looking at trends of patients being discriminated against because of substance use disorder.” As a result, she indicated, some facilities are coming under scrutiny. “It is important to recognize that all these patients need our care,” she said.
Talking about treatments for OUD, Dr. Azen noted, “Most people are aware of methadone. It’s highly effective in preventing deaths from OUD; it’s also a very restrictive treatment and not available to every person in the U.S.” On the other hand, buprenorphine is more available and incredibly effective, she explained, noting, “It truly treats OUD.” It also protects against getting to the level of respiratory depression related to overdoses.
Buprenorphine is an opioid partial agonist, which is considered to be safe and effective when used as prescribed. It acts on mu-opioid receptors at low doses as a partial mu agonist and keeps receptors stimulated. It saturates and has sealing effects. “It has a fascinating, complex pharmacology,” Dr. Azen noted.
The typical dose is 16 to 24 milligrams, said Dr. Azen. It can be titrated up if patients still have cravings or withdrawal symptoms. However, she stressed, “Once you get to about 32 milligrams, it won’t be effective if you add more.” She observed that when patients come to nursing homes, they typically are on a stable dose.
Dr. Azen also talked about how buprenorphine and naloxone sublingual tablets and film are used to treat OUD. Dosing on these is critical, as patients must hold them under their tongue until absorbed. Then, 30 minutes later, patients should rinse their mouths to help neutralize the acid. Dr. Azen suggested that this requires good nursing education, and having this information in the medication administration instructions is helpful. This medication can be administered simultaneously with other drugs, but it should be the last one given so that the full instructions can be followed.
Dr. Azen said that patients typically need to stay on this treatment for several years to truly stabilize. She observed that when they taper off too soon, they are more likely to relapse, which can be very dangerous. The best practice is to keep patients on this treatment, monitor it over time, and ensure the facility has medications available in a timely manner. This may mean including this drug in the facility’s emergency kit.
