TxRx ECHO | April 16 | Co-Occurring Mental Health Conditions and Substance Use Disorder

good afternoon everyone and welcome to the Tex RX medications for substance useed disorder Echo please note that we are recording these sessions for later distribution anything listed in the chat does not appear in the recording my name is sha pris and I will be facilitating today's session a few quick announcements before we begin to help us with attendance please enter your name affiliation and email into the chat uh you can access it by clicking on the speech bubble icon on the navigation bar uh the bottom of your window if you are one of our Bell Texas providers please make sure that you identify yourselves during the session if you are joining via phone please email your phone number and name to btx ata.edu some housekeeping please stay muted and unless you're speaking if you joined by the computer your mute button is on the bottom left of your Zoom controls if you are on the phone just press star six we encourage everyone to speak at these sessions especially during the discussion portion of the session we want to hear from as many of you as possible so please keep your comments brief to allow time for others to speak up you can also use the chat feature to share comments and questions please note that no predicted health information is allowed in either the chat or the discussion and that includes names emails uh addresses dates or any information that can easily identify an individual if you would like to view close captioning please navigate the bottom of your Zoom window and select the show captions option towards the end of the session uh the B Texas team will send out a link to an evaluation survey all participants filling out the survey will be automatically entered into a raffle for 30 Walmart gift card our didactic today is on co-occurring mental health conditions and substance Ed disorders and will be presented by Dr Eric parmon following that we will discuss a case presented by Dr Ralph lner we'll start with some introductions followed by didactics B well program announcements case presentation and open discussion thank you all again for joining today's Echo we look forward to learning alongside you and encourage you all to share your experiences and insights in today's conversation and with that we will do some introductions Dr King hello everybody I'm van King I'm the bwell medical director I'm a professor UT Health San Antonio and uh glad to be here H everybody thank you so much uh Dr Walker hi good afternoon Kristal Walker doctorally trained PA and I am the director of uh SS Clinical Services at my health my resources of tarant county in Fort Worth it's a mouthful I sometimes forget my own title but welcome everybody thank you so much Dr kowalek hi Alicia Dr kuk I'm with Bor College of Medicine and I'm medical director at Santa Maria Hospital thank you so much Dr paron hi everybody my name is Eric Perman I am um currently completing a t32 addiction Psychiatry research fellowship at Columbia University Irving Medical Center thank you so much for joining us today Dr lner hello I'm Dr lner I'm in I'm a uh primary care physician in the Texas Panhandle I do obot and uh also mental health um I'll be presenting a case today thank you so much uh J me Vidal hello everyone my name is Jasmine Vidal and I'm the tix RX program coordinator thank you for joining us today thank you and with that we will get started with our didactics Dr parmon you can take it away whenever you're ready thanks all right hi everybody uh hopefully you can see this screen okay so as I said already my my name is parman I am a psychiatrist I actually did my Psychiatry residency at UC San Antonio worked for many years with Dr King learn from the best so today I'm going to be talking about treatment for co-occurring psychiatric and substance use disorders and it's going to be a bit about medication treatment in particular and I wanted to make a a fairly bread and butter presentation because as I understand there are many levels of of governers here so I forgive me if it's you're already an addiction psychiatrist you you may already know all this stuff and that's okay all right I don't have any disclosures to report for better or worse okay so um learning objectives I want to us to be able to identify co-occurring psychiatric and substance use to S conditions develop an overall treatment framework identify specific treatments so that can be helpful to manage them all right so um in terms of the ideological theories of of co-occurring disorders and so what causes what's there's a couple different strains of thought and not really a consensus on what is doing what here so one thought is that there's something for an individual if a person has co-occurring psychiatric and substance use disorders maybe there's something that happened Upstream to both of them earlier in their life for instance that caused both to happen some there's another school of thought that at least for some people that substance use disorders May precipitate psych disorders in people who are particularly vulnerable and of course as a person deals with the consequences of their substance use disorder and the disarray that often causes that it not uncommonly leads to depression major depressive disorders Etc there's some for one school of thought that it goes the other way that sometimes people already with a psychiatric disorder might use substances and develop a substances disorder to deal with the symptoms or deal with the side effects of medications and probably for for many people it's bidirectional right and so they're mutually reinforcing a a psychiatric disorder can precipitate a substance disorder and vice versa so uh substance use disorders they're they're very common many people with substance use disorders particularly opioid use disorder particularly women with opioid use disorders have traumatic histories afterwards of yeah the the prevalence varies estimates but almost 80% uh based on some estimates and Trauma history often can lead to or contribute to post trumatic stress disorder with people who are um vulnerable or may contribute to development of personality disorders particularly portal and personal disorder and active as I mentioned active substance use disorders they not uncommonly create conditions that contribute to anxiety and depression and psychotic disorders or mood disorders bipolar Related Disorders the stimulants and so as you can see they they can really go in both directions and there's a very large percentage of people with substance use disorders who have some kind of diagnosable psychiatric condition so it's important to be able to recognize and and treat both so um some general treatment approaches it relies first on a good clinical evaluation you have to know that the patient has these things to be able to treat them as with any sort of treatments in terms of substance disorder and I would argue psychiatric disorders motivational interviewing is a very key piece of this and developing a patient Centric plan so it's it's really hard for person to address their substance these disorders if they're dealing with housing or food insecurity for instance so dealing with basic needs is often a very important part of the the plan oftentimes Psychotherapy is indicated there's for some substance use disorders that's the best treatment we have unfortunately we don't have some medications for certain substance use disorders like good ones for cannabis use disorder for instance that are FDA approved pharmacotherapy can be helpful and addressing their physical health needs all these are important to have a general treatment approach for people with coine disorders and successful treatment depends on you being aware that they're dealing with these things you can't Treet something if you don't know it's happening and part of that is you have to and you and the patient both need buy in for the treatments um if you're giving them a prescription and this is what you think will help them but they really this isn't what they think will work for them and they don't have a buy in it's probably not going to work and also you're can have the best thought for a treatments but if the if the person doesn't have access to the treatment then it's it's really not going to work if they can't afford the medications if they can't manage to get to the clinic during normal business hours Etc all right so uh this is very very Broad and sorry this is a busy slide but so just Psy psychiatric treatment and Broad stroke so this is uh Psychiatry residency condensed into a slide so um in general and this is a gross s of simplification so we can think of treating psychiatric conditions by the condition itself so depressive disorders and Broad strokes and anxiety disorders trauma Related Disorders ADHD and there's certain classes of medications that our evidence based in general for the overall conditions so for depressive disorders like major depression ssris are the classics of selective serotone reuptake inhibitors a typical antidepressants and of course there's therapy such as CBT which is a main stay um however we can also think about treating by symptom and this is important because sometimes when you have a person with curring disorders you're dealing with symptoms you have maybe a general sense of what the psychiatric condition is but your formulation is not completely set in stone it's hard to tell sometimes if it's a process maybe you're dealing with withdrawal and that's causing some of the anxiety or insomnia or if it's a substance induced depressive disorder for instance and sometimes you just you really you're dealing with symptoms and so there's certain medications that we can think of that and Broad Strokes treat those types of symptoms um and of course it's going to be really important to have an overall formulation and an idea of what you're treating so it's you can say okay well this this patient has insomnia I think it's primarily related to withdrawal and that's my conceptualization but maybe it's related to a depressive disorder or maybe some of both and so you can rationally start to pick some of these medications that might help s similar thing with substance use disorders so again we can have um treatment by condition treatment by symptoms here so I've boled the ones that are FDA approved like the gold standard treatment so for instance for nicotin use disorder the cold standard treatments we have nicotine replacement therapy we have Pon you can combine both and we have run andin which are all very good treatments for alcohol treatments are maybe not as good but we do have some FDA approved ones we have dulur alrix in a camper state which are the FDA approved ones but there's also many things that can and are often used off label for instance gapa penin to Pyramid backlin backlin that evid there's like a little bit of evidence that's why there's a question mark for some of this but it's not a very common treatment and it's not a very strong evidence base for opioids We have basically the best treatments the biggest effect sizes out of all the substance classes so we have nxone uh which of course comes in an oral formulation and a long long acting injectable methone and buprenorphine which also comes as a long acting injectable too for simulants we we really don't have great medication options there are some studies out there that do support using like psycho stimulus like for instance mix amphetamine salts listex amphetamine or treatment of cocaine use disorders there is a study coming out of Texas from tretti that really was a a good solid evidence base for perhaps considering treating methamphetamine use disorders with nxone and bupron for cannabis we again don't really have any FDA approved treatments there's some evidence that maybe anical cysteine can be used and that seems like the evidence space is stronger in adolescence versus adults not replicated very well some the findings in adults and we have modulators for the CB1 receptors for instance like NX amols that there's some evidence for it there have been some studies for instance for Gabapentin has some preliminary evidence but in general what we can also think of is treating by symptoms so the main kind of targets that we can think of is we can Target the cravings and we can Target the withdrawal and so to Target the Cravings oftentimes that's how we think maybe alrex Zone one of the reasons it works for conditions like alcohol use disorder yeah anical cine as I mentioned that's not to kind of work on Cravings maybe depron particularly for nicotine oftentimes your your patients will report that they just don't feel as much like like they don't have as much desire to to smoke we have The glt1 Agonist maybe there's some preliminary evidence and certainly anecdotal reports of I you know OIC and oftentimes people who are thinking OIC they report decreased cravings for substances and then the other broad category of symptoms that we can think of treating is withdrawal so very commonly that the main ones for withdrawal are anxiety and insomnia and of course each substance class has a different withdrawal phenomenon but these are very common and and pretty pretty well represented amongst substance classes so um for anxiety you have your antihistamines like hydroxyzine you have your Gaba receptor lians like Gabapentin ferone clonidine and for insomnia we have our atypical antidepressant like mortas aene Trazodone and then we have some of the second generation antic psychotics like kene hydroxyzine can work for that too and so effective treatment planning again just to hammer this point um you got to know that it what you're treating and the patient has to have bu and and one reason it can be helpful to talk about symptoms and managing symptoms is because that's often how the patient know how the person will talk about it why are they using the substance itself oftentimes is to deal with some of these symptoms they feel terrible when they go through withdrawal and that they can't sleep and for instance with cannabis use disorder withdrawal it's like yeah they classically a person can't really sleep very well they can't eat and so that could be why they they use or one of the reasons that they they use cannabis is to deal with some of the symptoms and to talk in terms of symptoms and getting on the same page it's like yeah we we're g to work together to deal with some of these symptoms and that can go a long way to having biner treatments and to be collaborative in that process but as I mentioned it's it's easy to get into the weeds if you're just chasing symptoms so it's important to also have a diagnostic formulation behind it so yeah maybe a person has anxiety that we think maybe there's a standalone anxiety disorder behind it too and it doesn't seem like they have a bipolar disorder we we screen for that and so there might be good rationale to create in the short term with with something like hydroxy but also at the same time starting a longer term treatment like an anti-depressant so some specific treatment issues things that sometimes I've encountered is that there's for some people there's a nervousness to use fenin for smaking sensation for a person with a depression a depressive disorder of a disorder because of this previously documented concern for mood and suicidality used to be blackbox warning it is no longer a blackbox warning about five years ago there was a seminal trial called the Eagles trial that showed that um essentially there were no worsen Neuropsychiatric side effects from these medications with people with mood disorders so it's it's a relatively safe medication of course there's always risks and benefits but I think it's veronin is very underused and oftentimes in this population that's one of the reasons that there's this misconception that there's a blackbox warning there's there's not for Al TR Zone if we're thinking of opio use disorders or alcohol use disorders or maybe even a simulant use disorder oftentimes people are are really nervous about the liver enzymes transaminitis is not an absolute contraindication and I think that some people they are a little too cautious that if it's out of reference range at all they shy away from using nrex Zone there's some evidence that suggests and certainly clinical practice to that it's reasonable to consider initiating treatment if the liver enzymes are within five times upper limit of normal and of course you want to check that again to make sure it's trending in the right direction but don't necessarily think that you can't prescribe Zone if a person has some liver abnormalities for stimulant yeah let's say you have a patient with ADHD and simul or rather and a substance use disorder some people think that it's an absolute Contra indication that oh no no no I can't I can't ever treat with a stimulant and that's not true there's actually good strong evidence-based that with ADHD co-occurring with substance disorders it's actually it improves overall outcomes it improves treatment retention adherence to treatments all cause mortality in some studies if you treat the ADHD including with the stimulant and of course you need to think through the risks and benefits but I would argue that it's important to consider treating ADHD um a couple other points so integrated and simultaneous care is is generally better than separate care fragmented care care so let's say you're an addiction medicine physician or provider and you're you're dealing you're treating them for yeah opioid use disorder and you're treating them for their hepatitis and you also are concerned that they have like a major depressive disorder and or a trauma disorder it's it will be better in general if you yourself are able or within your clinic in an integrated way to to treat them copper hensively versus referring them out because more appointments more Logistics more fragmentation of care often times providers don't communicate very well about care coordination it can be expensive all these issues can contribute um to a person not receiving adequate care and importantly I think the evidence is very clear that it's important to treat substance use disorders curring with psychiatric use disorders concurrently so treat them at the same time don't delay treatment until you deal with one to deal with the other it's important to treat them simultaneously of course it's important um I'm not saying that you need to manage absolutely everything out of this s yourself of course it's going to be important to appreciate things that are require a higher level of care like suicidality many psychosis imminent complicated withdrawal or other medical conditions UT another couple things I know I'm short on time here but keep in mind substance use does not equal a substance use disorder just because a person uses substances doesn't mean that they meet criteria so don't assume and if your goal doesn't meet the patient's goal then you generally the work is to find common ground and get on the same page and the best treatment is the one that the patient actually wants to do usually or as actually does in terms of psychotic disorders like frenia really consider long acting injectables when possible that's also true and I think for alcohol use disorders and opioid use disorders I I really am an advocate for long acting injectables like the long acting injectable form of malx zone or or the suade and it's okay to play the long game yeah just get them over the hump with some of these symptoms and with the goal to keep them care and treat them um and have them come back to you because the goal is to reduce harm so putting it all together uh and this is we've talked about a lot of this already um and so this is just kind of summing up what we've talked about so screen for things use screening tools there's common ones I know one that we're using the New York State Office of addiction and support services they've started using the assist screening tool for substances I'm not saying that that's the best one but there are many screening tools out there that can help you identify substance disorders and psychiatric disorders collaborate and really work together with your with the people with subes disorders offer evidence-based treatments and hopefully what I I'm hoping that a person who treats substance use disord even if you're not psychiatry trains you can still treat uncomplicated depressive disorders and anxiety disorders mild non-acute mood disorders if they're not forly manic or FL The Psychotic I think that that's fair game for a person hopefully to be able to treat even if you're not a specialist and of course the other way yeah I I'm hoping that everybody on this call if you're a prescriber can manage treating um curring disorders in terms of the the substance side with bicin alcohol use S disorder um and then yeah treat some of the side effects of the withdrawal phenomenons it's okay to think of let say a person has major depressive disorder and a substance D disorder and insomnia maybe think of using mortas aine trazodone If instead of a a major depressive disorder you think they might have a bipolar sort of maybe think of like copine or lanzapine if they have an alcohol use sort of with anxiety insomnia you can think of gabapentin and really the goal is with rational pharmacotherapy knocking out multiple birds with one stone so if they have like a tobacco use disorder and a major depressive disorder think about maybe proon in that situation or an anxiety disorder an alcohol use disorder maybe Gaba penon might be a reasonable Choice that's kind of what I I'm trying to convey as a take-home for rational phacos therapy um here's like just some common ones to really help get them over the hum clonidine I think it can be used for anxiety with or without withdrawal Gabapentin might be a good choice hydroxy cakil for a short term even if a person doesn't have like a schizophrenia or a bipolar disorder it it could be enough to get them through some of the withdrawal and the goal is to Ariz them while initiating some of the more durable treatments like the gold standard substance disorder treatments Psychotherapy ssris Mo St antic psychotics Etc yeah uh I I'm talking a little bit too long here so I'll skip this slide here um and here's just some examples of like a simple plan for instance this is the last slide oops me to advance that sorry here there we go yeah so for instance if you have like an overall medically healthy patient meeting criteria for major depressive disorder and alcohol use disorder complaining of anxiety you're not sure if it's meeting the criteria for Standalone anxiety disorder yeah of course screen them for higher level of care the imminent suicide risk complicated withdrawal and then maybe if you're satisfied that you can treat them as an out patient you might consider something like esram 5 to 10 milligrams starting off and then maybe some nrex Zone and Gaba Penton all together with the plan to follow them up pretty closely keep doing motivational enhancement motivational interviewing check for side effects check for uh make sure that they're getting some benefits you're going to try to clarify the diagnosis over time and if if it seems like maybe the anxiety remains after you're treating some of the withraw and perhaps you think that they have an anxiety like s and anxiety disorder you can at refer them to CBT for instance similar with cannabis use disorder let's say if you have a person with cannabis use disorder and they have like some mild psychotic symptoms maybe you're not sure if it's cannabis and juu maybe their in their 20s is this unmasking of a a primary psychotic disorder maybe they're smoking as well which is very common and they're they can't they can't eat and they can't sleep and they try to stop so consider as I said venin there's there's not really a blackbox morning for suicidality it's okay to use it maybe consider starting them on some ctip 50 milligrams follow them up closely consider TI trting kipine you're going to engage them in motivational enhancements and then over time if it appears like hey they're not using cannabis but they still have some psychotic phenomenon I'm thinking that maybe this is a primary psychotic disorder you might consider switching to a medication with a long acting formulation might consider cons assertive Community treatment family based vention skills training Etc so overall takeaway is I hope from this that even if you're not Psychiatry trained it's it's not scary to treat some of these things and your patients will do better for them so happy to take some questions sorry I ran a little bit over on timed thank you so much Dr parmon for this wonderful presentation uh we do have a couple minutes for some questions from our uh Learning Community here are there questions in in the chat yeah I just see a question here from Vanessa fears what is your opinion on orthomolecular treatment for individuals struggling struggling with alcohol use disorder I can't say that I really have read the literature based on that I mean yeah I I'll be curious to read more about that yeah I actually don't really have an opinion on that I I don't know if maybe Dr King knows more about it than I do but yeah actually I don't have an opinion okay vitam yeah I mean so like things like anical cysteine can be considered in some way like a supplement yeah I the the tricky thing with doing anything on evidence base is you have to have money to do the studies and if you're trying to do like vitamin and minerals it's hard to get a pharmaceutical company to want to push for that which is often times how these studies are done so the trick is that like if we're really trying to do evidence-based medicine it's hard to do those studies and at least for some of these things I haven't read very strong evidence based supporting them I mean there's some anecdotal evidence for some supplements um but it's just they're they're hard studies to get funded unfortunately there's another question uh from Kristen uh any thoughts on beiron has any data on T peti and aod being released yet yeah so um beon I've I've at least anecdotally used it with some success um I think oftentimes people who tend to respond to it tend to respond at higher dosage in that dose range you know some people of course you'll encounter opinions like oh it's just kind of like a placebo but I actually at least my own practice I have had people respond to it so yeah don't roll it out I think overall it's people tolerate it fairly well there's not a lot of risks involved in using booster own so it's something to consider but maybe keep your expectations modest uh and then I I haven't seen any of the the data on uh excuse me T TTI and that's a mouthful I know that some of these studies are ongoing and but yeah I haven't actually seen any of the data if it's been released yet Dr King you had a comment to make I thought at some point uh um no I was just going to say thanks Dr parman that was uh great I I I just saw a comment somebody uh somebody you know commented they really like the way you broke it down made it very sort of rational I I think we don't often see uh that approach and I I think especially for a broader audience that that is a nice way to present it so that people have some way to hang their hat on you know why patients may be on these various medicines yeah yeah thank you thank you so much this has been a wonderful discussion please keep your questions coming in the chat and uh uh and in the meanwhile we will move on to the next part of our uh session today uh Koo if you could please bring up the announcements thank you to claim your CME credit you must text by midnight tonight please text a 10 to 1000 95737 to 84452 1338 um you must register for each session you must text for each session by midnight to receive the CME credit next slide do you have a difficult case that you or your team have encountered sear offers you the opportunity to present any challenge your organization may be uh facing and receive feedback from our Hub of experts and the B broader Learning Community there is no need to prepare a formal presentation we will be sharing a case form with you to help with the presentation please uh email ca. next slide the center for uh substance use training and telling mentoring sead offers technical assistance for various substance use disorder needs and topics VI are a team of experts to request technical assistance please complete an online request form you can use the link in the chat next slide our webinar series driving in substance used disordered Service delivery in the postco era uh will be presenting um recognizing covid-19 related compassion fatigue and enhancing provider resiliency uh this is tomorrow at 12 noon please use the link in the chat to register uh it'll be a great session next slide and please join us for our next Tex RX Echo this will be on Tuesday May 21st at 12 noon with that we will move on to our case for today um Dr lner you can take it away whenever you're ready there it helps if I un mute um so coincidentally I have a case um of a patient who has both substance use and mental health issues um I'm going to be focusing on an area that um I don't normally focus on when I'm treating patients and that is U how to improve treatment of a male patient uh with opio disorder who's romantically involved with a female with opio disorder um one of my staff actually brought this up as uh something that uh she felt like um his girlfriend was holding him back so I have thought I'd look into that and and see see what uh uh what the literature says and just to give a little bit of background on this patient he has a substance use history um in terms of um you know he does use nicotine uh binges on alcohol uh abuses methamphetamine um in our area in the Texas Panhandle uh we do have MDMA in the uh meth um heroin he's used it in the past he smoked it um opioids fental popular these days um he's been using that um and but no ucin inhalant uh no benzos and uh but he did uh take some methadone recently um he and his girlfriend went through rehab um and they have supposedly not used any opioids since uh December 4th um although I did a tech method for the most part I I do think that they're being compliant um in terms of substance abuse uh counseling he's had it in the past um he's getting in the present um he's had inpatient treatment in impatient rehab he's not currently impatient um I'm using the we connect uh app with uh my patients so um he's using that to get uh Mutual uh support and peer support and then as far as uh medication used for opio juice disorder um we have buprenorphine that we're prescribing him and and it's also funded by bwell um although methadone is not part of his treatment he has used it uh at least once and I'm not using nxone um I've checked this I've checked it PDM MP and uh he doesn't he hasn't had any um opioids uh prescribed him um and uh he's had some benzos in the past uh prescribed but that was about it um depression um he um he does have a major depressive disorder moderate um also um he's having a lot of financial problems so he's able to afford the buprenorphine because it doesn't cost anything for him uh but any other medications even if they're uh a little bit of money um he just says he can't afford them um self-medicates with meth um and then he doesn't have Mania uh I don't detect any PTSD OCD or panic disorder no psychosis he does have ADHD and he self-medicates with meth as far as the dsm5 criteria are concerned for his substances Fentanyl and methamphetamine um he meets criteria in terms of substances taken in uh in larger amounts over a longer period of time than intended for example It's Not Unusual for me to see people are taking you know four or five grams of of Fentanyl and uh using a lot of meth um and then persistent desire or unsuccessful efforts to cut down or control substance use a great deal of time spent in activities to obtain the substance has been more so in in the past than current meth is readily available it's not doesn't take a lot of effort to get that um it's also cheaper than pharmaceutical medications apparently uh Cravings um he does have that and that's one of the reasons that um he wanted the treatment with buprenorphine and also a recurrent substance use um and uh failure to fulfill major role obligations at work he's he's not been able to hold a job um and continued substances despite having persistent recurrent social or interpersonal problems um uh that's also an issue uh particularly with the parents his parents and and her parents as far as important social occupational recreational activities um given up um it's a yes but he does have some Hobbies um a recurrent substance use in the situation which is physically hazardous he has had a overdose about a year ago um so um continued use despite having persistent recurrent psych physical and psychological problems likely caused by the substances um I I couldn't really tease that out um uh as well and then tolerance definitely as that withdrawal was a big motivation for using buprenorphine so one thing I'm finding uh with people who are using high dose fentanyls I have to use pretty high dose buprenorphine to control their Cravings um it does seem to uh become less of an issue over time uh but um sometimes it's hard for me to know exactly how much um to prescribe other than I want to make sure that they don't have cravings and they're not you know still having cravings and then getting methadone or other substances I I want him to just use buern orphin he's using River Ox ban um it's also called zalto is the brand name uh the dose is 20 milligrams day for clotting disorder he also um has been prescribed uh Lexapro as apram um but he's unable to afford it um Aderall again I prescrib that to him but um methamphetamine is a lot cheaper and uh he hasn't been able to afford the ader all um warrin is a sort of an emergency substitute for in casee he runs out of the uh River oxan prescribe that for him it only costs a dollar 80 but I'm not sure that he's gotten it either um terms of medical comorbidities he does have this clotting disorder he has also a suspicious lung nodule or mask that um needs to be followed up with a a CT chest we're trying to figure out how to get him um to get that uh it's pretty difficult because he doesn't have insurance uh he's also having a lot of abnormal weight loss which concerns me um in terms of the the mass in terms of the treatment plan um I have a lot of ideas on this and I I don't want to necessarily um you know squel all the the potential ideas or or thoughts um I'm going to uh basically point out a few things one of them is uh co-ed treatment uh is not really part of the conventional wisdom for early stage uh recovery or or substance abuse treatments you know usually have men uh uh male or female U treatment uh wings or or um facilities and women tend to get uh have a little bit harder time finding uh facilities interest interestingly enough and certainly don't know of any Co treatment other than outpatient um I never really thought about integrated relationship counseling one of the things that I read um is that people with opioid disorder don't have a lot of uh social or um interpersonal uh relationships with others uh so you don't want to necessarily discourage the only relationship that they might have that's positive and I have had uh couples that have come in um where they're both either using alcohol or substances and theyve sort of encouraged each other and help each other U stay sober so um with that I am going to go ahead and uh pause for a moment and um turn it over for suggestions questions um and criticism thank you so much Dr lner for presenting this case uh um I see a question here from Kristen in the chat has he been connected to an fqc or charity clinic or Pharmacy uh Dr lner you're muted sorry um so I'm not sure what fqc is but it sounds like it's some type of Charity um because that's what the next question is um so um maybe someone can comment on that uh but as far as Charity Pharmacy or clinic I'm not aware of any in this area but I'm certainly uh if somebody has suggestions I would definitely be interested because uh there's a lot that's not being treated in this patient because he can't afford the medic the medicine yeah this is Alicia Dr kuk so in fq is a federally qualified Health Center hi um so I I mean you can Google search but you're probably very aware of what free resources are available in your area and it may just be kind of a desert for that type of of um of research but thanks Dr Clancy I said uh said she can look up by zip so um maybe yall could connect on that I was curious about um you know if um you know he and maybe they are still side two kind of questions are still struggling um it looks like um for the most part there um his UD is pretty well managed with the pupin orphen um although the methadone you know being in his urine you know maybe concern but was is there any consideration or is it even an option in your area for Methadone and going to a full Agonist which um you know I always get leery of going above about four films a day on the borine or above 32 because we really do get that sealing effect um and my limited experience with it has been when I have done that that uh a lot of times it isn't that effective um and I see other use escalate um which you know again from a harm reduction standpoint you know diversion may not be that big a a deal but when my patient may be using those extra doses to fund ongoing other use that does become a big deal to me and so I don't know if that's something you've considered and and um what's available for your patient so that was one question I had right um so methadone um is is not Ava available in this area um it's 60 miles away and then if you don't have a reliable car you can't get to it um even in terms of vper orphen I've had people that U you know have had to tr travel you know a couple hundred miles so uh it's it's relatively new and I'm I'm really pretty much the only one who uh prescribes it in this area um so I would say that would that's a great idea um but unfortunately you know I'm not a federal clinic and any here yeah yeah um so I do um I do suspect that there's probably diversion um and but at the same time it's from a harm reduction standpoint um I'm um I I would like to get the uh the girlfriend uh back into treatment she was in treatment for a while and then she so dropped off um so I'm trying to get her back in um so so that's one of my goals but yeah you're absolutely right um I uh I'm torn about the whole diversion thing because you know it's just not something as a doctor that you like to see yeah yeah um yeah I I figured there was probably a huge barri to methodone up there because I know Sox's just now kind of getting out there with your work and stuff that you're doing um the other question I had was um I didn't hear anything about an assessment or um if there was you know any exploration of if there is any um interpersonal violence in the relationship on either direction and you know it can often be under um asked about with um you know uh the male partner in a more heterosexual relationship um and if that's something you've explored um the safety within relationship besides the safety of you know maybe serving as triggers for each other and things like that um that's a that's a great question and uh because I have treated her in the past um I do have some insight um she does have um um PTSD from um things that have happened um but not recent not from recent events um so um you know she's told me a lot she told me a lot about the relationship before I ever met him um and it seemed like um that was was was not part of it I have other patients where that is a big problem um but this this doesn't appear to be one of those um one of the things that I thought that I kind of uh I didn't even think about was whether uh buprenorphine would have a side effect in terms of rectile dysfunction or sexual dysfunction and then also in women having you know some effect on uh sexual relationships and at least now I'm going to ask you know I didn't even think to ask before but um I wonder if that's why um sometimes people use meth amphetamine is to sort of compensate for that in some way um so that was one thing that I was really curious about because I certainly don't see it in like lexic comp as being uh anywhere near the the top of side effects but it wouldn't surprise me if it wasn't and I know that opioids uh reduce testosterone so I'm kind of curious whether hph does that the long run I haven't seen it as much um in that case sorry hey yeah you know i' um as far as testosterone and bpan orphin U my understanding is that it really isn't as much of a problem as uh you know methadone or full or other full agonists are at at higher doses so I I I believe it is is more sparing with that um I I I have to um I have to give you some uh some uh props for uh you know trying to think about couples's therapy with with with these two but you know it's it's hard for me to to think about how one would try to do that uh if one is you know is is is often um using I mean I'm assuming she must be using you know elicit opioids all the time they're both using meth I would imagine yeah so really I I think the first order of business is is getting people you know in some kind of reasonable stable shape and uh um it would you know this doesn't sound like the couple that's building them you know each other up and uh help each other with their recovery this is is the more than half where they you know end up uh um in influencing each other to continue using so yeah this is probably the double decline uh but I I would say that um I just had never really thought about the question I just always you know I knew the conventional wisdom was not to do it and uh so I you know thought I'd look into why why is why don't you do it and I have had couples where there was this positive reinforcement um this isn't one of them I feel like uh this is a relationship where the um um the sum of the parts is less than each individual um at least in terms of recovery so but um you know one of the things that's a real issue is that they don't want to be in separate you know they don't want to separate and and go into rehab again separate so that's kind of why I was thinking about it but uh boy it's a challenge um I think the way I usually approach these things is like listen this isn't a permanent thing how is she going to stop if if you guys continue to use together so sometimes you can frame it as a positive thing for their relationship and their joint recovery by you know somebody taking the initiative um you know maybe it wouldn't work but um but over a period of time you know especially if if things aren't going any better then uh you know sometimes one person decides okay I mean she may end up actually being the one that ends up going to rehab just because you know sounds like she's probably doing that much worse but uh but I think G given a giving a a reasonable message over time um uh you know often times you know you know patients may consider it right you hope it doesn't happen after some you know bad thing has happened somebody lands in jail or something like that yes no I think um you know right now there is no coed inpatient sort of rehab type treatment that I'm aware of anywhere near here um but um out patient I can do some I I never thought about doing couples therapy for uh medication assisted treatment of opio use disorder I don't know that I'm that I'm considering it either but um at least I thought I'd uh I'd look at the question um I would say it has to be a very Niche expert kind of treatment I can't say I've ever read anything about it with you know with people that are are actively used right yeah I was I was wondering about your experience with um you know his partner when she was on um borine treatment on obot with you was meth still an issue when she was on but did she ever stabilize um so she um she did uh she did use meth occasionally when he wasn't uh in the picture um I guess he was dating someone else um but um she um she would use it intermittently and again I I don't know if if that's because um I never really asked a whole lot about the side effects of buprenorphine other than you know is it um causing you to have constipation or or things of that nature I never really thought about you know is it making you fatigued and uh are you using meth to compensate for this yeah yeah much less likely though as Dr King was pointing out then full Agonist which is what they're kind of you know we're using in now on instead I I haven't seen a lot occasionally but yeah much more common when I was working methodone to see that okay that's interesting thought um I see a couple of questions in the chat uh from the first one is from Daniel Sledge how does he afford rivo sapan I'm sorry I'm mispronouncing that name is he getting samples or is he on a patient assistance program uh I think his dad is paying for it um so his dad is giving him $300 or whatever it is uh to to pay for that U and then um you know he doesn't have he's having housing insecurity just got kicked they just got kicked out of their home because they never paid rent for the past six months so um uh I think it's a question of priorities like what do you want to spend your money on housing or car or medications and unfortunately some people have to make those kind of decisions right and we have a couple of questions here from Barbara monag is this patient eligible for medicine um usually young men um I don't know that they uh during covid yes but you know not currently um and then she uh even uh she's eligible for some type of uh uh insurance which is why she's not do well um but um she um had a surgery but even even for her Medicaid it's very I don't see a lot of young uh you know 41y old men that are on Medicaid um unless they have other disabilities thank you so much this has been a wonderful discussion um before we close up I thought uh Dr Walker you had something to share I saw you un mute at some point no I was just gonna ask if you um had access to the we connect app through bwell um because that might be a way for them to you know individually get some peer support and some extra wraparound services and some contingency management for the methampetamine use issues uh if that's a resource that you have to grab on to for the two of them uh yes he's uh he's using the we connect app and she's used it quite a bit in the past uh I don't know how much she's using it currently um but um yeah it's a great app and it's it's one that I use uh even for people that are not you know connected to substance I'll have him downloaded and and use the free version well thank you so much this has been a wonderful discussion and I will request uh Dr kowalchuk to provide a summary of the session please yeah so we have a um a a gentleman in his 40s who's um on obot uh with borine um for his opiate use disorder and that's uh fairly well managed um with with the borine at at maximal doses um but on ongoing struggles with methamphetamine use disorder um and has a partner with ongoing struggles with opiate and methamphetamine use disorder a female partner um and uh talking about strategies to keep um uh him engaged um to possibly get her back into treatment um and that for some uh couples uh you know there there are opportunities for Synergy in terms of um uh getting into and sustaining recovery and then for other couples it does not seem um to work out that way um that uh they can continue to spiral uh and so this is a a tough case to manage particularly in a low resource um you know um uh situation um that they both find themselves in um and in a an area of um relatively D of of more intensive services to be available um and so um you know ongoing uh work through motivational interviewing um keeping the patient that is actively engaged in in treatment um coming and in treatment um and um you know perhaps over time helping them reflect on um kind of if they're meeting their their personal goal um with the current status quo or not may maybe uh eventually effective in you know helping them decide to maybe uh move forward uh separately from their partner if their partner isn't able to engage and and get back um into treatment thank you great case thank you apologize thank you again Dr kowaluk and thank you Dr lner for bringing this case to us uh and thank you all for joining today's Echo session as a reminder to earn a c credits so please text the activity code one9 uh 5737 to uh the number the details are in the chat please to earn your c um we also request you to complete the post session survey using the link in the chat the survey will be open for one week if you would like to present a case um please email ca.edu thank you and have a wonderful rest of your day bye-bye

Channel: Be Well Texas

Views: 121

Keywords:

Id: TtYDBew9Xos

Length: 61min 38sec (3698 seconds)

Published: Mon Jun 24 2024