Patient Case 1 Discussion

Matthew A. Torrington, MD: What do you think you’re going to do for this guy? Is he a candidate for naloxone? What do you think so far?

Bill H. McCarberg, MD: I’m curious about the fact that he’s being given an opioid on top of the fact that he’s already taking a partial agonist drug buprenorphine. Ostensibly, that medication is for his opioid use disorder. I don’t understand the dose, but that’s why he is taking it. If you were given an appropriate dose for opioid use disorder, this amount of opioid in addition probably wouldn’t treat his pain very well either because it would be antagonized by the buprenorphine.

I’m curious about this whole setup. I don’t know if it’s unrealistic because I don’t know if the ED [emergency department] doctor knows the buprenorphine and the opioid together may not be a good combination. You may need to use more of the opioid if you want to overcome the buprenorphine dose. It’s certainly a risky situation because, at a low dose, the patient may not get enough pain relief and may start taking more of the medication. If the patient was given 100 pills, he would certainly have enough medication to do damage and would need something like naloxone and a discussion with the family on how to use that drug.

But I want to point out that in something like this—the patient now is stabilized, they’re in a cast, they’re going home—there are other options for this patient. Certainly, a nonsteroidal should be thought about. It can be highly effective in a patient like this who has inflammatory pain. We already know the patient got IV [intravenous] Tylenol in the hospital, and his pain level went from 10 to 6. That’s how I read his pain record. Just from the Tylenol he had a lot of pain relief, so maybe Tylenol with a nonsteroidal without adding the opioid would have been a better choice for this guy because he already shows substance abuse disorder, and it’s going to be 5 days before he sees his primary care doctor. I’d probably have him back to the primary care the next day, so you can see how he did with whatever regimen you gave him. That’s how I’d deal with this.

Daniel E. Buffington, PharmD, MBA: That’s a key point when we look at the transition from emergency department to home: trying to look at things that don’t create that scenario 5 or even 2 weeks till somebody gets into a particular practice to be evaluated. A more aggressive nonsteroidal would be beneficial, maybe even if there’s a concern over inflammation steroid upon leaving or a 3-day course to get them there as part of what may be driving some of that pain or discomfort. Clearly, a drive for communications on discharge is to specialty practice and shorter windows in that point for care.

Thomas R. Kosten, MD: As an alternative to this, I’m not sure exactly why he was getting the 2 mg of buprenorphine. But as an analgesic, buprenorphine at 2 mg presumably sublingual is quite a good dose for analgesia. It just doesn’t last that long, so you may have to give it 3 to 4 times a day to get actual analgesia from it. The advantage is that if you were then giving it, what would be the equivalent? At 8 mg a day, at least, that’s a dose that blocks many other opiates and things that he might overdose with. Buprenorphine is a good analgesic. It has a ceiling on it. This is the type of pain that I suspect would be more than sufficient. I bow to Bill’s expertise on whether he thinks that’s true, but these patients I’ve had that have taken 2 mg 4 times a day have gotten some remarkable pain relief from that as well because they’ve had opiates as a problem in the past. We’re dealing with that problem.

Matthew A. Torrington, MD: I love all of that. I’ll add a few things. A) You can increase the dose in frequency of buprenorphine. B) You could be more aggressive with your N sets. C) If you don’t do enough to treat this guy’s pain, you can drive him to the illicit market, and that’s when he becomes the real victim of overdose. Part of the point is that I see a lot of substandard pain treatment, which makes even reasonable people go to the illicit market to get something else to help them with their discomfort. Humans don’t want to suffer, and they’ll take a path to help them alleviate their suffering. If we don’t do an adequate job, they’ll take matters into their own hands. I love all those points. That’s really helpful. In California, you’d be giving this person…a prescription for naloxone because anytime you prescribe a controlled substance, you need to do that. In other states, it could be totally worth it. Any other comments about this case before we move on?

Thomas R. Kosten, MD: That dose of naloxone I prescribed would be the 8-mg dose because if he did go to the illicit market, unfortunately fentanyl might be in that. Then, you’re going to need a big dose of naloxone to do something about that.

Daniel E. Buffington, PharmD, MBA: Absolutely.

Bill H. McCarberg, MD: I want to point out that most of these naloxone compounds are covered by wherever they’re getting their medical care. But if they don’t have medical insurance, it can be very expensive. I called CVS, which has a furnishing ability in California. They don’t need a prescription, so the pharmacy can write a prescription under a state order that they can furnish the dose. I asked CVS, “How much does it cost the patient?” It’s $80 for the nasal Narcan generic, which is a hefty amount if patients don’t have a whole lot of money. If they don’t have insurance, it’s problematic. There are insurance cards that you can get in some places. But without insurance, it can run into a lot of money. You have to be aware of that.

Daniel E. Buffington, PharmD, MBA: Bill, you raise a great point in terms of ease of access and affordability. We all get very busy in point-of-care activities, but if you track legislative initiatives in your own states, you’ll find that there’s a lot of those specialty access protocols. In many cases, there’s state-funded access to product for those who fall outside some other type of insurance. Thus, it’s important for each of us to look at what’s happening in our own states that impact our area and communities.

Matthew A. Torrington, MD: Such great points. As you’re saying that, I’m thinking to myself, “We should dispense the naloxone in the ED.” This guy just was in a car crash. We’re expecting them to go to the pharmacy and get this stuff, and then who knows. If it costs extra, they’re not going to get it. If people had to pay for an AED [automated external defibrillator], would they? No, but it needs to be there anyway. That’s something I thought of that makes sense.

Bill H. McCarberg, MD: Matt, another thing is that this person has an opioid use disorder. I assume he was given the buprenorphine because of treatment for the opioid use disorder, even though it’s a subtherapeutic dose, but let’s just put that out there. He’s still drinking and smoking cigarettes, which put him at high risk for going outside the standard prescribing realm to get medication, like the internet. So he really is high risk given all these factors. This is the guy who needs naloxone and a discussion with the wife or the other members of his family about what to look out for if he overdoses.

This transcript has been edited for clarity.