Patient Case 2 Discussion

Matthew A. Torrington, MD: What does that make us think about in that case? What do you think?

Thomas R. Kosten, MD: I think several things that I wonder about in this. Is this a guy who just out of the blue, who decided “Let’s go buy some opiates at the local gas station and use them?” There seems to be like we’re missing something in this. High school just isn’t enough of an excuse. I think you have to think about longer term treatment, and I think based on the 8 mg of Naloxone that it took to reverse him and what’s on the street then he probably did get fentanyl in that. Then, the question is what do you want treat him with? Could you treat him with naltrexone? An injectable naltrexone lasts a month, so you don’t have compliance problems. Well, if he’s not opiate-dependent, that’s a real possibility, but I would first check how dependent is he on opiates. Assuming he is, then you’re really talking more likely about buprenorphine, and the buprenorphine dosages, as we said, are minimally now, probably 12 to 16 milligrams a day. Many people get up to 20 milligrams certainly in the VA [Veterans Affairs] population where average dose is 24 mg a day that people are getting. Much higher than we used to use. Now, will that dose block fentanyl? I realize we keep talking about fentanyl and the answer is that dose of buprenorphine will not. It’ll block every other opiate, but it won’t block fentanyl. What could you do? Well, there’s been a recent report sponsored by actually the company that makes the depot buprenorphine, that if you give depot buprenorphine at the 300 milligram dose every month, you get blood levels that are in fact sufficient to block certainly therapeutic dosages of fentanyl, but potentially, maybe twice the dose which would, of course, be potentially a lethal dose in some people. I think that it raises interesting questions about what new treatment alternatives we need to think about. One of them might end up being monthly 300 mg of injectable Sublocade, which is different than the FDA [Food and Drug Administration] guidance, which is they give 300 initially, but then typically shift to 100 per month. If you wanted to keep those blood levels up above 6, which is what you need to do to make it work against fentanyl, you’d need to give 300 every month. There’s no data by the way about whether naltrexone at the standard injectable doses we have, if that would block fentanyl. It will block all the other opiates without a doubt, but whether it will for fentanyl is not at all clear. There are some very interesting questions that get raised about this. What’s hidden behind that curtain of his chronicity with opiate use and what are your options?

Bill H. McCarberg, MD: Tom, would he have access to the drug? Namely, would his health care provider if it’s an HMO [health maintenance organization]? If he’s Medicare? Now, he’s 49 years old, so he’s not Medicare and he’s working so he is not Medicaid. Would he have coverage for that, or would it require prior authorization?

Thomas R. Kosten, MD: Well, I wish I could say that prior authorization, who would think to do that? Every insurance company apparently thinks to do that and puts you on the line with the social worker to say why you can’t prescribe this medication, which I’ve done. Usually, the injectable medications tend to be on the medical side of the benefit rather than the psychiatric side of the benefit and that’s a huge advantage because they’re used to paying for more expensive things on the medical side I’ve found. When you tell them how much say, just if I can mention a trade name, Sublocade would actually cost for 300 milligrams a month, they don’t bat an eye. If you did that for a psychiatric patient, they would just hang up the phone. Again, I bow to Dan’s expertise on this in terms of anything around cost. It’s not cheap. There’s no 2 ways about it, but I don’t quite know. Dan, do you know much on that?

Daniel E. Buffington, PharmD, MBA: Well, there’s a couple of issues packed in there. One is that a lot of pharmacies, like I said, do have access to discounted programs. Certainly, as new products come out there are incentive cards for discounted pricing for patients. That’s something to talk to the manufacturers about but there are state programs from state to state that provide it. Tom, I think you brought up an important point on this case. It doesn’t seem to be complete and one of the issues is this should be a wake-up call. Look at psychosocial factors, the risk factors for depression, the risk factors for substance use disorder. This is an opportunity and I think a commonly expressed shortcoming is to know where do you route these people for that next type of intervention? The other is Matt, I think you brought this up earlier, if used, and we don’t know much about this patient’s background is that’s what we’re talking about now, this would’ve been a moment that is followed up by EMS [emergency medical services] and an intervention for continued monitoring even if it’s to get them routed to some type of support program to get them started. Bill, you brought it up is, and if they don’t have access, and if it does turn out that they are a repetitive user and significant at-risk behavior, then they should be provided the supportive care of access to Naloxone products.

Matthew A. Torrington, MD: By the way, great guys, you guys are amazing. I would say that number 1, this person absolutely needs comprehensive individualized multimodal treatment over time that’s biologic, psychologic, social, spiritual, and nutritional to have the best possible chance of overcoming his challenges. We just got what happened in the ER [emergency room]. They don’t know anything about him. Unfortunately, the ER has never been great at routing these patients into treatment, but fortunately, it’s getting better and better and better. In California, some ERs are even starting buprenorphine, which is amazing. Because you could give this guy Sublocade if you had it in the emergency room right there. You could start them on buprenorphine. You could refer them into treatment. There are so many things that you could do with this teachable moment, but I’m afraid that in real life, many times this guy wakes up and goes home, and not much else happens.

Bill H. McCarberg, MD: That’s definitely true, Matt. I see this as a primary care issue because all we have is he has chronic pain, had an opioid use before, but we don’t know what his chronic pain is. How much medication is he taking? What has been done to that chronic pain after this MVA [motor vehicle accident]? Has he been evaluated by physical therapy? Is he on any kind of nonsteroidal? Is it musculoskeletal? Would duloxetine be a valuable adjunct for him to treat his probable depression since he's lost his job in addition to that? I think all of those things need to be addressed and primary care is really a good place to do this because the primary care provider probably knows this patient pretty well, knows the family, has got the inside and outs of what’s happened to this job loss and could really follow up on this in a more comprehensive manner and get to the bottom of it, to send out referrals where needed, and not have this happen again. This guy got very close to dying if you can see, a heart rate of 28, blood pressure real low, and it is not that unusual for him to have something happen like this again if he's not adequately addressed and evaluated right now. It’s the wake-up call like you say, and we need to take the handle on this and run with it because he’s going come in dead next time.

This transcript has been edited for clarity.