Addiction Medicine · Supplementary · from Addiction Medicine

Case 1: Opioid Use Disorder — Medication-Assisted Treatment

Patient Presentation

Demographics: 29-year-old female registered nurse (license currently suspended)

Chief Complaint: "I need help — I've been using fentanyl and I'm going to lose everything"

History of Present Illness: This 29-year-old female registered nurse presents voluntarily to the addiction medicine clinic seeking treatment for opioid use disorder. She reports a 3-year history of escalating opioid use that began with diversion of hydrocodone and oxycodone from her workplace. She initially started taking leftover patient medications for back pain following a lifting injury at work. Over time, she began diverting medications more frequently and in larger quantities to manage worsening withdrawal symptoms.

Six months ago, she transitioned to using illicitly obtained fentanyl (snorting pressed pills) after she was caught diverting controlled substances and her nursing license was suspended pending investigation by the state board of nursing. She currently uses approximately 4-6 pressed fentanyl pills daily at a cost of $100-150/day. She has depleted her savings and recently pawned her grandmother's jewelry. She experienced one non-fatal overdose 3 weeks ago that was reversed with naloxone by a friend.

She presents today 14 hours after her last fentanyl use and is in moderate opioid withdrawal. She has not eaten in 2 days and has been vomiting and having diarrhea. She reports strong cravings and is motivated to enter treatment, stating she wants to get her nursing license back, repair her relationship with her family, and "get her life back." She has no prior addiction treatment history.

Past Medical History:

• Lumbar strain (work-related injury, 3 years ago)
• Hepatitis C (recently diagnosed, genotype 1a, untreated)
• Depression (untreated)
• No prior psychiatric hospitalizations
• No prior addiction treatment

Medications:

• None prescribed
• Active fentanyl use (illicit pressed pills, 4-6 daily)

Social History:

• Registered nurse (license suspended 6 months ago)
• Unmarried, in a relationship with a partner who also uses opioids
• No children
• Estranged from parents and siblings who are aware of her substance use
• Lives in a rented apartment, behind on rent
• History of sharing snorting equipment
• One prior naloxone reversal (3 weeks ago)
• No IV drug use (snorting route only)
• No alcohol or benzodiazepine use
• Denies suicidal ideation

Family History:

• Father with alcohol use disorder (in recovery for 10 years)
• Paternal uncle died of heroin overdose at age 42
• Mother with generalized anxiety disorder
• No siblings with substance use disorders

Physical Examination

• Vital Signs: BP 148/92 mmHg, HR 102 bpm, RR 20/min, Temp 37.4°C, SpO2 98% on room air, BMI 21.2, Weight 56 kg
• General: Thin-appearing female, visibly uncomfortable, restless, yawning frequently. Appears anxious and tearful
• HEENT: Dilated pupils (6 mm bilaterally, reactive). Rhinorrhea. Lacrimation. No nasal septal perforation on anterior rhinoscopy
• Cardiac: Tachycardic, regular rhythm, no murmurs
• Lungs: Clear to auscultation bilaterally
• Abdomen: Hyperactive bowel sounds, mild diffuse tenderness without guarding or rebound. No hepatomegaly
• Skin: Piloerection ("gooseflesh"). Diaphoretic. No track marks. No abscesses. No rashes
• Musculoskeletal: Diffuse myalgias reported, muscle twitching in lower extremities
• Neurologic: Alert, oriented x3. Restless. Tremor of hands. No focal deficits
• COWS (Clinical Opiate Withdrawal Scale) Score: 22 (moderate withdrawal)
• Resting pulse >100: 2
• Sweating: 2
• Restlessness: 3
• Pupil size dilated: 5
• Bone/joint aches: 2
• Rhinorrhea/lacrimation: 2
• GI upset: 2
• Tremor: 1
• Yawning: 2
• Anxiety/irritability: 1

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• ECG: Sinus tachycardia, QTc 410 ms (normal, relevant for methadone consideration)
• FibroScan (liver elastography): 7.8 kPa (F1-F2, mild fibrosis)
• PHQ-9: Score 16 (moderately severe depression)
• GAD-7: Score 12 (moderate anxiety)
• Columbia Suicide Severity Rating Scale: No current suicidal ideation

Clinical Image

Diagram illustrating the three FDA-approved medications for opioid use disorder (methadone, buprenorphine, naltrexone) and their mechanisms of action at the mu-opioid receptor as full agonist, partial agonist, and antagonist, respectively. Source: Educational illustration.

Diagnosis

Opioid Use Disorder, Severe (DSM-5), with Physiologic Dependence — Currently in Moderate Withdrawal

Key Diagnostic Criteria (DSM-5 — meets 8 of 11 criteria, Severe):

• Opioids taken in larger amounts over longer period than intended
• Persistent desire or unsuccessful efforts to cut down
• Great deal of time spent obtaining, using, or recovering from opioids
• Craving or strong desire to use opioids
• Recurrent use resulting in failure to fulfill major role obligations (loss of nursing license)
• Continued use despite social/interpersonal problems (family estrangement)
• Important activities given up or reduced
• Tolerance (escalation from hydrocodone to fentanyl)
• Withdrawal symptoms when not using
• Additional: continued use despite physical problems (hepatitis C)

Treatment Plan

1. Immediate withdrawal management and buprenorphine induction:

• Given fentanyl use (long-acting lipophilic synthetic), standard buprenorphine induction carries high risk of precipitated withdrawal; use a micro-dosing (Bernese method) induction protocol:
• Day 1: Buprenorphine/naloxone 0.5 mg sublingual twice daily (continue fentanyl use)
• Day 2: 1 mg twice daily
• Day 3: 2 mg twice daily
• Day 4: 4 mg twice daily (begin reducing fentanyl)
• Day 5: 8 mg twice daily (stop fentanyl)
• Day 6-7: Consolidate to 16-24 mg daily
• Adjunctive comfort medications: clonidine 0.1 mg every 8 hours PRN (for autonomic symptoms), loperamide for diarrhea, ondansetron for nausea, dicyclomine for abdominal cramps, trazodone 50-100 mg for insomnia

1. Maintenance buprenorphine therapy: Target dose 16-24 mg/day buprenorphine/naloxone sublingual. Once stabilized, consider transition to monthly buprenorphine extended-release injection (Sublocade 300 mg x2, then 100 mg monthly) to eliminate daily medication adherence burden
2. Hepatitis C treatment: Refer to hepatology. Initiate HCV treatment with sofosbuvir/velpatasvir 12-week course after stabilization on buprenorphine (timing does not need to wait for sobriety). Check for drug-drug interactions with buprenorphine (none significant with sofosbuvir/velpatasvir)
3. Psychiatric care: Start SSRI for depression (sertraline 50 mg daily, titrate as needed). Continue monitoring with PHQ-9 and GAD-7. Individual psychotherapy (cognitive behavioral therapy for substance use disorders)
4. Psychosocial treatment:

• Individual counseling (weekly): motivational enhancement therapy transitioning to CBT
• Group therapy: process group 2-3 times/week
• 12-step facilitation or SMART Recovery referral
• Peer recovery support specialist

1. Harm reduction: Naloxone (Narcan) nasal spray prescribed for patient and identified contacts. Education on overdose prevention. Fentanyl test strips provided
2. Professional recovery program: Referral to state professional recovery program for healthcare professionals. This program monitors recovery, facilitates nursing license reinstatement, and provides workplace monitoring upon return to practice
3. Follow-up: Weekly visits for first month (COWS scoring, urine drug screens, medication management), then biweekly, then monthly. Urine drug screens at each visit (confirm buprenorphine and norbuprenorphine present, fentanyl absent)

Key Learning Points

• Buprenorphine micro-dosing (Bernese method) induction is increasingly used for patients using fentanyl, as traditional induction requiring 12-24 hours of abstinence frequently fails due to fentanyl's lipophilicity and prolonged tissue redistribution, leading to precipitated withdrawal even at 48-72 hours of abstinence
• Medication for opioid use disorder (MOUD) with buprenorphine or methadone reduces all-cause mortality by 50% and overdose mortality by 70-80%; it is first-line treatment for OUD and should be offered to all patients
• Standard urine immunoassay drug screens test for morphine/codeine metabolites (natural opiates) and will NOT detect fentanyl; specific fentanyl immunoassays or confirmatory testing (LC-MS/MS) must be ordered separately
• Healthcare professionals with substance use disorders have excellent recovery outcomes (75-90% sustained recovery at 5 years) when enrolled in structured professional monitoring programs that include workplace monitoring, random drug testing, and contingency management
• Hepatitis C treatment should not be delayed until completion of addiction treatment; concurrent treatment is safe and effective, and HCV treatment during MOUD has similar SVR rates to the general population

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