Psychiatry · Year 2 · from Psychiatry
Case 2: Opioid Use Disorder - Medication-Assisted Treatment
Patient Presentation
Demographics: 29-year-old female
Chief Complaint: "I want to stop using. I'm tired of this life."
History of Present Illness: A 29-year-old woman presents to an addiction medicine clinic seeking treatment for opioid use disorder. She began using prescription oxycodone at age 23 after a back injury and escalated to heroin use 2 years ago when pills became too expensive. She currently injects heroin 3-4 times daily, spending approximately $150-200/day. Her last use was 6 hours ago. She has tried to quit "cold turkey" multiple times but has never made it past 3 days due to severe withdrawal symptoms. She has overdosed twice in the past year, both times reversed with naloxone by bystanders. She is homeless, engaging in sex work to support her habit, and recently learned she is pregnant (approximately 8 weeks by LMP). She is terrified she will lose the baby. She has heard about "medication that can help" and wants to start today.
Physical Examination:
- Vital signs: BP 128/82, HR 78, T 37.0C
- General: Thin female, track marks on bilateral arms
- Pupils: 3 mm, reactive (not yet in withdrawal)
- No signs of withdrawal currently (last use 6 hours ago)
- Nasal septum intact
Clinical Opiate Withdrawal Scale (COWS): Score 4 (no withdrawal yet - too early)
Workup:
- Urine drug screen: Positive for opioids, negative for others
- HCV antibody: Positive with detectable viral load (chronic HCV)
- HIV: Negative
- HBsAg: Negative
- Pregnancy test: Positive
- CBC: Normal
- CMP: Normal
- LFTs: Mildly elevated (ALT 52, AST 48)
Diagnosis: Opioid Use Disorder, severe; Pregnancy (8 weeks); Hepatitis C, chronic
Treatment:
- Discussed medication options: Buprenorphine vs. methadone
- In pregnancy, both buprenorphine and methadone are standard of care
- Methadone requires daily visits to OTP initially; buprenorphine allows office-based treatment
- Patient prefers buprenorphine for flexibility
- Explained need to be in mild-moderate withdrawal before buprenorphine induction (COWS ≥8-12) to avoid precipitated withdrawal
- Instructed to return tomorrow morning after minimum 12-16 hours since last use
- Day 2: COWS score 14 (moderate withdrawal)
- Began buprenorphine induction with sublingual buprenorphine 4 mg
- Additional 4 mg doses given every 2 hours as needed
- Total day 1 dose: 12 mg
- Day 2-3: Titrated to 16 mg daily for symptom control
- Referred to high-risk OB clinic for prenatal care
- Connected with hepatology for HCV treatment (can begin after pregnancy)
- Social work referral for housing assistance
- Urine drug screens weekly initially
- At 4-week follow-up: No illicit opioid use, stable on buprenorphine 16 mg daily
- Prenatal care ongoing, ultrasound shows normal fetal development
- Plan for hospital delivery with communication to obstetrics about MAT
Clinical Pearl: Buprenorphine and methadone are both standard of care for opioid use disorder in pregnancy - withdrawal attempts are associated with fetal distress and relapse. Buprenorphine induction requires the patient to be in mild-moderate withdrawal (COWS ≥8-12) to avoid precipitated withdrawal (the partial agonist displacing full agonist can cause acute withdrawal). Neonatal opioid withdrawal syndrome will occur with MAT but is manageable and preferable to untreated OUD in pregnancy. Harm reduction measures including naloxone prescription and Hepatitis C treatment are essential components of care.