Family Medicine · Year 3 · from Family Medicine

Case 2: Opioid Use Disorder in Primary Care

Patient Demographics

  • Age: 34 years old
  • Sex: Male
  • Occupation: Unemployed (former construction worker)

Chief Complaint

"I need help. I'm addicted to pills and I want to stop before I lose everything."

History of Present Illness

Mr. James Turner is a 34-year-old man presenting seeking help for opioid addiction. He reports taking oxycodone for the past 3 years, initially prescribed for a work-related back injury. Over time, his tolerance increased, he started taking more than prescribed, and he has been buying pills "on the street" for the past year after his prescriptions were discontinued. He is currently using 120-180 mg of oxycodone equivalents daily. He has tried to quit on his own several times but develops severe withdrawal symptoms (nausea, diarrhea, muscle aches, anxiety) within 12 hours.

He recently lost his job and his wife has threatened to leave with their two children if he doesn't get help. He has never used heroin or injected drugs. His last use was 8 hours ago, and he is beginning to feel early withdrawal symptoms.

Past Medical History

  • Chronic low back pain (work injury 3 years ago)
  • No surgeries
  • No psychiatric history

Family History

  • Father: Alcohol use disorder
  • Mother: Anxiety

Social History

  • Smokes 1 pack/day
  • No alcohol (stopped when opioid use increased)
  • Married, two children (ages 5 and 7)
  • Unemployed x 2 months
  • Previously worked in construction
  • High school education

Physical Examination

  • Vital Signs: BP 138/88 mmHg, HR 92, Temp 98.8F, RR 18
  • General: Anxious-appearing, diaphoretic, restless
  • HEENT: Pupils 4mm reactive (early dilation), rhinorrhea, lacrimation
  • Cardiovascular: Tachycardic, regular
  • Abdomen: Hyperactive bowel sounds, no tenderness
  • Extremities: No track marks, no edema
  • Skin: Piloerection (goosebumps), diaphoresis
  • Neuro: Alert, oriented, tremulous

Assessment with COWS Score

  • Clinical Opiate Withdrawal Scale (COWS): 16 (moderate withdrawal)
  • Resting pulse: 2 (89-100)
  • Sweating: 2
  • Restlessness: 2
  • Pupil size: 2 (moderately dilated)
  • Bone/joint aches: 2
  • Runny nose/tearing: 2
  • GI upset: 2
  • Tremor: 1
  • Yawning: 1
  • Anxiety/irritability: 0
  • Gooseflesh: 0

Assessment and Diagnosis

  1. Opioid use disorder, moderate-severe - Meets DSM-5 criteria (tolerance, withdrawal, loss of control, continued use despite consequences, craving)
  2. Opioid withdrawal, moderate - COWS 16
  3. Chronic low back pain - Underlying condition, needs non-opioid management

Management Plan

Medication for Opioid Use Disorder (MOUD):

Buprenorphine/naloxone (Suboxone) Initiation:

  • Office-based initiation protocol
  • Wait until COWS ≥12 (moderate withdrawal) before first dose
  • Start buprenorphine/naloxone 4mg/1mg sublingual
  • May repeat 4mg/1mg in 1-2 hours if withdrawal persists
  • Target dose Day 1: 8-16 mg buprenorphine
  • Titrate to 16-24 mg daily over first week for maintenance
  • Prescriber must have X-waiver (note: as of 2023, X-waiver requirement removed)

Alternative Options Discussed:

  • Methadone: Requires licensed opioid treatment program (OTP), daily dosing initially
  • Naltrexone: Extended-release injection, requires 7-14 days opioid-free first

Adjunctive Medications for Withdrawal Symptoms:

  • Clonidine 0.1 mg every 6 hours PRN for autonomic symptoms
  • Ondansetron 4 mg every 8 hours PRN for nausea
  • Loperamide 2 mg PRN for diarrhea
  • Ibuprofen 600 mg every 8 hours for muscle aches

Behavioral Support:

  • Referral to addiction counselor
  • Recommend 12-step program (Narcotics Anonymous) or SMART Recovery
  • Family counseling offered
  • Discuss relationship between sobriety and keeping family together

Harm Reduction:

  • Naloxone (Narcan) nasal spray prescribed for home
  • Educate patient and wife on overdose reversal
  • Discuss fentanyl contamination risk in street drugs

Pain Management:

  • Physical therapy referral for back pain
  • Non-opioid alternatives: NSAIDs, acetaminophen, duloxetine
  • Buprenorphine provides some analgesia

Follow-Up

  • Return in 24-48 hours for dose adjustment
  • Weekly visits during induction phase (first month)
  • Monthly visits once stable
  • Urine drug testing at each visit
  • Long-term MOUD recommended (years, potentially lifelong)

Teaching Points

  1. DSM-5 criteria for OUD: Problematic opioid use with ≥2 criteria in 12 months (tolerance, withdrawal, larger amounts, inability to cut down, time spent obtaining/using/recovering, craving, failure to fulfill obligations, social problems, hazardous use, continued use despite problems, giving up activities).
  1. MOUD is first-line treatment: Buprenorphine, methadone, and naltrexone all reduce mortality, overdose, and illicit opioid use. Medication alone is more effective than behavioral treatment alone.
  1. Buprenorphine in primary care:
  • Partial opioid agonist with ceiling effect (safer in overdose)
  • Can be prescribed in office setting
  • X-waiver no longer required (as of December 2022)
  • Start when in moderate withdrawal (COWS ≥12) to avoid precipitated withdrawal
  1. Harm reduction: Naloxone should be prescribed to all patients with OUD. Every minute without naloxone in an overdose increases mortality risk.
  1. Long-term perspective: OUD is a chronic disease. Relapse is common and does not indicate treatment failure. Long-term MOUD is more effective than short-term tapering.

All cases for this lecture as Markdown