# Presentation: 007180

## Welcome

## Training CurriculumBased on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs

- Module 9: TIP Chapter 10

## Course Goals

- The goals of this training are to...
- Familiarize you with the content of TIP 43; and
- Increase your awareness of issues related to medication-assisted treatment of opioid addiction.

## Module 9:  Medical Problems

- During this module, you will:
- Investigate considerations for assessing medical problems in MAT patients;
- Study acute infections which commonly occur in MAT patients;
- Identify infectious diseases frequently found in MAT patients; and
- Examine treatment concerns for disabilities, pain management, and other conditions in MAT patients.

## Medical Problems

## Medical Assessment

- Some medical problems are more prevalent and severe in people addicted to opioids.
- These conditions can be life-threatening.
- Many patients in MAT have chronic diseases.
- Management of chronic pain for MAT patients is particularly challenging because of the role of opioids in pain treatment.
- General approach in OTPs is to remain alert and knowledgeable, facilitate preventive measures, and provide ongoing medical and emergency care.

## Medical Assessment:  Integrated Services

- Applicants with medical issues may sometimes be denied treatment admission for addiction because an OTP cannot manage their medical needs.
- Unavailable or fragmented services may cause patients to leave MAT prematurely or relapse.
- Many medical problems associated with opioid addiction should be treated either within the OTP or through liaisons with outside specialists and programs.

## Medical Assessment:  Integrated Services

- Medical services for the most common medical problems should be provided at the OTP, with expansion to other medical services.
- Each OTP should clearly define the medical services it offers on site versus by referral.
- OTPs should establish links with medical providers and programs skilled in treating problems that go beyond the direct services of the OTP.

## Medical Assessment:  Referral Services

- Patients need to understand an OTP’s policies regarding services provided on site versus by referral.
- Referral services should be part of a patient’s opioid addiction treatment plan.
- Primary care responsibility should be established either on site or through a community provider.
- OTPs also should inform local hospitals about their services when a MAT patient is admitted to a hospital.
- OTP staff should be ready to help patients understand procedures and care received off site.

## Medical Assessment:Routine Testing and Followup

- OTPs should establish protocols for both assessment of acute problems and periodic reassessments.  Recommendations include routine testing for:
- Hepatitis A, B, and C; syphilis and other sexually transmitted diseases; TB; HIV infection; hypertension; diabetes; and
- Liver and kidney functions.
- Physical examinations of patients in MAT should be performed at least annually.
- Tuberculin tests should be performed every 6 to 12 months, depending on regional factors.

## Acute Infections

- OTP medical staff, in particular those performing intake assessments, should recognize most potentially life-threatening infections related to opioid abuse.
- Some of these conditions can mimic opioid or intoxication withdrawal.
- Patients may be unaware of the severity of their condition or may attribute their symptoms to withdrawal.
- Because patients are focused on avoiding withdrawal, their descriptions of their histories may be unhelpful.

## Acute Infections:  Endocarditis

- Infection of the inner lining of the heart and its valves.
- Should be considered in any patient with recent injection marks and fever or a newly appearing heart murmur.
- Previously treated endocarditis might produce persistent heart murmur.
- Patients who have survived endocarditis by having a valve replacement are at increased risk.
- Fever in patients with a heart murmur always merits careful investigation.

## Acute Infections:  Soft-Tissue Infections

- Soft-tissue infections, such as abscesses and cellulitis, involve inflammation of skin and subcutaneous tissue, including muscle.
- Contaminated injection sites often swell and become tender.
- A fluctuant abscess might need incision and drainage.
- Patients with abscesses or cellulitis might not have fever.

## Acute Infections:  Necrotizing Fasciitis

- Necrotizing fasciitis, also called flesh-eating infection, is usually caused by introduction of the bacterium Streptococcus pyogenes into subcutaneous tissue.
- The infection spreads along tissue planes and can cause death from overwhelming sepsis within days without much evidence of inflammation.
- Some patients may lose large areas of skin, subcutaneous tissue, and even muscle.
- Case fatality rates from 20 to more than 50 percent have been reported.

## Acute Infections:  Necrotizing Fasciitis

- Should be considered when pain at an injection site is more severe than expected from redness or warmth at the site.
- Edema, fever, hypotension, and high white blood cell counts are additional clues.
- Treatment includes extensive debridement and intravenous antibiotics.
- Earlier ingestion of antibiotics may result in partial treatment of necrotizing fasciitis and modify its diagnosis and course.

## Acute Infections:  Wound Botulism

- Caused by Clostridium botulinum, usually found in contaminated food.
- Causes loss of muscle tone, including respiratory muscle weakness, making it life threatening.
- Presenting symptoms and signs (difficulty swallowing or speaking, blurred vision, and impaired body movements) may mimic signs of intoxication.
- An epidemic among people who injected drugs occurred in the 1990s, particularly in California.

## Name That Disease!

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## Patients with Disabilities

- OTPs increasingly must address the needs of disabled patients.
*TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities*, discusses the requirements of the Americans with Disabilities Act.
- Many patients with AIDS have disabilities such as visual or hearing impairments, or they may lack the strength to visit an OTP.
- Prevalence of illicit drug use may be higher for persons with disabilities than for others.

## Patients with Disabilities:  Home Dosing

- Home dosing is an important option for patients whose disabilities preclude daily OTP visits.
- Some patients are ineligible. Those with medical problems that affect neurological functioning may be unable to manage their medication without supervision.
- Patients who are medically compromised and continue to abuse substances usually are ineligible for take-home dosing.
- These patients pose major challenges for OTPs, and treating them requires creative planning.

## Patients with Disabilities:  Home Dosing

- For patients who do not meet take-home eligibility criteria, home dosing sometimes can be negotiated.
- Some OTPs identify someone to assist with dosing. These individuals can be educated about treatment medications and made responsible for picking them up, ensuring safe storage, and administering them.
- For patients who cannot identify such people, OTPs might negotiate medication support through the Visiting Nurses Association or comparable programs.

## Patients with Disabilities:  Home Dosing

- Some OTPs deliver medication directly to disabled patients’ homes, but such arrangements may be impractical, and delivery often is expensive.
- Switching from methadone to LAAM might ease the accessibility problem somewhat, but the future availability of LAAM is doubtful.
- Buprenorphine might also might be considered for home dosing.

## Patients with Disabilities:  Home Dosing

- Some OTPs deliver medication directly to disabled patients’ homes, but such arrangements may be impractical, and delivery often is expensive.
- Switching from methadone to LAAM might ease the accessibility problem somewhat, but the future availability of LAAM is doubtful.
- Buprenorphine might also might be considered for home dosing.

## Hospitalization of MAT Patients

- OTP physicians should communicate with the attending physician and hospital health care team.
- A patient in MAT will probably require larger doses of medication for anesthesia; adequate pain relief may require additional medication.
- Hospital staff should prevent patients from obtaining and using illicit substances or abusing prescription drugs.
- Some patients in MAT are hospitalized frequently. OTP staff members may be able to monitor such patients to facilitate early treatment.

## General Medical Conditions and MAT

- As patients become engaged in MAT, they are more likely to take better care of themselves.
- Medical care should be identical to that given patients not in MAT.
- General advice on diet, exercise, smoking prevention, and stress management should be integrated into MAT.
- Age and risk-appropriate medical screening should be discussed with patients during regular examinations.

## Pain Management

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## Module 9:  Medical Problems

## Training CurriculumBased on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs

- Module 9: TIP Chapter 10