Case Study of Opioid Use Disorder - PDF

CASE STUDY Patient E, 54 years of age, presents with active opioid use disorder. He began using prescription opioids for back pain after having served in the infantry. His usage eventually resulted in his leaving military service prior to retirement, and he currently works in construction. The pati...

CASE STUDY Patient E, 54 years of age, presents with active opioid use disorder. He began using prescription opioids for back pain after having served in the infantry. His usage eventually resulted in his leaving military service prior to retirement, and he currently works in construction. The patient reports having relied on prescription opioids until three years ago, when he started using heroin. He buys 10 bundles per day of what is described as heroin but is most likely synthetic fentanyl. He has accidentally overdosed on two occasions, and emergency medical services used naloxone nasal spray to revive him. He is seeking care at an intensive outpatient program for treatment. After reviewing goals of care with the patient, the clinician identifies that he has residual chronic back pain in addition to cravings for opioids when not using. The patient is diagnosed with opioid use disorder. Patient E states that he recently sought care for his back pain and was referred to physical therapy and advised to take nonsteroidal anti-inflammatory drugs (NSAIDs) as needed for pain management. The possibility of methadone maintenance is discussed, but the patient does not want to have to go daily for dosing and is afraid that it will impair his ability to work around heavy machinery. Safety issues are also reviewed, and nasal naloxone is prescribed for emergency use. The patient\'s partner receives education on use as well. The patient states he does not wish to take a medication, but he starts attending daily 12-step meetings and working with a drug counselor. Within five days, Patient E is able to successfully complete detoxification. However, after about six weeks he experiences a relapse. His partner administers nasal naloxone after finding him unconscious. When Patient E returns for follow-up, various options for medication-assisted therapy are discussed, and he decides to enroll in buprenorphine/naloxone therapy, with a goal of eventually being maintained on monthly buprenorphine injection. The clinician emphasizes the need for continued counseling and the need to understand that, like all chronic diseases, patients with opioid use disorder are subject to relapse. The patient is advised of the importance of seeking help early in the event of a relapse. The biologic basis of substance use disorder is stressed; there is no judgement or shame. Patient E does well on buprenorphine/naloxone therapy and is attending physical therapy for his back pain. He has continued with regular 12-step meetings and individual psychotherapy. At each follow-up appointment, the need to keep naloxone nasal spray available for emergency use is emphasized.