Pearls And Pitfalls of Protocols: The Changing Landscape of Opioid Use Disorder

Abstract: In the March 2022 State of the Union address, President Biden declared that “beating the opioid epidemic” is the first objective of the national Unity Agenda. Deaths from opioid use disorder continue to rise with millions of patients suffering from this addiction. C-L psychiatrists face an evolving landscape of what now constitutes opioid use disorder. Many protocols currently in place for the treatment of opioid use disorder were developed when the available illicit opioid supply consisted primarily of heroin. In most areas of the United States, fentanyl has penetrated the heroin supply, and in some regions, fentanyl has replaced heroin almost entirely. Standard protocols frequently fall short of addressing the withdrawal faced by today’s patient with opioid use disorder. This virtual symposium will prepare the C-L psychiatrist with the knowledge and skills necessary to navigate new protocols being developed to address this growing need. Learners will be presented with case examples during each 20-minute session of the workshop and learn to apply the treatment strategies presented by the speakers.

In the first session, Dr. Zwiebel will present complex cases of buprenorphine induction utilizing various strategies to transition off fentanyl or methadone and onto buprenorphine. Learners will be guided through the strategies of micro-induction, macro-induction, and modified traditional induction to best treat patients in a variety of settings.

In the second session, Drs. Martin and Lopez-Pastrana will educate learners on identifying contaminants in the illicit opioid supply to provide better coverage of multi-substance withdrawal, especially xylazine, an increasingly common alpha-2 adrenergic agonist known as “tranq”. Learners will be able to apply their new clinical knowledge about contaminants to adapt opioid withdrawal protocols to better treat patients struggling with both opioid and contaminant withdrawal. Dr. Martin will also speak about the process of developing public health initiatives to address xylazine use.

In the third session, Dr. Kleinman will address the role of short-acting opioids in treating hospitalized patients experiencing withdrawal from fentanyl and other high-potency synthetic opioids. Learners will gain an understanding of the potential role of short-acting, full-agonist opioids in facilitating initiation of buprenorphine and methadone and relieving patient suffering during hospitalizations.

In the last session, Dr. Gulkis will educate learners about the most up to date strategies for harm reduction in clinical settings. She will discuss overcoming the stigma associated with naloxone among patients, the decreasing efficacy of naloxone in the community in the face of rising fentanyl use, and implementation of motivational interviewing to promote harm reduction.

Dr. Gulkis will then lead the group in a question-and-answer session.