Application of the steps in SBIRT
The purpose of this assignment is for students to:
Improve their ability to formulate diagnoses based on clinical presentation of patients
Design relevant treatment plan
Link pathophysiologic concepts to medication choices
Collaborate without outside providers and resources
Activity Learning Outcomes
Through this discussion, the student will demonstrate the ability to:
Describe the psychodynamic principles of alcohol, opioids, stimulants and benzodiazepines
Discuss harm reduction principles in SUD
Discuss FDA approved treatment options for SUD
List the benefits of using medication assisted treatment (MAT) for SUD
Identify resources to complete the DATA waiver process
Discuss when and how to taper patients off of common addictive medications, such as benzodiazepines and psychostimulants
Identify treatment options for special populations
Application of the steps in SBIRT
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach used by healthcare providers to identifying patients with and at risk of substance use disorders. The goal of SBIRT is to prevent and reduce substance abuse complications such as disease, injuries, and accidents. In the current case, the patient has chronic pain, which she manages with Oxycontin, an opioid analgesic. She is asking for an early refill. The care provider needs to determine whether the patient has developed tolerance or addiction to this opioid-based pain killer. The patient should be screened for opioid dependence using the DAST drug screening questionnaire. The interventions that will follow will depend on the screening outcomes. The intervention includes educating the patient on how to safely use the opioid-based pain medicine to reduce the risk of addiction and providing education on the effects of opioid addiction (Foli et al., 2021). The third stage will entail referring the patient to specialized services such as rehabilitation, if she is positive for addiction.
Additional Questions for this Patient
During history taking, asking the additional patient questions will help understand the patient’s condition better and understand her risk for opioid addiction better. The further questions will include: when the patient was diagnosed with inflammatory arthritis, when she started taking the pain medication, which pain medication she is taking, when the Oxycodone was prescribed, who prescribed it, what dose of Oxycodone, and how often she is taking, the date of the last Oxycodone refill, the frequency of her pain flare-ups.
The treatment plan will entail prescribing the patient the first-line treatment therapy for inflammatory pain, which is NSAIDs and corticosteroids. In addition, the patient should be educated on the effects of long-term use of opioids and referred to a physical therapist for training on appropriate exercises to help keep joints flexible and improve joint strength. The patient could be referred to a rheumatologist for further evaluation of arthritis complications. The provider also needs to follow up with the original provider to get further details on the opioid prescription.
The patient shows signs of opioid withdrawal: anorexia, diarrhea, yawning, and sweating. He also shows some psychological disturbances, thus may benefit from a combined approach of pharmacotherapy and psychotherapy. The COWS score indicated the patient to be in moderate withdrawal. It is essential to obtain baseline urine drug screening to help approximate the last time the patient ingested the drug. To manage the withdrawal symptoms, the patient received buprenorphine in the office. The patient should be monitored for 60 minutes after the administration of the initial dose, followed by titration of buprenorphine in the office until withdrawal symptoms subside.
The patient should follow up 24 hours to a week after receiving initial treatment of buprenorphine in the office. She will need weekly follow up until a stable dose of buprenorphine is reached. Then the follow-up can be biweekly to monthly but may need more frequent follow-up visit if there is a relapse. The patient should be referred to a psychiatrist and behavioral therapist for counseling, to help manage psychological disturbances. The follow-up plan would include random drug screening at office visits to detect relapse.
Safe Taper Schedule for a Patient Taking Alprazolam (Xanax) 2mg TID.
Gradually tapering of Xanax aims at giving the body time to adjust progressively to functioning without Xanax and lessening the severity of the withdrawal symptoms (Brogan et al., 2019).
Week one: the dose should not be reduced by more than a milligram (administer 1 mg).
Week two: reduce the Xanax dose by 25 % (administer 0.75 mg).
Week three: reduce Xanax dose by 25 % (administer 0.5 mg).
Weeks four through eight: no further dose reductions (administer 0.5 mg)
Weeks nine and beyond: continually reduce the dose by 25 % until the patient is no longer taking the medication.
Studies indicate that a patient on a benzodiazepine for an extended time benefits from tapering (Fluyau, Revadigar & Manobianco, 2018). Long-time use of benzodiazepines like Xanax makes an individual physically dependent on the drug. Therefore, an attempt to instantly stop the drug use may cause psychosis, anxiety, or seizures. Therefore, such an individual should work with the care provider to design a safe tapering plan.
Brogan, K., Siefert, A., Whitson, E., Kirsh, L., & Sweetan, V. (2019). Psychotropic Drug Withdrawal and Holistic Tapering Strategies: A Case Series. Adv Mind Body Med, 33(4), 4-16. https://s3.amazonaws.com/kajabi-storefronts-production/sites/53102/themes/2147951893/downloads/wJ5ekWGIRPaW82cPx7rg_PsychotropicDrugWithdrawal.pdf
Fluyau, D., Revadigar, N., & Manobianco, B. E. (2018). Challenges of the pharmacological management of benzodiazepine withdrawal, dependence, and discontinuation. Therapeutic advances in psychopharmacology, 8(5), 147-168. https://journals.sagepub.com/doi/full/10.1177/2045125317753340
Foli, K. J., Huang, W., Adams, N., Kersey, S., Good, B., Ott, C., & Duha, M. S. (2021). Nurses Substance Use Education Through a Massive Open Online Course (NSUE-MOOC). Purdue University, School of Nursing, West Lafayette, Indiana.