homeless male with a history of polysubstance abuse | My Assignment Tutor

Substance Use Disorder John Doe, a 65 y/o homeless male with a history of polysubstance abuse, was seen by me at my current job after he was transferred from the hospital to the sub-acute rehab. He presented to the hospital from a homeless shelter in Baltimore City with right upper extremity pain and generalized weakness. Though the patient reported to the hospital that his last drug use was two months prior, his urine toxicology screen was positive for fentanyl and heroin. During his hospital course, he was treated for right arm cellulitis secondary to infection from intravenous drug use (IVDU). Of note, he was hospitalized six weeks prior for heroin overdose. Upon stabilization, he was transferred to my facility for continued IV antibiotics and physical therapy. I was consulted to see him for questionable dementia and agitated behavior. During our visit, Mr. John Doe was not very cooperative. He was very irritable and verbally aggressive, using profanity and talking down on the staff.  He often answered a question with a question. For example, when asked what he was treated for in the hospital, he responded, “Did you not see my record?” He was not open to discussing his substance use disorder, and he was not forthcoming about when he last used illicit drugs. How I Handled the Situation: I reviewed his current right arm infection with him and its etiology, being his IVDU. I counseled him on seeking help and getting into an addiction program like the Suboxone or methadone program. Associated risks of continuing in the habit, including death, were also reviewed with John Doe. He was partially receptive to the information. My Concerns: Patient’s angry, defensive attitude, not being honest about his drug use, and not seeing the need for getting help. Even though he recently had an overdose, he was not willing to seek help. Owing to his attitude, he pushed away people who were willing to help him. My dilemma in this situation is this: How do you get help for someone who needs it yet, is rejecting it? In 2017, up to six million Americans had an opioid use disorder and 47, 600 Americans died from an opioid-related overdose (Haffajee & Frank, 2019). Neurotransmitters and CYP-450 enzymes According to Saddock et al. (2015), opioid, dopamine, and GABA are the neurotransmitters involved in developing substance abuse. Most notably, dopamine neurons found in the nucleus accumbens in the ventral tegmental area of the brain are involved in the reward sensation. In treating John Doe, Suboxone would have been my choice of treatment for his heroin/fentanyl abuse. Suboxone is a medication made up of buprenorphine and naloxone. Buprenorphine is a partial agonist that binds to the mu (μ) opioid receptor (Haffajee & Frank, 2019). It blocks the euphoric effects of opioids. It also helps to reduce the unpleasant symptoms associated with opioid withdrawal (Haffajee & Frank, 2019). Buprenorphine has a ceiling effect in that its euphoric effects plateau rather than increase with higher dosing (Haffajee & Frank, 2019). Naloxone is an opioid antagonist that blocks opioids at opioid receptor sites (Haffajee & Frank, 2019). Suboxone has been shown to be clinically effective in reducing opioid withdrawal symptoms and curbing cravings among those with opioid use disorder (Haffajee & Frank, 2019). Buprenorphine is a cytochrome P450 3A4 (CYP3A4) substrate. For example, if buprenorphine is taken with CYP3A4 inhibitors like grapefruit juice, erythromycin, or verapamil, these products will increase the serum concentration of buprenorphine (UpToDate, 2021). On the other hand, if buprenorphine is taken with CYP3A4 inducers like Dilantin, phenobarbital, or Tegretol, these medications will reduce the serum concentration of buprenorphine. Prescribing Suboxone for substance use disorder is limited to clinicians who have met the DEA criteria and for prescribing this medication and have obtained the DEA “X” number (UpToDate, 2021). References Haffajee, R. L., & Frank, R. G. (2019). Generic drug policy and suboxone to treat opioid use disorder. Journal of Law, Medicine & Ethics, 47(S4), 43–53. https://doi.org/10.1177/1073110519898042 Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. UpToDate. (2021). Buprenorphine and naloxone: Drug information. UpToDate. Retrieved April 19, 2021, from https://www.uptodate.com/contents/buprenorphine-and-naloxone-drug-information?search=suboxone&source=panel_search_result&selectedTitle=1~19&usage_type=panel&kp_tab=drug_general&display_rank=1#F143123  Suboxone_article.pdf (499.191 KB) 


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