Patient with an Addiction to Norco | My Assignment Tutor

Challenging Case – Patient with an Addiction to Norco Norco is a prescription drug that belongs to analgesics. It is used in the treatment of symptoms related to moderate to extreme pain. However, frequent usage of this painkiller is habit-forming and is, thus, susceptible to abuse. This is because most people tend to rely on the drug and use it unprescribed. Considering the adverse side effects of Norco usage, mitigation plans for medication withdrawal among addicts should be developed. Efficient and better pain management requires eliminating the chemical dependency on Norco, which would require the medical intervention of Buprenorphine drug administration. Dependency on the opioid Norco causes neurotransmitters to fire at a higher rate. These neurotransmitters account for the individual’s mood, motivations and consequently result in addiction development. Each of the neurons produces more neurotransmitters, such as dopamine, glutamate, serotine, and acetylcholine, which can stimulate or dampen brain activity. The cytochrome P450 enzymes are involved in the activation deactivation of endogenous and exogenous compounds, such as drugs (National Institute on Drug Abuse, 2021). The most significant CYP-450, CYP3A4, and CYP2D6 enzymes are essential for drug metabolism and influence a patient’s response. Administration of buprenorphine blocks opiate receptors that calm functionality of neurotransmitters and enzymes, reversing effects of opioids.  Buprenorphine is a partial opioid agonist of the µ-receptor for the management of opioid addiction. It is available in variable dosages of 2, 4,8, and 12 mg administered by dissolving under the tongue. The initial dosage of the drug varies from 2 – 4 mg, and it is administered after a significant period of abstinence from opioid usage. The drug’s half-life and slow dissociation from opioids allow for less than daily dosing, with accumulative administration of 3 times a week (Ling, 2012). The titration plan for the drug is between 2 – 4 mg with intervals of approximately two hours as required for progressive withdrawal symptoms with dosages of up to 8–16 mg on day one, 8–16 mg on day two, and 12–24 mg on day three. Before initiating Buprenorphine usage, patients should be aware of critical aspects of the drug such as drug efficacy, safety profile, and how drug side effects. Usage of the drug includes constipation, dizziness, drowsiness, headache, and nausea. The side effects can last up to 3 days (“Buprenorphine – Alcohol and Drug Foundation”, 2021). The tracking of the effectiveness of administered drugs requires a follow-up medical plan. The evaluation would include determining the severity of the substance abuse-related problems. Additionally, the re-occurring mental disorders must be accessed to determine the efficacy of the Buprenorphine treatment plan.  Under safe prescription and care by physicians, buprenorphine is an effective treatment of opioid addiction. It is recommended that withdrawal from the drug usage should be gradual and under medical supervision to prevent unpleasant effects. However, failed or no response of the medication by buprenorphine instigates a review and change of treatment plans and medications. Patients who are unresponsive to buprenorphine treatment should be referred to methadone or abstinence-based treatment References Buprenorphine – Alcohol and Drug Foundation. (2021). National Institute on Drug Abuse. (2021). Impacts of drugs on neurotransmission. Ling, W. (2012). Buprenorphine implant for opioid addiction. Pain Management, 2(4), 345-350. 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. 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  Suboxone_article.pdf (499.191 KB) 


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