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CPSUD Interactive Case Studies
Certified Pharmacist in Substance Use Disorders (CPSUD)
The Scenario: Initiating Buprenorphine for OUD
You are a CPSUD working in a community pharmacy with a collaborative practice agreement to initiate buprenorphine. A 28-year-old patient presents wanting to start treatment, stating they are "ready to quit" using illicit fentanyl. Your role is to assess the patient's readiness for induction, identify risks, and provide counseling to ensure a safe and successful start to Medications for Opioid Use Disorder (MOUD).
Patient Data & Guidelines
Patient Profile & History
- Diagnosis: Opioid Use Disorder, severe (fentanyl).
- Time Since Last Use: 8 hours.
- Current Symptoms: Mild anxiety, yawning, some muscle aches.
Buprenorphine Induction Guidelines
- Buprenorphine can cause precipitated withdrawal if given to a patient who is not in a sufficient state of withdrawal.
- Patient must be in at least moderate withdrawal before the first dose, typically defined as a Clinical Opiate Withdrawal Scale (COWS) score of 13 or higher.
Your Task
Task 1: Based on reported symptoms, what level of withdrawal is the patient currently in?
Answer:
The patient is in mild withdrawal. Their symptoms (anxiety, yawning, muscle aches) correspond to a low score on the COWS scale, likely between 5 and 12.
Task 2: Is it safe to instruct the patient to take their first dose of buprenorphine now? Why or why not?
Answer:
No, it is not safe. The guidelines require a state of moderate withdrawal (COWS ≥ 13) to prevent precipitated withdrawal. Buprenorphine is a partial agonist and, if given too early, will displace the full agonist (fentanyl) from opioid receptors, causing a sudden and severe withdrawal syndrome.
Task 3: What is a special consideration for buprenorphine induction in a patient who uses illicit fentanyl?
Answer:
Illicit fentanyl is highly lipophilic (it stores in fat cells) and has a very high affinity for the mu-opioid receptor. This means it can take much longer for the patient to enter withdrawal compared to heroin or prescription opioids. Patients often need to wait 24, 48, or even 72+ hours after their last use before it is safe to start buprenorphine. A standard 12-24 hour waiting period is often insufficient and is a common cause of precipitated withdrawal in this population.
Task 4: What is the appropriate counseling and action plan for a safe home induction?
Answer:
The plan is to provide clear instructions, manage expectations, and create a safety net.
- Educate on Waiting: Explain in simple terms why they must wait until they feel significantly worse ("like a bad flu"). Emphasize the risk of precipitated withdrawal if taken too early, especially with fentanyl.
- Provide a COWS Checklist: Give them a simple checklist of symptoms (runny nose, goosebumps, large pupils, severe restlessness) that indicate they are in moderate withdrawal and it is safe to start.
- Instruct on "Microdosing": Instruct the patient to start with a very small piece of a film (e.g., 2 mg), wait 1-2 hours to see if they feel better or worse, and only take more if symptoms improve or stay the same. This is a "low and slow" approach to minimize risk.
- Provide Naloxone: Co-prescribe and dispense naloxone and counsel the patient and a family member on its use as a crucial safety measure.
The Scenario: Managing Severe Alcohol Withdrawal
A 52-year-old male with a history of severe Alcohol Use Disorder (AUD) is admitted to the hospital for surgery. On post-op day 2, he becomes agitated, tremulous, and hypertensive. The surgical team consults you, the CPSUD, for recommendations on managing his acute alcohol withdrawal, which they suspect is complicated.
Clinical Data & Assessment
Patient Profile
- History: Reports drinking a pint of vodka daily for 10+ years. Last drink was > 48 hours ago.
- Vitals: BP 165/100, HR 120, Temp 38.5°C.
- Symptoms: Severe tremors, profuse sweating, auditory hallucinations.
CIWA-Ar Assessment
The nurse completes a CIWA-Ar assessment:
- Tremor: 5
- Sweats: 6
- Anxiety: 5
- Agitation: 4
- Auditory Disturbances: 3
- Total Score: 32
Score Key: >20 indicates severe withdrawal.
Your Task
Task 1: Based on the CIWA-Ar score and symptoms, what is the severity of his withdrawal, and what is the most serious complication he is at risk for?
Answer:
A score of 32 indicates severe withdrawal. The presence of hallucinations and severe autonomic hyperactivity (high BP, HR, temp) means he is at extremely high risk for, or is already entering, delirium tremens (DTs), a medical emergency that can lead to seizures, rhabdomyolysis, and death if not treated aggressively.
Task 2: The resident suggests chlordiazepoxide (Librium). Why is IV lorazepam (Ativan) a better choice for this patient?
Answer:
IV lorazepam is superior for two key reasons:
- Metabolism: Lorazepam is metabolized via glucuronidation, which is generally preserved even in patients with alcoholic liver disease. Chlordiazepoxide undergoes oxidative metabolism, which is often impaired, leading to accumulation of the drug and its active metabolites, causing prolonged sedation.
- Route of Administration: The patient's symptoms are severe and require rapid control. The IV route provides the fastest onset and most reliable absorption. Oral medications may not be appropriate or reliably absorbed in a severely agitated patient.
Task 3: What is the "gold standard" benzodiazepine protocol for managing severe alcohol withdrawal?
Answer:
A symptom-triggered protocol is the gold standard. This involves assessing the patient's CIWA-Ar score at regular, frequent intervals (e.g., every hour initially). A dose of benzodiazepine (e.g., lorazepam 2-4 mg IV) is administered only when the score is above a pre-defined threshold (e.g., CIWA > 10). This approach tailors treatment to the patient's individual needs, resulting in a shorter duration of therapy and a lower total benzodiazepine dose compared to fixed-dose schedules.
Task 4: What critical adjunctive medication must be administered to prevent a severe neurological complication?
Answer:
High-dose parenteral thiamine (Vitamin B1) is absolutely essential. Chronic heavy alcohol use leads to severe thiamine deficiency. Repleting thiamine is critical to prevent the development of Wernicke-Korsakoff syndrome, a devastating and often irreversible neurological disorder causing confusion, ataxia, and amnesia. It is crucial to administer thiamine *before* administering any glucose-containing IV fluids.
The Scenario: Co-Occurring PTSD and Stimulant Use Disorder
A 32-year-old military veteran is referred to your clinic for his severe Cocaine Use Disorder. During the intake, he reveals that his cocaine use began after his deployment as a way to "stay awake and on guard." He endorses classic symptoms of Post-Traumatic Stress Disorder (PTSD), including nightmares, flashbacks, and hypervigilance. He also admits to using non-prescribed Xanax from a friend to "calm his nerves." As the CPSUD, you must develop an integrated treatment plan.
Clinical Data & Guidelines
Patient Profile
- Diagnosis: Severe Cocaine Use Disorder; Post-Traumatic Stress Disorder (provisional).
- Patient Statement: "The cocaine helps me stay alert. The Xanax is the only thing that stops the panic."
- Urine Drug Screen: Positive for cocaine and benzodiazepines.
Clinical Practice Guideline (VA/DoD)
- First-line pharmacotherapy for PTSD are the SSRIs (sertraline, paroxetine) and the SNRI (venlafaxine).
- Benzodiazepines should be avoided in PTSD as they can interfere with trauma processing and have a high potential for misuse.
- An integrated treatment approach addressing both PTSD and SUD simultaneously is recommended.
Your Task
Task 1: What is the likely clinical relationship between his PTSD symptoms and his use of both cocaine and non-prescribed Xanax?
Answer:
This is a classic example of a **"self-medication" cycle**. The patient is using cocaine (a stimulant) to combat the numbing symptoms of PTSD and to maintain a state of hypervigilance. He is then using non-prescribed alprazolam (a sedative) to counteract the anxiety, insomnia, and over-stimulation caused by both the PTSD and the cocaine use. The two substances are being used to manage the symptoms of the underlying, untreated psychiatric illness.
Task 2: The patient asks you for a prescription for Xanax. Why is this strongly contraindicated, and what evidence supports this decision?
Answer:
Prescribing a benzodiazepine is strongly contraindicated for two main reasons:
- It Worsens PTSD: As stated in the guidelines, benzodiazepines can interfere with fear extinction and memory consolidation, which are key components of trauma recovery. They can inhibit the effectiveness of gold-standard psychotherapies for PTSD.
- High Misuse Potential: The patient already has a severe SUD and is using non-prescribed benzodiazepines. Prescribing one would be adding a highly addictive substance to an already dangerous polysubstance use pattern, creating a new dependence and increasing overdose risk.
Task 3: What is the most appropriate first-line medication to recommend for his underlying PTSD?
Answer:
An SSRI, specifically sertraline, is the most appropriate first-line choice. It is FDA-approved for PTSD and has a large evidence base supporting its efficacy in reducing hyperarousal, intrusive thoughts, and avoidance symptoms. By treating the core PTSD symptoms, it can reduce the patient's perceived "need" to self-medicate with cocaine and benzodiazepines.
Task 4: What non-pharmacologic treatment is the "gold standard" for PTSD and must be part of his integrated care plan?
Answer:
Trauma-focused psychotherapy is the gold standard and an essential component of his care. Evidence-based modalities like Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT) are the most effective treatments for PTSD. His integrated plan must include a referral to a therapist specializing in these treatments alongside pharmacotherapy and substance use counseling to be successful.
