Download Medical Management of the Buprenorphine Patient

Common Medical Problems
in Opioid-Addicted Patients
Diana L. Sylvestre, MD
Assistant Clinical Professor of Medicine
University of CA, San Francisco
Executive Director
Organization to Achieve Solutions in Substance-Abuse
(O.A.S.I.S.)
Oakland, CA
Case Discussion
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R.B., 53 y.o A.A. male, 26 yr. history of IDU,
regular use 2 yr. Sober for 2 weeks after a
recent 21-day methadone detox but now using
small amounts of heroin again. Requesting
buprenorphine therapy.
Only medical problem: sometimes his BP is
high, but never took medications.
Only medication INH: 4 mo.? Brings records.
Heavy drinker for about 5-10 years in his 30’s
but none for 7 years, heroin is only drug
currently used.
Case Discussion, cont.
A review of his records is notable for:
Platelets 126,000 (150-450)
WBC 2,400 (3,500-10,000)
Alkaline Phosphatase 128 (65-110)
AST 46 (20-45)
ALT 67 (30-50) 6 mo ago, 39 1 yr ago
Case Discussion, cont.
Summary: healthy 53 yo IDU on INH with
mild thrombocytopenia, leukopenia, and
hepatic inflammation who would like to
start buprenorphine.
What are the most likely diagnoses?
Differential Diagnosis
Hepatitis C
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Often asymptomatic
60-94% of IDU’s have been exposed
70-85% have chronic, active infection
10% cirrhosis after 2 decades
Mild transaminitis is common, although LFTs
are often normal
Thrombocytopenia, neutropenia related to
portal hypertension
Differential Diagnosis
1. Hepatitis C
2. INH: TB
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Mild LFT abnormalities in 10-20%
Increased with HCV?
Alcoholism exacerbates
Differential Diagnosis
1. Hepatitis C
2. INH
3. HIV
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15-20% of long-term IDU’s are infected
The majority of HIV-infected IDU’s are
coinfected with HCV
Abnormal LFT’s, leukopenia
Thrombocytopenia not uncommon
Differential Diagnosis
1. Hepatitis C
2. INH
3. HIV
4. Hepatitis B
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Serologic evidence of HBV infection is
found in 72-89% of IDU’s
Chronic infection develops in 5%
65% of HBV infections are subclinical
Transmission by parenteral, sexual, or
perinatal routes
Differential Diagnosis
1. Hepatitis C
2. INH
3. HIV
4. Hepatitis B
5. Alcoholic Hepatitis
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High rates of comorbid alcoholism in
opioid-dependent patients
Liver toxicity exacerbated by HCV
AST>ALT
The Need for Vigilance
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As this case indicates, the majority of longterm IDUs presenting for buprenorphine
therapy will have a number of potential
comorbid medical conditions that need to
be addressed.
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What are the screening recommendations?
Hepatitis C
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Hepatitis C antibody indicates exposure, not
active disease: ~25% remit spontaneously
LFT’s persistently normal in 1/4
PCR testing to diagnose active disease (>$100)
Genotype: best predictor of treatment response
(genotype 1=40%, genotype 2,3 =80%) (>$250)
Vaccinate for HBV, HAV
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SCREEN: HCV Ab, LFT’s, CBC
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Hepatitis B
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Infection-related immunity: surface antibody and
core antibody (HBSAb+ and HBcAb+)
Immunization leads to HBSAb+ alone
Lone HBcAb +: loss of SAb or low-level infection
HBV surface antigen is positive with active
infection. Confirm with HBV DNA.
Treatment: high-dose IFN, lamivudine
Vaccinate non-immune IDUs for HBV (3 shots)
SCREEN (at least): HBSAb, HBSAg
HIV
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HIV antibody positivity confirmed with Western
Blot analysis
AIDS= CD4 <200 or AIDS-defining diagnosis
Follow infection with CD4 and HIV viral load
HAART therapy standard: 3 drugs
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RT’s, NNRTI’s, PI’s
HCV an opportunistic infection in HIV
SCREEN: HIV Ab
Tuberculosis
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More common in patients with IDU, ethnic
minorities, homeless, HIV, and alcoholism
Multi-drug resistance problematic
PPD+: 1 cm (HIV-), .5 cm (HIV+)
CXR if +, hospitalize if active pulmonary TB
PPD+ treatment is 6 mo INH/B6 (12 mo HIV+),
watch for hepatotoxicity
Initial therapy for active TB is 4 drugs
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SCREEN: Annual PPD
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Other Considerations
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STD’s: higher rates of syphilis, HPV,
chlamydia, GC
Bacterial infections: soft tissue, endocarditis
COPD: cigarettes, pneumonia
Hepatitis A: offer vax if HCV+
SCREEN: annual RPR, physical exam, refer
for preventive health care
Case Discussion, cont.
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Based on screening recommendations,
R.B. has the following testing performed:
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CBC, Chem panel with LFT’s
HBV Surface Ab, Ag
HCV Ab
HIV Ab
RPR
No PPD needed in previous reactor
Results
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Hct and WBC wnl, platelets 137,000
(>150,000)
Chem panel and LFT’s normal
RPR + at 1:4, FTA negative
HBV SAb and SAg negative
HIV negative
HCV Ab: repeatably positive
Case Discussion, cont.
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You tell R.B. that his testing indicates that he
has been exposed to hepatitis C, but that he
will need further testing in order to determine
whether he is actively infected.
You counsel him about the importance of
alcohol abstinence, indicating that the low
platelet count suggests liver damage.
Because of your concerns about the extent
of liver damage, you refer R.B. for additional
evaluation prior to starting buprenorphine.
Results
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HCV RNA PCR 749,000 IU/ml
Genotype 1a
HAV IgG negative
Abdominal ultrasound: enlarged
heterogeneous liver, mild
splenomegaly
Outcome
R.B.’s regular physician is willing to
consider hepatitis C treatment, but
only if he is sober. On the basis of a
normal albumin, bilirubin, and PT, she
believes that his liver function appears
adequate, and agrees that
buprenorphine therapy is indicated.
She vaccinates him for HAV and HBV.
Follow-up
After a 3 month stabilization on buprenorphine,
RB was referred for liver biopsy, which showed
grade 3 inflammation and stage 3 fibrosis.
Based on these results, R.B. is undergoing a 48week course of pegylated interferon and
ribavirin. Aside from interferon-related
depression that has required treatment with an
SSRI, he is tolerating the therapy nicely, and a
12-week viral load showed undetectable virus.
He remains drug-free on buprenorphine.
Summary
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Chronic medical conditions, especially
infectious diseases, are common in
IDUs.
The office-based buprenorphine
practitioner may be the IDU’s only
contact with the medical system
Summary (cont.)
Therefore, all office-based buprenorphine
patients need:
1. A full annual physical examination
2. Screening for:
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HCV
HBV
HIV
TB
Syphilis
Summary (cont.)
*** IDU’s can be difficult patients and are
complicated to manage medically. If
you will be referring your patients for
medical treatment, develop your
physician referrals with great care,
and interact liberally with them.