March 2013 Newsletter - American College of Medical Toxicology

Principles of neuro-transmission and pharmacology are the basisfor development of pharmacological treatments for addiction.The toxicologist is in a prime position to propose novel therapiesor guide investigative studies on existing pharmaceuticals. Giventhe difficulties in conducting randomized controlled studies onpoisonings and overdose, research on therapeutics for addictionmay be a venue to expand academic studies. Research topics canrange from efficacy of pharmacological treatments for cocaineaddiction to evaluation of the safety profile of naltrexone whenprescribed for alcohol dependence.Emerging patterns of recreational drug use are often identified inthe emergency department. Patients intoxicated with bath saltspresented with difficult to control agitation and were initiallyrecognized by paramedics and emergency departmentphysicians due to the nature of their clinical signs andsymptoms. Often the Emergency Department is the only medicalsetting that these patients encounter- many do not haveadditional medical problems that require regular care through aprimary care physician or psychiatrist. Toxicologists are in aunique position to offer screening for drug abuse or dependenceto these patients and counsel them on the physical and mentalhealth effects of their drug use. Studies in various health-caresettings on brief screening and counseling demonstrate costeffectiveness and observed decreased drug and alcohol use(Madras et al., 2009). Screening and counseling for tobacco andalcohol abuse and dependence is a natural extension of servicesalready provided by a toxicology consultation; expanding thescope of service would reinforce the economic value and qualityof patient care provided by the toxicology consultation service.There are a number of validated screening tools that can be used(for example -- CAGE, AUDIT, or DAST) and counseling skillscan be enhanced through online training or lectures provided bychemical dependency specialists.Addiction medicine is a small but growing specialty with manysimilarities to the field of toxicology. Toxicology would be servedwell to incorporate addiction medicine education into coretraining. Proficiency in addiction medicine principles broadensthe skills that toxicologists are able to utilize for managingpoisoned patients and offers further opportunities forpractice. The curriculum provided by toxicology fellowshipprograms could easily be expanded to incorporate academic andpractical experience in addiction medicine. Prescription drugmisuse remains a top public health concern and this is theopportune time for toxicologists to dedicate their involvement inthis critical issue.ACMT has identified Addiction Medicine as one of the six practicepathways to develop and highlight for career and practice opportunities.For more information about opportunities to expand your practice inaddiction treatment or to become active in the addiction medicinesection please contact section chair Timothy Wiegand, MD attimothy_wiegand@urmc.rochester.edu1.! Manchikanti, L., et al., Opioid epidemic in the United States. PainPhysician, 2012. 15(3 Suppl): p. ES9-38.2.! CDC grand rounds: prescription drug overdoses - a U.S. epidemic.MMWR Morb Mortal Wkly Rep, 2012. 61(1): p. 10-3.Return to Table of ContentsBilling Addiction Medicine Services as a Medical Toxicology ConsultantExamples of Suboxone Induction and Smoking CessationTim Wiegand, MD, FACMTThere are an increasing number of patients presenting to the hospital maintained on Suboxone and many of them will have need or expertise instarting/stopping/maintaining Suboxone along with other services a Toxicologist is able to provide. The following case illustrates reimbursementopportunities for adding addiction management such as Suboxone induction and tobacco cessation to your inpatient Medical Toxicology ConsultService.A 54 year-old gentleman had been treated for opioid dependence by one of the local addiction psychiatrists and had been doing well forover 2 years. He’d completed an intensive outpatient treatment program for prescription opioid dependence and been maintained on 16mg (8/2 mg SL BID) of SL buprenorphine daily with monthly visits. The patient had a long history of tobacco use although for severalyears he had been trying to quit. He had severe COPD and frequent bouts of bronchitis with COPD exacerbations. I had become involvedwith his care after he had been admitted to the hospital this winter with respiratory distress and severe COPD exacerbation. He’dpresented to the Emergency Department with respiratory distress from a COPD exacerbation and despite receiving oxygen, nebulizertreatments and antibiotics, deteriorated and required intubation. His sedation requirements were quite high. The ICU team hadn’tinitially understood that the fentanyl effect would be quite limited due to the patient’s regular and prescribed use of buprenorphine. Infact, the Suboxone hadn’t been ordered for continuation during the admission history and physical. The admitting resident hadn’tunderstood the purpose, not to mention the implications that the maintenance dose of 16 mg buprenorphine would have on the patient’sadmission. Over the first week, the patient’s respiratory function improved and he was extubated. During intubation he had beenmaintained on a combination of fentanyl and midazolam and he had a very difficult time with any weaning of the fentanyl –which hadbeen infused at 200 mcg/hour with additional boluses throughout the day. The doses of fentanyl were dropped over the next couple ofdays post-intubation but the patient became very diaphoretic, his heart rate increased and he had severe anxiety with the dosagedecrements. On the third day of this, after his extubation, a MICU resident who had spent time on toxicology recommended that theMICU consider buprenorphine to facilitate the wean from opioids and suggested they call for a consult to provide recommendations American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 6