Clinical Vignette
Patient: "Mr. P," 32-year-old electrician, presenting requesting medication-assisted treatment after his third overdose requiring naloxone reversal.
Chief Concern: "It started with Percocet after my back surgery 5 years ago. When my doctor stopped prescribing, I bought pills on the street. When pills got too expensive, I switched to heroin. I've overdosed 3 times. I don't want to die."
History of Present Illness: Mr. P underwent lumbar disc surgery 5 years ago and was prescribed oxycodone 10mg for post-surgical pain. Over 6 months, his dose escalated from 10mg twice daily to 30mg four times daily (120mg/day). When his surgeon tapered the prescription, he experienced withdrawal (rhinorrhea, myalgia, diarrhea, anxiety, insomnia) and began purchasing oxycodone from street sources. For 2 years he maintained his use through illicit prescription opioids, spending $200-400 daily. When pill prices increased, he transitioned to heroin (intranasal, then iv) 2 years ago. His current use: 1-2 grams of heroin daily, IV route. He has overdosed 3 times, each reversed with naloxone by paramedics. He injects in his antecubital fossae, which show scarring and track marks. He has no stable housing (lost apartment), his girlfriend left, he lost his electrician job, and he has depleted his savings. He has attempted to quit 'cold turkey' twice, lasting 2-3 days before the withdrawal became unbearable.
Medical History: Three naloxone reversals. Track marks with scarring. Hepatitis C positive (from needle sharing). History of post-surgical opioid prescription.
Mental Status Exam: Appears older than stated age. Track marks visible. Rhinorrhea. Pupils dilated (in mild withdrawal). Speech normal. Mood 'desperate.' Affect anxious, tearful. Thought process logical. Motivated for treatment. No psychotic symptoms. No suicidal ideation (but acknowledges he may die from an overdose). Insight good.
Step 1: Opioid Use Disorder DSM-5-TR Criteria
Criteria met (summary):
(1) Larger amounts/longer period — dose escalated far beyond prescription. (2) Unsuccessful efforts to cut down — 2 failed 'cold turkey' attempts. (3) Great deal of time spent — obtaining heroin consumes most of each day. (4) Craving — intense craving during withdrawal. (5) Failure to fulfill obligations — lost job. (6) Continued despite social problems — relationship dissolution, housing loss. (7) Activities given up — hobbies, social connections abandoned. (8) Physically hazardous use — IV injection, 3 overdoses. (9) Continued despite knowledge of problems — Hep C, needle complications, near-fatal ODs. (10) Tolerance — dose escalated from 20mg to equivalent of grams of heroin daily. (11) Withdrawal — documented withdrawal symptoms upon cessation. 11/11 CRITERIA MET. SEVERITY: SEVERE.
Step 2: Medication-Assisted Treatment Options
| Medication | Mechanism | Setting | Key Features | Considerations for This Patient |
|---|---|---|---|---|
| Buprenorphine (Suboxone) | Partial mu-opioid agonist | Office-based (waivered provider) | Ceiling effect reduces overdose risk; sublingual or injectable formulations | FIRST-LINE CHOICE: office-based, patient motivated, reduces overdose risk |
| Methadone | Full mu-opioid agonist | OTP (opioid treatment program) only | Daily observed dosing initially; most evidence for retention in treatment | Alternative if buprenorphine insufficient |
| Naltrexone (Vivitrol) | Mu-opioid antagonist | Office-based | Blocks opioid effects; monthly IM injection; requires 7-10 days opioid-free | Useful post-detox; requires opioid-free period (difficult for this patient currently) |
Treatment Recommendation
Buprenorphine (Suboxone) induction using the micro-induction protocol is recommended. Mr. P is motivated, can access office-based treatment, and the partial agonist ceiling effect provides overdose protection during the stabilization period. Hepatitis C treatment coordination is concurrent priority.
Diagnostic Formulation
Diagnostic Conclusion
Opioid Use Disorder, Severe (F11.20): All 11 DSM-5-TR criteria met. Classic prescription-to-heroin transition over 5 years. Severe with physiological dependence. Three near-fatal overdoses. Hepatitis C from needle sharing. Treatment: (1) Buprenorphine-naloxone (Suboxone) induction — office-based. (2) Hepatitis C treatment with DAAs (direct-acting antivirals). (3) Psychosocial: contingency management (strongest evidence for treatment retention in OUD) + CBT relapse prevention. (4) Naloxone rescue kit prescribed for patient and close contacts. (5) Housing stabilization and vocational rehabilitation.
Teaching Points
- The prescription-to-heroin transition is a well-documented pathway in the opioid crisis. Patients develop physiological dependence on prescribed opioids, lose prescription access (due to tapering, doctor shopping restrictions, or prescription monitoring programs), transition to diverted prescription opioids, and eventually switch to heroin due to lower cost and higher availability.
- Medication-Assisted Treatment (MAT) is the evidence-based standard of care for OUD. Buprenorphine, methadone, and naltrexone all reduce overdose death. MAT is NOT 'substituting one addiction for another' — it is medical treatment that normalizes brain function, reduces craving, and allows patients to function.
- Buprenorphine's partial agonist pharmacology provides a ceiling effect: above a threshold dose, additional opioid effect plateaus, reducing overdose risk. This ceiling effect also limits abuse potential compared to full agonists (heroin, methadone).
- Naloxone availability (rescue kits) is a life-saving harm reduction strategy. Every patient with OUD and their close contacts should carry naloxone. Mr. P's 3 naloxone-reversed overdoses demonstrate its effectiveness.
- Hepatitis C is common among people who inject drugs (PWID) due to needle and equipment sharing. Modern direct-acting antiviral (DAA) treatment cures Hepatitis C in >95% of cases within 8-12 weeks. Active substance use is NOT a contraindication to HCV treatment.