“Ms. B” is a 28-year-old woman with a 4-year history of illicit prescription opioid use by the oral and nasal routes. She began by occasionally sharing pills with friends at parties, then progressed to 1–2 pills a day and steadily increased to an average of 250–350 mg of oxycodone or its equivalent per day but sometimes taking up to 450 mg a day. She sporadically inhaled heroin but denied injecting it, and she was consuming 5–9 drinks (mixed or straight vodka) 6–7 nights per week. She had attended community college for a year but did not graduate, and she was working in a medical office. She obtained opioids by buying them “on the street,” by “doctor shopping” using a vague complaint of back injury with severe pain, or by forging prescriptions, carefully rotating the pharmacies where she filled them to avoid raising pharmacists’ suspicions. She debated with herself about quitting because she felt that her life was “ruined and going nowhere,” and she sought treatment because she became frightened after nearly getting caught stealing prescription pads at work. She also reported feeling sad, with crying spells and feelings of hopelessness and self-deprecation, but without suicidal ideation.
Ms. B was addicted to prescription opioids and alcohol and was also depressed; although she acknowledged an opioid problem, she did not initially acknowledge her alcohol problem. The main reason she sought treatment was the anxiety she experienced after nearly getting caught stealing prescription pads. Her acute anxiety was situational, but it was unclear whether her long-standing depression was substance induced or an independent disorder.
Ms. B had heard about buprenorphine from friends, and she agreed to office-based treatment with counseling and pharmacotherapy with a buprenorphine-naloxone preparation. She was started on a daily dose of 8 mg/2 mg, which was increased to 12 mg/3 mg on day 2, to 16 mg/4 mg on day 4, and then, in gradual increments, to 24 mg/6 mg by the third week, at which point she reported that opioid cravings and withdrawal were suppressed for the entire day. She experienced mild alcohol withdrawal shortly after treatment began, with tremulousness and tachycardia that resolved with 200 mg of chlordiazepoxide in divided doses over 2 days. Psychosocial treatment included intensive outpatient group counseling three times a week, individual therapy with a social worker, medication management by an addiction psychiatrist, and encouragement to participate in Narcotics Anonymous (NA).
She was strongly motivated to stop opioids and quickly reduced her use from daily to twice weekly and from many to 1–2 pills a day, and by the fourth week she stopped use altogether. She was ambivalent about abstaining from alcohol, and her belief in her ability to drink in moderation fluctuated; she continued binging with 4–5 drinks at a time, 2–4 nights per week. Therapy focused on encouragement and praise for progress and feedback that highlighted her problematic alcohol and opioid use and the discrepancies between her intentions and her actual behaviors. After 8 weeks, Ms. B was persuaded that she could not limit her drinking, and she stopped altogether and committed to total abstinence.
Ms. B’s depressive symptoms continued, and by the second week she agreed to a trial of sertraline. Her initial intention was to take buprenorphine-naloxone for brief detoxification; she expressed disdain for the possibility of becoming dependent on it as a mere “substitute.” But as her opioid use stopped and her depressive symptoms improved, she became more comfortable with continuing buprenorphine-naloxone for an indefinite period and agreed to defer any decision about tapering until she felt “strong enough.” She continued buprenorphine-naloxone, and after 3 months of intensive outpatient group therapy, she stepped down to one group and individual counseling session per week and monthly physician visits.
Around month 4, Ms. B stopped attending group therapy, expressing financial difficulties and the feeling that she no longer needed it. Around month 5, citing personal incompatibility, she stopped seeing her therapist and declined to increase the frequency of physician visits, which was offered as a replacement. At month 6, she began a relationship with a man she met at an NA meeting and began complaining of anorgasmia from sertraline. The sertraline dosage was decreased from 200 to 150 mg/day, and while the anorgasmia improved, depressive symptoms returned despite having maintained opioid and alcohol abstinence. The sertraline dosage was restored to 200 mg, but her depression did not improve, and she was switched to escitalopram, which produced only modest improvement. Augmentation with lithium was tried but stopped after a few doses because it made her feel “weird.”
Ms. B’s stressors continued, among them mounting financial difficulties and romantic disappointment when her new boyfriend relapsed to heavy drinking and it took a month for her to break off the relationship. A friend invited her to a party at which she relapsed to drinking, and she soon stopped taking buprenorphine-naloxone and relapsed to opioid use as well. After 2 weeks of intermittent binging on alcohol and prescription opioids, she presented at an urgently scheduled visit saying that she had not been taking her medications, had again stopped using opioids and alcohol for 3 days, was miserable, and wanted to get “back on track.” She was restarted on buprenorphine-naloxone and sertraline; the sertraline was titrated to 300 mg/day, and risperidone, 0.5 mg h.s., was added. With ongoing encouragement, she agreed to reengage in NA, and after a few weeks she started with a new therapist. She maintained abstinence and remission from depression for 6 months.