The patient, "John," is a 29-year-old, Alaskan Native male and Afghanistan War veteran who developed a serious alcohol use disorder and an opioid use disorder following his military service. He was living homeless on the streets of Seattle, smoking heroin several times per day.

John came to the Veteran’s Administration (VA) in Seattle seeking help. Because of the VA’s long wait list for treatment slots for patients with opioid use disorder, we had recently started an interim buprenorphine program inspired by a letter to the editor in the New England Journal of Medicine. The letter, signed by several clinicians, noted the dangers of making patients wait for treatment. Through a clinical pilot study, the group of physicians who signed the letter evaluated the efficacy of an interim regimen of buprenorphine for reducing illicit opioid use and found “a higher percentage of specimens that were negative for illicit opioids than those in the control group at 4 weeks (88% vs. 0%), 8 weeks (84% vs. 0%), and 12 weeks (68% vs. 0%).” According to the study, “Among patients on a waiting list to receive comprehensive treatment, interim dosing with buprenorphine, paired with technology-assisted components intended to support adherence, was associated with a statistically significant reduction in the use of illicit opioids and intravenous drugs as compared with remaining on the waiting list alone over 12 weeks.”

The team decided to start John on buprenorphine/naloxone immediately on the day of his presentation and rapidly titrated up to 16/4 mg per day. On this dosage, he reported a complete absence of withdrawal symptoms and had stopped using heroin. He noted that he was still having some heroin cravings so we also placed him on transdermal clonidine based upon findings in another study -“Clonidine Maintenance Prolongs Opioid Abstinence and Decouples Stress From Craving in Daily Life: A Randomized Controlled Trial With Ecological Momentary Assessment.” The study, published in the American Journal of Psychiatry, was “the first to demonstrate efficacy of clonidine for relapse prevention in treatment-seeking opioid users, which would be a novel and important indication for clonidine, adding to its current use in opioid detoxification.”

The combination of buprenorphine and clonidine put John’s cravings under control. John has not used heroin or alcohol for four months, has returned to regular employment, and has the opportunity to move into an apartment. He’s doing so well, in fact, he is considering moving home to Alaska.

Andrew Saxon MD FASMby Andrew Saxon, MD, FASM

Andrew J. Saxon, MD, FASM, is a professor in the Department of Psychiatry and Behavioral Sciences, University of Washington. Dr. Saxon is also the Director of the Center of Excellence in Substance Abuse Treatment and Education at the VA Puget Sound Health Care System, as well as the Director of the Addiction Psychiatry Residency Program at the University of Washington. Dr. Saxon is a lead mentor for the Providers’ Clinical Support System for Medication Assisted Treatment.