MN665 Unit 8 substance use case study example

One Loop, Two Disorders: Treating Opioid Use Disorder and PTSD Together in a 33-Year-Old Home Health Aide

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Purdue University Global

MN665: PMHNP Diagnosis and Management Across the Lifespan II

Unit 8 Assignment

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[Date]

Composite patient written as a model document. Doses and induction methods are bracketed; nothing here is a prescribing instruction.

Why the Conditions Are Treated Together

Treating these conditions one after the other would fail her. Waiting for sobriety before addressing her trauma leaves the source of her nightly use untouched, so the nightmares keep driving her back to fentanyl. Treating her trauma while she is still using, without medication to steady her, invites relapse, because exposure work raises distress in the short term. So every recommendation below is tested against both conditions at once.

Part 1: Formulation

A composite 33-year-old home health aide has used fentanyl daily for two years. She began with pills a coworker offered after a back injury, and now uses powder she smokes. She left a partner who beat and strangled her four years ago; he lives in the same county. Her PTSD Checklist for DSM-5 score is 54, well above the score of 33 suggested as a cutoff for probable PTSD (Blevins et al., 2015). She has nightmares most nights, startles easily and avoids the neighborhood where they lived.

Her use follows a loop with four points, which the case study draws as a cycle:

Night: she wakes from a nightmare about him, heart pounding.

Use: she smokes fentanyl to get back to sleep.

Next afternoon: withdrawal begins, with sweating, restlessness, a racing heart and poor sleep.

Evening: that arousal makes the memories stronger and the nightmares more likely, and the loop begins again.

Each point in the loop feeds the next, which is why treating only the drug or only the trauma leaves the loop intact.

Part 2: Medication for Opioid Use Disorder

Two medications have the strongest evidence: methadone and buprenorphine. Both reduce illicit opioid use and the risk of overdose death.

Methadone deserves its credit. In a Cochrane review, methadone retained more people in treatment than flexible doses of buprenorphine, and at adequate doses the two drugs suppressed illicit opioid use similarly (Mattick et al., 2014). For many people, especially those using high-potency opioids, methadone's retention advantage is decisive.

For her, the practical demands decide it. Methadone for opioid use disorder is dispensed through an opioid treatment program, which usually means visiting a clinic every day at first. Her job has her driving between clients' homes on a schedule that changes weekly, and she said she would lose the job if she had to be at a clinic every morning. Losing the job would remove her income and her main source of daily structure. Buprenorphine can be prescribed in an office and taken at home, and since the federal waiver requirement was removed at the end of 2022, any clinician with a standard DEA registration that includes Schedule III can prescribe it.

Buprenorphine is also judged against the PTSD half of the loop. By preventing withdrawal the next afternoon, it should reduce the daily surge of arousal that strengthens her memories and nightmares.

Fentanyl complicates the first days. Because fentanyl is stored in fat and cleared slowly, starting buprenorphine too soon after last use can bring on sudden, severe withdrawal. The method of induction is left in brackets here, as [a composite induction method], to be chosen by her prescriber after discussion with her, since several approaches are in use and each has tradeoffs.

Choice: buprenorphine, with methadone kept as the fallback if she cannot stay in treatment on buprenorphine.

Part 3: Trauma Treatment Without Waiting

The main objection to exposure therapy during active substance use is that reliving trauma will drive her back to using. The COPE trial tested that directly. People with both PTSD and substance dependence who received 13 sessions of integrated prolonged exposure alongside usual substance use treatment had a greater reduction in PTSD severity at nine months than those receiving usual treatment alone, with no increase in the severity of their substance dependence (Mills et al., 2012).

That finding answers both tests. Exposure work reduces PTSD symptoms, and it did not raise substance use or dependence severity in the trial. She is referred to a therapist trained in integrated exposure for co-occurring PTSD and substance use, starting once she is stable on buprenorphine, which should take a few weeks rather than months.

Part 4: Sleep

Night is where the loop closes, so sleep gets its own plan. Benzodiazepines are ruled out: in 2016 the FDA added a boxed warning against combining opioids with benzodiazepines because of the risk of profound sedation, slowed breathing and death. She is taught a nightmare response routine: lights on, feet on the floor, a grounding exercise and a written plan to call a named friend rather than use. Imagery rehearsal for nightmares will be added in therapy, and a nonaddictive medicine for trauma nightmares will be considered by her prescriber if they continue.

Part 5: Two Kinds of Danger

Overdose. Fentanyl carries a high risk of overdose, especially after a period of reduced use when tolerance falls. She is given naloxone, which has been sold over the counter since 2023, and taught to use it; her roommate is shown as well. She is told that tolerance drops quickly, so a return to her old amount after a few days off buprenorphine could kill her.

Her former partner. He strangled her, which is associated with a much higher risk of later homicide by a partner. That risk is separate from the risk of overdose and needs its own response. With her consent, she is referred to a domestic violence advocate who can help with a safety plan, a protective order if she wants one, and changes to her work schedule so that she does not visit clients near his neighborhood alone.

Measurement and Review

Urine drug testing at each visit, reviewed with her as information rather than as a verdict. The PTSD checklist repeated monthly. A simple diary of nightmares and use, reviewed weekly. Her job attendance, which she tracks herself, as a measure that matters to her. Each measure is chosen to read one point in the loop: the diary reads the night, the drug test reads the use, the checklist reads the memories and her attendance reads whether the next afternoon has become livable. If one point improves while another does not, the plan knows where to look. The plan is reviewed at eight weeks. If she is still using regularly on buprenorphine, the dose, support and the option of methadone are revisited.

References

Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489-498. https://doi.org/10.1002/jts.22059

Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2014(2), CD002207. https://doi.org/10.1002/14651858.CD002207.pub4

Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S., Sannibale, C., Barrett, E. L., Merz, S., Rosenfeld, J., & Ewer, P. L. (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. JAMA, 308(7), 690-699. https://doi.org/10.1001/jama.2012.9071