In a 33-year-old male on extended-release buprenorphine/naloxone (Brixadi) who is actively using alcohol and kratom (mitragynine 20 ng/mL) and has labs showing glucose 132 mg/dL, BUN 7.8 mg/dL, chloride 97 mmol/L, CO₂ 31 mmol/L, total protein 8.4 g/dL, albumin 5.6 g/dL, cotinine 1609 ng/mL, buprenorphine 121 ng/mL, norbuprenorphine 182 ng/mL, ETG >12500 ng/mL, ETS >5000 ng/mL, sertraline >2500 ng/mL, what is the appropriate management?

Management of Active Alcohol and Kratom Use in Patient on Brixadi

This patient requires immediate intervention for ongoing polysubstance use while on extended-release buprenorphine, with priority given to addressing the severe alcohol use (ETG >12,500 ng/mL, ETS >5,000 ng/mL) and kratom use (mitragynine 20 ng/mL), while continuing Brixadi therapy and addressing the supratherapeutic sertraline level.

Immediate Clinical Actions

1. Continue Brixadi Treatment

The buprenorphine level of 121 ng/mL with norbuprenorphine 182 ng/mL indicates therapeutic dosing and medication adherence 1. Do not discontinue Brixadi despite ongoing substance use - the FDA label explicitly states that patients who continue to misuse or abuse substances should be provided with or referred for more intensive and structured treatment, not medication discontinuation 1.

2. Address Active Kratom Use

The mitragynine level of 20 ng/mL confirms active kratom use. The current Brixadi dose appears adequate for kratom blockade - case series demonstrate that buprenorphine/naloxone doses between 8-16 mg effectively treat kratom use disorder, with 68% achieving negative mitragynine tests by 4 weeks 2. Since this patient is already on extended-release buprenorphine:

• Continue current Brixadi dosing - the therapeutic buprenorphine levels suggest adequate coverage
• Monitor for kratom use with specific mitragynine/7-hydroxymitragynine testing (standard urine drug screens do not detect kratom) 3, 4
• The 7-OH level >250 ng/mL indicates use of concentrated 7-hydroxymitragynine, which is significantly more potent than traditional kratom 5

3. Manage Severe Alcohol Use Disorder

The ETG >12,500 ng/mL and ETS >5,000 ng/mL indicate heavy, recent alcohol consumption. This represents the most immediate mortality risk due to combined CNS depression with buprenorphine 1:

• Assess for alcohol withdrawal immediately - check vital signs, CIWA score
• Initiate alcohol-specific pharmacotherapy: Consider naltrexone (after ensuring adequate opioid-free interval if switching from Brixadi, though concurrent use with buprenorphine is contraindicated), acamprosate, or gabapentin for alcohol use disorder
• Refer to intensive outpatient or residential treatment - the combination of active alcohol and kratom use while on medication-assisted treatment indicates need for higher level of care 1

4. Address Supratherapeutic Sertraline Level

Sertraline >2,500 ng/mL is significantly elevated (therapeutic range typically 10-150 ng/mL):

• Evaluate for intentional overdose or medication non-compliance (taking multiple doses at once)
• Monitor for serotonin syndrome - check for agitation, tremor, hyperreflexia, diaphoresis, hyperthermia
• Review dosing schedule with patient and consider directly observed therapy if adherence is questionable

Laboratory Interpretation

Metabolic Concerns

• Glucose 132 mg/dL: Mildly elevated, monitor for diabetes risk
• BUN 7.8 mg/dL: Low-normal, may reflect poor protein intake or dilution from alcohol use
• Chloride 97 mmol/L: Low-normal
• CO₂ 31 mmol/L: Slightly elevated, suggests possible metabolic alkalosis or compensation
• Total protein 8.4 g/dL, Albumin 5.6 g/dL: Both elevated, likely hemoconcentration from dehydration

Tobacco Use

Cotinine 1609 ng/mL confirms active heavy tobacco use - offer smoking cessation resources.

Treatment Algorithm

Step 1: Assess immediate safety

• Vital signs, mental status, withdrawal risk (alcohol > opioid given Brixadi coverage)
• Rule out acute intoxication requiring medical stabilization

Step 2: Maintain Brixadi therapy

• Verify injection site integrity (no tampering attempts) 1
• Confirm next scheduled dose timing
• Do NOT discontinue despite ongoing use 1

Step 3: Escalate intensity of psychosocial treatment

• Refer to intensive outpatient program (IOP) or residential treatment - this is non-negotiable with active polysubstance use
• Increase frequency of clinical monitoring and urine drug screening
• Consider contingency management interventions

Step 4: Add alcohol-specific interventions

• Pharmacotherapy for alcohol use disorder (gabapentin 900-1800 mg/day divided TID is safest option given buprenorphine)
• Alcohol-focused counseling and mutual support groups

Step 5: Optimize sertraline management

• Reduce dose if taking excessive amounts
• Consider switching to directly observed therapy or weekly dispensing

Critical Pitfalls to Avoid

1. Do not discontinue Brixadi - this increases overdose risk and abandons the patient 1
2. Do not underestimate alcohol risk - combined CNS depression with buprenorphine significantly increases overdose and death risk 1
3. Do not use standard opioid urine screens for kratom - requires specific mitragynine/7-hydroxymitragynine testing 3
4. Do not assume kratom is benign - the 7-OH level >250 indicates use of concentrated, high-potency product that can cause severe withdrawal 6, 5
5. Do not attempt rapid buprenorphine dose escalation - Brixadi's long-acting nature means adjustments are not rapidly reflected in plasma levels 1

Monitoring Plan

• Weekly visits initially with urine drug screening including specific kratom alkaloid testing
• Vital signs and CIWA scoring at each visit until alcohol use stabilizes
• Buprenorphine levels if concern for medication diversion or non-adherence
• Liver function tests given alcohol use and multiple medications
• Reassess level of care weekly - if no improvement in 2-4 weeks, residential treatment is indicated