What is the recommended treatment approach for a 29-year-old female with a history of substance use disorder (SUD), including cocaine, fentanyl, alcohol, and cannabis use, who also has anxiety and major depressive disorder (MDD), and is currently taking trazodone (Oleptro) 150mg and lexapro (Escitalopram) 20mg, and is interested in starting Medication-Assisted Treatment (MAT)?

Medication-Assisted Treatment for a 29-Year-Old Female with Polysubstance Use Disorder and Co-occurring Mental Health Conditions

For this patient with multiple substance use disorders including fentanyl use and co-occurring depression and anxiety, buprenorphine-based medication-assisted treatment (MAT) should be initiated as the first-line approach, combined with cognitive behavioral therapy (CBT) to address both the substance use disorders and mental health conditions.

Assessment of Current Situation

This patient presents with:

• Multiple substance use disorders (cocaine, fentanyl, alcohol, cannabis)
• Co-occurring anxiety and major depressive disorder (MDD)
• Current medications: trazodone 150mg and lexapro 20mg
• Nightmares 2-3 times/week
• Hand tremors
• Last substance use: 9/4/25 (recent)

Recommended Treatment Approach

1. Medication-Assisted Treatment Selection

• Primary MAT recommendation: Buprenorphine/naloxone

  • Buprenorphine is an evidence-based medication for opioid use disorder (fentanyl) 1
  • Starting dose: 4-8mg on day 1, titrating to maintenance dose of 8-16mg daily
  • Must be initiated when patient is in mild-moderate withdrawal (12-24 hours after last opioid use)
  • Advantages: office-based treatment, lower overdose risk, treats both opioid withdrawal and cravings

• Alternative MAT option: Naltrexone

  • Can address both alcohol use disorder and opioid use disorder 2
  • Would require 7-14 days opioid-free period before initiation 3
  • Initial dose: 25mg for 1-3 days, then 50mg daily maintenance 2
  • Extended-release injectable formulation (380mg monthly) is available 2
  • Reduces relapse rates by approximately 50% when combined with psychosocial interventions 2

2. Psychosocial Interventions

• Cognitive Behavioral Therapy (CBT)

  • First-line behavioral approach for treating substance use disorders 1
  • Combined CBT plus pharmacotherapy shows significantly better outcomes than pharmacotherapy alone 1
  • Addresses cognitive, affective, and environmental risks for substance use
  • Provides training in behavioral self-control skills

• Contingency Management

  • Highly effective for stimulant use disorders (cocaine) 1
  • Can be combined with CBT for polysubstance use
  • Provides rewards for drug-free urine samples

3. Management of Current Psychiatric Medications

• Escitalopram (Lexapro) 20mg

  • Continue current dose as it addresses both anxiety and depression
  • Monitor for potential interactions with buprenorphine (generally minimal)

• Trazodone 150mg

  • Continue for management of sleep disturbances and nightmares 4
  • Low-dose trazodone is effective as an off-label hypnotic for sleep disorders in patients with MDD 4
  • Monitor for potential side effects including dizziness, which may worsen hand tremors

4. Addressing Specific Symptoms

• For hand tremors:

  • Evaluate if alcohol-withdrawal related
  • Consider reducing trazodone dose if tremors worsen
  • Monitor for benzodiazepine withdrawal if previously used

• For nightmares:

  • Continue trazodone which may help with sleep architecture
  • Consider prazosin if nightmares persist despite trazodone

Implementation Plan

1. Initial Phase (Weeks 1-2):

   • Begin buprenorphine/naloxone induction when patient shows signs of mild-moderate withdrawal
   • Titrate to effective dose (typically 8-16mg daily)
   • Start weekly CBT sessions
   • Continue current psychiatric medications
   • Provide education on overdose prevention and naloxone

2. Stabilization Phase (Weeks 3-12):

   • Maintain effective buprenorphine dose
   • Continue CBT with focus on both substance use and mental health
   • Consider adding contingency management for cocaine use
   • Monitor for side effects and medication interactions
   • Assess treatment response at 12 weeks 2

3. Maintenance Phase (Months 4-12):

   • Continue effective MAT for at least 6-12 months
   • Gradually reduce frequency of CBT sessions based on progress
   • Continue monitoring psychiatric symptoms and adjust medications as needed

Potential Challenges and Solutions

• Polysubstance use:

  • While buprenorphine addresses opioid use, additional strategies needed for cocaine, alcohol, and cannabis
  • Prioritize addressing life-threatening withdrawal first (alcohol), then opioid dependence, then stimulant use 2

• Medication interactions:

  • Monitor for serotonin syndrome with combined escitalopram and trazodone
  • Avoid benzodiazepines due to risk when combined with buprenorphine

• Treatment adherence:

  • Consider once-monthly injectable formulations if daily adherence becomes problematic
  • Implement contingency management to reinforce treatment adherence

Monitoring and Follow-up

• Weekly visits during first month
• Urine drug screens at each visit
• Liver function tests at baseline and every 3-6 months 2
• Regular assessment of mental health symptoms
• Evaluate for side effects at each visit

This comprehensive approach addresses the patient's polysubstance use disorder while maintaining treatment for co-occurring mental health conditions, with the goal of reducing morbidity and mortality associated with substance use disorders.