Supporting Sustained Recovery for Opioid Use Disorder

Transcription

1 Supporting Sustained Recovery for Opioid Use Disorder RCPA Conference Hershey, PA October 3, 2018

2 Agenda Scope of the opioid epidemic Medication-assisted treatment (MAT) What does MAT involve? What are the benefits and effects of MAT? How is MAT integrated into a comprehensive treatment plans to support long-term recovery? 2

3 Scope of the opioid epidemic

4 The Denver Post Sep 20, 2016 CBS News June 29, 2017 The Telegraph June 13, 2017 The Guardian March 6, 2018 Stat News August 22, 2016 CBS News May 23,

5 Opioid use disorder (OUD) A medical condition Like all substance use disorders (SUD), OUD is a condition characterized by a pattern of compulsive substance use in spite of the harmful consequences of repeated use. Does not discriminate affects individuals of all ages, gender, race, social and economic status A chronic brain disease; not a character flaw or moral failing Office of the Surgeon General, Facing Addiction in America: The Surgeon General s Report on Alcohol, Drugs and Health Addressing the challenges Stigma around SUD can make people feel ashamed or afraid to seek the help they need It is a chronic, complex disease difficult to treat The marketplace offers wide variability in treatment Members struggle to find effective evidencebased care Individuals are vulnerable to predatory practices 1. Retrieved from 5

6 Early exposure and dependence Opioid dependence can start in just a few days. 1 80% of heroin users report starting on prescription opioids prior to transitioning to heroin. 2 Risk of chronic opioid use increases with each additional day of opioid supplied starting with the third day Reinberg, S. (2017). Opioid Dependence Can Start in Just a Few Days. Retrieved from 2. Muhuri, P. (2013). CBHSQ Data Review: Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. Retrieved from 3. Anuj Shah, A., Hayes, C., Martin, B., Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use United States, MMWR Morb Mortal Wkly Rep 2017;66. Retrieved from 6

7 Death due to opioid overdose 25,000 20,000 15,000 10,000 Deaths due to illicit opioids up 134% from 2012 to National per capita opioid prescribing rates decreased 13.1% from 2012 to , National Center for Health Statistics, Centers for Disease Control and Prevention. 2. Guy GP Jr., Zhang K, Bohm MK, et al. Vital Signs: Changes in Opioid Prescribing in the United States, MMWR. Morbidity and Mortality Weekly Report 2017;66: Retrieved from Heroin and fentanyl Both Common prescription opioids 7

8 Prescription opioid use by age and gender Opioid prescribing by age 1 Patients in opioid treatment by age and gender 2 <13 < % 5% 3% 4% 9% 12% 13% 12% 16% 15% 20% 19% 30% 33% % 1% 11% 8% 14% 17% 9% 16% 21% 23% 37% 41% Male Female 1. UnitedHealthcare large ASO employer 2017 claims experience. 2. UnitedHealthcare ASO covered lives 2016, served by Optum Behavioral Health. 8

9 CDC Guidelines for opioid prescribing Opioids are not first-line therapy for chronic pain Non-opioid and non-pharmacologic treatments are preferred Offer MAT for OUD MAT has proven the most effective treatment for OUD 3 Short duration for acute pain 3 days of therapy should be sufficient, longer than 7 days rarely needed Lowest effective dose at start Less than 50 morphine equivalent dosing (MED) per day at treatment initiation Avoid opioids in combination with benzodiazepines Avoid these drugs in combination because of increased overdose risk Minimize dose escalation Avoid increasing dosage to 90 MED per day 9

10 Prevention Chronic back pain management When people try chiropractic care or physical therapy for back pain first, patients are 60% less likely to use opioids 1 1. Optum analytics based on UHC commercially insured population,

11 Minimizing early exposure Alignment with CDC guidelines Aggressive first-fill morphine-equivalent dose (MED) and days supply edits Max of 49 MED per day and max 7-day supply on all new short-acting opioid scripts Narrowed refill window (75% to 90% used) on all opioid prescriptions to limit early refills and stockpiling Limit of two 7-day supply fills within a 60-day time frame Prior authorization on all first-fill for a long-acting opioid and opioid-based cough preparations in pediatrics 11

12 Optum experience Pharmacy edits for short-acting prescription opiates Compliance with CDC guidelines 94.7% compliance 29.9% improvement 95.2% compliance 13.5% improvement 96.0% compliance 4.5% improvement First-fill opioid scripts < 50 MED per day First-fill opioid scripts 7-days supply Opioid prescriptions dosed < 90 MED among current chronic users On average, 45% of first-fill scripts nationally are not in compliance with CDC guidelines 1 1. Note: Results are based on June 2017 vs December 2017 client data and short-acting opioid script volume and do not represent a guarantee of results. 12

13 Medication-assisted treatment (MAT)

14 Substance use disorders are viewed as a chronic disease Relapse is a common part of any chronic disease SUD treatment is similar to medical interventions (e.g., the choice between surgery or medication) Member s previous clinical experiences, individual psychosocial variables, effective treatment choices and outcomes Chronic illness is best managed in the individual s local community to aide the development of readily available local recovery supports Direct correlation between treatment engagement and best outcomes Treatment provided must be person-centric and individualized Primary goal is to move from acute intervention to long-term recovery Acute treatment planning is based on an individual s current presentation, past substance use treatment, medical, psychiatric, and social history Long-term recovery is focused on each person s strengths, challenges and barriers to treatment, and continuity of care No correlation between the intensity of the treatment setting (i.e., inpatient, residential) and treatment engagement and outcomes 14

15 Benefits of MAT 1 Minimize withdrawal symptoms 2 3 Reduce opioid cravings Prevent relapse Restore normal physiological functioning Chance of remission (no opioid misuse) greater than detoxification or psychosocial treatment alone % 1. Calculated by Optum, based on relative risk ratios from the meta-analysis in: Nielsen S, Larance B, Degenhardt L, Gowing L, Kehler C, Lintzeris N. Opioid agonist treatment for pharmaceutical opioid dependent people. Cochrane Database of Systematic Reviews 2016, Issue 5. Art. No.: CD DOI: / CD pub2, pages 17 and

16 MAT plays a critical role for those with OUD It is the standard of care for treatment of OUD 1 MAT uses FDA-approved medications with counseling and behavioral therapies to treat substance use disorders and prevent opioid overdose. 2 Methadone Buprenorphine Naltrexone 1. National Drug Control Strategy: FY 2016 Budget and Performance Summary, p SAMHSA, Medication Assisted Treatment: Medication and Counseling Treatment. Retrieved from 16

17 MAT works on opioid receptors Three medications and three mechanisms of action: Methadone: an opioid receptor AGONIST Fully activate opiate receptors Overdose shuts down the respiratory center and causes death Other agonists: heroin, morphine and oxycodone Buprenorphine: an opioid receptor PARTIAL AGONIST Partially activate opiate receptors Built in ceiling effect prevents overdose by themselves Cause immediate withdrawals if opioids are in the system Naltrexone: an opioid receptor ANTAGONIST Block and prevent activation of opiate receptors No overdose potential Cause immediate withdrawals if opioids are in the system 17

18 METHADONE Agonist therapy Only provided by federally-regulated clinics Synthetic, long-acting, full opioid agonist Chemically unlike morphine or heroin but acts on the same opioid receptors Narcotic blockade by cross-tolerance Eliminates symptoms of withdrawal Benefits of maintenance Ability to focus on activities of daily living Improvement in productive behaviors Employment, education, care-giving Marked drop in criminal activity and arrests Normalization of death rates compared to general public Diminishes experience of opiate euphoria Reduces drug hunger or cravings Blocks reinforcing intoxication Mt Sinai J Med Jan;68(1):

19 METHADONE Replacement therapy Induction Maintenance Discontinuation Outcomes Typical first dose is 20 mg to 30 mg (FDA methadone induction max is 40 mg) Steady state achieved within 10 days Typical dose is mg/day Protracted side effects: sweating, constipation, weight gain, pregnancy Slow taper: 10 mg/month until mg/day, then 2 5 mg/month Conversion to buprenorphine: mg methadone and then stop for 72 hours Protracted withdrawals: malaise, depression, anxiety, insomnia, pain, cravings Maintenance: 50 80% 1-year retention rate Discontinuation: 20 30% abstinence after three years Most relapse in first month 59% used heroin over the 2-year follow-up Greater criminal activity and incarceration rates Poor outcomes with comorbid alcohol dependence and substance abuse Mt Sinai J Med Jan;68(1):

20 BUPRENORPHINE Partial agonist therapy Brand products:* Suboxone Zubsolv Bunavail Regulated by the DEA (Drug Enforcement Agency) Require special DEA prescribing license (DATA 2000) Eliminates the addictive, reinforcing and euphoric characteristics of a full agonist Ambulatory and outpatient settings Three stages of treatment: 1. Induction 2. Stabilization 3. Maintenance Treatment considerations Absence of opiates in the system Avoidance of sedative use Can be used at all levels of care Can be used while treating psychiatric and medical comorbidities Can be used with MAT for nicotine use disorder Cannot be used simultaneously with naltrexone or methadone *Contains small amount of naloxone **Except naltrexone 20

21 BUPRENORPHINE Stages of treatment Intake Induction Stabilization Maintenance Establish suitability for treatment Discuss substance use history Assess readiness for change Confirm support systems/networks Review treatment plan/expectations Sign patient contract Day 1 Member in moderate withdrawal Initiate induction Additional medications as needed Day 2 Re-evaluate Discuss side effects, adjust dosage Prescription only to last until next visit Review ongoing counseling and sober support use Continue to assess withdrawal symptoms Member begins stable daily dose Begin counseling, group therapy and sober supports Relapse prevention and planning Weekly follow-up and drug screening Prescription only to last until next visit Continue stable daily dosage Decrease visit frequency Continue UDS with prescriptions Taper Long taper: more than 30 days Moderate taper: 14 to 30 days Rapid taper: 3 to 5 days 21

22 Opioid detox : Facts and fictions Opiate withdraw symptoms Symptoms of opioid withdrawal are not life-threatening Clinical management does not require 24-hour nursing care Untreated withdrawal symptoms often result in continued use Opioid withdrawal management Detox only is not considered treatment for OUD Detox only does not decrease the incidence of relapse Detox only does not increase community sobriety or tenure Detox only does increase the risk for unintentional overdose 22

23 BUPRENORPHINE Detox Rapid induction-reduction with buprenorphine Induction phase 1 to 2 days Typically seen in inpatient detox or enhanced programming Reduction phase Rapid reduction: 3 to 5 days Detox has no compelling reason More likely to overdose upon relapse Has not considered treatment Moderate reduction: 14 to 30 days No compelling reason for short-term reduction Unwilling or unable to engage in treatment with ongoing treatment Long reduction: 30 days or longer Compelling reason to engage in rehabilitation Unwilling or unable to engage in ongoing therapy Post-taper phase Indefinite period Continue individual therapy, group therapy, sober supports Address medical, behavioral and social problems 23

24 NALTREXONE Antagonist therapy Used to prevent relapse or diminish the effect of opioid use Naltrexone causes withdrawal symptoms if an opiate is in the system Oral challenge for 5 7 days followed by intramuscular injection Oral challenge for 5 14 days after detox or methadone conversion Two dosing schedules for oral Naltrexone 50 mg/day; can increase to 100 mg/day if needed 100 mg M W F +150 mg over the weekend One dosing schedule for injectable naltrexone Given as a 380 mg intramuscular injection dose every four weeks Special pharmacy order; not self-administered Vivitrol : brand name of long acting formulation 24

25 BUPRENORPHINE MAT considerations for special populations Pregnant women MAT for maintenance is preferred over MAT for withdrawals Either methadone or buprenorphine can be prescribed; however, if a pregnant patient is stable on methadone do not change to buprenorphine Infants born to women who received buprenorphine during pregnancy 1) developed milder neonatal opioid withdrawal symptoms (NAS) than those born to women who received methadone, and 2) needed fewer post-delivery hospital days MAT should begin immediately when a pregnant opiate addict presents for treatment; MAT should be continued through the pregnancy If a patient is using buprenorphine, the drug should be used alone (without naloxone) Breastfeeding is encouraged on both medications Adolescents All treatment options are to be considered Some MAT are not FDA-approved for adolescents Clinical reasoning for not providing MAT should always be documented 25

26 What our experience shows 1. Based on Healthcare Analytics review from to claims data for Optum Commercial Business; there were 10,373 members who were admitted to a facility-based level of care with an opiate-based primary diagnosis.2. McLellan AT1, Arndt IO, Metzger DS, Woody GE, O Brien CP. The effects of psychosocial services in substance abuse treatment. JAMA Apr 21;269(15):

27 Dispelling a myth about MAT Many objections to MAT are based on the belief that it replaces one dangerous drug with another SUDs are characterized by harmful consequences of repeated use DSM-5 criteria for diagnosis: Maladaptive Pattern of Substance Use Leading to clinically significant impairment or distress over 12 months Note: Withdrawal and tolerance symptoms by themselves do not denote a substance use disorder MAT is a treatment Most people using MAT are quite functional again and are able to fulfill their responsibilities 27

28 MAT need significantly exceeds capacity 1 Physicians are not prescribing. Only 3.5% of 900,000 U.S. physicians who can write prescriptions for opioid painkillers have obtained a DATA 2000 waiver to prescribe buprenorphine and only a fraction of those licensed actually prescribe it. 2 Only 23% of public and less than 50% of private-sector treatment programs offer any FDA-approved medications to treat SUD/OUD. 3,4 Even in programs that do offer MAT, only 34.4% of patients receive it August 2015, Vol 105, No. 8, American Journal of Public Health. 2. Vestal, C. In Drug Epidemic, Resistance to Medication Costs Lives, The PEW Charitable Trusts. January 11, Knudsen HK, Roman PM, Oser CB. Facilitating factors and barriers to the use of medications in publicly funded addiction treatment organizations. Journal of Addiction Medicine 2010;4(2): Knudsen HK,, Abraham AJ, Roman PM. Adoption and Implementation of Medications in Addiction Treatment Programs. Journal of Addiction Medicine (1):

29 Importance of community tenure Treatment in an individual s home community improves the chance of sustained recovery Allows people to create a readily accessible support system (primary care providers, mental health professionals, friends, family, peers, and community sober supports). ASAM treatment guidelines suggesting that psychosocial treatment in conjunction with MAT should include... links to existing family supports and referrals to community services. 29

30 The rising trend of destination treatment A cottage industry has formed to influence consumers to choose high-cost, ineffective treatment centers Most consumers are not aware of what treatment options exist. Stigma causes many to seek anonymous help. Call centers advertise aggressively (online, late-night television, billboards) to connect with consumers when they are ready to engage. Destination centers buy these leads and charge exorbitant fees for inadequate care. 105% 142% higher 30- and 90-day readmission rates per year 1 304% higher cost Over 1,000% for 90-day episodes of care 2 increase in lab testing utilization from Optum comparative analysis of average annual readmission rates for in-network and out-of-network residential SUD treatment programs authorized for members from January to December Data includes membership in all age cohorts from the commercial book of business. Bolstrom, May Comparison of average 90-day episode-of-care cost for out-of-network residential treatment ($42212) to that for in-network residential treatment ($10440-$15291); Episode of Care is defined as claims between three days prior to admission through 90 days after discharge; Bolstrom, May Increase in claims for four common lab test CPT codes for substance use; Source: FAIR Health Study: The Impact of the Opioid Crisis on the Healthcare System: A Study of Privately Billed Services, September

31 The ER as a first step to long-term treatment SEE NOTES: This is one area where the ER, health plans and community providers can work together to have an effective intervention with follow-up arranged before discharge The emergency department is a health care setting in which patients with opioid use disorders commonly present Emergency physicians are thus uniquely positioned to intervene to help patients with opioid use disorders at a critical moment in the addiction cycle. David Kan, CSAM 31

32 Supporting long-term recovery

33 Support long-term recovery Help individuals avoid relapse 40 60% average relapse rate amongst opioid abusers in the U.S. 1 91% of patients who overdose receive an opioid prescription within 10 months. 2 Support chronic populations and recovery 1. Connect individuals with certified peer support specialists Uniquely qualified support resources that have made the journey from substance abuse to recovery themselves 2. Equip individuals with recovery tools Mobile apps offer guidance, reminders and immediate help when needed 3. Continuously monitor pharmacy claims data Inform doctors and pharmacists how to reach out to individuals who may need extra support to avoid relapse Drug Utilization Review (DUR): concomitant use of opioids and MAT 1. National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. Accessed July 2017; 2. Ann Intern Med. 2016; 164:1-9; 3. Psychiatric Serv in Advance

34 Long-term recovery: Peer support Offer personalized assistance through certified peer support specialists Engage individuals to design recovery plans based on strengths and goals Coordinate with the care system to ensure adherence Demonstrate they are successful in their own recovery Engagement with peers is important in all stages of treatment and recovery 24% Reduction in inpatient days1 21% Reduction in overall behavioral health costs 1 1 Results from an Optum January 2017 analysis of 338 members who enrolled in Optum peer support services between February 1, 2014 and February 28, 2016; results are within six months after enrollment compared to six months prior to enrollment; participants had continuous eligibility for six months pre- and post-referral and at least one behavioral health (mental health and/or substance use) claim during that period; Source: Ten Eyck, 11/06/

35 Discussion

36 Thank you. Contact information: Jeffrey Meyerhoff Senior Medical Director, Optum Behavioral Health Tel: (763)

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