Medication Assisted Treatment in an Ideal Micro-Practice. Case: Typical Opioid Dependent Patient. John Machata, MD Wickford Family Medicine

Transcription

1 Medication Assisted Treatment in an Ideal Micro-Practice Case: Typical Opioid Dependent Patient John Machata, MD Wickford Family Medicine

2 Micro Practice No Secretary No Nurse(¼ FTE NCM mandated by RI-CTC) No Biller Scheduling- Online Appts-1/2-1 hour no waiting Patients communicate directly by secure /text or phone

3 Ideal Medical Care Goals Mirror RI-CTC s Mission: 1- Enhance Doctor-Pt Relationship 2- Improve Quality of Care 3- Lower Health Care Costs RI-IMPs - high quality, lower costs and highest patient satisfaction compared to all RI-CTC.

4 Anthony White male 55 yo Snorting Heroin for 20+ years 2 grams QD

5 Day 1 Visit- 1 Hour HPI PMHx PE Soc Hx Fam Hx ROS Alle Drug Hx- HIV/Hep B & C risk, Drugs of Abus Controlled Substance Agreement Urine Drug Screen Check RI Drug Monitoring Program

6 Anthony 1 ppd cigarettes / day Uses Rx opioids at times Snorting = HIV/Hep B/C risk Occasional marijuana / Etoh 1-2 drinks/week PHQ-2 Down, Interest- avoiding withdrawal Worries a lot Works- good job No car Deeply in debt

7 Barriers to Effective MAT Polysubstance Abuse Psychiatric Instability Patient prefers High to straight Social/Economic Issues Bupe not as good as methadone for pain

8 Day 1 Visit Urine Drug Screen Assess Withdrawal Status Initiate Rx- At home Buprenorphine/Naloxone 8/2 - up to 16 mg See Back Next Day

9 Opioid Withdrawal Anxiety Irritability Restlessness Insomnia Nausea Abdominal cramps Arthralgias Myalgias Rhinorrhea Piloerection

10 Receptor Affinity AFFINITY is the strength with which a drug physically binds to a receptor Buprenorphine s affinity is very strong and it will displace full agonists like heroin and methadone Full Agonist Bound to Receptor Mu Receptor Bup affinity is higher Therefore Full Agonist is displaced

11 Bupeprenorphine Precipitated Withdrawal Displaces full agonist off receptors % Receptor 40 Intrinsic 30 Activity no drug low dose DRUG DOSE high dose Full Agonist (e.g. heroin) A Net Decrease in Receptor Activity if a Partial Agonist displaces Full Agonist Partial Agonist (e.g. buprenorphine)

12 Bupeprenorphine is a Partial Opioid Agonist Mu receptor Partial Agonist Binding Less reinforcing Very little abuse potential

13 Partial Agonist Activity Levels Full Agonist (e.g. heroin, methadone) % Receptor Intrinsic Activity At higher doses, even when partial agonist binds all receptors, maximal agonist effect is never achieved Partial Agonist (e.g. buprenorphine) Like full agonists, partial agonist drugs increase activity at lower doses no drug low dose DRUG DOSE high dose

14 Effects of Buprenorphine Dose on µ-opioid Receptor Availability in a Representative Subject MRI Bup 00 mg Binding Potential (Bmax/Kd) Bup 02 mg 4 - Bup 16 mg 0 - Bup 32 mg Slide Courtesy of Laura McNicholas, MD, PhD

15 Buprenorphine Safety No alteration of cognitive functioning (Patients feel normal ) No organ damage Partial agonist ceiling prevents respiratory depression

16 Anthony Day 2 visit No precipitated withdrawal Irritable, anxious, bad sleep OK to increase up to 24 mg UDS - Etoh metabolites

17 First Week of Treatment See daily until stable- half hour appointment Assess efficacy of MAT- Goal- Pt feels normal Must go to 12 Step meetings or counseling Review UDS Two family members/friends checking in daily Recommend obtain Narcan to address OD

18 Anthony Day 3 visit Felt normal OK to maintain 24 mg Experiment with 20 mg Go to 12 Steps at least 3x/week Return following week

19 Anthony Week 2 Still feels normal 20 mg worked- no withdrawal Went 12 Steps at least 3x/week UDS to see if adherent/clean Return following week

20 Anthony Week 3 Feels best in years Going to12 Steps 3x/week UDS- No Etoh metabolites Return following monthly for Rx

21 Medication Assisted Treatment 1) Attend Appointments 2) Take Buprenorphine 3) Avoid Drugs of Abuse = clean UDS 4) Go to Counseling and/or 12 Steps 5) Daily contact with 2 friends/family

22 MAT + Primary Care Symbiotic Monthly visits- ½ hour More frequent - psychiatrically unstable,relapse, dirty urines, missing meds PCP- 80% of opioid dependent patients Visits - 50% MAT 50% Family Medicine

23 Anthony Ongoing Care PHQ-2 Negative Little Worry Monitor Etoh report and UDS Needs HIV/Hep B/C testing Eager to Stop Smoking- Plan $ - Paying of his debts

24 Anthony Footnote Did not make it to 1 month follow-up Refused ride from co-worker Very high probability of using I reached out via text/phone/ inviting Rx

25 MAT Rx = Provider Satisfaction Prognosis is good Treatment life-transforming Patients are incredibly grateful Frequent visits opportunity to provide excellent primary care

26 Thank You For Your Time and Attention