Cannabis and Opioids in AANHPI David Kan, MD, DFASAM University of California, San Francisco

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1 Substance Use in AANHPI Cannabis and Opioids in AANHPI David Kan, MD, DFASAM University of California, San Francisco In general: Lower rates of illegal drug use Binge Alcohol use Substance Use Disorder Native Born > SUD vs. Foreign Born Asian American men across various ethnic groups (Chinese, Filipinos, Vietnamese, and Koreans) reported similar levels of alcohol use problems Chinese and Vietnamese males > alcohol problems than their female, Korean females tended to have more alcohol use problems than Korean men populations/racial ethnic minority Substance Use in AANHPI in California PI middle and high school males (ages years) highest rates of Highest rate of lifetime smoking (18.7%) Past month cigarette smoking (39.3%) Lifetime methamphetamine use (12.8%) past month methamphetamine use (11.7%) PI middle and high school males (ages years) highest Rates of cannabis use (22%) along with African Americans at the same rate Binge alcohol use rate (22.3%) Gay and bisexual AANHPIs who engaged in substance use were more likely to also engage in risky sexual behaviors than those who did not use substances Substance Use Treatment in AANHPI Women>Men seek treatment Factors Cultural issues Stigma Lack of culturally competent services Gender role conflicts Racism /SMA pdf /SMA pdf 1

2 SUD in AANHPI Lifetime SUD Diagnosis Percentage Native American 18.4% White 11.3% Black 8.7% Hispanic 7.2% AANHPI 3.8% Past Month Use years AA/NH/PI: 3.5% (alcohol 2.1%, any drug 2.0%) White: 9.0% (alcohol 6.3%, any drug 5.0%) Black: 5.0% (alcohol 2.3%, any drug 3.7%) Cannabis in AANHPI Group Past Year CUD Presence CUD in users of Cannabis AA 0.8% 17% NH/PI 1.3% 12.6% White 1.5% 13.7% Black 2.5% 19.1% Hispanic 1.8% 19.6% Native American 3.7% 24.6% Mixed Race 2.8% 15.8% First specific drug associated with illicit drug use Cannabis (SAMHSA NSDUH 2015) 2

3 Cannabis Medicalization Cannabis Legalization (Maxwell, Mendelson 2016) (Maxwell, Mendelson 2016) Legalization Impact FFR1.13 Past Month Cannabis Use among People Aged 12 or Older, by Age Group: Percentages, Colorado Legalized 2014 Washington Legalized cannabis possession 3.5 years and 2 year of retail sales Arrests drop Violent crime decreased Traffic fatalities little change Adolescent use drops (from 20.81% to 18.35%) (NSDUH) Adult use increases (16.8% to 19.91%) (NSDUH) ED Visits increased (152.9/100K to 256.5/100K) (drugpolicy.org, Maxwell, Mendelson 2016) Age Group or Older to to or Older + Difference between this estimate and the 2017 estimate is statistically significant at the.05 level. 3

4 FFR1.34 Cannabis Use Disorder in the Past Year among People Aged 12 or Older, by Age Group: Percentages, FFR1.28 Past Year Cannabis Initiates among People Aged 12 or Older, by Age Group (in Millions): Note: Estimates of less than 0.1 million round to 0.0 million when shown to the nearest tenth of a million. Age Group or Older to to or Older + Difference between this estimate and the 2017 estimate is statistically significant at the.05 level. Age Group or Older to to or Older + Difference between this estimate and the 2017 estimate is statistically significant at the.05 level. Cannabis Use Disorder Impairment in school or work function Neglecting previously enjoyed activities Use in hazardous situations Differentiating use disorder vs. recreation Careful assessment of presenting problems or impairments Denial of problems by user vs. reports from reliable collateral sources Denial of use despite + drug testing Cannabis Use Disorder Screening Impairment in social, academic, vocational functioning without explanation Exacerbation or poor response to treatment of a condition known to be affected by cannabis use Observed Stigmata of use Chronic Conjunctival injection Cannabis odor on clothing Yellowing on fingertips Increase in appetite or cravings for foods outside of mealtime Self Report useful if there there are no adverse consequences for acknowledging use (Hrothoj 2012) In the past year, how often have you used cannabis (Newton 2011) In ED >2 times Sensitivity 0.96, Specificity

5 Cannabis Use Disorder Highly variable course Risk Factors Earlier age of first use Early and rapid progression to first use Concurrent use of other psychoactive substances Tobacco and alcohol Co Morbid Psychiatric Illness Adverse Childhood Events Peer use of drugs Social Isolation Cannabis and SUD comorbidity N=34653 NESARC respondents Interviewed , Cannabis use SUD (OR 6.2) CUD (OR 9.5) AUD (OR 2.7) Nicotine Dep (OR 1.7) Not significant: new mood or anxiety disorder Blanco 2016, JAMA Cannabis and Opioid Mortality In states with Medical Cannabis laws Decreases in opioid analgesic overdose mortality Decreases strengthen over time year 1 ( 19.9%; 95% CI, 30.6% to 7.7%; P =.002) year 2 ( 25.2%; 95% CI, 40.6% to 5.9%; P =.01) year 3 ( 23.6%; 95% CI, 41.1% to 1.0%; P =.04) year 4 ( 20.2%; 95% CI, 33.6% to 4.0%; P =.02) year 5 ( 33.7%; 95% CI, 50.9% to 10.4%; P =.008) year 6 ( 33.3%; 95% CI, 44.7% to 19.6%; P <.001) JAMA Intern Med. 2014;174(10): doi: /jamainternmed Cannabis and Cognition Research Findings on Effects of Cannabis on Executive Functions Executive Function Acute Effects Residual effects Long term Effects Impaired (light Attention/ use)/normal(heavy Concentration use) Mixed findings Largely normal Decision Making and Risk Taking Mixed Findings Impaired Impaired Inhibition/ Impulsivity Impaired Mixed Findings Mixed Findings Working Memory Impaired Normal Normal Verbal Fluency Normal Mixed Findings Mixed Findings Note: Acute = 0 6 hours after use; Residual 7h 20d after use: Long term >3 weeks (Crean 2011, J Addict Med) 5

6 CUD Treatment Adult treatment seekers Used daily on average 10 years Have attempted to quit more than six times Comorbidity with other SUD MAT for Cannabis Reduce Use N Acetylcysteine mg BID Doubled rates of negative UDS Combined with counseling CM 1. Gray, et al Am J Psychiatry 2012; 169: MAT for Cannabis Reduce Withdrawal Symptoms Gabapentin 1 300/300/600 Reduces withdrawal symptoms Combined with counseling CBT+MI Cannabis Withdrawal Gabapentin Common Symptoms Mood Anger or aggression Irritability Nervousness or anxiety Behavioral Decreased appetite weight loss Restlessness Sleep difficulties, including strange dreams Causes greatest distress 1. Mason, et al, Neuropharmacology (2012) 37,

7 NASEM 2016 on Cannabis and Health Comprehensive Review Available on line Executive summary clinically helpful NASEM Findings on Cannabis and Mental Health Substantial Evidence Development of schizophrenia and non affective psychosis Risk is dose dependent Limited evidence of a statistical association Increase in positive symptoms of schizophrenia Likelihood of developing bipolar disorder among regular or daily users Development of any anxiety disorder except social anxiety disorder Increase severity of PTSD symptoms health effects of cannabis and cannabinoids the current state NASEM Findings on Cannabis and Health Substantial evidence Chronic pain Increased risk for MVA Moderate evidence of association Short Term insomnia treatment No evidence All cause mortality Occupational accidents or injuries Death due to cannabis overdose Opioids 7

8 Overdose Deaths The Infamous Article Cited by scientific articles 31 NEJM

9 A Brief History of Pain Guidelines Opioids 1992 Agency for Health Care Policy and Research (AHCPR) Acute Pain Management Guidelines 1997 American Society of Anesthesiologists and American Academy of Pain Medicine Clinical guidelines for management of chronic pain 1998 Federation of State Medical Boards Model Policy for the Use of Controlled Substances for the Treatment of Pain. Each of these guidelines emphasizes that doctors should be free to prescribe opiates without worrying about sanctions. Opioids Narcotic pain reliever Side effects: sedation, constipation, itching, nausea, respiratory suppression, dependence, addiction, death Indicated for: Short term acute pain Postsurgical Acute injury Very limited evidence for Chronic non cancer pain Opioid Beliefs vs. Reality Belief Sedating Good for all pain conditions Non addicting if prescribed and monitored Pain is the 5 th vital sign Reality Activating after some period of time Indicated for acute but not chronic pain in most Rates of aberrant use in chronic prescribing 15 45% Pain is subjective and cannot be tested. However, functional restoration can be measured Opioid Prescribing as a predictor Initial prescribing is a predictor of future prescribing At least one day initial rx Opioid use at 1 year 6% Opioid use at 3 years 2.9% 70% of patients with 7 days rx 7.3% have opioids 31 days Largest increase is when first prescription supply >10 or 30 days or 700 MME

10 Highest Risk Initial Prescribing: 1 and 3 year risk of being on any opioid Long acting opioid initiation 27.3% at 1 year; 20.5% at 3 years Tramadol 13.7% at 1 year; 6.8% at 3 years Hydrocodone short acting 5.1% at 1 year; 2.4% at 3 years Oxycodone short acting 4.7% at 1 year; 2.3% at 3 years Schedule III IV 5.0% at 1 year; 2.2% at 3 years How much is too much? HR 1.44 OR 1.32 HR 3.73 OR 1.92 Hazard Ratio (HR) Any overdose event Odds Ration (OR) Fatal overdose event Both relative to 1 9 MME HR 8.87 OR CDC Risk Factors for Prescription Opioid Misuse and Overdose Medicaid enrollees 40% had at least one Overlapping prescriptions for pain relievers, Overlapping pain reliever and benzodiazepine prescriptions, Long acting or extended release prescription pain relievers for acute pain, and High daily doses. Patient Groups

11 Opioid Naïve Limit rx to 3 days if not <7 days Can write for partial fill of Schedule II Short Acting oxycodone or hydrocodone product Minimum effective dose PDMP Prior to Rx Q4 mo thereafter Chronic Opioid Therapy Opioid tapers? PDMP Address risk Controlled Substance Agreement Watch CNS depressants Naloxone rx >90MME, Risk of OD, Coprescribed Opioids + BZD Refer for assessment/consult Addicted/Substance Use Disorder Identify Naloxone rx Refer for treatment Medication Assisted Treatment Buprenorphine Methadone Naltrexone Opioid Use Disorder Treatment Where it can be FDA Indications Effectiveness for Administration provided Opioid Use Disorder Methadone OUD licensed opioid OUD and pain 74% to 80% OUD: pill, liquid, injectable for treatment programs management hospitalized patients Pain any DEA licensed Pain: Pill and injectable forms provider Buprenorphine and OUD X waivered OUD and pain 60% to 90% OUD: daily sublingual, buccal, Buprenorphine Naloxone physicians. Requires 8 management film, and tablet, one month hours training. Panels (depending on depot injection, 6 month capped at 30, 100, 275 formulation and dose) implant depending upon setting Pain: Injectible, transdermal, Pain any DEA Physician buccal film Naltrexone No restrictions OUD and Alcohol Use OUD 10% to 20% Daily pill or monthly injectable Disorder Naloxone (overdose Any setting, prescribed or Reverse respiratory May require high Intranasal spray, intravenous, reversal) dispensed by clinician, suppression in doses for high potency intramuscular, or furnished by pharmacy, suspected overdose illicit drug use (e.g. subcutaneous injectable dispensed by lay staff in fentanyl and community settings, first carfentanyl) responders content/uploads/2017/12/pdf Why Health Plans Should Go to the MAT.pdf 44 11