OPIOID REPLACEMANT THERAPY: AN OVERVIEW

Transcription

1 OPIOID REPLACEMANT THERAPY: AN OVERVIEW Matthew Felgus MD FASAM Matthew A Felgus, MD, FASAM mafelgus@wisc.edu matthewfelgusmd.com 6333 Odana Rd, Ste 3, Madison WI (608) Board Certified in Addiction Medicine Board Certified in Psychiatry Learning Objectives Understand the various types of medication assisted treatment for Opioid Use Disorder Understand the positives and drawbacks of each type of medication assistance Understand the necessary treatment in addition to medication for Opioid Use Disorder 1

2 Full mu agonists Oxycodone Hydrocodone Hydromorphone Fentanyl series HEROIN Methadone Morphine Meperidine Oxymorphone Codeine Opioids Partial mu agonist Buprenorphine Mixed Agonist/Antagoni st Pentazocine Butorphanol Nalbuphine Tramadol (Ultram) AND ALL ARE ADDICTIVE Opioid Metabolism 2

3 Opioids: The Science Opioid Receptor Subtypes Mu : euphoria, causes withdrawal Kappa: pain control, no euphoria Delta: feeling good Lambda Opioids: The Science All animals have opioid receptors throughout their brains Related to survival of the species Opioids do not eliminate pain, but decrease the arousal that accompanies pain Cause an increase in norepinephrine Endorphins: self-produced opioid compounds Opioids: The Science CNS depressant similar to effects of alcohol Greatest risk is of respiratory depression Opioid + Benzodiazepine = recipe for an overdose ENERGY from an opioid = brain wiring for addiction 3

4 Poll Question 1 Which of the following are warning signs that someone could become addicted to their opioid medication? Family history of alcoholism Drinking 7 or more drinks per week High current life stressors (e.g. divorce) History of high anxiety Poll Question 2 Which of the following are warning signs that someone could become addicted to their opioid medication? History of past trauma Past history of alcohol dependence Concurrent use of a benzodiazepine Cannabis use 2-3x/week BEFORE YOU START OPIOIDS: Past overuse of CNS depressants (alcohol or benzodiazepines) increase the risk of opioid overuse. Likely a greater risk than overuse of other substances (cocaine, cannabis) but both MD and patient must maintain awareness History of family members becoming ENERGIZED from opioid medication Greater than 7 drinks per week (not rare in WI) 4

5 Education not Punishment Higher risk factors does NOT mean someone is intending to abuse their opioid medication Sometimes it is necessary to utilize opioid medication and this should be done as safely as possible Nobody starts using anything planning to develop an addiction Educating the patient/client that they are higher risk in a non-judgmental way can make a major difference ENERGIZED by Opioids Most people become tired, nauseous, cloudy after taking an opioid Some people become energized This appears to be a genetic variation ( does run in families) This will likely occur at first exposure (including in children) Education to this risk factor is key to preventing addiction ENERGIZED by Opioids Positive Reinforcement: If it makes you feel good, you re going to do it again. And again This is a major risk factor for addiction to opioids People who develop an opioid addiction often say they had no idea this could happen to them (may be otherwise upstanding citizens) 5

6 <3 Min Conversation for ALL Patients Prior to Opioid Rx If you feel energized after taking this medication, you need to call the office. This shows you may have the brain wiring to develop an addiction to this type of pain medication. It is based on genetics and isn t anything you are doing wrong. It is not about willpower or good character. It can happen to anybody with this type of brain wiring and most people don t know they have it until they take this kind of prescription. However, you need to be very cautious with any opioids never take extra and, if you can, have somebody else hold it. Opioid Withdrawal Syndrome Elevated pulse rate/blood pressure Perspiration Restlessness Pupil Dilation Joint Aches Muscle Aches GI Cramping Tremor Yawning Anxiety Goosebumps Runny nose Watery Eyes Nausea/Vomiting Opioid Withdrawal Syndrome Assessment Grade 1 lacrimation, rhinorrhea, yawning, insomnia, agitation, diaphoresis Grade 2 arthralgias, myalgias, abdominal cramps, muscle twitches Grade 3 tachycardia, hypertension, tachypnea, fever, anorexia, nausea, severe restlessness Grade 4 diarrhea, vomiting, dehydration, hyperglycemia 6

7 Opioid Withdrawal Onset and Peak symptoms dependent on opioid or opiate abused Variable to the individual Heroin - onset 8 hours with peak symptoms 24 to 48 hours after last use Methadone - onset 24 to 48 hours with peak symptoms within 48 to 96 hours after last use Subjective symptoms may persist for weeks WHY? GENETIC VULNERABILITY + STRESSOR Oxycontin (OC) Controlled release of oxycodone hydrochloride Introduced in late 1990s Usually crushed or chewed in abuse (rapid release) Dramatic increase in use from 1999 Something about this opiate seemed more abused than the others = more euphoria Formulation changed 2010 to prevent abuse but users adapted 7

8 Oxycontin (OC) A 2010 change in a controlled release formulation of oxycodone (OxyContin, Purdue Pharma) that was intended to prevent abuse of the prescribed opioid has had the unintended consequence of causing many abusers to switch to heroin, new research shows. Medscape July, 2012 Heroin Use 90% white >50% employed 89% High school diploma or beyond Intranasal use is most common 2014 National Survey on Drug Use and Health Case Study Rebecca is a 30 year old student/ waitress with a 10+ year history of opioid dependence, primarily heroin. She has been in and out of treatment, both residential and outpatient at least 15 times. Treatments have included both methadone and buprenorphine but she has never gone longer than 6 months without heroin. 8

9 Case Study Rebecca has had social anxiety since middle school and experiences panic attacks several times per week. She has taken medication and had weekly therapy for years, as well as involvement in yoga and other relaxation techniques. Case Study She reports that the panic attacks cause her to fear she is going to die. Both her job and sitting in class worsen the social anxiety, which leads to more panic attacks. Despite not wanting to relapse, it feels as though heroin is the only thing that relieves her anxiety even for a night. Case Study Rebecca can t stay off heroin until her anxiety is managed She can t manage her anxiety while in the cycle of relapse 9

10 The Mental Health Big 4 for Driving Addiction Anxiety Trauma Depression Insomnia Opioids and Anxiety Extremely common presentation High degree of overlap between withdrawal and anxiety sxs While anxiety isn t responsible for the opiate epidemic, it is a major barrier for individuals to stop using Opioids and Anxiety Opioids are wonderful numbing agents and individuals with anxiety (and PTSD) want to be numbed We as treaters need to be more mindful of our messages about anxiety 10

11 Opioid Withdrawal Increased BP Increased HR Sweating/Chill s/hot flashes Restlessness Dilated Pupils GI Cramps/ Gooseflesh Diarrhea Runny Nausea/Vo nose/wa miting tery eyes Feeling of Dying Tremor Yawning Bone Pain Muscle Aches Anxiety Increased BP ness Increased HR Sweating/Chills/Hot flashes Heart attack feeling/chest pain Restlessness Shortness of GI Cramps/Diarrhea Breath/Smothering/ Choking Shaking/Tremor Room closing in Inability to Concentrate Fear of going crazy/dying Out of Body Depersonalization/Numb Dizzy/Lightheaded/Tingli ng Anxiety or Withdrawal: How to Treat? Avoid addictive medications (NO BENZODIAZEPINES!) Focus on treatment of symptoms: Sleep, Anxiety, GI upset Even if a pt is getting support for their recovery (MD, AA/NA) please treat their mental health 11

12 Medication Assisted Tx for Opioid Dependence Buprenorphine (e.g. Suboxone ) Naltrexone (oral or IM- Vivitrol ) Methadone Opioid Replacement: WHY? OPIOID USE HAS EXPLODED AND SHOWS NO SIGN OF SLOWING!!! Buprenorphine Partial mu agonist with high affinity Will displace any other mu agonist precipitating withdrawal Buprenex - injectable form - only indication is for analgesia Subutex 2 & 8mg sublingual tablets buprenorphine Suboxone Buprenorphine/naloxone combination 2/0.5mg, 4/1mg, 8/2mg & 12/3 mg sublingual films. Also, available in generic 2mg and 8mg pills 12

13 Buprenorphine/Naloxone Zubsolv -- Buprenorphine/naloxone combination 0.7/0.18mg, 1.4/0.36 mg, 2.9/.71mg,5.7/1.4 mg, 8.6/2.1mg Equivalent to 1, 2, 4, 8, and 12 mg suboxone dosages Better bioavailability (so lower amount of bup) Pills tend to crumble when cut Buprenorphine/Naloxone Bunavail -- Buprenorphine/naloxone combination 2.1/0.3mg,4.2/0.7mg, 6.3/1mg (equal to 4, 8 and 12 mg suboxone) Sticks to inside of cheek Better bioavailability? Not recommended to cut in order to taper Buprenorphine/Naloxone Dosage Range: not agreed upon Research shows receptors saturated at 16mg although some prescribers go MUCH higher Manufacturer does NOT recommend >24 Quick detox vs. slow (1-5+yr.) detox vs. maintenance Is it possible to taper off without relapse? 13

14 Buprenorphine/Naloxone Half-life is hours (average 35 hrs.) so only needed once daily Safer in OD since less respiratory depression than other opioids Best if used as past of a treatment program Buprenorphine/ Naloxone Yes, you can get high.if not opioid dependent Diversion of prescription Party drug for those without an opioid habit Prevention of opioid withdrawal in those using Self detox for those trying to quit Buprenorphine/Naloxone MDs take an 8 hour class to prescribe NPs take a 24 hour class to prescribe Not enough prescribers for demand? No addiction training needed 14

15 Buprenorphine/Naloxone 30 Patient Cap at initial license 100 Patient Cap after 1 year 275 Patient Cap increase as of 2016 for specialists Better access vs. increase in buprenorphine mills? Buprenorphine: WHY? Effective, proven treatment in reducing use Buprenorphine: WHY? Effective, proven treatment in reducing use Keeps clients in treatment (carrot) 15

16 Buprenorphine: WHY? Effective, proven treatment in reducing use Keeps clients in treatment (carrot) Blocking agent for other opioids Buprenorphine: WHY? Effective, proven treatment in reducing use Keeps clients in treatment (carrot) Blocking agent for other opioids Less likely to be abused (but not impossible) Buprenorphine: WHY? If used properly (lowering doses) clients can be tapered off opioids 16

17 Buprenorphine: WHY? If used properly (lowering doses) clients can be tapered off opioids This is important with a younger population Buprenorphine: WHY? If used properly (lowering doses) clients can be tapered off opioids This is important with a younger population One component of a well-rounded treatment program Buprenorphine: WHY NOT? Over reliance on medication vs. recovery tools 17

18 Buprenorphine: WHY NOT? Over reliance on medication vs. recovery tools Doses can be too high (clients appear stoned.) This is less likely than with methadone Buprenorphine: WHY NOT? Over reliance on medication vs. recovery tools Doses can be too high (clients appear stoned.) This is less likely than with methadone Establishing a potential lifelong dependence on opioid medications Buprenorphine: WHY NOT? Opioid Replacement for a less severe habit (may be started at a higher dose than the amount of street opioid used) 18

19 Buprenorphine: WHY NOT? Opioid Replacement for a less severe habit (may be started at a higher dose than the amount of street opioid used) It is possible to abuse opiate replacement meds (methadone and suboxone) Buprenorphine: WHY NOT? Opioid Replacement for a less severe habit (may be started at a higher dose than the amount of street opioid used) It is possible to abuse opiate replacement meds (methadone and suboxone) Diversion to street Methadone What does it do? Stops withdrawal and craving Blocks effects of other opioids Reduces drug use and criminal activity to acquire drugs Decreases HIV, safer in pregnancy than street opioids 19

20 Methadone In use since 1960s Must be given in a licensed clinic (expect if used for pain treatment) Can be overdosed At high doses, individuals can appear to nod out Rationale: Methadone It works to stop use of other opioids It lowers IVDU It is oral, long-acting (but still controversial and highly regulated) Methadone May be used for detox or maintenance Starting dose 30mg May give an additional 10mg first 24 hours Maintenance doses vary: mg A physician may continue to administer methadone for a patient during a hospitalization; otherwise must be given in a clinic if for addiction treatment 20

21 Methadone Yes, you can get high Are high doses (>150 mg.) necessary to maintain abstinence OR treating sxs of other disorders (dep, anx)? OR BOTH?? Why are we as treaters so avoidant of discomfort of withdrawal solely in this population? Opioid Receptor Blockade Naltrexone Oral Daily Vivitrol Injection of naltrexone Lasts 4 weeks Naltrexone (oral) Approved in 1994 for treatment of alcohol dependence Decreases alcohol consumption by likely blocking positive reinforcing effects Blocks opioid receptors Biggest challenge is compliance (continuing medication) 21

22 Naltrexone Side Effects Nausea Sleepiness Abnormal rise in liver enzymes Mood blunting or depression/lack of runner s high type of feeling possible (less likely with injection) Vivitrol Injectable form of Naltrexone Blocks effects of opioids for 4 weeks More residential treatment programs + corrections offering this option at discharge Alternative to Replacement Therapy as can not be combined with opioids including suboxone Good option for motivated individuals Vivitrol Concerns Injection does not always last 4 weeksmay wear off in 3 1/2 weeks but insurance will not cover early injection Pain medication may not be as effective (accident or emergent surgery) Must have NO opioids in system for 7-14 days in order to start 22

23 Vivitrol Concerns Mood blunting or depression/lack of runner s high type of feeling Shift to abuse of another substance (alcohol, meth) Monthly injection makes it easy not to do other treatment Injectable Naltrexone: WHY? It s not an opioid Injectable Naltrexone: WHY? It s not an opioid It can not be abused (no high) 23

24 Injectable Naltrexone: WHY? It s not an opioid It can not be abused (no high) No street value Injectable Naltrexone: WHY? It s not an opioid It can not be abused (no high) No street value It saves lives Injectable Naltrexone: WHY? It s not an opioid It can not be abused (no high) No street value It saves lives Injection as leaving incarceration or rehab does help prevent overdose 24

25 Injectable Naltrexone: WHY NOT? Injection is expensive ($ /vial) Injectable Naltrexone: WHY NOT? Injection is expensive ($ /vial) Not an opioid and does not numb feelings (still can have cravings) Injectable Naltrexone: WHY NOT? Injection is expensive ($ /vial) Not an opioid and does not numb (still can have cravings) May be done under duress 25

26 Injectable Naltrexone: WHY NOT? Injection is expensive ($ /vial) Not an opiate and does not numb (still can have cravings) May be done under duress Patients may try to overcome block as injection wears off and overdose In Summary: Addiction is a disorder of brain wiring that turns into a drive to numb out Shame is a major part of addiction We can not make anybody ready for treatment We can offer options for treatment along with compassion and good boundaries Final Thoughts Nearly all individuals who become addicted are trying to numb something, and need our help to learn to feel again Medication alone will not solve the issue of substance abuse and addiction but may be one piece of the puzzle 26

27 Final, Final thoughts Healing is a s-l-o-w process and relapse is the rule rather than the exception The medical profession has a lot to learn about the above, and the majority of MDs are not trained in treating addictions THANK YOU 27