Follow-up Question and Answer Webinar: Advances in Recognition and Treatment of Substance Use Disorders in Primary Care

Transcription

1 Follow-up Question and Answer Webinar: Advances in Recognition and Treatment of Substance Use Disorders in Primary Care Richard Ries, MD University of Washington June 12,

2 Ries Disclosures Current Research Grant Funding Provided by: NIDA/NIH, NIAAA/NIH, NIMH/NIH The contents of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information. 2

3 Planning Committee, Disclosures AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below: The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this webinar to disclose: AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, Sharon Joubert Frezza, and Justina Andonian. All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. The content of this CME activity has been reviewed and the committee determined the presentation is balanced, independent, and free of any commercial bias. Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products. 3

4 Target Audience The overarching goal of PCSS-O is to offer evidence-based trainings on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction. Our focus is to reach providers and/or providers-in-training from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators. 4

5 Educational Objectives At the conclusion of this activity participants should be able to: Summarize what SBIRT is and how it can improve medical care and reduce costs Apply some of the basics of substance abuse treatment that can be accomplished in primary care settings: Screening (alcohol) Brief intervention/motivational interviewing Referral to substance abuse treatment settings when needed Pharmacotherapy for substance use disorders that can be undertaken in the primary care setting 5

6 Question 1 Can you comment on divided doses for Buprenorphine instead of since daily dose when there is opiate addiction and chronic pain? Response: Mary is a 32 yo female on Bup/Nx 8 mg a day for the last year and doing very well over the last 9 months. She arrives today saying that she is having moderate tooth pain responsive to Tylenol and was told she will need a root canal procedure by her dentist in 3 days. What are the key elements of your management here? 6

7 Root Canal Pain Management 1. Make sure to tell ALL your patients to inform their health care givers of all kinds that they are on Buprenorphine (i.e. Ask Mary Did you tell your dentist you are on Buprenorphine?) 2. She says, Yes, and he wants you to tell him how to handle the pain issues. 3. You say, This will be easy you will double the daily dose of Buprenorphine from 8 mg once a day to 8mg twice, or if needed, 3x a day starting the day of the procedure and ending 3 days later. Acetaminophen as needed too. 4. Buprenorphine works great for pain, better given 2 or 3x a day, and an advantage of the lower maintenance doses is having room to increase dose. 7

8 Question 2 Which specific opioids cause significant QT prolongation besides methadone? Response: LAAM - no longer used and methadone are the main ones. 8

9 Question 3 How do you handle weaning benzodiazepines when used in conjunction with opioids? Response: Avoid Benzo s as much as possible most docs I know, consider Benzos as one of the toughest issues to deal with in opioid patients. Benzo s are also one of the most commonly found substances in accidental opioid overdose deaths. How fast can you wean benzodiazepines? Response: Complex answer based on dose, duration, motivation, and if a co-occurring panic or other major anxiety disorder is present. 9

10 Question 4 Can you give naltrexone orally along with a Vivitrol shot in selected cases? Response: While I am unaware of any controlled research on this question, I have done this to good effect on rare occasions - adding another 50 mg a day oral dose. The standard dose of injectable Naltrexone is corollary to about 50 mg a day, and many of us use oral doses of 100, or even 150 mg a day. 10

11 Question 5 With experience, I am able to recognize 1-day old to 1-week old needle injections on the skin of my patients on Buprenorphine treatment. Should I start right away with Naltrexone and stop Buprenorphine? Or should I give one more chance? Response: No, I wouldn t stop Buprenorphine, but I would: a. Check recent urine drug screens for all substances b. Ask the patient about the needle marks and what they were using, and what they think about this use c. Negotiate a plan to deal with the details of a and b 11

12 Question 6 Is Naltrexone contraindicated in patients with Hepatitis C? Response: No, not contraindicated unless Liver enzymes are > 5x normal high end. The black box warning has been removed. Naltrexone is much kinder to the liver than alcohol or used needles. 12

13 Question 7 Are side effects different between oral and injectable Naltrexone? Response: Worse with oral, so I start with 25 mg for a week, then go to 50 and almost never get nausea. Often insurance companies won't cover the injectable because of the high cost. Is there a case to be made for the use of the injectable over oral that would address this reluctance? Response: Documented trial of oral Naltrexone, with adherence problems and/or high morbidity/cost of alcohol or opioid problems. 13

14 Question 8 Do you have an opinion for when methadone should be used instead of buprenorphine? Response: Methadone is stronger than Buprenorphine, and studies show less drop out and better attendance and follow through. Structure of Methadone Rx will work better for patients with histories of non-adherence problems, or a big street use history. 14

15 Question 9 Do you have an opinion about the use of buprenorphine in methadone maintenance type setting? Response: Yes, it works great many patients do better at least initially with more attention, structure and monitoring (i.e. Daily observed administration, contact with staff, etc.) Downside of some Methadone settings may be the concentration of street/criminal crowd, so alternative locations may be advisable. 15

16 Providers Clinical Support System for Medication Assisted Treatment Sponsored by Center for Substance Abuse Treatment/SAMHSA Ask a clinical question: From Download clinical tools, helpful forms and concise guidances (like FAQs) on specific questions regarding opioid dependence, use of buprenorphine, information on training and peer support. 16

17 References Anton RF, Myrick H, Wright TM, Latham PK, Baros AM, Waid LR, Randall PK. Gabapentin combined with naltrexone for the treatment of alcohol dependence. Am J Psychiatry Jul;168(7): doi: /appi.ajp Epub 2011 Mar 31. PubMed PMID: ; PubMed Central PMCID: PMC Anton RF, O Malley SS, Ciraulo DA, et al, COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA;295(17): Ballantyne J, Mao J. Opioid therapy for chronic pain. N Engl J Med. 349: Dawson DA, Pulay AJ, Grant BF: A comparison of two single-item screeners for hazardous drinking and alcohol use disorder. Alcoholism: Clin Exp Res 34: 1-11, Donovan DM, Anton RF, Miller WR, Lonnabaugh R, Hosking JD, Youngblood M, COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence (The Combine Study) examination of posttreatment drinking outcomes. J Stud Alcohol Drugs. 69: Federation of State Medical Boards,

18 References Fishbain DA, Rosomoff HL, Rosomoff RS: Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain; 8: Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcoholism: Clinical and Experimental Research 26: Fuller RD, Willford WO, Lee KK, Derman R: Veterans Administration cooperative study of disulfiram in the treatment of alcoholism: study design and methodological considerations. Control Clin Trials 5(3): Garbutt JC, Kranzler HR, O Malley SS, Gastfriend DR, Pettinati HM, Silverman BL, Loewy JW, Ehrich EW: Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA ;293: Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol interventions for trauma patients treatment in emergency departments and hospitals: a cost benefit analysis. Annals of Surgery 241:

19 References Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med Jan;174(1):70-7. doi: /jamainternmed PubMed PMID: ; PubMed Central PMCID: PMC Maxwell, J.C Trends in the abuse of prescription drugs. Gulf Coast Addiction Technology Transfer Center, McNicholas, L. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction: A treatment improvement protocol (TIP 40). Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Myrick H, Malcolm R, Randall PK, Boyle E, Anton RF, Becker HC, Randall CL. A doubleblind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res Sep;33(9): doi: /j x. Epub 2009 May 26. PubMed PMID: ; PubMed Central PMCID: PMC

20 References National Survey on Drug Use and Health: National Findings 2006, SAMHSA, Rockville, MD. September National Survey on Drug Use and Health, SAMHSA, Rockville, MD. 2008, 2009 Office of National Drug Control Policy (ONDCP) O Malley SS, Jaffe AJ, Chang G, Schottenfeld RS, Meyer RE, Rounsaville B: Naltrexone and coping skills therapy for alcohol dependence. Arch Gen Psychiatry 49: , Paterick TJ, Carson GV, Allen MC, Paterick TE: Medical informed consent: general considerations for physicians. Mayo Clinic Proc, : Passik SD, Kirsh KL. Managing pain in patients with aberrant drug-taking behaviors. J Supportive Oncology; 3: Paulozzi, L.J., Budnitz, D.S., Xi, Y, Increasing deaths from opioid analgesics in the United States. Pharmacoedidemiology and Drug Safety 15,

21 References Smith PC, Schmidt SM, Allensworth-Davies D, et al. Primary care validation of a single question alcohol screening test. J Gen Int Med 24: , U.S. Public Health Service: A clinical practice guideline for treating tobacco use and dependence: A US public health service report. J Am Med Assoc; 283: Walsh SL, Sullivan JT, Preston KL, Garner JE, Begelow GE: Effects of naltrexone on response to intravenous cocaine hydromorphone, and their combination in humans. J Pharmacol Exp Ther ; VA/DoD CPG SUDs, 21

22 PCSS-O Colleague Support Program and Listserv PCSS-O Colleague Support Program is designed to offer general information to health professionals seeking guidance in their clinical practice in prescribing opioid medications. PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management. Our mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties. The mentoring program is available at no cost to providers. For more information on requesting or becoming a mentor visit: Listserv: A resource that provides an Expert of the Month who will answer questions about educational content that has been presented through PCSS-O project. To join pcss-o@aaap.org. 22

23 PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN),and International Nurses Society on Addictions (IntNSA). For more information visit: For questions pcss-o@aaap.org Funding for this initiative was made possible (in part) by Providers Clinical Support System for Opioid Therapies (grant no. H79TI023439) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by 23 the U.S. Government.