Steven Prakken MD Director Medical Pain Service Duke Pain Medicine

Size: px
Start display at page:

Download "Steven Prakken MD Director Medical Pain Service Duke Pain Medicine"

Transcription

1

2 Steven Prakken MD Director Medical Pain Service Duke Pain Medicine

3

4 Misuse Abuse Addiction Total Pain Population Webster LR, Webster RM. Pain Med. 2005;6(6):

5 DSM IV Abuse defined as 2 elements to meet criteria. Dependence as 3 elements to meet criteria. DSM V (May 2013) Substance Use Disorders, no abuse vs dependence Mild (2-3), Moderate (4-5) Severe (6 and more) Research impact of DSM IV and V criteria SUD increase since 2012?

6 Pharmacological indicators Tolerance withdrawal Impaired control Greater amount and longer use Unable to quit Time to obtain extensive Craving Social impairment Role failure Use with known social harm Social loss due to use Risky use Use in spite of physical danger Use with continued psych/social harm Severity score -Mild (2-3) -Moderate (4-5) -Severe (6 and more)

7 Rate in last year for 2016, SAMHSA 7.5% of population with SUD (20.1million) 75% with ETOH 37%% with illicit drug 12% with both Rate in Pain and Primary Care 8% - 12%. (Systematic review from 38 studies, with 26% primary care settings, 53% pain clinics) 2017 NSDUH Report, Vowles 2015

8 Percent in Past Year Substance Use Disorder Past Year, Aged 12 or Older and Older 12 to to or Older SAMHSA 2017

9 Pain Reliever Use Disorder Past Year, Aged 12 or Older and Older 12 to to or Older SAMHSA 2017

10 SAMHSA 2017

11 Rate in last year for 2016, SAMHSA 4.4% of population (11.8 mil) No change from % say that their misuse is for pain, tension, sleep, or mood 12% say they use to get high or feel good Rate in Pain and Primary Care 21-29% (Systematic review from 38 studies, with 26% primary care settings, 53% pain clinics) Misuse is not SUD 2017 NSDUH Report, Vowles 2015

12 Past research has found that 29% to 60% of people with opioid addiction report chronic pain. Methadone clinic patients with increased sensitivity to pain. (Fishbain) Peles 2008 Fishbain 2012

13 There is no consistent pattern of differences evident when comparing CNCP patients with a history of SUD versus those without on demographic, pain, or psychiatric variables. Multidisciplinary approach along with UDS, CSRS, frequent visits, limited opioid amount, etc. all reduce risk of misuse Benjamin J. Morasco 2011

14 Slightly higher rate in pain clinics No substantial changes in rate for decades Those w/wo SUD are not clearly different pain patients than others. So how do you handle this in the clinic??

15 SUD has to meet criteria Not a gut check diagnosis mild might be considered abuse Document social/role deterioration Craving of medication, not pain control Using with known harm when they know, not you Checking UDS/CSRS consistently for data Collateral information Risk factors by history ORT, family and personal history Misuse is not SUD

16 Hardest distinction Return to criteria SUD Misuse is not SUD Be CURIOUS as to reason for misuse When, why, hoped for what outcome? Authoritarian intervention usually not therapeutic Sudden medication dose changes are high risk Does not mean no limits approach

17 SAMHSA 2016

18 Opioid stim Depressed and need tx ADHD tx Don t give sleep aides if stimulated by opioid Opioid sedation Anxiety relief relative to pain Helping rumination Sleeping aide MRJ Helping pain and anxiety Misuse is a cue about what they feel is needed So replace it Likely not SUD

19 Does it exist? Duke Pain HU study, N=570, top and bottom 100 of the cohort Overall average of 5 opioid trials per patient 48% at least 1 opioid stimulating 62% at least 1 opioid sedating Oxycodone 24% stim vs MS 9% stim What is the etiology Mu receptor Glial cell Unknown Influence on addiction Influence on OIH

20 Patient short on medication, again! Curious as to why, when, how much, etc Most common reasons (decreasing order) Pain control Impulsivity Poor memory Selling Intervention 3 bottle system Reduced availability Partner holding, shorter scripts Fully random UDS/pill count

21 Curious, what is the story Common reasons Short UDS not accurate Selling Intervention Admission of being short? Then back to previous slide UDS at different parts of script cycle UDS not accurate? No meds of any kind Observed UDS in future Make sure UDS test looks for the missing opioid

22 UDS with meds not currently prescribed Curious as to reason Common reasons Misuse, then to previous slide (pain, mood, etc) Impulsivity Have to have SUD vs misuse of other medication Other prescriber Intervention Clarification of med list or prescribing roles Limitation of current meds if dangerous Medication destruction of old scripts House sweeps by others

23 Morphine and/or fentanyl in UDS = heroin Fentanyl in many SUD products now Metabolites not present Just took pill Dipped pill Not tested for P450 issue Pill count accuracy suspect Pills available for count, street contract

24 Send for SUD evaluation Make sure they will apply criteria Carful if abstinence based in SUD eval if pain patient Find someone that understands pain and opioids Choose safer opioid Tramadol Tapentadol Buprenorphine

25 Partial agonist at Mu very high affinity Strong antagonist at Kappa x more potent than morphine Sublingual and transdermal Bioavailable 40% buccal, 30%SL, 15% transdermal QT prolongation X4 less than methadone Site of action spinal > brain Pergolizzi 2010, Khanna 2015

26 No confusion if you just remember Partial Agonist Will activate receptor only partially Is etiology to any w/d, not naloxone Very high affinity for Mu Will dominate at the receptor Potential precipitated withdrawal Incomplete reversal by naloxone Half life hrs

27 Addiction With Naloxone Bunavail Suboxone Zubsolv Without Naloxone Subutex (least expensive) Pain Butrans Belbuca

28 Respiratory Has ceiling effect, safest opioid Full agonists with up to 11% respiratory depression Constipation Much lower incidence (1-5%) No sphincter of Oddi spasm Use in pancreatic pain? Renal failure Bile elimination No increase in blood levels Hemodialysis does not effect levels Stable pain control Dahan 2010, Shipton 2005, Cuer 1989, Boger 2006, Filtz 2006

29 Cognitive Better visual, psychomotor, cognitive function vs morphine or methadone Less impaired driving Depression Less depressogenic, Active antidepressant effect? Both likely due to Kappa antagonist effect Davis 2012, Soyka 2005, Karp 2014, Mello 1985

30 Immunosuppression Does not - reduce NK cell function Increase cortisol Reduce ACTH levels Change cytokine expression Hormonal impact Does not Reduce testosterone Reduce hormone levels Davis 2012, Aloisi 2011, Bleisener 2005, Hallinan 2009,

31 Tolerance Slower than for morphine and fentanyl Antihyperalgesia Effect on antihyperalgesia >analgesia Reduction vs prevention central sensitization? QTc Methadone up to 29% of patients Methadone 4x buprenorphine for cardiac death Koppert 2005, Vandera 2000, Anchersen 2009

32 Pain Review showing efficacy in 25/26 trials No analgesic ceiling effect Some evidence of no antagonistic effect on other Mu opioid agonists Can use full agonists if need Kappa antagonism may reduce euphoria of others Neuropathic pain Effective in review May work through antihyperalgesia Raffa 2014, Davis 2012, Butler 2013, Induru 2009, Benedetti 1998, Hans 2007, Pergolizzi 2010

33 No Waiver needed for any buprenorphine product if using for disease of pain Butrans FDA approve in 2013 Patch technology 5, 7.5, 10, 15 and 20 mcg/hr 7 day patch Belbuca FDA approved 10/2015 Buccal patch, dissolving 75 to 900 mcg patches

34 Transdermal patch MCG doses of 5, 7.5, 10, 15, 20 Starting dose: 5 mcg if <30mg MEQ 10mcg if MEQ

35 Buprenorphine buccal film MCG doses of 75, 150, 300, 450, 600, 750, 900 For bid dosing

36 MSE dose prior to tapering to 30 mg Less than 30 mg oral MSE mg oral MSE mg oral MSE Greater than 160 mg oral MSE Starting dose 75 mcg every 12 hrs 150 mcg every 12 hrs 300 mcg every 12 hrs Consider alternative tx

37 Clinical application Opioid misuse within pain MRJ or other med use Previous potential SUD Active SUD, non-opioid Street opioid use for pain Death rate Cultural safety Mono vs dual product Buprenorphine cost on Good Rx

38 When using Suboxone/Subutex No waiver needed, for disease of pain Decision to begin buprenorphine Educate about precipitated withdrawal Not naloxone effect Not reversible Consider test dose Start when COWS score mild to moderate If on other opioids Suggest 1-2mg bid start if opioid naïve

39

40 Induction for Suboxone or Subutex. STOP full agonist, wait for COWS of >8-10, then. Day 1. 4mg initial dose, repeat in 2 hrs at 2-4mg, may repeat at 2-4 mg in another 2-6 hrs if need, total max of 12 mg if need. May consider smaller initial test dose. Stop at the dose that reverses withdrawal Common first day dose is 8mg Day 2. repeat once the dose that worked day 1, if after 12 mg the first day there was poor response then may add 4mg for 16mg total dose. No higher for a week and then may increase by 2mg every 2-4 days. 16mg most common SUD tx dose 32mg max effective dose

41 Anderson 2017

42 Anderson 2017

43 Questions?

44 death rate (UK study) 57 bup vs 2366 methadone total number.022 vs.137 per 1000rx rates Most with multiple drugs present All MAT, did not break out contributing factors Review of buprenorphine exposures ( ) 6000 exposures (up to 18 y/o) 11 deaths 7 deaths in children under 6 y/o (single med) 4 in y/o (multiple meds) Marteau 2015, Post 2018

45 Agonists Oxycodone, oxymorphone, hydrocodone, morphine, methadone, codeine, fentanyl, tramadol, tapentadol Partial Agonists Buprenorphine?? Antagonists (Mu) Naloxone, naltrexone Agonist/Antagonist Butorphanol, nalbuphine, pentazocine Pergolizzi 2010

46

Buprenorphine pharmacology

Buprenorphine pharmacology Buprenorphine pharmacology Victorian Opioid Management ECHO Department of Addiction Medicine St Vincent s Hospital Melbourne 2018 Page 1 Opioids full, partial, antagonist Full Agonists - bind completely

More information

USE OF BUPRENORPHINE FOR CHRONIC PAIN

USE OF BUPRENORPHINE FOR CHRONIC PAIN Psychiatry and Addictions Case Conference UW Medicine Psychiatry and Behavioral Sciences USE OF BUPRENORPHINE FOR CHRONIC PAIN MARK SULLIVAN, MD, PHD PSYCHIATRY AND BEHAVIORAL SCIENCES ANESTHESIOLOGY AND

More information

Steven Prakken MD Chief, Medical Pain Service Duke Pain Medicine

Steven Prakken MD Chief, Medical Pain Service Duke Pain Medicine Steven Prakken MD Chief, Medical Pain Service Duke Pain Medicine International Association for the Study of Pain "Pain is an unpleasant sensory and emotional experience associated with actual or potential

More information

Buprenorphine as a Treatment Option for Opioid Use Disorder

Buprenorphine as a Treatment Option for Opioid Use Disorder Buprenorphine as a Treatment Option for Opioid Use Disorder Joji Suzuki, MD Assistant Professor of Psychiatry Harvard Medical School Director, Division of Addiction Psychiatry Brigham and Women s Hospital

More information

Medical Assisted Treatment. Dr. Michael Baldinger Medical Director Haymarket Center Harborview Recovery Center

Medical Assisted Treatment. Dr. Michael Baldinger Medical Director Haymarket Center Harborview Recovery Center Medical Assisted Treatment Dr. Michael Baldinger Medical Director Haymarket Center Harborview Recovery Center Current Trends Prescription Drug Abuse/Addiction Non-medical use of prescription pain killers

More information

Substitution Therapy for Opioid Use Disorder The Role of Suboxone

Substitution Therapy for Opioid Use Disorder The Role of Suboxone Substitution Therapy for Opioid Use Disorder The Role of Suboxone Methadone/Buprenorphine 101 Workshop, December 10, 2016 Leslie Lappalainen, MD, CCFP, dip ABAM Prepared by Mandy Manak, MD, ABAM, CCSAM

More information

OAT Transitions - focus on microdosing. Mark McLean MD MSc FRCPC CISAM DABAM

OAT Transitions - focus on microdosing. Mark McLean MD MSc FRCPC CISAM DABAM OAT Transitions - focus on microdosing Mark McLean MD MSc FRCPC CISAM DABAM Disclosures No pharmaceutical industry or other financial conflicts of interest Study Physician for research funded by Canadian

More information

Slide 1. Slide 2. Slide 3. Opioid (Narcotic) Analgesics and Antagonists. Lesson 6.1. Lesson 6.1. Opioid (Narcotic) Analgesics and Antagonists

Slide 1. Slide 2. Slide 3. Opioid (Narcotic) Analgesics and Antagonists. Lesson 6.1. Lesson 6.1. Opioid (Narcotic) Analgesics and Antagonists Slide 1 Opioid (Narcotic) Analgesics and Antagonists Chapter 6 1 Slide 2 Lesson 6.1 Opioid (Narcotic) Analgesics and Antagonists 1. Explain the classification, mechanism of action, and pharmacokinetics

More information

OST. Pharmacology & Therapeutics. Leo O. Lanoie, MD, MPH, FCFP, CCSAM, ABAM, MRO

OST. Pharmacology & Therapeutics. Leo O. Lanoie, MD, MPH, FCFP, CCSAM, ABAM, MRO OST Pharmacology & Therapeutics Leo O. Lanoie, MD, MPH, FCFP, CCSAM, ABAM, MRO Disclaimer In the past two years I have received no payment for services from any agency other than government or academic.

More information

Latest Press Release. How much for 30 mg adderall

Latest Press Release. How much for 30 mg adderall corp@stantec.com Latest Press Release How much for 30 mg adderall S 14-2-2008 Hi my name is Rachel i have been on suboxone for almost a year as of OCT 1st, and I have become the person I guess I am to

More information

An overview of Medication Assisted Treatment (MAT) and acute pain management on MAT

An overview of Medication Assisted Treatment (MAT) and acute pain management on MAT An overview of Medication Assisted Treatment (MAT) and acute pain management on MAT Goals of Discussion Recognize opioid use disorder (OUD) Discuss the pharmacology of medication assisted treatments (MAT)

More information

(Adapted with permission from the D-H Knowledge Map Primary Care Buprenorphine Guidelines)

(Adapted with permission from the D-H Knowledge Map Primary Care Buprenorphine Guidelines) Buprenorphine Initiation and Maintenance in Pregnancy (Adapted with permission from the D-H Knowledge Map Primary Care Buprenorphine Guidelines) Assessment The diagnosis of OUD should be confirmed by DSM-5

More information

GOALS AND OBJECTIVES

GOALS AND OBJECTIVES SUBOXONE AND VIVITROL: ARE THERE DISPARITIES SURFACING IN MEDICATION ASSISTED TREATMENTS? P R E S E N T E D B Y D R. K I AM E M AH A N I A H & D R. M Y E C H I A M I N T E R - J O R D AN GOALS AND OBJECTIVES

More information

Chronic Pain, Opioids, & Addiction: Assessing and Managing Risk

Chronic Pain, Opioids, & Addiction: Assessing and Managing Risk Chronic Pain, Opioids, & Addiction: Assessing and Managing Risk Randy Brown MD, PhD, FASAM Associate Professor, Dept of Family Medicine Director, Center for Addictive Disorders, UWHC Director, UW Addiction

More information

Recognizing Narcotic Abuse and Addiction and Helping Those With It

Recognizing Narcotic Abuse and Addiction and Helping Those With It Recognizing Narcotic Abuse and Addiction and Helping Those With It Michael McNett, MD Medical Director for Chronic Pain Member, WI Med Society Opioid Subcommittee Ancient History 1995: OxyContin approved

More information

12/14/2018. Disclosures. Buprenorphine. Drug-Receptor Interactions. Affinity

12/14/2018. Disclosures. Buprenorphine. Drug-Receptor Interactions. Affinity ECHO Ontario Chronic Pain Bootcamp OPIOID CHALLENGE Buprenorphine/Naloxone: What and How? Friday, December 7, 2018 Disclosures Presenters: John Flannery & Andrew Smith Conflicts of Interest: None John

More information

9/13/2017. Buprenorphine Treatment (Suboxone) Disclosures. We ve Got a Big Opioid Problem. Selahattin Kurter, MD Spectrum Healthcare

9/13/2017. Buprenorphine Treatment (Suboxone) Disclosures. We ve Got a Big Opioid Problem. Selahattin Kurter, MD Spectrum Healthcare Buprenorphine Treatment (Suboxone) Selahattin Kurter, MD Spectrum Healthcare Board Certified in Psychiatry and Addiction Medicine Disclosures No financial reimbursement for this lecture Consultant for

More information

Opioid dependence and buprenorphine treatment

Opioid dependence and buprenorphine treatment Opioid dependence and buprenorphine treatment David Roll, MD Revere Family Health, Cambridge Health Alliance Instructor in Medicine, Harvard Medical School Joji Suzuki MD Medical Director of Addictions

More information

Opioid Agonists. Natural derivatives of opium poppy - Opium - Morphine - Codeine

Opioid Agonists. Natural derivatives of opium poppy - Opium - Morphine - Codeine Natural derivatives of opium poppy - Opium - Morphine - Codeine Opioid Agonists Semi synthetics: Derived from chemicals in opium -Diacetylmorphine Heroin - Hydromorphone Synthetics - Oxycodone Propoxyphene

More information

Methadone Maintenance

Methadone Maintenance Methadone Maintenance A Practical Guide to Pharmacotherapy Methadone/Buprenorphine 101 Workshop, April 1, 2017 Ron Joe, MD, DABAM Objectives I. Pharmacology Of Methadone II. Practical Application of Pharmacology

More information

Opioids Research to Practice

Opioids Research to Practice Opioids Research to Practice CRIT Program May 2009 Daniel P. Alford, MD, MPH Associate Professor of Medicine Boston University School of Medicine Boston Medical Center 32 yo female brought in after heroin

More information

Disclosures. Topics of today s training 4/24/2017. Evolving Treads in Medication Assisted Treatment. Christopher J Davis D.O.

Disclosures. Topics of today s training 4/24/2017. Evolving Treads in Medication Assisted Treatment. Christopher J Davis D.O. Evolving Treads in Medication Assisted Treatment Christopher J Davis D.O. CAADC, FASAM Medical Director, The Ranch of Pennsylvania Medical Director, Pyramid Healthcare Diplomate of The American Board of

More information

Medication Assisted Treatment. Michael Palladini, RPh MBA CAC

Medication Assisted Treatment. Michael Palladini, RPh MBA CAC Medication Assisted Treatment Michael Palladini, RPh MBA CAC palladini.michael@gmail.com History of MAT Addiction as a Disease The concept of addiction as a disease of the brain challenges deeply ingrained

More information

Pharmacotherapy for opioid addiction. Judith Martin, MD Medical Director BAART Turk Street Clinic San Francisco

Pharmacotherapy for opioid addiction. Judith Martin, MD Medical Director BAART Turk Street Clinic San Francisco Pharmacotherapy for opioid addiction Judith Martin, MD Medical Director BAART Turk Street Clinic San Francisco Disclosure slide No commercial conflicts to disclose. Gaps in current treatment of opioid

More information

6/6/2018. Nalbuphine: Analgesic with a Niche. Mellar P Davis MD FCCP FAAHPM. Summary of Advantages. Summary of Advantages

6/6/2018. Nalbuphine: Analgesic with a Niche. Mellar P Davis MD FCCP FAAHPM. Summary of Advantages. Summary of Advantages Nalbuphine: Analgesic with a Niche Mellar P Davis MD FCCP FAAHPM 1 Summary of Advantages Safe in renal failure- fecal excretion Analgesia equal to morphine with fewer side effects Reduced constipation

More information

Tapering Opioids Best Practices*

Tapering Opioids Best Practices* Tapering Opioids Best Practices* Chuck Hofmann, MD, MACP 5 th Annual EOCCO Office Staff and Provider Summit September 28, 2017 Disclosure No Conflicts of Interest to report Learning Objectives Understand

More information

Prescription Opioids

Prescription Opioids What are prescription opioids? Prescription Opioids Opioids are a class of drugs naturally found in the opium poppy plant. Some prescription opioids are made from the plant directly, and others are made

More information

Dr Alistair Dunn. General Practitioner Whangarei

Dr Alistair Dunn. General Practitioner Whangarei Dr Alistair Dunn General Practitioner Whangarei 1982 Temgesic = Buprenorphine Sublingual opiate analgesic 0.2 mg Popular drug of abuse 1991 Temgesic NX = Bup & Nalxone Nalxone added to deter abuse 1999

More information

Optimizing Suboxone in Opioid Addicts

Optimizing Suboxone in Opioid Addicts Optimizing Suboxone in Opioid Addicts David Chim, D.O. Integrated Substance Abuse Programs Dept. of Psychiatry, UCLA K30 Translational Research Interest March 24, 2009 dchim@mednet.ucla.edu www.uclaisap.org

More information

Opioid Review and MAT Clinic CDC Guidelines

Opioid Review and MAT Clinic CDC Guidelines 1 Opioid Review and MAT Clinic CDC Guidelines January 10, 2018 Housekeeping Use chat feature to inform everyone who s at your clinic Click chat on Zoom option bar Chat Everyone the names of those who are

More information

Opioid Replacement Therapy

Opioid Replacement Therapy Opioid Replacement Therapy Matthew A. Felgus, MD mafelgus@wisc.edu 6333 Odana Rd, Suite 3, Madison, WI 53719 (608) 257-1581 Board Certified in Addiction Medicine Board Certified in Psychiatry matthewfelgusmd.com

More information

Analgesia for Patients with Substance Abuse Disorders. Lisa Jennings CN November 2015

Analgesia for Patients with Substance Abuse Disorders. Lisa Jennings CN November 2015 Analgesia for Patients with Substance Abuse Disorders Lisa Jennings CN November 2015 Definitions n Addiction: A pattern of drug use characterised by aberrant drug-taking behaviours & the compulsive use

More information

Building capacity for a CHC response to Ontario's Opioid Crisis

Building capacity for a CHC response to Ontario's Opioid Crisis Building capacity for a CHC response to Ontario's Opioid Crisis Rob Boyd Oasis Program Director Luc Cormier, RN, MScN Community Health Nurse Sandy Hill Community Health Centre #AOHC2016 @rboyd6 @SandyHillCHC

More information

Best Practices in Prescribing Opioids for Chronic Non-cancer Pain

Best Practices in Prescribing Opioids for Chronic Non-cancer Pain Best Practices in Prescribing Opioids for Chronic Non-cancer Pain Disclosures S C O T T S T E I G E R, M D, F A C P, D A B A M A S S I S T A N T C L I N I C A L P R O F E S S O R D I V I S I O N O F G

More information

Opioids Research to Practice

Opioids Research to Practice Opioids Research to Practice CRIT Program May 2010 Daniel P. Alford, MD, MPH Associate Professor of Medicine Boston University School of Medicine Boston Medical Center 32 yo female brought in after heroin

More information

Developed and Presented by Randall Webber, MPH, CADC JRW Behavioral Health Services

Developed and Presented by Randall Webber, MPH, CADC JRW Behavioral Health Services Developed and Presented by Randall Webber, MPH, CADC JRW Behavioral Health Services www.randallwebber.com MAT clients are still addicted Truth: MAT clients will experience withdrawal symptoms if they stop

More information

Charles P. O Brien, MD, PhD University of Pennsylvania No financial conflicts, patents, speakers bureaus

Charles P. O Brien, MD, PhD University of Pennsylvania No financial conflicts, patents, speakers bureaus Pain & Opioid Epidemic 2018 Charles P. O Brien, MD, PhD University of Pennsylvania No financial conflicts, patents, speakers bureaus Opioids 3400 BC Mesopotamia, Joy plant 1843 morphine by syringe 1874

More information

SUBOXONE Film, SUBOXONE Tablets, and SUBUTEX Tablets. Risk Evaluation and Mitigation Strategy (REMS) Program

SUBOXONE Film, SUBOXONE Tablets, and SUBUTEX Tablets. Risk Evaluation and Mitigation Strategy (REMS) Program SUBOXONE Film, SUBOXONE Tablets, and SUBUTEX Tablets Risk Evaluation and Mitigation Strategy (REMS) Program Office-Based Buprenorphine Therapy for Opioid Dependence: Important Information for Prescribers

More information

Opiates & Opioids Opioids

Opiates & Opioids Opioids Opiates & Opioids Opioids Opiates Pharmacologic principals important in primary care Present in opium from seedpod of Papaver somniferum Morphine, codeine Opioids Ted Parran MD FACP Are manufactured Isabel

More information

Prescription Opioid Addiction

Prescription Opioid Addiction CSAM-SCAM Fundamentals Prescription Opioid Addiction Presentation provided by Meldon Kahan, MD Family & Community Medicine University of Toronto Conflict of interest statement I received funds from Rickett

More information

Suboxone, Zubsolv, Bunavail (buprenorphine with naloxone sublingual tablets and film), Buprenorphine sublingual tablets

Suboxone, Zubsolv, Bunavail (buprenorphine with naloxone sublingual tablets and film), Buprenorphine sublingual tablets Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.32 Subject: Suboxone Drug Class Page: 1 of 7 Last Review Date: June 24, 2016 Suboxone Drug Class Description

More information

Medication Assisted Treatment. Nicole Gastala, MD

Medication Assisted Treatment. Nicole Gastala, MD Medication Assisted Treatment Nicole Gastala, MD Objectives Training Goals: To enhance the understanding of the participants in use of medication assisted therapy To increase the knowledge of participants

More information

Medication-Assisted Treatment (MAT) Overview

Medication-Assisted Treatment (MAT) Overview Medication-Assisted Treatment (MAT) Overview 2014 Opiate Conference: Don t Get Me Started Hyatt Regency, Columbus, Ohio June 30-July 1, 2014 Christina M. Delos Reyes, MD Medical Consultant, Center for

More information

Buprenorphine: An Introduction. Sharon Stancliff, MD Harm Reduction Coalition September 2008

Buprenorphine: An Introduction. Sharon Stancliff, MD Harm Reduction Coalition September 2008 Buprenorphine: An Introduction Sharon Stancliff, MD Harm Reduction Coalition September 2008 Objective Participants will be able to: Discuss the role of opioid maintenance in reducing morbidity and mortality

More information

OPIOID SUBSTITUTION THERAPY RISKS & BENEFITS

OPIOID SUBSTITUTION THERAPY RISKS & BENEFITS OPIOID SUBSTITUTION THERAPY RISKS & BENEFITS LEO O. LANOIE, MD, MPH, FCFP, CCSAM, ABAM, FISAM, MRO Dr. Leo Lanoie, 2017 DISCLAIMER In the past year I have accepted funds from Purdue for speaking OPIOID

More information

AETNA BETTER HEALTH Prior Authorization guideline for Narcotic Analgesic Utilization

AETNA BETTER HEALTH Prior Authorization guideline for Narcotic Analgesic Utilization AETNA BETTER HEALTH Prior Authorization guideline for Narcotic Analgesic Utilization Policy applies to all formulary and non-formulary schedules II V opioid narcotics, including tramadol and codeine, as

More information

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

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

More information

2/21/2018. What are Opioids?

2/21/2018. What are Opioids? Opioid Crisis: South Carolina Responds Carolyn Bogdon, MSN, FNP-BC Coordinator for Emergency Department Medication Assisted Treatment Program Medical University of South Carolina Opioid Crisis: A Mounting

More information

Opioid Use in Youth. Amy Yule M.D. March 2,

Opioid Use in Youth. Amy Yule M.D. March 2, Opioid Use in Youth Amy Yule M.D. March 2, 2018 An opioid is a substance that acts on opioid receptors Beta-endorphin Endogenous opioids Dynorphin Opiates Natural products of the poppy plant Morphine Heroin

More information

Opioid Use Disorders &Medication Treatment

Opioid Use Disorders &Medication Treatment Agency medical director comments Opioid Use Disorders &Medication Treatment Charissa Fotinos, MD, MSc Deputy Chief Medical Officer Washington State Health Care Authority Learning Objectives: 1) Review

More information

BDSI Corporate Overview

BDSI Corporate Overview BDSI Corporate Overview June 2017 1 2017 BioDelivery Sciences International Inc. All Rights Reserved. Jefferies 2017 Healthcare Conference Dr. Mark A. Sirgo President and Chief Executive Officer June 6

More information

Opioids Research to Practice

Opioids Research to Practice Opioids Research to Practice CRIT Program May 2008 Daniel P. Alford, MD, MPH Associate Professor of Medicine Boston University School of Medicine Boston Medical Center 32 yo female brought in after heroin

More information

SW OREGON OPIOID SUMMIT. Medication Assisted Recovery for Opioid Use Disorder. Gregory S. Brigham, Ph.D. Adapt / SouthRiver CHC / Compass

SW OREGON OPIOID SUMMIT. Medication Assisted Recovery for Opioid Use Disorder. Gregory S. Brigham, Ph.D. Adapt / SouthRiver CHC / Compass SW OREGON OPIOID SUMMIT Medication Assisted Recovery for Opioid Use Disorder Gregory S. Brigham, Ph.D. Adapt / SouthRiver CHC / Compass Opioid Agonists Mu (μ) receptors stimulated by opioids causing full

More information

Buprenorphine Access in California

Buprenorphine Access in California Buprenorphine Access in California James J. Gasper, PharmD, BCPP Pharmacy Benefits Division Department of Health Care Services james.gasper@dhcs.ca.gov Source: CDPH Vital Statisitics Death Statistical

More information

Karen F Marlowe, Pharm D, BCPS Certified Pain Educator Auburn University Harrison School of Pharmacy University of South Alabama School of Medicine

Karen F Marlowe, Pharm D, BCPS Certified Pain Educator Auburn University Harrison School of Pharmacy University of South Alabama School of Medicine Karen F Marlowe, Pharm D, BCPS Certified Pain Educator Auburn University Harrison School of Pharmacy University of South Alabama School of Medicine A 58 year old patient 20 year history of alcohol, opioid

More information

Medication-Assisted Treatment. What Is It and Why Do We Use It?

Medication-Assisted Treatment. What Is It and Why Do We Use It? Medication-Assisted Treatment What Is It and Why Do We Use It? What is addiction, really? o The four C s of addiction: Craving. Loss of Control of amount or frequency of use. Compulsion to use. Use despite

More information

Morphine equivalent calculator suboxone

Morphine equivalent calculator suboxone Morphine equivalent calculator suboxone Gogamz Menu Best Way To Lose 30 Pounds In 6 Months Fat Burner Waist Belt Fat Burn And Target Heart Rate how much weight would i lose calculator Fastest Fat Burner

More information

Drug Information Common to the Class of Extended-Release and Long-Acting Opioid Analgesics (ER/LA opioid analgesics) Avinza Butrans

Drug Information Common to the Class of Extended-Release and Long-Acting Opioid Analgesics (ER/LA opioid analgesics) Avinza Butrans FDA Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics 7/9/2012 Drug Information Common to the Class of Extended-Release and Long-Acting Opioid Analgesics (ER/LA

More information

NALTREXONE DAVID CRABTREE, MD, MPH UNIVERSITY OF UTAH HEALTH, 2018

NALTREXONE DAVID CRABTREE, MD, MPH UNIVERSITY OF UTAH HEALTH, 2018 NALTREXONE DAVID CRABTREE, MD, MPH TREATMENT OF OPIOID USE DISORDER (OUD) Majority of people who develop OUD are not receiving treatment Only a small fraction of patients are offered treatment with medications

More information

THE OPIUM POPPY OPIOID PHARMACOLOGY 2/18/16. PCTH 300/305 Andrew Horne, PhD MEDC 309. Papaver somniferum. Poppy Seeds Opiates

THE OPIUM POPPY OPIOID PHARMACOLOGY 2/18/16. PCTH 300/305 Andrew Horne, PhD MEDC 309. Papaver somniferum. Poppy Seeds Opiates OPIOID PHARMACOLOGY PCTH 300/305 Andrew Horne, PhD andrew.horne@ubc.ca MEDC 309 THE OPIUM POPPY Papaver somniferum Sleep-bringing poppy Poppy Seeds Opiates Opium Poppy Straw 1 OPIATES VS. OPIOIDS Opiates:

More information

MEDICALLY ASSISTED TREATMENT IN PROBLEMATIC OPIOID Punta Cana 2018

MEDICALLY ASSISTED TREATMENT IN PROBLEMATIC OPIOID Punta Cana 2018 MEDICALLY ASSISTED TREATMENT IN PROBLEMATIC OPIOID USE @joelbordman Punta Cana 2018 Copyright 2017 by Sea Courses Inc All rights reserved. No part of this document may be reproduced, copied, stored, or

More information

Implementing Buprenorphine Treatment in Opioid Treatment Programs Webinar 2, October 3, 2018

Implementing Buprenorphine Treatment in Opioid Treatment Programs Webinar 2, October 3, 2018 Implementing Buprenorphine Treatment in Opioid Treatment Programs Webinar 2, October 3, 2018 Judith Martin, MD, Medical Director of Substance Use Services, San Francisco Department of Public Health Webinar

More information

Linking Opioid Treatment in Primary Care. Roxanne Lewin M.D.

Linking Opioid Treatment in Primary Care. Roxanne Lewin M.D. Roxanne Lewin M.D. The Facts Fewer than 10 percent of individuals with an alcohol use disorder and only about 20 percent of individuals with an opioid use disorder receive specialty treatment. Many individuals

More information

HOPE. Considerations. Considerations ISING. Safe Opioid Prescribing Guidelines for ACUTE Non-Malignant Pain

HOPE. Considerations. Considerations ISING. Safe Opioid Prescribing Guidelines for ACUTE Non-Malignant Pain Due to the high level of prescription drug use and abuse in Lake County, these guidelines have been developed to standardize prescribing habits and limit risk of unintended harm when prescribing opioid

More information

Opioid Step Policy. Description. Section: Prescription Drugs Effective Date: April 1, 2018

Opioid Step Policy. Description. Section: Prescription Drugs Effective Date: April 1, 2018 Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Opioid Step Policy Page: 1 of 6 Last Review Date: March 16, 2018 Opioid Step Policy Description

More information

MAT IN PREGNANCY KAYLA LIFE STAGE 1: ADOLESCENCE LIFE STAGE 2: EARLY ADULTHOOD. family History of addiction. addiction to oral opioids

MAT IN PREGNANCY KAYLA LIFE STAGE 1: ADOLESCENCE LIFE STAGE 2: EARLY ADULTHOOD. family History of addiction. addiction to oral opioids MAT IN PREGNANCY R. COREY WALLER MD, MS PRINCIPAL, HEALTH MANAGEMENT ASSOCIATES FACULTY, INSTITUTE FOR HEALTHCARE INNOVATION (IHI) CHAIR, LEGISLATIVE ADVOCACY COMMITTEE, ASAM KAYLA LIFE STAGE 1: ADOLESCENCE

More information

Medication Assisted Treatment. MAT Opioid dependence/addiction Opioid treatment programs OTP Regulation of OTP Office Based Treatment

Medication Assisted Treatment. MAT Opioid dependence/addiction Opioid treatment programs OTP Regulation of OTP Office Based Treatment Medication Assisted Treatment MAT Opioid dependence/addiction Opioid treatment programs OTP Regulation of OTP Office Based Treatment Opioid Drugs Opium Morphine Heroin Codeine Oxycodone Roxycodone Oxycontin

More information

B. Long-acting/Extended-release Opioids

B. Long-acting/Extended-release Opioids 4 Opioid tolerance is assumed in patients already taking fentanyl 25 mcg/hr OR daily doses of the following oral agents for 1 week: 60 mg oral morphine, 30 mg oxycodone, 8 mg hydromorphone, 25 mg of oxymorphone

More information

Kurt Haspert, MS, CRNP University of Maryland Baltimore Washington Medical Center

Kurt Haspert, MS, CRNP University of Maryland Baltimore Washington Medical Center Kurt Haspert, MS, CRNP University of Maryland Baltimore Washington Medical Center Data from the National Vital Statistics System Mortality The age-adjusted rate of drug overdose deaths in the United States

More information

Index. E Elderly. See also Older patients analgesic efficacy and opioid adverse effects, 280

Index. E Elderly. See also Older patients analgesic efficacy and opioid adverse effects, 280 A Acute pain, methadone maintained patients, 33 Addiction antisocial behaviors, 24 definition, 15 Drug Addiction Treatment Act 2000, 140 heroin, 41 morphine, 91 opioid, 16 related counseling, 23 treatment

More information

John Murphy DO, MS Lynx Healthcare

John Murphy DO, MS Lynx Healthcare Addiction to Pain Medication and Treatment John Murphy DO, MS Lynx Healthcare No Disclosures Objectives 1 Understand basic neurobiology and learning theory around opioid addiction 2 Identify aberrant behavior

More information

Treatment Alternatives for Substance Use Disorders

Treatment Alternatives for Substance Use Disorders Treatment Alternatives for Substance Use Disorders Dean Drosnes, MD, FASAM Associate Medical Director Director, Chronic Pain and SUD Program Caron Treatment Centers 1 Disclosure The speaker has no conflict

More information

Hospital Based Opioid Management A case based, peer discussion

Hospital Based Opioid Management A case based, peer discussion Hospital Based Opioid Management A case based, peer discussion A NNA MURLEY SQUIBB M.D. A S S O C I A T E P R O G R A M D I R E C T O R, S O I N F A M I L Y M E D I C I N E R E S I D E N C Y Disclosures

More information

Opioid Treatment in North Carolina SEPTEMBER 13, 2016

Opioid Treatment in North Carolina SEPTEMBER 13, 2016 Opioid Treatment in North Carolina SEPTEMBER 13, 2016 Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2007 Source Where Respondent Obtained

More information

OPIOID REPLACEMANT THERAPY: AN OVERVIEW

OPIOID REPLACEMANT THERAPY: AN OVERVIEW 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 53719 (608) 257-1581 Board Certified in

More information

Opioids: Use, Abuse and Cause of Death. Jennifer Harmon Assistant Director - Forensic Chemistry Orange County Crime Laboratory

Opioids: Use, Abuse and Cause of Death. Jennifer Harmon Assistant Director - Forensic Chemistry Orange County Crime Laboratory Opioids: Use, Abuse and Cause of Death Jennifer Harmon Assistant Director - Forensic Chemistry Orange County Crime Laboratory jharmon@occl.ocgov.com Opioid: Any psychoactive chemical that resembles morphine

More information

Pharmacology of Selected Opioid Analgesics

Pharmacology of Selected Opioid Analgesics Pharmacology of Selected Opioid Analgesics Harvey Berman, PhD, MPH Department of Pharmacology and Toxicology hberman@buffalo.edu 829-2658 Note: I plan to discuss only some of the slides, the others (O)

More information

Opioids. Sergio Hernandez, MD

Opioids. Sergio Hernandez, MD Opioids Sergio Hernandez, MD Required Slide Disclosures 1. SIGNIFICANT FINANCIAL INTERESTS NO SIGNIFICANT FINANCIAL, GENERAL, OR OBLIGATION INTERESTS TO REPORT 2. GENERAL AND OBLIGATION INTERESTS All general

More information

Module II Opioids 101 Opiate Opioid

Module II Opioids 101 Opiate Opioid BUPRENORPHINE TREATMENT: A TRAINING FOR MULTIDISCIPLINARY ADDICTION PROFESSIONALS Module II Opioids 101 Module II Goals of the Module This module reviews the following:! Opioid addiction and the brain!

More information

Opioids. October 29, Addiction Medicine Review Course CSAM, Newport Beach, CA

Opioids. October 29, Addiction Medicine Review Course CSAM, Newport Beach, CA Opioids October 29, 2010 Addiction Medicine Review Course CSAM, Newport Beach, CA Daniel P. Alford, MD, MPH, FACP, FASAM Associate Professor of Medicine Boston University School of Medicine Boston Medical

More information

Opioid Analgesics. Recommended starting dose for opioid-naïve patients

Opioid Analgesics. Recommended starting dose for opioid-naïve patients Opioid Analgesics Goals: Restrict use of opioid analgesics to OHP-funded conditions with documented sustained improvement in pain and function and with routine monitoring for opioid misuse and abuse. Promote

More information

Disclosure Statement. Learning Objectives. American Psychiatric Nurses Association. Christian J. Teter, PharmD, BCPP 1 BUPRENORPHINE UPDATE

Disclosure Statement. Learning Objectives. American Psychiatric Nurses Association. Christian J. Teter, PharmD, BCPP 1 BUPRENORPHINE UPDATE BUPRENORPHINE UPDATE Christian J. Teter, Pharm.D., BCPP Associate Professor, Psychopharmacology College Of Pharmacy, University Of New England Portland, ME E-Mail: cteter@une.edu Image Source: pubchem.ncbi.nlm.nih.gov

More information

What is an opioid? What do opioids do? Why is there an opioid overdose crisis? What is fentanyl? What about illicit or bootleg fentanyls?

What is an opioid? What do opioids do? Why is there an opioid overdose crisis? What is fentanyl? What about illicit or bootleg fentanyls? What is an opioid? What do opioids do? Why is there an opioid overdose crisis? What is fentanyl? What about illicit or bootleg fentanyls? What is an opioid? What do opioids do?: The term opioid can be

More information

Safe Practices and Action Items

Safe Practices and Action Items Safe Practices and Action Items Karen F Marlowe, Pharm D, BCPS Certified Pain Educator Auburn University Harrison School of Pharmacy University of South Alabama School of Medicine Case Study A 58 year

More information

Overview of Essentials of Pain Management. Updated 11/2016

Overview of Essentials of Pain Management. Updated 11/2016 0 Overview of Essentials of Pain Management Updated 11/2016 1 Overview of Essentials of Pain Management 1. Assess pain intensity on a 0 10 scale in which 0 = no pain at all and 10 = the worst pain imaginable.

More information

Overview of Medication Assisted Treatment Methadone, Buprenorphine and Naltrexone

Overview of Medication Assisted Treatment Methadone, Buprenorphine and Naltrexone Overview of Medication Assisted Treatment Methadone, Buprenorphine and Naltrexone Alexander Y. Walley, MD, MSc Associate Professor of Medicine Director, Addiction Medicine Fellowship Boston University

More information

Opioid Conversions Mixture of Science and Art

Opioid Conversions Mixture of Science and Art Opioid Conversions Mixture of Science and Art Matthew J. Pingree, MD Assistant Professor Division of Pain Medicine Physical Medicine and Rehabilitation and Anesthesiology Mayo Clinic, Rochester Pingree.Matthew@Mayo.edu

More information

Pharmacy Medical Necessity Guidelines: Opioid Analgesics

Pharmacy Medical Necessity Guidelines: Opioid Analgesics Pharmacy Medical Necessity Guidelines: Effective: January 1, 2019 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED) Benefit

More information

Medication Assisted Treatment

Medication Assisted Treatment Meeting the Needs of Your Clients: Building Competencies in Mental Health and Addiction Services Medication Assisted Treatment November 5, 2018 In partnership with: House Keeping Because this is a webinar,

More information

Blueprint for Prescriber Continuing Education Program

Blueprint for Prescriber Continuing Education Program CDER Final 10/25/11 Blueprint for Prescriber Continuing Education Program I. Introduction: Why Prescriber Education is Important Health care professionals who prescribe extended-release (ER) and long-acting

More information

Opioid Dependence and Buprenorphine Management

Opioid Dependence and Buprenorphine Management Opioid Dependence and Buprenorphine Management Kevin Kapila, MD Fenway Health Medical Director of Behavioral Health Instructor in Medicine Harvard Medical School Learning Objectives Understand the rationale

More information

Opioids- Indica-ons, Equivalence, Dependence and Withdrawal Methadone Maintenance (OST) Paul Glue

Opioids- Indica-ons, Equivalence, Dependence and Withdrawal Methadone Maintenance (OST) Paul Glue Opioids- Indica-ons, Equivalence, Dependence and Withdrawal Methadone Maintenance (OST) Paul Glue Scope Pharmacology of Opioids Equivalence Dependence and Withdrawal Methadone Maintenance (OST) 3 Opioid

More information

Management of high risk MMT patients. Meldon Kahan MD Methadone Prescribers Conference Toronto, Nov 15, 2013

Management of high risk MMT patients. Meldon Kahan MD Methadone Prescribers Conference Toronto, Nov 15, 2013 Management of high risk MMT patients Meldon Kahan MD Methadone Prescribers Conference Toronto, Nov 15, 2013 CFPC CoI Templates: Slide 1 Faculty Disclosure Faculty: Meldon Kahan Relationships with commercial

More information

Clinical Policy: Opioid Analgesics Reference Number: OH.PHAR.PPA.13 Effective Date: 10/2017 Last Review Date: 6/2018 Line of Business: Medicaid

Clinical Policy: Opioid Analgesics Reference Number: OH.PHAR.PPA.13 Effective Date: 10/2017 Last Review Date: 6/2018 Line of Business: Medicaid Clinical Policy: Reference Number: OH.PHAR.PPA.13 Effective Date: 10/2017 Last Review Date: 6/2018 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important

More information

The Prescription Review Program and College Expectations. Dr. Rashmi Chadha MBChB MScCH CCFP MRCGP Dip. ABAM

The Prescription Review Program and College Expectations. Dr. Rashmi Chadha MBChB MScCH CCFP MRCGP Dip. ABAM The Prescription Review Program and College Expectations Dr. Rashmi Chadha MBChB MScCH CCFP MRCGP Dip. ABAM April 28, 2017 Disclosure Relationship with commercial interests: None Professional roles: Addictions

More information

LONG TERM PHARMACOTHERAPY OF OPIOID DEPENDENCE

LONG TERM PHARMACOTHERAPY OF OPIOID DEPENDENCE LONG TERM PHARMACOTHERAPY OF OPIOID DEPENDENCE DR. SHILPA ADARKAR ASSOCIATE PROFESSOR DEPARTMENT OF PSYCHIATRY & DRUG DEADDICTION CENTRE OF EXCELLENCE SETH GSMC & KEMH LONG TERM OPTIONS FULL AGONIST PARTIAL

More information

1/26/2016. These are my own thoughts! Safe Workplace Safe Workforce Proven benefits of Stay At Work / Return To Work Process (SAW/RTW)

1/26/2016. These are my own thoughts! Safe Workplace Safe Workforce Proven benefits of Stay At Work / Return To Work Process (SAW/RTW) Dr. Paul A. Farnan farnan@mail.ubc.ca HealthQuest Occupational Health Corporation Alliance Medical Monitoring I have no financial interests or affiliation with any pharmaceutical industry or manufacturer

More information

Buprenorphine 2.0: I have my waiver, now what? Dr. Ritu Bhatnagar, M.D., M.P.H. Dr. John Ewing, M.D., FASAM. Disclosures

Buprenorphine 2.0: I have my waiver, now what? Dr. Ritu Bhatnagar, M.D., M.P.H. Dr. John Ewing, M.D., FASAM. Disclosures Buprenorphine 2.0: I have my waiver, now what? Dr. Ritu Bhatnagar, M.D., M.P.H. Dr. John Ewing, M.D., FASAM Disclosures Dr. Bhatnagar: no disclosures to report Dr. Ewing: no disclosures to report 1 Our

More information

PAIN & ANALGESIA. often accompanied by clinical depression. fibromyalgia, chronic fatigue, etc. COX 1, COX 2, and COX 3 (a variant of COX 1)

PAIN & ANALGESIA. often accompanied by clinical depression. fibromyalgia, chronic fatigue, etc. COX 1, COX 2, and COX 3 (a variant of COX 1) Pain - subjective experience associated with detection of tissue damage ( nociception ) acute - serves as a warning chronic - nociception gone bad often accompanied by clinical depression fibromyalgia,

More information

Overview of Opioid Use Disorder

Overview of Opioid Use Disorder Overview of Opioid Use Disorder Doug Burgess, MD Medical Director of Outpatient Services, Truman Medical Centers Assistant Professor of Psychiatry, University of Missouri- Kansas City Objectives History

More information