MAT 101: TREATMENT OF OPIOID USE DISORDER

Transcription

1 MAT 101: TREATMENT OF OPIOID USE DISORDER WITH SPECIAL EMPHASIS ON BUPRENORPHINE/NALOXONE ICADD May 22, 2018 Alicia Carrasco, MD Debby Woodall, LCSW, ACADC Magni Hamso, MD, MPH Terry Reilly Health Services University of Washington Boise Internal Medicine Residency

2 No relevant disclosures. DISCLOSURES

3 POLLEVERYWHERE.COM

4 LEARNING OBJECTIVES Understand the scope of the opioid overdose epidemic Define opioids, opioid use disorder (OUD), addiction and recovery Identify evidence-based treatment options for OUD Understand why buprenorphine/naloxone is an effective treatment for OUD

5 SCHEDULE Introductions 10 minutes Overview minutes Group Work 30 min Report Back and Summary 15min

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13 WHAT ARE OPIOIDS? Prescription pain medicines such as hydrocodone (Norco), oxycodone, morphine, fentanyl Illegal drugs such as heroin Stimulate the opioid receptor in the brain to decrease pain, as side effects make people feel good (euphoria) and slow breathing (overdose risk)

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17 Surgeon General s Report 2016

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19 OPIOID USE DISORDER A problematic pattern of opioid use leading to clinically significant impairment or distress is manifested by two or more of the following within a 12-month (with 2-3 = mild, 4-5 = moderate, 6+ severe): A.Impaired control: 1. taking more or for longer than intended 2. unsuccessful efforts to stop or cut down use 3. spending a great deal of time obtaining, using, or recovering from use 4. craving for substance. B. Social impairment: 5. failure to fulfill major obligations due to use 6. continued use despite problems caused or exacerbated by use 7. important activities given up or reduced because of substance use. C. Risky use: 8. recurrent use in hazardous situations 9. continued use despite physical or psychological problems that are caused or exacerbated by substance use. D. Pharmacologic dependence: 10. tolerance to effects of the substance 11. withdrawal symptoms when not using or using less.

20 ASAM DEFINITION OF ADDICTION a primary, chronic disease of brain reward, motivation, memory, and related circuitry pathologically pursuing reward and/or relief of withdrawal symptoms by substance use without treatment or engagement in recovery activities, addiction is progressive and can result in disability & death.

21 ASAM DEFINITION OF RECOVERY a process of sustained action that addresses the biological, psychological, social and spiritual disturbances aims to improve the quality of life... is the consistent pursuit of abstinence

22 TREATMENT OF OPIOID USE DISORDER

23 PATIENT CASE 27yo with diabetes, depression/anxiety, IV heroin use comes in to see you. Heroin x 10yrs, mostly IV Multiple admissions for detox Couch surfing.

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25 Harm Reduction TREATMENT OPTIONS Naloxone for reversal of opioid overdose; low & slow ; not alone Needles/Injection technique HIV/HCV testing HAV/HBV vaccines

26 Detox TREATMENT OPTIONS Studies limited by lack of long-term follow-up May work for motivated individuals with short substance use history and low level of dependence High risk of overdose after any period of abstinence, without MAT

27 TREATMENT OPTIONS Detox Psychosocial interventions Limited effectiveness on own Can help with detox Recommended in addition to MAT

28 TREATMENT OPTIONS Detox Psychosocial interventions Medication Assisted Treatment

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30 MEDICATION ASSISTED TREATMENT BupPractice 2013

31 Opioid antagonist NALTREXONE* Oral daily dosing or once monthly intramuscular injection Blocks intoxicating/reinforcing effects of opioids May work in highly motivated individuals with strong support and limited substance use Some interest pre-release, to reduce overdose High relapse rates, very limited evidence Increased risk of overdose after antagonist wears off *Naloxone is short-acting injectable or intranasal version used for reversal of opioid overdose

32 METHADONE Opioid agonist Benefits Stay in treatment Decreased heroin use Decreased criminal activity Improved mortality Decreased HIV & HCV Typical dose mg/d Barriers Stigma Daily dosing Expensive

33 BUPRENORPHINE/NALOXONE

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35 BUPRENORPHINE/NALOXONE Partial opioid agonist Stimulates receptors only so far, almost eliminating risk of overdose (ceiling effect) Binds receptors so tightly, that no other opioids can get in, also reducing risk of overdose Mixed with naloxone, to prevent misuse/diversion

36 KAKKO ET AL. LANCET 2003

37 FIELIN ET AL. JAMA 2014

38 SAMHSA EVALUATION OF DATA WAIVER PROGRAM 2006

39 SAMHSA EVALUATION OF DATA WAIVER PROGRAM 2006

40 SAMHSA EVALUATION OF DATA WAIVER PROGRAM 2006

41 SCHWARTZ ET AL. AJPH 2012

42 TSUI ET AL. JAMA 2014

43 SORDO ET AL. BMJ 2017

44 PATIENT CASE 27yo man with diabetes, depression/anxiety, IV heroin use comes in to see you. Heroin x 10yrs, mostly IV Multiple admissions for detox Couch surfing.

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46 REQUIREMENTS Moderate to severe opioid use disorder Interest in treatment <60mg methadone/day, <1g heroin/day*

47 CONTRAINDICATIONS Chronic pain on opioids** Severe alcohol use disorder Severe benzodiazepine use disorder Severe psychiatric illness Severe hepatitis/impaired hepatic function

48 OFFICE-BASED THERAPY Licensed provider Buprenorphine agreement Induction Maintenance & monitoring

49 LICENSED PROVIDER 8hr online training (24hrs NP/PA) DEA-X number 30 patients the first year, then 100 per year; can apply to increase to 275 Random audits by the DEA Trainings buprenorphine.samhsa.gov FREE: pcss.now.org

50 BUPRENORPHINE AGREEMENT Goals and expectations Frequent visits Regular urine drug testing Regular PMP reports Stopping parameters

51 INDUCTION hours since last opioid Mild-moderate withdrawal to avoid precipitated withdrawal Limited prescription with clear parameters for uptitration: 8mg on day 1, 16mg on day 2, 24mg on day 3 if persistent withdrawal symptoms, use clonidine, loperamide, ibuprofen If wake up able to eat breakfast, likely reached correct dose

52 PATIENT CASE Our patient returns to clinic three days after starting home induction. Has titrated dose up to 24mg/6mg per day, taking two 8mg/2mg tabs in the AM and one in the PM Denies withdrawal symptoms or cravings.

53 MAINTENANCE Every 1-2 weeks until stable, then monthly Counseling Regular urine drug testing

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55 SUMMARY Understand the scope of the opioid overdose epidemic Define opioids, opioid use disorder (OUD), addiction and recovery Identify evidence-based treatment options for OUD Understand why buprenorphine/naloxone is an effective treatment for OUD

56 GROUP TIME! Break into groups to discuss cases Spend about 10 minutes per case Report back to big group around 4:45pm

57 THANK YOU

58 REFERENCES National Center for Injury Prevention and Control. Policy Impact: Prescription painkillers overdoses. CDC, Nov Amato L et al. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Amato L et al. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Center for Behavioral Health Statistics & Quality. Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. HHS Publication No. SMA , NSDUH Series H Clark RE. Responses of state Medicaid programs to buprenorphine diversion: doing more harm than good? JAMA 2013; 173(17): Cunningham C et al. A comparison of buprenoprhine induction strategies: patient-centered home-based inductions versus standard-ofcare office-based inductions. J Subst Abuse Treat 2011; 40(4): Cunningham C et al. Buprenorphine treatment in an urban community health center: what to expect. Fam Med 2008; 40(7): Donaher PA & C Welsh. Managing opioid addiction with buprenorphine. AFP 2006; 73: , Donroe JH, Holt SR & JM Tetrault. Caring for patients with opioid use disorder in the hospital. CMAJ 2016; 118(17-18): Fareed A et al. Effect of buprenorphine dose on treatment outcome. J Addictive Diseases; 31(1): Fiellin DA et al. Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. NEJM 2006; 355(4): Fiellin DA & PG O Connor. Office-based treatment of opioid-dependent patients. NEJM 2002; 347(11): Fiellin DA et al. Primary Care-based buprenorphine taper vs maintennace therapy for prescription opioid dependence. JAMA 2014; 174(12): Fudala PJ et al. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. NEJM; 349(10): Johnson RE et al. A comparison of levomethadyl acetate, buprenorphine, and methadone for opioid dependence. NEJM 2000; 343(18): Kakko J et al. One-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. Lancet 2003; 361:

59 REFERENCES Magura S et al. Buprenorphine and methadone maintenance in jail and post-release: a randomized clinical trial. Drug Alcohol Depend 2009; 99(1-3): Mayet S et al. Psychosocial treatment for opiate abuse and dependence. Cochrane McKnight-Eily LR et al. Vital signs: communication between health professionals and their patients about alcohol use 44 states and the District of Columbia, MMWR 2014; 63(1): Moore BA et al. Primary care office-based buprenorphine treatment: comparison of heroin and prescription opioid dependent patients. JGIM 2007; 22: Noska A et al. Managing opioid use disorder during and after acute hospitalization: a case-based review clarifying methadone regulation for acute care settings. J Addict Behav Ther Rehabil 2015; 4(2): Oliva EM et al. Trends in opioid agonist therapy in the Veterans Health Administration: is supply keeping up with demand? Am J Drug & Alcohol Abuse 2013; 39(2): SAMHSA. Behavioral Health Barometer: Idaho, HHS Publication No. SMA ID. Rockville,MD: SAMHSA, SAMHSA. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. USDHHS/SAMHSA SAMHSA. The SAMHSA evaluation of the impact of the DATA Waiver Program. SAMHSA Schuchkit MA. Treatment of opioid-use disorders. NEJM 2016; 375: Schwartz RP et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, AJPH 2013; 103: Scott KM et al. Association of mental disorders with subsequent chronic physical conditions: World Mental Health Survesy from 17 countries. JAMA Psychiatry 2016; 73(2): Smith PC et al. A single-question screening test for drug use in primary care. Arch Intern Med 2010; 170(13): Smith PC et al. Primary care validation of a single-question alcohol screening test. JGIM 2009; 24(7): Sordo et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ 2017; 357: j1550. Sullivan LE & DA Fiellin. Narrative review: buprenorphine for opioid-dependent patients in office practice. Ann Intern Med 2008; 148: Tsui JI et al. Association of opioid agonist therapy with lower incidence of hepatitis C virus infection in young adult injection drug users. JAMA 2014; 174(12): USDHHS, Office of the Surgeon General. Facing Addiction in America: The Surgeon General s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November Volkow ND, Koob GF & AT McLellan. Neurobiological advances from the brain disease model of addiction. NEJM 2016; 374: Wish ED et al. The emerging buprenorphine epidemic in the United States. J Addictive Diseases 2012; 31: 3-7. Yokell MA. Buprenorphine and buprenorphine/naloxone diversion, misuse, and illicit use: an international review. Curr Drug Abuse Rev 2011; 4(1):