8/14/2017. Practical Approach to Office Based Addiction Treatment. Objectives. Foundation For Success Treating SUD
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1 Practical Approach to Office Based Addiction Treatment ELIZABETH A DAVIS, MD SOUTH END COMMUNITY HEALTH CENTER BOSTON, MA AUGUST 17, 2017 Objectives To understand Impact of addiction as a public health emergency Best practices for treating substance use disorders (SUD) Individualization of goals of treatment Role of MAT among patients with SUD and chronic pain Appropriate choices for MAT Impact of SUD on co-morbid illness To recognize the necessary components of managing patients with SUD Inventory of steps to consider Foundation For Success Treating SUD Requires flexibility and transparency from the team Structure and ground rules to manage chaos are a guide Expect patients to deceive, but hold them to higher standard Relapsing remitting disease Modulate expectations - cure is not the goal Rely on team-based care, never worry alone Expect the support of colleagues and fellow staff Education of staff necessary to reduce stigma Learn from your patients who best declare their needs 1
2 Not Addressed Detailed management of chronic pain Properties of specific opioids DSM definitions of abuse and dependence Screening tools (CAGE, DAST, PHQ2/9) Specific cases not covered in depth Perioperative pain management Pregnancy Methadone maintenance Overdose management Drug-drug interactions Epidemic 2010 opioid OD plateaued/decreased while heroin OD increased Beginning of physicians limiting prescriptions Mortality trend 72:28 male : female Contaminants vary by location Patients often unaware they are taking fentanyl HCV Bimodal Trend 20/30 year-olds Baby boomers Opioid Deaths
3 Massachusetts Data 1999 to 2013 opioid Rx quadrupled nationwide % increase in OD-related deaths in MA Largest increase of any other state 1724 deaths in 2015,?deaths in 2016, anticipated Fentanyl counterfeiting since 2013, highest MA, NH, OH, PA Opioid-related overdose deaths 2016 (n=1933), 17% increase over confirmed cases in 2015 and 42% increase over deaths Jan-Mar 2017 (38% confirmed), decrease from 2016 Q1 Who Should Be Treated? Paradigm Shift for individuals with SUD From: readiness for change To: harm reduction treat first (inpatient or outpatient) Chronic Pain Those with dependence but not abuse Whose pain is incompletely covered by escalating doses of opioids Who have h/o SUD Those whose behaviors are currently suggestive of SUD Those with co-morbid psychiatric and complex social problems Recommendation often perceived as pejorative Recognition that chronic pain is a unique entity Requires intensive support that a program can provide Why Opiates Best Option Repeated use impose brain changes that transcend mind over matter Drivers of Cravings and Compulsive Behavior: Signals delivered both via a chemical (neurotransmitters) and an electrical system Both systems operate like a thermostat with changing set points Response to opiates rewires neurotransmitter systems long-term 3
4 Basis for Replacing Opiates with Opiates Brainstem (Fight or Flight) Opiates put breaks on arousal When deprived of opiates, hyperarousal ensues (irritability, dilated pupils, piloerection, etc) Midbrain Reward center (eating, sex, learning) hijacked by opiates (make all else mundane) Prefrontal Cortex (excitatory system, planning) Excitatory system, sends messages from external cues that stimulate deeper structures Memory involved, drives cravings and compulsions Dysphoria may occur simultaneously because of paradoxical effect in the brainstem Tolerance vs Dependence vs Abuse Tolerance Dose increase required to achieve same effect Dependence Need to keep taking drug to avoid withdrawal Resolves following detox within days to weeks of last use Addiction Intense craving and compulsive use Negative impact on relationships, work, basic functions Driven by environmental factors, genetics, psychological conditioning Team Structure RN as team leader is a successful model MA is optional but beneficial for larger programs Prescriber: MD or NP PCP or in Behavioral Health Case Manager/Navigator Facing inward and outward Point of Care Testing in community for STIs Therapist Group Leaders, any member of the team Peer Counselors Pharmacist (specialty), designated pharmacy 4
5 If There is No Team Lone provider needs: Preparation to manage intense behavior Flexibility to face challenges, Meeting patients where they are in their recovery Backup coverage for prescriber The more supports available, the broader the capacity to care for more complex patients RN and Prescriber the minimum Outside Collaborators PCP Groups, Counselors Case Managers Components of Treatment Initial Assessment Referral must come form PCP RN reviews contracts and treatment expectations, overdose training Determines role for MAT Psychological evaluation Induction - provider, RN Usually on the third visit Determine need to quick start if high risk Monitoring RN and Provider Tier assignment Overdose training Counseling and Groups Discharge team decision Staff Education and Reducing Bias Staff Education Overdose prevention and narcan use Sensitivity and de-escalation Consultant trainings of core staff and clinic-wide techniques in motivational interviewing Nationwide webinars related to SUD for additional protocol and case-specific support 5
6 Initial Assessment Post-referral Detailed substance use, social, and legal history What, when, how Understanding triggers, settings of use Resources available to patient Psychological assessment Medical History, need for HCV/HIV treatment, Diabetes Risk assessment (risk score) PMP Communication with Parole Officer or other collaterals Labs: Hep A,B,C, HIV, RPR, STI, CMP, CBC, HCG, Utox Separate evaluation with Behavioral Health provider Necessity for individual therapy Determine if (not) candidate for Group therapy Contracts (Visit 1 or 2) Program expectations Expectations for MAT Pharmacy Release of Information Parental Consent Translation into other languages Birth control plan for women Individual and Group Therapy Studies are limited but suggest better retention and fewer relapses Groups vary in terms of size, characteristics, objectives Substance specific Gender specific Co-morbid psychiatric problems Behavioral, skill-based, supportive Process group Ongoing vs self-limited program with homework Individual therapy Motivational interviewing Behavioral therapy (CBT/DBT) Trauma specific therapy Psychotherapy 6
7 Medication Assisted Therapies Choice of medication Suboxone, Naltrexone (opioids) Naltrexone, disulfram, acamprosate (EtOH) Tier assignment to determine frequency of visits Daily (Methadone) Weekly (Suboxone) Monthly (Naltrexone/Vivitrol) Prevents relapse and improves retention Induction Buprenorphine COWS >6-12, 2-4 mg Initiation of Naltrexone COWS > 6-12, 25 mg Methadone Long-acting opiate agonist Causes dependence but less likely tolerance (i.e. consistent dose adequate) Prescribed in licensed facilities, often privately owned Advantages May be preferable for heavy users Complete agonist effect at therapeutic doses with less euphoria Screening and counseling built in, good for resource poor areas Disadvantages Significant risk for sedation and overdose Daily visits standing in line, setting rife with high risk behavior Prolonged QTc risk Sexual dysfunction like any opiate Single daily dose not ideal for chronic pain Buprenorphine Buprenorphine partial agonist Shares properties of both Methadone (agonist) and Naltrexone (antagonist) Fewer side effects than Methadone, most notably less respiratory depression Naloxone (opiate blocker) added to minimize high if injected Pre-induction, use comfort meds: Clonidine, tizanidine, flexeril, bentyl, zofran, immodium, anxiolytics Tab vs film, usually film unless insurance dictates tabs Dose determination, range from 8-24 mg daily 8 mg therapeutic, 16 mg average (often best 1-3 g IV daily use) Advantages Flexibility and privacy Can use with acamprosate and disulfram Significant mood improvement for individuals with difficult-to-treat MDD 7
8 Case 1 45 year old woman with chronic back and knee pain and remote history of polysubstance abuse Multiple trials of non-opiate and opiate medications Suboxone initiated 8 mg strips bid Pain continues and patient not completely satisfied What Would You Do? Trial of splitting strips 1 strip in the am and ½ strip divided throughout the day Patient says pain is improved somewhat but starts running out of script a day early Increase dose with agreement this is the limit 1 strip tid Transitioning from Methadone to Buprenorphine Tapering Methadone may require months, dose decreases usually 5-10 mg weekly Coordinate with Methadone clinic Rate may depend on prior experience with withdrawal Or, taper methadone dose to the point of patient discomfort; with objective withdrawal symptom documentation via COWS Target mg daily for one to two weeks prior to transition Begin Buprenorphine at least hours after last methadone dose using COWS score as a guide Anticipate unexpected changes to plan based on patient s symptoms 8
9 Naltrexone, Vivitrol Naltrexone / Vivitrol (Not Naloxone which is Narcan) Opiate receptor blocker (Naloxone pushes opiates off the receptors) Greater affinity for receptors than opiates Reduces pleasure response to opiates and reduces cravings for EtOH Advantages Promotes independence, may be preferred by employed individuals Concomitant EtOH and opiate abuse Used in correctional facilities in preparation for discharge Easier to use in settings with less support Disadvantages Cannot use with Buprenorphine May not be as successful in sustaining sobriety Vivitrol wears off as month progresses Contraindications Naltrexone Hepatitis, transaminitis > 5 x normal Significant renal failure Chronic pain, opiate dependent Significant psychiatric illness, +SI Hypersensitivity to naltrexone or diluent Pregnancy, breast feeding Bleeding diathesis and morbid obesity preclude use of IM formulation Initiation Naltrexone Naltrexone induction [in clinic] Negative Naltrexone Challenge No signs of withdrawal after min of ingesting 25 mg PO or mg IM Positive Challenge Early symptoms of anxiety and increased HR Subsides after 4-6 hours Initiate with oral formulation to mitigate allergic reactions, side-effects and adverse reactions. Vivitrol may be started after 1-2 wk trial 50 mg PO 9
10 Transition from Buprenorphine to Naltrexone Reduce buprenorphine dose to 2 mg daily Reduction should be gradual over course of a week or month Maintain this dose for 1 week 5-7 days after final dose, oral naltrexone induction in clinic In case of discontinuing Naltrexone there is no withdrawal phenomenon Monitoring Frequency based on tier assignment, weekly typical COWS Scheduled vs random screening Testing tailored to high risk behaviors (i.e. STI) Opportunity to review OD education, provide Narcan Safe prescribing PMP prior to prescribing Use one pharmacy, exceptions arise Fax prescriptions after patient seen Current Opioid Misuse Measure (COMM) Screening Tools Urine screen Frequency based on Tier, tool for engagement Stand outside bathroom, no flushing or hand washing Point of care (immediate, less sensitive) vs lab False positives due to cross reactivity Additional medications of concern tested separately (i.e. gabapentin) Oral Swabs test, point of care Presence of Suboxone (film), suspect diversion or abusing opiates No eating or drinking within 30 min of test Adequate saliva Pill/strip Counts another tool if inconsistencies arise EtOH breath tests available 10
11 Aberrant Behaviors Red Flags Over sedation during visits Non-adherence to monitoring Lost/stolen scripts Running out early Suspect selling prescription Evident by clean urines that are: Absence of prescribed drug or Inappropriate metabolites Grounds for Discharge Diversion More than three positive urines Tampering with urine samples Lack of engagement, missed appointments Behavioral problems Must offer referral to another program including higher level of care Detox, Dual Diagnosis, IOP, Partial Hospitalization, Half-Way House, Sober House Increasing Treatment Intensity Discharge may not be in best interest of patient Concomitant EtOH and opiate dependence on Naltrexone May continue to drink but at high risk for OD Fentanyl (and carfentanyl) contamination See treatment with buprenorphine as reducing harm Continue to engage patient Active psychiatric illness (i.e. mania, psychosis) Patients may be more difficult to engage 11
12 Tapering off Buprenorphine Withdrawal peaks between 3 and 5 days, ends days Lacrimation, rhinorrhea, tremors, chills, gooseflesh Restless leg, insomnia, anxiety, abdominal distress. Protracted abstinence syndrome (anxiety, insomnia, depression) Buprenorphine should be tapered over days, weeks, or months, depending on patient tolerance of symptoms Perioperative Pain Management Goals for managing perioperative pain Maintain baseline opiate requirements Avoid withdrawal and associated pain sensitivity Higher doses and scheduled frequency may be required due to decreased pain tolerance and cross-tolerance to opioid analgesics Case 2 60 year old with history of opiate abuse managed with Suboxone 8 mg bid scheduled for knee replacement 12
13 Option for Perioperative Pain Management Last dose Suboxone the morning of procedure Single dose MS Contin 15 mg on the day of procedure MS Contin 15 mg bid and short acting for breakthrough x 1 week until seen by Suboxone prescriber Methadone 30 mg another option to manage baseline opiate needs and short acting opiates for pain management Perioperative Pain Management Vivitrol If reversal required, anesthesia should be involved If possible, use regional analgesia or use of non-opioid analgesics Other Considerations Clinic policies and protocols Work flow for Prescriber and RN visits MA availability Dedicated RN Polysubstance Abuse and Marijuana Billing Point of care testing Groups if led by MD, DO, NP, licensed therapist, psychologist 13
14 Handouts Protocol SUPPORT Wellness SUPPORT Wellness Agreement Part 1 (Buprenorphine) SUPPORT Wellness Agreement Part 2 (Vivitrol) Vivitrol Medication Initiation Protocol Link to Home Induction Visit Checklist SUPPORT Wellness OBOT Quick Induction Link to Current Opiate Misuse Measure 14
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