Overview of Opioid Use Disorder

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1 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

2 Objectives History and epidemiology of opioid use disorders Why do people become addicted to opiates and why is it difficult to stop Overview of medication assisted treatment of opioid use disorders Questions

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4 TABLE Drug relationships for withdrawal Methadone, 1 mg, is equivalent to Codeine, 30 mg Dromoran, 1 mg Fentanyl, 0.01 mg Heroin, 1 2 mg Hydrocodone, 0.5 mg Hydromorphone, 0.5 mg Laudanum (opium tincture), 3 ml Levorphanol, 0.5 mg Meperidine, 20 mg Morphine, 3 4 mg Oxycodone, 1.5 mg Paregoric, 7 8 ml Textbook of Substance Abuse Treatment, 4 th ed. Galanter, M.D., Marc.

5 Opiate Use - A Brief History 1980s Mass opiophobia leading to reports of pain undertreatment 1898 Heroin synthesized as safer, non-addictive upgrade from morphine, mass distribution 1970 Controlled Substances Act categorized regulated drugs under 5 schedules 2000s JCAHO deems pain fifth vital sign, opioid prescribing further increased dramatic rise in opioid misuse, abuse, ED visits 3400 BC Opium poppy cultivated in Mesopotamia 1800s Morphine isolated from opium, widely used in Civil War 1916 Oxycodone synthesized as safer upgrade from heroin 1990s New extendedrelease opioids, expanded use 2010s abusedeterrent formulations, education and public awareness, drug monitoring programs TIME [

6 SOURCE: National Institute on Drug Abuse,

7 A Growing Problem Chronic pain is defined as pain beyond the usual aches and pains that lasts for at least 3 months 10 % of all Americans report pain lasting longer than one year (Centers for Disease Control and Prevention, NATIONAL Center for Health Statistics 2006) The use of Chronic Opioid Therapy has increased dramatically over the last 20 years Emphasis on pain control (Now considered a vital sign) Aggressive marketing Decreased time spent with patients Improved treatment outcomes Change in patient expectations Not enough prescriber education

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12 Missouri Prescribing Patterns?

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14 Non-Prescription Use of Opioids In a month, 4.3 million Americans use prescription painkillers nonmedically Last year, 1.9 million Americans met criteria for prescription opioid use disorder Average age of first use 21.2 Despite increase in opioid prescriptions, there has been no overall change in amount of pain reported by Americans.

15 Age at time of Opioid Abuse/Misuse

16 Overdose On the Rise The most common drugs involved in OD include Methadone Oxycodone (OxyContin) Hydrocodone (Vicodin) More people died from drug OD in 2014 than any year on record. More than 6/10 involved an opioid. From , 165,000 Americans died from overdoses related to prescription opioids Americans die every day from overdose of prescription painkillers

17 Rates of Hospital Inpatient and ED Visits for Opioid Overuse by Region

18 60,000 Causes of Death in America ,000 40,000 30,000 20,000 10,000 0 Drug Overdoses HIV/AIDS Car Crashes Gun Homicides Source: Centers for Disease Control

19 Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: Note: The percentages do not add to 100 percent due to rounding. 1 The Other category includes the sources "Wrote Fake Prescription," "Stole from Doctor's Office/Clinic/Hospital/Pharmacy," and "Some Other Way." Source: SAMHSA, 2011 National Survey Drug Use and Health

20 Heroin Use in the USA - Increasing 580 people initiate heroin use daily 2014 heroin OD deaths >10,500 (quadrupled from 2002) Mortality rate tripled since 2010, more than doubled among 18- to 25-yearolds Among new heroin users, approximately 75% report having abused prescription opioids prior to using heroin

21 Prescription Street Value - Roughly $1/mg - Large number of purchasers naive to illegal drug market so cost fluctuates So why do people move to heroin? - One study found availability is a large factor

22 DSM- 5 Criteria for Substance Use Disorder 2 or more of the following: Failure to fulfill obligations at work, home or school Recurrent use in hazardous situations Continued use despite recurrent social or interpersonal problems Tolerance Withdrawal Larger amounts/longer period than intended Persistent desire to cut back/quit Great deal of time using or recovering from use Social, occupational, recreational activities given up Continued use despite knowledge of physical, psychological consequences INTENSE CRAVING

23 Addictive Behavior = Survival Behavior Gone Awry (Courtesy of Steve LaRowe, PhD) Over the course of evolution, we have developed circuits in our brains that promote our survival. Drugs of addiction activate this survival circuitry to an exaggerated degree, and with chronic use, essentially take it over. In the late stages of addiction, an individual is basically a survivalist doing whatever it takes to acquire and use drugs regardless of the costs. Motivation has changed

24 Hijacking the Basic Survival Circuitry (Courtesy of Steve LaRowe, PhD)

25 Survival Circuits (Courtesy of Steve LaRowe, PhD) 1. Reward Circuitry -- LIKING 2. Memory Circuitry 3. Motivation, Drive Salience Circuitry CRAVING/WANTING 3. Orbital-Frontal Cortex 1. VTA 1. Nucleus Accumbens 2. Hippocampus 2. Amygdala

26 Opioid withdrawal Opioid Withdrawal Flushing Diarrhea Muscle cramps Flu-like sxs Nausea Agitation Hallucinations Stomach cramps Sleep problems Sweating STOP DRUG Days

27 Opioid Withdrawal Syndrome Protracted Symptoms Deep muscle aches and pains Insomnia, disturbed sleep Poor appetite Reduced libido, impotence, anorgasmia Depressed mood, anhedonia Drug craving and obsession

28 Environment Exposure Physical Illness Cognition Genes Traumatic Experiences Perceived Norms Substance Use Disorder Learned Coping Strategies Positive Effects Withdrawal Mental Illness Support Group Access to Treatment

29 Treatment of Opioid Use Disorder Prevention Education Patients and the public in general Physicians Monitoring Prescription Monitoring Programs Physician prescribing practices Access to appropriate Treatment for chronic pain Treatment Detoxification Limited efficacy- high relapse rates Treat co-morbid illnesses 12-step and community support groups

30 Medications for the treatment of withdrawal symptoms Symptom relief Autonomic excitability (jittery,restless)- clonidine Nausea/vomiting- perphenazine, ondansetron Diarrhea- Lomotil, loperamide Muscle cramps- cyclobenzaprine, methacarbamol Pain- NSAIDS Insomnia- trazodone, zolpidem

31 Medication Assisted Treatment (MAT) of Opioid Use Disorder Pharmacological Methadone: reduces mortality and morbidity, illicit drug use, criminal activity Suboxone (buprenorphine): more accessible, less potential for euphoric effects or overdose Naltrexone: perhaps better for patients with current employment, Sobriety as a contigency

32 Methadone Long acting opioid with limited euphoric effect Highly structured programs Ability to level up Dosing: mg/day Downsides: Limited access and flexibility Highly stigmatized Expensive and time consuming Can be associated with sedation, constipation and potentially dangerous interactions with other medications May be most appropriate for those with more severe opioid use disorders- highly structured treatment

33 Methadone regulations Regulated by Substance Abuse and Mental Health Services Administration (SAMHSA) and state agency Only provided in opiate treatment programs One year history of dependence and current use 18 and older, if younger must have failed 2 non opiate treatments in the prior 12 months and guardian consent Daily dosing, limited take home if doing well in the program Take home dose increases with successful time in clinic, up to 2 week supply after a year and a maximum of a month supply after 2 years Psychosocial treatments

34 Buprenorphine/naloxone (Suboxone) Regulation: Drug Addiction Treatment Act, (DATA 2000) allowing qualified physicians to prescribe Schedule III, IV, and V medications for the treatment of opioid addiction. MDs can receive training and obtain special permission from the DEA to prescribe this Makes opiate dependence treatment more accessible Required to refer to substance abuse treatment

35 Suboxone Partial activation of opioid receptor sites Prevents withdrawal and cravings Ceiling effect makes them safer in terms of overdose Opioids are unable to produce effect/euphoria Suboxone also contains naloxone Opioid receptor blocker Not absorbed sublingually Prevents injection

36 Partial vs. Full Opioid Agonist death Opiate Effect Full Agonist (e.g., methadone) Partial Agonist (e.g. buprenorphine) Dose of Opiate Antagonist (e.g. Naloxone)

37 Suboxone Dosing: 8 16 mg/day, ceiling of 24-32mg/day Most common side effects Constipation, sweating Usually not much sedative effect Potentially dangerous in patients with severe liver disease, uncontrolled alcohol use and use of other sedating medications

38 Buprenorphine/naloxone Three Stages of treatment: Induction: 2-3 day period of observed administration must be in mild to moderate opiate withdrawal Can be done in the hospital or in community setting Stabilization: Meeting weekly to monitor SE and cravings adjust dose to curb cravings and minimize withdrawal Maintenance: achieved sobriety stable dose

39 Rough Graph of Suboxone Induction Opiates Suboxone 20 0 Pre-Treatment Day 1 Day 2 Category 4

40 Naltrexone How it works: blocks opioids from binding to their receptors No effect from opiates Decreased cravings Patients have to be free from opioids for several days prior to starting this medication Can cause nausea, headaches and rare cases of liver damage. Prescription opiates will not work for pain control Available as a long acting injection (Vivitrol) Useful in individuals whose livelihood is contingent on sobriety

41 Duration of Treatment Substance use disorders are chronic diseases Genetics, life experiences, coping strategies, long term exposure to substances and other factors all contribute to the development of the condition. Not substituting one drug for another Decision to taper or stop is based on clinical picture and personal choices about treatment Like any other treatment, it is based on analysis of risk v. benefits

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43 What treatment looks like html

44 Questions?

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