MGH Inpatient Addictions Consult Team Management of Opioid Use Disorder

Transcription

1 MGH Inpatient Addictions Consult Team Management of Opioid Use Disorder Christopher Shaw RN, ANP, PMHNP, CARN AP Nursing Director, MGH, SUDS Initiative Addictions Consult Team Leader

2 Objectives Understand substance use disorder as a chronic illness and describe effective treatment for Opioid use disorder Review of MGH response to current OUD Pharmacotherapy for opioid use disorder (OUD) Full Opioid Agonist Methadone, Partial Agonist Buprenorphine, Full Opioid Antagonist Naltrexone Considerations of Pain management with (OUD) By participating in this presentation clinicians will have increased awareness of issues related overdoses, management of withdrawal and complications and lack of access to evidence based treatment Case Examples

3 MGH SUDs Initiative Mission To improve the quality, clinical outcomes and value of addiction treatment for all MGH patients with SUD. To accomplish this mission, patients must have access to evidence based treatment that is readily available and standardized across the system.

4 Drug overdoses now leading cause of death for Americans under 50

5 National Opioid-Related Inpatient Hospitalizations and ED Visits

6 Natural History of Opioid Use Disorder Using to feel good Needing to use more to feel normal Using to keep from getting sick

7 When you can stop you don't want to, and when you want to stop, you can't. Luke Davies, Candy

8 A Disease of Gene Environment Development Onset depends on many intrinsic and extrinsic factors Biology Genes/Development Environment DRUG/ALCOHOL Brain Mechanisms Addiction Slide courtesy of Dr. Compton, NIDA hcme.org

9 Addiction Primary, chronic brain disease characterized by compulsive drug seeking and use despite harmful consequences Involves cycles of recurrence and remission 40-60% genetic American Society of Addiction Medicine. April 12, NIDA. August,

10 Neurobiology of Addiction Neurophysiologic processes underlie the uncontrolled, compulsive behaviors defining the addicted state. These hard-wired changes in the brain are considered critical for the transition from casual to addictive drug use

11 Major Brain Regions with Roles in Addiction

12 The Neurobiology of Opioid Addiction Involves Brain Pathways (mesolimbic) and Neurotransmitters (dopamine) Priming first use Drug Cues -people, places, things Craving Stress Tolerance to Euphoric effects from chronic use Dysphoria Post Use

13 Defining Chronic Illness Long in duration often with protracted clinical course Associated with persistent and recurring health problems Multi factorial in etiology, often heritable No definite cure Requires ongoing medical care Goodman RA, et al. Prev Chronic Dis 2013;10: Martic CM. Can Fam Physician Dec; 53(12): hcme.org

14 A Treatable Disease NIDA. Principles of Drug Addiction Treatment McLellan et al., JAMA, 284: , 2000.

15 SUD Meets Criteria for Chronic Illness Common features with other chronic illnesses: Heritability Influenced by environment and behavior Responds to appropriate treatment Without adequate treatment can be progressive and result in substantial morbidity & mortality Has a biological/physiological basis, is ongoing and long term, can involve recurrences long term lifestyle modification practice/definition of addiction hcme.org

16 Similar to Management of Diabetes No cure Goal is prevention of acute and chronic complications Individualized treatment plans and targets Treatment includes: Medication Lifestyle changes Regular monitoring for complications Behavioral support

17 What is Effective Treatment? Pharmacothera py Recovery Supports Psychosocia l Intervention s

18 Volkow et al. J. Neurosci., December 1, 2001, 21(23): Visualizing Recovery

19 Initial State Limited benefit from current treatment models High acuity, med + psych + substance dx Limited success in treatment outcome Lack of integrated treatment options, limited evidence based care Significant social needs unmet (social determinants of health) Care is poorly coordinated, short term focus, in silos with limited communication Challenge: How can current models be modified to address needs and break the cycle? 19

20 Medications for Addiction Treatment Work

21 Common blood-borne virus Hepatitis C (HCV) Leading cause of chronic liver disease Globally, 10 million PWID High prevalence, combined w/high infectivity of HCV, presents > challenges to prevention. 10 times more infectious than HIV: 3% 10% chance per injection compared to 0.3% for HIV Receptive Needle Sharing Partners can be at greatest risk. 20 to 30% of persons who inject drugs are infected with HCV w/in 2 years of starting use

22 HCV in USA Deaths related to HCV now exceed deaths related to HIV in the United States, and co-infected patients bear a significant proportion of that mortality. In the US estimated million individuals living with chronic HCV infection. Up to 25% of approximately 1.2 million people infected with HIV-1 in the United States also have HCV J Infect Dis Mar 15; 207(Suppl 1): S1 S6.

23 Acute infections: IV drug use (IDU) Localized and systemic infectionsaccount for 60% of hospital admissions for IDUs (Wilson et al., 2002) Treatment of infections requires antimicrobial therapy and addressing complex social issues (Sulis,2009) Increased risk of infection by unsterile practices injecting drugs via or contaminated drugs (Weaver, 2010) Education, prevention, harm reduction

24 Skin/Soft Tissue Infections

25 Endocarditis Responsible for 5% to 20% of hospital admissions among IDUs 5% to 10% of the overall death rate among IDUs (Miro et al., 2003) Staphylococcus aureus, including methicillinresistant S.aureus, common causative organism in 60% to 70% of cases Requires long-term IV antibiotic therapy Peripherally inserted central catheter (PICC) for antibiotic administration complicates discharge

26 Treatment Issues Safety risk of discharging home with a PICC Discharging patient on oral antibiotics is ineffective management Prolonged hospitalization Lack of appropriate treatment facilities available Behavioral difficulties Require collaborative integration: Managing withdrawal

27 Death rates 15 times >for PWID - due to multiple factors. Sharing or reusing syringes Using unsterile diluents such as tap water, using saliva to mix drugs, soda Sharing or reusing cookers, cotton, filters Lack of skin cleaning before injecting, failure to rotate injection sites Contaminants and filler agents in crushed prescription opioids Subcutaneous injection is a risk for abscesses and cellulitis (Binswanger, 2000) Repeatedly flush syringes back and forth to ensure complete emptying (Gordon and Lowy, 2005)

28 Case Study Antonio 33 year old man admitted with septic emboli to lungs, liver, spleen, has heart valve vegetation, ICU stay for 12 days Responds to medical interventions and his story emerges-

29 Psychosocial History Lives with wife and 2 young children in a neighborhood of Boston Works as an artist and does well supporting family, he has strong extended family support

30 Substance Use History Prescribed oxycodone for sports injury in senior year of HS continued use on his own 1 st introduced to Heroin on honeymoon insufflated and went on to use IV heroin (recreationally) IV heroin daily for ten years and hiding it from everyone but his wife Is AMAZED that he is drug free for nearly 2 wk.

31 Hospital Course and Beyond DX w/endocarditis needs 6 to 8 wks IV antibiotics Went to State Hospital to complete course of IV antibiotics, (6 to 8 weeks commonly) Worsening symptoms similar to CHF, indicating found to have worsening valve disease Transferred back to MGH for emergent repair of valve, which is successful Antonio goes home with family to complete IV antibiotic treatment He declines opioid medications for pain management post surgery. He declines medications for treatment of addiction

32 Pharmacotherapy for Opioid Use Disorder: Evidence-Based For Opiate Use Disorder: 3 FDA approved meds include opioid agonist(methadone), partial agonist (buprenorphine) opioid antagonist (naltrexone). > 1.5 million with OUD = 80 percent in America do not receive treatment. Evidence based medications should be accessible to patients

33 Pharmacology of Treatments Antagonist (naltrexone)

34 Goal of Medications for Addiction Treatment Relieve withdrawal symptoms Block effects of other opioids Reduce cravings Restore normal reward pathway

35 Detoxification versus Maintenance Pharmacological management: tapering with methadone or buprenorphine sudden opioid cessation and use of alpha 2 adrenergic agonists to relieve symptoms Most patients resume opioid use after detoxification Detoxification alone should not be promoted as effective treatment

36 Details of Treatment Agonist treatment consists of daily methadone or buprenorphine Stable level of opioid effect is experienced as neither intoxication nor withdrawal, but as normal Requires waivered prescriber or opioid treatment program The aims of agonist maintenance treatment include: reduction or cessation of illicit opioids and associated risks improvement in psychological and physical health Antagonist treatment consists of once monthly injection Any Licensed prescriber can prescribe naltrexone

37 Goals of Therapy Maximal function Stabilization and normalization of the brain Establishment of durable hedonic tone Engagement in care and recovery Prevention of disease transmission Restoration of health Prevention of death In illness or injury alleviate suffering Achieve appropriate dosage NOT to see how fast a patient can taper off medication

38 Methadone Long acting, full opioid agonist Binds to and occupies mu opioid receptors Prevents euphoria from other mu agonists Alleviates withdrawal symptoms Administered in licensed OTP

39 Methadone Federal law: initial dose mg, not to exceed 40 mg in day 1 Suppresses cravings (60 120mg+) Can prolong QTc with risk of Torsades de Pointes Respiratory depression can be a side effect at any dose Increases overdose risk significantly if mixed with sedative hypnotics and ETOH

40 Methadone Myths Substitutes one addiction for another Prevents true recovery Should not be used long term Liquid Handcuffs Babies born to mothers treated with Methadone are addicted Rots teeth Damages bones Turns people into zombies Causes overdoses

41 Methadone Facts Opioid Agonist Therapy: Medication, or Treatment preferred Reduces drug use Reduces the risk of infectious disease transmission Reduces criminal activity Reduces the risk of overdose Reduces death Increases treatment retention Improves social functioning Cost effective Safe

42 To Taper or to Maintain, That is the Question No question, actually.. Longer treatment, better outcomes Consistent with chronic disease model Think DM, CAD, COPD As with any medication no set limit Minimum of 12 months, but better outcomes with longer durations Continually reassessed and individualized

43 Treatment Must Maintained

44 Hospitals Have Opportunity to Initiate Treatment Initiating methadone in hospital: 82% present for follow-up addiction care Buprenorphine vs. detox among inpatients: Bupe: 72.2% enter into treatment after discharge Detox : 11.9% enter treatment after discharge Buprenorphine vs. referral in ED: Bupe: 78% engaged in treatment at 30 days Referral: 37% engaged in treatment at 30 days J Gen Intern Med. Aug 2010; 25(8): ; JAMA Intern Med 2014 Aug;174(8): ; D'Onofrio et al. JAMA 2015 Apr 28;313(16):

45 Treatment in the ER is effective Opioid dependent patients often use ER for care Yale study of 329 patients randomized to ER initated Buprenorphine treatment, or Referral to service or Brief Intervention 78% who engaged in buprenorphine treatment vs 37% referred and 45 % BI Fewer days of self reported opioid use D'Onofrio et al. JAMA 2015 Apr 28;313(16):

46 Buprenorphine Partial opioid agonist. Occupies opioid receptors (and displaces other agonists due to higher affinity so can induce withdrawal), Less intense due to ceiling effect Sublingually due to poor GI bioavailability. Combined with naloxone in sublingual tabs to reduce potential for IV misuse (naloxone has poor sublingual bioavailability but good parenteral bioavailability). Waivered physicians/nps/pas may prescribe outpatient. Patient limits apply. May be prescribed by nonwaivered physicians for acute inpatient withdrawal (Noska, 2015)

47 Buprenorphine If given prior to s/s withdrawal USE COWS to initiate as it precipitated withdrawal occurs Pregnancy/postpartum considerations: Category C. available evidence does not show any causal adverse effects on pregnancy or neonatal outcomes from buprenorphine treatment. Neonatal Abstinence Less intense than methadone associated NAS). Like methadone, buprenorphine largely accepted as preferable to active drug use (better self care/prenatal care) Advantage over methadone(no need for daily clinic dosing). If methadone treatment unavailable or refused, buprenorphine should be considered. Due to risk for fetal and maternal withdrawal effects, non-naloxone buprenorphine recommended. Low levels available in breastmilk.

48 Buprenorphine Initiation Must be in mild to moderate withdrawal before taking initial dose This can be done in office or at home Many patients have taken buprenorphine before patients can be our guide hcme.org

49 How Long Should Treatment Last? Long term or even throughout life. Aim of treatment not only to reduce or stop opioid use, but to improve health and social functioning, and to help patients avoid some of the more serious consequences of drug use. Long term treatment is common for many medical conditions, it should not be seen as treatment failure, but rather as a cost effective way of prolonging life and improving quality of life, Supports natural and long term process of change. World Health Organization /1/ _eng.pdf

50 Which Patients are Likely Better for Longer history of use Agonist Therapy? Patients with history of overdoses, particularly following detoxification Patients with serious mental illness, disorganized, homeless Patients who have been opioid free but never felt normal Patients with chronic pain requiring chronic opioid treatment

51 Rate per 1000 person years Deaths Increase When Medication Stopped Overdose Mortality InTreatment Out of Treatment Overdose Mortality N= people treated with buprenorphine over years (Sordo BMJ Apr 26;357:j1550.)

52 Naltrexone Full mu opioid antagonist Blocks euphoric effect of mu opioid agonists No dependence, no need to wean Not scheduled no special training or license needed Reduces relapse rates hcme.org

53 Naltrexone Will precipitate withdrawal if agonists (full or partial) are occupying mu receptors Must be 7 10 days opioid free Increased risk of overdose if try to overcome blockade Increased risk of overdose end of month or missed dose because of loss of tolerance Monthly IM dosing improves adherence, Oral naltrexone ineffective Substantially less stigma hcme.org

54 Naltrexone Side Effects Generally well tolerated GI upset/vomiting Diarrhea Headache Injection site reactions Allergic pneumonitis hcme.org

55 Naltrexone Caution opioid blockade and pain Contraindication if active opioid use or concurrent opioid maintenance Caution overdose potential Must review with patients, must inform of risk of overdose and set safety plan hcme.org

56 Head to Head Comparison: buprenorphine vs XR naltrexone Buprenorphine XR naltrexone post/suboxone vs vivitrol head head comparison/ Lee JD et al. The Lancet Nov 14. pii: S (17)32812 X

57 Pain Management Goals of pain treatment for pts on MAT remain the same as other pts!-control pain and improve function. Reassure that Maintenance doses will be given and pain will be managed aggressively Utilize concurrent nonpharmacological and non-opioid therapies. Treat comorbidities (mental health).

58 Maintenance = Analgesia Patients who are physically dependent on opioids (i.e. methadone or buprenorphine) must be maintained on daily equivalence before ANY analgesic effect is realized with opioids used to treat acute pain Opioid analgesic requirements are often higher due to increased pain sensitivity and opioid cross tolerance Peng PW, Tumber PS, Gourlay D: Can J Anaesthesia 2005 Alford DP, Compton P, Samet JH. Ann Intern Med

59 Decreased Pain Threshold In experimental pain studies Patients with active opioid use disorder have less pain tolerance than peers in remission or matched controls Patients with a h/o opioid use disorder have less pain tolerance than siblings without an addiction history Patients on opioid maintenance treatment (i.e. methadone, buprenorphine) have less pain tolerance then matched controls Methadone maintained women had increased pain and required up to 70% more oxycodone equivalents after cesarean delivery Alford D, PCSS. Managing Acute & Chronic Pain with Opioid Analgesics in Patients on Medication Assisted Treatment, December hcme.org

60 Under treated Pain and Addiction Increases patient anxiety and mistrust of medical community Increases aberrant behavior Increases risk of relapse or ongoing harmful drug use and its consequences Infections, overdose, leaving AMA Does not prevent or treat addiction hcme.org

61 Acute Pain Management for Patients on Methadone Maintenance Continue maintenance dose Treat with short acting opioids Methadone maintenance dosed every 24 hours will not provide analgesia beyond 6 8 hours Opioid analgesics will not cause excessive CNS or respiratory depression due to opioid cross tolerance Risk of relapse to active drug use may be higher with inadequate pain management than with the use of opioid analgesics Alford DP, Compton P, Samet JH. Ann Intern Med hcme.org

62 Acute Pain Management for Patients on Buprenorphine Maintenance Options: 1. Continue buprenorphine and titrate short acting opioid analgesic 2. D/C buprenorphine, use opioid analgesic, then re induce 3. Divide buprenorphine to every 6 8 hours 4. Use supplemental doses of buprenorphine 5. If inpatient: d/c buprenorphine start methadone 20 40mg (or other extended release, long acting opioid) use short acting, immediate release opioid analgesics then re induce w/ buprenorphine when acute pain resolves Alford DP. Handbook of Office Based Buprenorphine Treatment of Opioid Dependence Alford DP, Compton P, Samet JH. Ann Intern Med 2006 Book SW, Myrick H, Malcolm R, Strain EC. Am J Psychiatry

63 Opioid Agonists with Buprenorphine? Theoretical concern: Buprenorphine (a partial mu agonist) may antagonize the effects of previously administered opioids or block the effects of subsequent administered opioids However experimental mouse and rat pain models Combination of buprenorphine and full opioid agonists (morphine, oxycodone, hydromorphone, fentanyl) resulted in additive or synergistic effects Receptor occupancy by buprenorphine does not appear to cause impairment of mu opioid receptor accessibility Slide courtesy Dan Alford, MD Kogel B, et al. European J of Pain Englberger W et al. European J of Pharm

64 Chronic Pain and Addiction Management with Buprenorphine Maintenance Mechanism of Action? Reversal of opioid induced hyperalgesia or tolerance from high dose opioids? Does treatment of OUD lead to better pain relief? Sublingual formulation approved for addiction not pain treatment Can be used off label Parenteral and transdermal formulations approved for pain not addiction treatment Can not be used off label under Drug Addiction Treatment Act of 2000 Opioid induced abnormal pain sensitivity: implications in clinical opioid therapy. Mao J. Pain Dec; 100(3): Alford D, PCSS

65 What About Surgery? Discontinuing buprenorphine/naloxone in anticipation of surgery Risks relapse by stopping buprenorphine during high anxiety preoperative period Has never been evaluated and is based on a theoretical concern of pharmacological principles

66 Acute Pain Buprenorphine Maintenance Treatment Accumulating Research Retrospective cohort of 1 st 24 hours after surgery in 11 BM and 22 MM patients on patient controlled analgesia (PCA) No significant differences in pain scores, incidence of nausea, vomiting or sedation No significant differences in PCA morphine requirements Slide courtesy of Dan Alford, MD Macintyre PE et al. Anaesth Intensive Care 2013

67 What happened to Antonio? He kept in contact with our staff during his home convalescence and came to cardiology, surgery and infectious disease outpatient appointments. He reported these were the best days of his life as he felt that he could finally be the best father he could possibly be to his two young daughters and he felt totally at peace with his extended family Unfortunately Antonio died a few weeks into treatment from a pulmonary embolism.

68 Developing a True Continuum of Care Recovery Coaches Inpatient (ACT) Bridge Clinic Outpatient Community Prevention, Education & Evaluation

69 Nurses Facilitate Immediate Access, linkages to Care & Treatment Engagement Emergency Department Inpatient (ACT) Bridge Clinic Inpatient Nursing Care Outpatient Evaluation, Immediate Treatment, Engagement

70 An Example of a Health System Response Inpatient Addiction Consult Team Outpatient Addiction Champion Teams The MGH Substance Use Disorder Initiative Urgent Bridge Clinic Recovery Coaches

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73 Advanced Practice Role in Prescribing Apply/train for your buprenorphine waiver on.pdf Consider specialty certificationhttp://

74 References Massachusetts General Hospital, (2016). Professional Learning Needs Assessment for Nurses. Norman Knight Center for Clinical and Professional Development. National Institute on Drug Abuse. Trends & Statistics Retrieved from on November 9, 2015 Rauen, C., Shumate, P., & Gendron-Trainer, N. (2016). Certification test prep" Gaining trust through certification. Critical Care Nurse, 36(6), Retrieved February 21, 2017, from Substance Abuse and Mental Health Services Administration (SAMHSA). (October 2014). Health care and health systems integration. Retrieved from Substance Abuse and Mental Health Services Administration (SAMHSA). (September, 2015). SAMSA behavioral health trends in the United States: Results from the 2014 national survey on drug use and health. Retrieved from Watson, H., Maclaren, W., & Kerr, S. (2007). Staff attitudes towards working with drug users: Development of the Drug Problems Perceptions Questionnaire. Addiction, 102(2),