Medication-Assisted Treatment: The Public Health Imperative

Transcription

1 Medication-Assisted Treatment: The Public Health Imperative Presentation for DSAMH Fall Conference September, 2015 Shannon M. Terwedo, M.P.A., FACHE

2 Overview of the Problem of Opioid Use Disorder: The Data

3 Opioid Rx s Dispensed by US Retail Pharmacies

4 Growing Trend Switching from Rx Opioids to Heroin 2

5 National Institute of Drug Abuse 3

6 National Institute on Drug Abuse 4

7 Opioid and SUD in Utah -Utah spent $237,756,799 on health care related costs of opioid abuse, that s $81.00/per capita (2014 estimate) 5-135,450 adults 18+ in need of SUD Treatment -14,726 adults 18+ served or about 11% 6

8 Opioid Abuse in Utah -Opioids are the 2 nd most abused drug, about 24% of SUD admissions 7 -IV Injection Drug Use is 23.3% at Admission -Utah averages about 33 deaths/month due to opioid overdose Shannon M. Terwedo, M.P.A., FACHE, progen9220@gmail.com

9 Addressing the Problem: Medication-Assisted Treatment

10 Opioid Addiction: A Chronic Disease ASAM Definition: Chronic relapsing brain disease characterized by compulsive drug seeking behavior and drug use despite harmful consequence. 9

11 Neurobiology of Opioids -attach to specific proteins referred to as opioid receptors in the brain, spinal cord, GI tract and other body organs -repeated use stops the body s production of natural opioids such as endorphins and encephalins -repeated use produces tolerance to opioids requiring higher doses to get the same effect 10

12 Symptoms of Opioid Use Disorder Physical -Analgesia -Sedation -Euphoria -Respiratory Depression -Small pupils -Nausea, vomiting -Itching/flushed skin -Constipation -Slurred speech -Confusion/poor judgement 11

13 Symptoms of Opioid Use Disorder Behavioral -Using larger amounts overtime -Using despite interference with major obligations/social functioning -Unreliable -Moody -Suicidal thoughts/attempts -Preoccupation with getting/using opioids -Doctor shopping, use of other illicit drugs -Deception/criminal activity -Risky behaviors -unprotected sexual activities -needle sharing -driving while impaired 12

14 Treating the Disease of Opioid Use Disorder It s time for everyone to wake up and accept that abstinence-based treatment only works in under 10 percent of opiate addicts,. All proper prospective studies have shown that more than 90 percent of opiate addicts in abstinence-based treatment return to opiate abuse within one year. -Mary Jeanne Kreek, M.D., Senior Attending Physician,Rochefeller University, Laboratory of Biology of Addictive Diseases. 13

15 Medications to Treat Opioid Use Disorder Opioid Agonist: occupies same CNS receptors as the addictive drug but are safer because they are longer acting and less likely to produce harmful behaviors present in addiction to short-acting addictive opioids. Methadone: A full agonist that enters and leaves the CNS receptors slower than short-acting opioids, once a therapeutically appropriate dose is reached, withdrawal symptoms are blocked and as are the euphoric effects of short-acting opioids.

16 Buprenorphine: A partial agonist that binds but incompletely activates CNS receptors producing a similar effect of a full agonist (methadone) but at increasing doses does not create as great an agonist effect as a full agonist. Naltrexone: An antagonist that blocks the CNS receptors and the physiologic effects of opioids. 14

17 OTP MAT= Medication + SUD Counseling -Drug Testing/Monitoring -Communicable Disease Assessment/Testing -Rx Drug Monitoring Program Database (PMDP) -Psycho-Social Assessment -Physician Assessment, Diagnosis, Med Order -Daily Nurse Med Dispensing/Monitoring -Care Coordination other care providers -SUD Treatment Plan -SUD Counseling (Individual and Group) -Case Management, Referral -Take-Home Med Assessment and Mgmt -Annual Physical 15 Medication And Behavorial Integraton

18 MAT: Phases of Treatment Methadone/Buprenorphine Acute- (days to months) focus on eliminating use of illicit opioids/other drugs, lessening of behavioral symptoms Rehabilitative-Empower Patients to deal with major life problems Supportive Care-Patients resume primary responsibility for their lives and receive take-home medication Medical Maintenance-Patient continues to receive take-home medication, frequency/intensity of counseling reduced Tapering (Optional)-Taper Readiness Assessment Continuing Care-Ongoing medical follow up with PCP after successful taper 16

19 Harm Reduction Reduce Harm to the Patient: Tx maintenance, support and patient retention as patient moves back and forth through treatment phases, benefits the patient s overall health and chance of long term success. Reduce Harm to Families: Improve both physical and behavioral symptoms and family relationships. Reduce Harm to the Public: Retention in treatment minimizes risky behavioral symptoms that endanger the public such as transmitting communicable diseases (STD s, TB), crime, driving while impaired. Reduce Harm during Pregnancy: Pregnant women reduce/eliminate their use of harmful illicit drugs and receive OB/GYN care-coordination, pregnancy-oriented counseling and case management support resulting in healthier babies.

20 Coordination of Care -Identifying of other care patients are receiving outside of the OTP that may impact their SUD recovery. -Screening for suspected co-occurring disorders and co-morbidities that need to be addressed and making appropriate referrals for care and following up with patients. -Recognizing when a co-occurring disorder medication or co-morbidity treatment must be coordinated with MAT. Obtaining patient permission to coordinate care with other treating providers. -Developing collaborative relationships with the rest of the medical and behavioral health community.

21 Status of MAT in Utah

22 Status of MAT in Utah -Number of OTP s in UT: 13-6 (SL Co.), 3 (UT Co.), 2 (Davis Co.) 1 (Washington Co.), 1 (Weber Co.) -Number of Persons receiving MAT from UT OTP s: 2600 (1.9% of those needing treatment) -Increase in # of Persons receiving MAT from : 12% -Number Receiving Buprenorphine from UT OTP s: Number of Physicians with waivers to provide Buprenorphine in UT (OBOT): Unknown -Number of Physicians using waivers to provide Buprenorphine in UT: Unknown -Number of Patients receiving Rx s from OBOT s: Unknown

23 UT Statewide OTP Demographic Data CY GENDER Male Female 41% 59%

24 UT Statewide OTP Demographic Data CY 2014 AGE < > 65 3% 0% 7% 20% 42% 28%

25 UT Statewide OTP Demographic Data CY 2014 MARITAL STATUS Married Single Other 10% 32% 58%

26 UT Statewide OTP Demographic Data CY 2014 RACE American Indian/Alaskan Native Asian Black/African American Pacific Islander White Multi Racial 5% 1% 1% 1% 0% 92%

27 UT Statewide OTP Demographic Data CY 2014 ETHNICITY Hispanic Non Hispanic 8% 92%

28 UT Statewide OTP Demographic Data CY 2014 EMPLOYMENT Employed FT Employed PT Disbled Student FT Student PT Homemaker Unemployed Retired 2% 25% 48% 7% 6% 1% 1% 10%

29 OTP s vs OBOT s -OBOT s Rx buprenorphine and do drug testing -OBOT s do not provide SUD Counseling though it s recommended -OBOT s do not have infrastructure to support recovery and they are not required to be accredited -Limited efforts to link OBOT s with OTP s to create a SUD continuum of care -OTP s Rx and dispense buprenorphine, methadone and other related MAT medications -OTP s integrate medication and SUD counseling -OTP s have infrastructure and protocols to support recovery

30 Naloxone: Brand Name Vivitrol 19 -Injected IM every days for Alcohol and/or Opioid SUD -Requires 7-10 days or longer of abstinence from opioids -Generally contraindicated for patients with long term opioid use or in long term opioid agonist therapy -Expensive, though often covered by insurance -Has higher risk of overdose on lower amounts of opioids due to lack of tolerance for opioids created by this antagonist tx -Requires SUD counseling and support

31 Barriers to Medication-Assisted Treatment in Utah -RESISTANCE -To understanding of SUD and MAT as evidence-based and standard of care by the Behavioral Heath Community -From Courts and Penal Institutions for the same reason -From public and private third-party payors (Medicaid, Medicare, Commerical Insurers) to fund treatment for this chronic disease

32 Other Barriers to MAT in Utah -Mental health degree curriculums are limited in content on MAT -Lack of referrals to MAT due to Resistance -Shortage of mental heath professionals -Lack of availability in Utah rural areas -Lack of a coordinated care continuum for MAT between OTP s and OBOT s

33 Utah: Opportunities/Recommendations -Develop better data on physicians who prescribe MAT and discuss all MAT services in official reports -Create a centralized coordinated system of assessment & referral for those with SUD to include MAT, jointly develop assessment tools -Connect all MAT providers with each other and the healthcare/ mental health continuum including third-party funding sources and insist on mental health parity in all forms for all third-party payers both public and private

34 Utah: Opportunities/Recommendations -Integrate acceptance and access to all forms of MAT with the Drug Courts, Penal system and DCFS -Increase the no. of mental health professionals statewide and ensure curriculums include comprehensive understanding of MAT in SUD 2015 Shannon M. Terwedo, M.P.A., FACHE,

35 Footnotes 1 IMS s National Prescription Audit (NPA) & Vector One : National (VONA). (2015). Retrieved August 22, 2015, from Used with permission 2 Growing Trend Switching from Prescription Opioids to Heroin. (2015). Retrieved August 22, 2015, from 3 National Overdose Deaths, Number of Deaths from Rx Opioid Pain Relievers. (2015). Retrieved August 22, 2015, from Used with permission. 4 National Overdose Deaths, Number of Deaths from Heroin. (2015). Retrieved August 22, 2015, from Used with permission. 5 Health Care Costs from Opioid Abuse: A State by State Analysis. (2015). Retrieved August 24, 2015, from 6 Division of Substance Abuse and Mental Health 2014 Annual Report (p. 17). (2014). Division of Substance Abuse and Mental Health, Utah Department of Human Services.

36 7 Ibid. p Ibid. pp. 53, Opioid Addiction Disease, 2015 Facts & Figures. (2015). Retrieved August 24, 2015, from 10 America s Addiction to Opioids: Heroin and Prescription Drug Abuse. (2015). Retrieved August 22, 2015, from 11 Signs and Symptoms of Opioid Abuse. Retrieved September 1, 2015, from 12 Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs, A Treatment Improvement Protocol TIP 43. Chapters 4, 8. (2005). U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, (HHS Publication No. (SMA) : 2005). 13 Cherkes, J. (2015, January 28) Dying to be Free. Retrieved August 25, 2015 from, 14 TIP 43, pp. 290, 26. America s Addiction to Opioids: Heroin and Prescription Drug Abuse. (2015). Retrieved August 22, 2015, from 15 TIP 43, Chapters 4, 8.

37 16 Ibid. Chapter Utah OTP Quarterly Report, 2 nd Quarter 2015, Utah Division of Substance Abuse and Mental Health, Department of Human Services, Salt Lake City, Utah. 18 Utah Statewide OTP Demographic Data 2014, Utah Division of Substance Abuse and Mental Health, Department of Human Services, Salt Lake City, Utah. 19 Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide. (2015). U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, (HHS Publication No. (SMA) : 2015).