Confronting the Opioid Epidemic: Suboxone in Primary Care

Transcription

1 Confronting the Opioid Epidemic: Suboxone in Primary Care Kami Harless, MD 1

2 The Opioid Epidemic 2

3 The Opioid Epidemic 3

4 Washington Epidemic 4

5 King County Epidemic 5

6 King County Epidemic 6

7 Outline Opioid dependence treatment options Efficacy of treatment options Buprenorphine in primary care Ideal candidates for buprenorphine Unique opportunities for buprenoprhine Barriers to success The future of medication assisted treatment 7

8 Treatment Options Agonist Therapy Methadone Buprenorphine LAAM Heroin Maintenance Programs Antagonist Therapy: Naltrexone Psychosocial Therapy 8

9 Treatment Options Agonist Therapy Methadone Buprenorphine LAAM Heroin Maintenance Programs Antagonist Therapy: Naltrexone Psychosocial Treatment 9

10 Efficacy of Buprenorphine 2014 Cochrane Review: 31 trials Buprenorphine vs Placebo Retention Suppression of illicit opioids in urinalysis Buprenorphine vs Methadone Retention Suppression of illicit opioids in urinalysis 10

11 Cochrane Review Buprenorphine vs Placebo: Retention: Bup doses >2mg Illicit opioid suppression in UA: Bup doses >16mg Buprenorphine vs Methadone: Retention: Methadone more effective than flexible dosing buprenorphine Illicit opioid suppression in UA: Methadone more effective than flexible dosing buprenorphine 11

12 Cochrane Review 12

13 Making a Case for Buprenorphine Saftey of agonist therapy: 2006 New South Wales study Overdoses in 9mo period RR methadone 4.25 Pharmacokinetics Long acting full agonist High affinity partial agonist 13

14 Making a Case for Buprenorphine Patient attitudes: Reduced number of medical visits More convenient locations Removed from illicit drug markets often around methadone clinics Improved patient-provider relationships Improved sense of autonomy, support, and trust from their provider Reduced stigma Positive patient-provider relationships are associated with positive addiction treatment outcomes. 14

15 Who s A Good Candidate? Factors indicating good outcome Prescription opioid addiction only Patient highly motivated History of reliability and compliance High functional level: employment/housing Supportive psychosocial environment Relative contraindications Dependence on other CNS depressants Multiple previous treatments with frequent relapses Severe opioid addiction High risk environment for relapse Poor support system 15

16 Who s A Good Candidate? 16

17 Who s A Good Candidate? Targeted marketing to the private sector Private Clinics, Out-of-Pocket, Privately Insured Caucasian, Employed, Stable patients 17

18 Unique Opportunities within the Safety Net Buprenorphine in Public Sector Healthcare Specific characterstics that are especially suited for low-income patient population Local/Regional incentives: Medicaid formularlies State level media campaigns Prescriber support networks 18

19 Buprenorphine: Reaching Vulnerable Populations Chronic Disease Management New York City Harm Reduction Pilot 2005 Past Incarceration/Recent Release San Francisco Department of Public Health HIV Treatment 19

20 Buprenorphine: Reaching Vulnerable Populations Chronic Disease Management New York City Harm Reduction Pilot 2005 Past Incarceration/Recent Release San Francisco Department of Public Health HIV Treatment 20

21 Chronic Disease Management 21

22 Buprenorphine: Reaching Vulnerable Populations Chronic Disease Management New York City Harm Reduction Pilot 2005 Past Incarceration/Recent Release San Francisco Department of Public Health HIV Treatment 22

23 NYC Harm Reduction Model 23

24 Buprenorphine: Reaching Vulnerable Populations Chronic Disease Management New York City Harm Reduction Pilot 2005 Past Incarceration/Recent Release San Francisco Department of Public Health HIV Treatment 24

25 Recent Incarceration/Release 25

26 Buprenorphine: Reaching Vulnerable Populations Chronic Disease Management New York City Harm Reduction Pilot 2005 Past Incarceration/Recent Release San Francisco Department of Public Health HIV Treatment 26

27 San Francisco Department of Public Health 27

28 Buprenorphine: Reaching Vulnerable Populations Chronic Disease Management New York City Harm Reduction Pilot 2005 Past Incarceration/Recent Release San Francisco Department of Public Health HIV Treatment 28

29 HIV Treatment 29

30 Barriers to Success Access Time Comfort 30

31 The Future Harm Reduction Depot/Implant 31

32 Resources Buprenorphine Wavier June 2015 Practice Update PCSS-B Mentor Site Buprenorphine Rounds (Cherry Hill) 32

33 References 33

34 Thank you! Questions? 34