THE OPIOID CRISIS 9/19/2018 DEFINING THE CRISIS DEFINING THE CRISIS NUMBER OF OPIOID-RELATED OVERDOSE DEATHS IN ALABAMA

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1 THE OPIOID CRISIS DEFINING THE CRISIS KATHLEEN DUPPER, MD MEDICAL DIRECTOR, HUNTSVILLE RECOVERY 19 th Annual Perinatal Conference: The Opioid Crisis September 21, 2018 DEFINING THE CRISIS NUMBER OF OPIOID-RELATED OVERDOSE DEATHS IN ALABAMA 1

2 OVERDOSE DEATHS BY AGE PRESCRIPTION DISTRIBUTION BY STATE Source: CDC and prevention 11.4% OF NON-PREGNANT WOMEN AGE USE ILLICIT DRUGS 5.4% OF PREGNANT FEMALES REPORT ILLICIT USE OF DRUGS IN PAST MONTH NATIONAL SURVEY ON DRUG USE AND HEALTH, samhsa, 2014 PREGNANCY AND SUBSTANCE USE, DRUG WAR FACTS,

3 WHAT FUELED THE CRISIS? 1980 THE LETTER 5 TH VITAL SIGN PHARMACEUTICALS 1980 THE LETTER NEJM, 1980 PAIN IS THE FIFTH VITAL SIGN OXYCONTIN APPROVED BY FDA FENTANYL APPROVED BY FDA JCAHO PAIN TREATMENT INITIATIVE The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a comprehensive description of patient s rights and standard of care of pain management. PHARMACEUTICALS Recommendation: make pain assessment/management priority of daily practice. -Consider pain intensity the 5 th vital sign. Measure along with temperature, pulse, respiration and blood pressure. -Patient s rights: Full pain work up when pain is not easily characterized OXYCONTIN MARKETED AS LESS ABUSIVE 1998 JOINT COMMISSION DECLARES PAIN 5TH VITAL SIGN 2010 OXYCONTIN REFORMUALTED. 3

4 UNDERSTANDING OPIOIDS ANALGESIA EUPHORIA MOTIVATION 5 TH VITAL SIGN/JACHO OXYCONTIN REFORMULATED BRIEF REVIEW OF OPIOID PHARMACOLOGY MU OPIOID RECEPTOR OPIATES AND OPIOIDS 3 MAIN EFFECTS: *ANALGESIA *EUPHORIA *MOTIVATION MU OPIOID RECEPTOR ENDOGENOUS OPIOIDS- ENDORPHINS, ENKEPHALIN,DYNORPHINS 4

5 OPIOIDS TAKEN IN LARGER AMOUNTS OVER LONGER PERIODS OF TIME OPIOID USE DISORDER (OUD) : DSM5 CRITERIA PERSISTENT DESIRE TO CUT DOWN INCREASED AMOUNT OF TIME SPENT OBTAINING AND USING OPIOIDS CRAVINGS FAILURE TO FULFILL OBLIGATIONS INTERPERSONAL PROBLEMS DECREASED SOCIAL/OCCUPATIONAL ACTIVITIES RECURRENT USE DESPITE SITUATIONS WHICH ARE HAZARDOUS PERSISTENT USE DESPITE IMPACT ON PHYSICAL/MENTAL WELL-BEING SOLUTIONS TO THE CRISIS SCREEN/IDENTIFY TREAT PREVENT SCREEN/IDENTIFY PATIENTS WITH OUD TREAT PATIENTS WITH OUD PREVENT NEW CASES OF OUD TOLERANCE WITHDRAWALS SCREENING -ACOG RECOMMENDS UNIVERSAL SCREENING OF ALL PREGNANT WOMEN FOR SUBSTANCE USE/ABUSE BEFORE PREGNANCY AND IN FIRST TRIMESTER sbirt.ontrackny.org Screening Brief Intervention Referral to Treatment QUESTIONNAIRE TOOLS CRAFFT -Have you ever ridden in a CAR driven by someone who was high or using drugs? -Do you ever use drugs to RELAX, feel better about yourself or fit in? -Do you ever use alcohol or drugs while you are by yourself or ALONE? -Do you ever FORGETthings you did while using drugs? -Do your FAMILYor friends tell you to cut down? -Have you ever gotten in TROUBLE while using drugs? 5P s PARENTS: Did any of your parents have a problem with alcohol or drug use? PARTNER: Does your partner have a problem with alcohol or drug use? PEERS: Do any of your friends have a problem with alcohol or drugs? PAST:In the past, have you had difficulties in your life because of medications and drugs, including prescription medications? PREGNANCY: In the last month, have you used any alcohol or used any drugs? 5

6 MEDICATION ASSISTED TREATMENT FOR PREGNANT WOMEN WITH OUD, OPIOID AGONIST PHARMACOTHERAPY IS THE RECOMMENDED THERAPY AND IS PREFERABLE TO MEDICALLY SUPERVISED WITHDRAWAL BECAUSE WITHDRAWAL IS ASSOCIATED WITH HIGH RELAPSE RATES, WHICH LEAD TO WORSE OUTCOMES. MORE RESEARCH IS NEEDED TO ASSESS THE SAFETY (PARTICULARLY REGARDING MATERNAL RELAPSE), EFFICACY, AND LONG-TERM OUTCOMES OF MEDICALLY SUPERVISED WITHDRAWAL. -ACOG COMMITTEE OPINION NUMBER 11, AUGUST 2017 Opioid dependent women not in treatment should be encouraged to start opioid agonist maintenance treatment with methadone or buprenorphine. Pregnant women who are taking opioid agonist maintenance treatment should be encouraged not to cease it while they are pregnant. WHO GUIDELINES, 2014 BENEFITS OF OPIOID AGONIST THERAPY IN PREGNANCY MATERNAL BENEFITS: DECREASE RISK OF HIV, HBV, HCV INCREASED PARTICIPATION IN PRENATAL CARE 70 % REDUCTION IN OVERDOSE DEATHS FETAL BENEFITS: DECREASE IN INTRAUTERINE GROWTH RESTRICTION DECREASE IN PRETERM DELIVERY DECREASE IN INTRAUTERINE FETAL DEMISE DECREASE IN FETAL STRESS DUE TO STABLE OPIOID LEVELS. MEDICATION ASSISTED TREATMENT: METHADONE -FULL AGONIST INITIATE AS EARLY IN PREGNANCY AS POSSIBLE STARTING DOSE IS TYPICALLY BETWEEN 15-25MG HALF LIFE ESTIMATED AT HOURS. START LOW AND GO SLOW LONG DATA HISTORY INCREASE DOSE TO ACHIEVE 24 HOUR CONTROL OF CRAVINGS/WITHDRAWALS DAILY SUPERVISED DOSING WITH COUNSELING PATIENT DOES NOT NEED TO BE IN WITHDRAWALS TO BEGIN METHADONE AVERAGE DOSE MG DAILY OUTPATIENT OR INPATIENT INITIATION WITH FOLLOW UP AT OUTPATIENT CENTER. 6

7 MEDICATION ASSISTED TREATMENT: METHADONE -FULL AGONIST NAS INCIDENCE IS NOT DEPENDENT ON METHADONE DOSE PATIENTS OFTEN REQUIRE INCREASE DOSE IN 3 RD TRIMESTER CONSIDER GROWTH ULTRASOUNDS MONTHLY ESPECIALLY IF MOTHER SMOKES SPLIT DOSING SHOULD BE CONSIDERED DUE TO THE INCREASED VOLUME OF DISTRIBUTION IN PREGNANT WOMEN. DOSING IS ADJUSTED POSTPARTUM. IF NEED FOR NON-STRESS TEST ARISES, OBTAIN IN AFTERNOON TO AVOID PEAK OF DOSE, WHICH IS 3-4 HOURS AFTER DOSING MEDICATION ASSISTED TREATMENT: BUPRENORPHINE - PARTIAL AGONIST PATIENT MUST BE IN WITHDRAWALS TO INITIATE THERAPY (COWS SCALE) TYPICAL STARTING DOSE IS 2-4MG. SMALL INCREMENTAL DOSE CHANGES ARE EFFECTIVE. INCREASING AMOUNTS OF DATA ON USE AND SAFETY ENCOURAGE BREASTFEEDING HALF LIFE HOURS POSSIBLY IMPROVED ACCESS TO CARE EVIDENCE OF SHORTER DURATION AND LESS SEVERITY OF NAS RISK OF MEDICATION NOT BEING ADEQUATELY EFFECTIVE LESS RISK OF OVERDOSE IN PREGNANCY, BUPRENORPHINE ALONE IS RECOMMENDED (NO NALOXONE) FEWER DRUG INTERACTIONS POSSIBLY LESS EFFECTIVE IN HEAVY IV USERS/POLYSUBSTANCE USERS ENCOURAGE PATIENT TO BREASTFEED INDUCTION FROM METHADONE TO BUPRENORPHINE ASSOCIATED WITH HIGHER RATES OF DISSATISFACTION WITH BUPRENORPHINE. MORE DATA NEEDED FULL AGONISTS AND PARTIAL AGONISTS NALTREXONE: FULL ANTAGONIST WITH NO AGONIST EFFECT WITH VERY LIMITED RESEARCH IN PREGNANT WOMENT AND CURRENTLY NOT RECOMMENDED IN PREGNANCY THE MOTHER STUDY: MATERNAL OPIOID TREATMENT: HUMAN EXPERIMENTAL RESEARCH Landmark study showing buprenorphine can be as effective as methadone Primary Outcomes: Similar prevalence of treatment for NAS (same incidence of NAS at 50%) Less NAS severity & treatment required with buprenorphine due to lower severity of withdrawals[babies needed about ½ the meds as babies on methadone] Shorter neonatal length of stay with buprenorphine [about half the time] Secondary Outcomes: Increased gestational age Increased birth weight Decreased duration of NAS treatment. Jones, NEJM, 2010 This Photoby Unknown Author is licensed under CC BY-SA 7

8 METHADONE AND BUPRENORPHINE FOR OPIOID DEPENDENCE DURING PREGNANCY: A RETROSPECTIVE COHORT STUDY JOURNAL ADDICTION MEDICINE MARCH/APRIL 2015VOL 9-ISSUE 2-P Addressed some of the concerns of the MOTHER STUDY 609 patients started on bup (361) or methadone (248) from years at University of VT 19 patients switched to methadone out of 361 ( only 5 of those switched due to bup not strong enough or SE). *mother study placebo controlled double blind, but real life, the decision is more complex and determined by other factors Hep c moms more likely to start on methadone. 80% mom smokers (both groups)30% groups had c-section-both groups Most switched because they needed more intensive monitoring due to +UDS. Evidence suggests bup gives outcomes at least as good as methadone. *retrospective analysis- looked at cases where the choice of med was made by the patient and physician and studied the outcomes Both groups similar prenatal care with 65% starting in 1 st Trimester. PT s in bup group were more likely to already be in treatment prior to getting pregnant vs. methadone. Babies born to bup moms had a significantly longer gestational age, had higher birth wt and head circumference CASE STUDY 1 33 YO FEMALE REPORTS SHE IS ABOUT 8 WEEKS PREGNANT. ABUSING OPIATES: 17 YEARS. She started using pills with friends at school and has been using IV for 9 years. AVERAGE DAILY USE: roxycodone 30mg x 8-12/IV/day. OTHER SUBSTANCE USE: METHAMPHETAMINE 1-2 X/MONTH. Her boyfriend had been selling, so access was easy. He has stopped selling. Admits to h/o Xanax use, up to 8-20mg per day, but goes extended time without any use. Last used benzo 5 days ago. Typically they come around 1-2 times per month. THC use is daily. Denies tobacco. Denies alcohol. Denies cocaine. PMH: anxiety/depression- dx age 7. MEDS: none PSH: 2 previous elective ab SOCIAL: SINGLE. LIVES WITH BOYFRIEND. UNEMPLOYED. CASE STUDY 2 24 YO BF PRESENTS WITH REPORT SHE IS ABOUT 10 WEEKS PREGNANT. ABUSING OPIATES: 6 YEARS AVERAGE DAILY USE: ROXYCODONE 30MG X 3/SNORT/DAY SHE REPORTS NEAR ABSTINENCE WITH LAST PREGNANCY, BUT USE HAS INCREASED. CURRENTLY IN WITHDRAWALS. OTHER SUBSTANCE USE: THC USE 2-3 TIMES PER WEEK. SMOKES TOBACCO DAILY. NO BENZO/ ALCOHOL/ AMPHETAMINES OR COCAINE. PMH: NONE MEDS: NONE PSH: NONE SOCIAL: LIVES WITH HER BOYFRIEND AND 3 YO CHILD, UNEMPLOYED. SHE HAS LIMITED USE OF A CAR. CASE STUDY 3 38 YO WF REPORTS SHE IS 20 WEEKS PREGNANT ABUSING OPIATES : 15 YEARS AVERAGE DAILY USE: HEROIN 1G/IV/DAY OTHER ABUSED SUBSTANCES: COCAINE SEVERAL TIMES PER WEEK. DENIES ANY ALCOHOL/BENZO/TOBACCO/THC/AMPHETAMINES. PMH: HEP C-UNTREATED MEDS: NONE PSH: NONE SOCIAL: DIVORCED. WORKS AS DANCER. 3 CHILDREN MGM HAS CUSTODY. 8

9 20 YO FEMALE PRESENTS AT 24 WEEKS GESTATATION. THIS IS HER FIRST PREGNANCY. SHE HAS NOT HAD ANY PRENATAL CARE. ABUSING OPIATES: 3 YEARS RESOURCES ACOG Committee Opinion of Opioid Abuse, Dependence and Addiction in Pregnancy, Reaffirmed 2016 ACOG Committee Opinion Opioid Use and Opioid Use Disorder in Pregnancy, August 2017 CASE STUDY 4 AVERAGE DAILY USE: NORCO X 8-10/PO/DAY. SHE ADMITS TO HAVING TRIED SUBOXONE OFF THE STREETS. SHE C/O WITHDRAWALS. OTHER SUBSTANCE USE: DENIES BENZO/ALCOHOL/THC/TOBACCO OR COCAINE. SHE ADMITS TO USING ADDERALL SPORADICALLY TO HELP WITH HER ONLINE CLASS WORK Talking points on NAS and MAT: National Institute on Drug Abuse. America s addiction to opioids: heroin and prescription drug abuse. Bethesda (MD): NIDA;2014. Substance abuse reporting and pregnancy: the role of the obstetrician-gynecologist. Committee Opinion No.473 American College of Obstetricians and Gynecologists. Obstet Gynecol 2011: 117: 20 Treatment Improvement Protocol (TIP) Series, No. 43. Rockville (MD): Substance Abuse in Mental Health Services Administration; 2005.p PMH: ADD DIAGNOSED IN CHILDHOOD. MEDS:NONE PSH: REPAIR OF FX ARM IN CHILDHOOD SOCIAL: LIVES WITH PARENTS. NO CHILDREN. COLLEGE STUDENT. 9