Use of Suboxone and Other Treatment Modalities: Myths, Facts & Tips for Better Outcomes

Transcription

1 Use of Suboxone and Other Treatment Modalities: Myths, Facts & Tips for Better Outcomes MPHP Prescribers Summit 2018 Gulfport, MS March 13, 2018 Scott Hambleton, MD, DFASAM Medical Director, MRO Mississippi Physician Health Program i o n

2 No Disclosures Todays speaker has no disclosure of real or apparent conflict related to the content of this presentation. 2

3 Objectives: 1. Discuss factors which have contributed to the U.S. prescription drug crisis. 2. Describe medication assisted treatment and other treatment modalities. 3. Describe buprenorphine for opioid replacement therapy. 3

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5 The Comprehensive Addiction & Recovery Act (CARA) Passed on March 11, 2016 First major legislation since the Controlled Substances Act of 1970 Expand education and prevention Make naloxone available to first responders Provide resources to treat incarcerated individuals 5

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7 What is Driving the Increase in Heroin Use & Deaths? A key factor is low cost and high purity of heroin. Cost of one gram: 1982: $2, : $465 7

8 Fentanyl: Game Changer 20,000 deaths in % increase in 3 years 50X potency heroin 100X potency morphine Carfentanil = 10,000X potency morphine ( pdf/cdc-update82616.pdf) 8

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10 Adverse Selection: Opioid Use Patients with mental health and substance abuse co-morbidities are more likely to receive chronic opioid therapy than patients who lack these risk factors. (Sullivan, Pain, 2010) 10

11 Addiction: Primary, Chronic Brain Disease Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (ASAM Public Policy Statement, 2011) 11

12 Screening: General Tips Identify high risk patients Eliminate harmful/ineffective therapy Avoid controlled substances for chronic conditions Opioids Benzodiazepines (CDC Guidelines, 2016) 12

13 Screening for SUD: Single Question How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons, or for the way it made you feel? 100% sensitive 73.5% Specific (Smith PC, et al., 2010) 13

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15 Log in page 15

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21 Urine Drug Testing (UDT): Negative Results Negative test does NOT: R/O substance use R/O out SUD Negative test DOES mean: Targeted substance has not been used in detection window Possible use below cut off level (ASAM Consensus Document, 2017) 21

22 Point of Service UDT 12 panel + Temperature Cost: $2.50 per cup 22

23 Abbreviations OTP = opioid treatment program ORT = opioid replacement therapy MAT = medication assisted treatment 23

24 MAT: Medication Assisted Treatment FDA approved medications for: Tobacco Use Disorder: OTC nicotine replacement formulations; Varenicline; Bupropion. Alcohol Use Disorder: Acamprosate, Naltrexone; Disulfuram. Opioid Use Disorder: buprenorphine; methadone; Naltrexone. ( 24

25 Meds for Opioid Withdrawal Clonidine PO or transdermal mg every 6 8 hours Maximum dose of 1.2 mg/day Benzodiazepines for anxiety(inpatient) Loperamide for diarrhea Acetaminophen/NSAIDS for pain Ondansetron or other agents for nausea (ASAM National Practice Guideline, 2015) 25

26 Naloxone (Narcan) Opioid receptor antagonist Temporarily reverses an opioid overdose Effects last minutes Many formulations; Injectible 1mg/mL ($) Narcan Nasal Spray ($$) Evzio 2mg auto-injector ($$$) Indicated for: h/o OD, SUD, >50MME, or concurrent BZOs (CDC Guidelines, 2016) 26

27 Naltrexone versus Naloxone Naloxone: IV/IM/intranasal Onset: IV = 1-2 minutes Duration: minutes Uses: Emergent OD reversal Buprenorphine preps. (SAMHSA) PO/IM Naltrexone: Onset: minutes Duration: Oral: hrs IM: 30 days Uses: Addiction(opioids/EtOH) 27

28 Naltrexone To treat alcohol/opioid addiction Blocks effects of opioids Lasts; 1-2 days(po) 30 days(im) Formulations: Vivitrol (360mg IM) Revia (50 mg PO) (SAMHSA) 28

29 Effectiveness of MAT AAFP Buprenorphine Therapy for Opioid Use Disorder (March 2018): The CDC Guideline for Prescribing Opioids for Chronic Pain (March 2016): The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (June 2015): 29

30 DATA 2000 Drug Addiction Treatment Act of 2000 Qualified physicians may prescribe/dispense FDA approved Schedule III, IV, and V opioid medications for the treatment of opioid addiction Methadone is Schedule II Buprenorphine is Schedule III (SAMHSA) 30

31 Physician & Program Data Mississippi Physicians with DATA 2000 Waiver: 184 ( 31

32 Buprenorphine Waiver Multiple online courses 32

33 Opioid binding sites (green) Reward Pathway (orange) 33

34 Buprenorphine Pharmacology Semisynthetic, partial µ-opioid agonist Partial agonists activate receptors, but not to the same degree as full agonists. less euphoria less respiratory depression less sedation k-receptor antagonist (blocks dysphoria) (ASAM National Practice Guideline, 2015) 34

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36 Buprenorphine Pharmacology Metabolized by the liver via cytochrome P450 Slow rate of dissociation from mu opioid receptor Long duration of action Half-life of hours (mean 37) Prolonged suppression of opioid withdrawal Short duration of analgesia Maximal effects at 24mg (Suboxone) (ASAM National Practice Guideline, 2015) 36

37 Precipitated Opioid Withdrawal Highest affinity of µ-opioid receptor of any opioid Occurs with buprenorphine induction prior to onset of mild to moderate opioid withdrawal Occurs with naltrexone/naloxone administration during opioid intoxication Induction: Short acting opioids: hours Long acting opioids: hours (ASAM National Practice Guideline, 2015) 37

38 Buprenorphine Formulations: Treatment of Opioid Use Disorder (Am Fam Physician Mar 1; 97(5): ) 38

39 Buprenorphine vs Naltrexone: Treatment Options Maintaining short-term opioid abstinence with extended-release naltrexone should be considered an equal treatment alternative to buprenorphinenaloxone as medication-assisted treatment for opioiddependent individuals. 39

40 MAT: Considerations for Acute Pain Buprenorphine: Acute pain: NSAIDS(ketorolac) Moderate pain: divided doses or extra doses of bupe Elective surgery: d/c hours before Severe acute pain: high potency opioids/regional anesthesia Naltrexone: IM: d/c 30 days before elective surgery PO: d/c 72 hours before elective surgery (ASAM National Practice Guideline, 2015) 40

41 Replacing One Drug for Another Would you say the same thing about nicotine patches compared to smoking? 41

42 Diversion Strategies Frequent office visits (weekly in early treatment) Urine drug testing Recall visits for pill counts Use of PDMP Limiting use of Subutex (monotherapy): Lactating or pregnant females Naloxone allergies (ASAM National Practice Guideline, 2015) 42

43 Patient Characteristics Associated with Successful MAT Substance-free, safe home environment Stable or controlled medical or psychiatric comorbidities Sporadic opioid use is not uncommon in the first few months (ASAM National Practice Guideline, 2015) 43

44 Treatment Resources

45 Thank You!!! 45

46 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5 th ed., Text Rev. Washington, DC: American Psychiatric Association; American Society of Addiction Medicine. Appropriate use of drug testing in clinical addiction medicine. Journal of Addiction Medicine. Consensus Document. 2017; 11: doi: /ADM American Society of Addiction Medicine. Public Policy Statement: Short Definition of Addiction. 2011; Published August 15, Accessed August 22,

47 Centers for Disease Control and Prevention. CDC Guidelines for Prescribing Opioids for Chronic Pain United States Accessed September 13, Center for Disease Control and Prevention. Prescription painkiller overdoses: A growing epidemic, especially among women. CDC Vital Signs. July /index.html. Accessed September 10,

48 Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016; 374: doi: /NEJMra Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. Journal of Addiction Medicine. 2015;9(5): doi: /adm

49 Krebs EE, Lorenz KA, Bair MJ, et al. Development and Initial Validation of the PEG, a Three-item Scale Assessing Pain Intensity and Interference. Journal of General Internal Medicine. 2009;24(6): doi: /s Ries RK. Principles of Addiction Medicine 5th ed. Chevy Chase, MD: American Society of Addiction Medicine; Smith PC, Schmidt SM, Allensworth-Davies D, et al. A singlequestion screening test for drug use in primary care. Archives of Internal Medicine. 2010;170(13): doi: /archinternmed

50 Substance Abuse and Mental Health Services Administration Clinical advances in non-agonist therapies. Report of proceedings. May 11,

51 Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA , NSDUH Series H- 52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration. Managing chronic pain in adults with or in recovery from substance use disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration,

52 Tanum L, Solli KK, Latif Z, Benth JŠ, Opheim A, Sharma- Haase K, Krajci P, Kunøe N. Effectiveness of Injectable Extended-Release Naltrexone vs Daily Buprenorphine- Naloxone for Opioid DependenceA Randomized Clinical Noninferiority Trial. JAMA Psychiatry. 2017;74(12): doi: /jamapsychiatry Zoorob R, Kowalchuk A, Grubb MM. Buprenorphine therapy for opioid use disorder. Am Fam Physician Mar 1;97(5):