The Substance Abuse Epidemic and the Essential Role for the Family Physician

Transcription

1 The Substance Abuse Epidemic and the Essential Role for the Family Physician Joseph Garbely, D.O., FASAM Medical Director VP of Medical Services 1 ASAM Disclosure of Relevant Financial Relationships No Relevant Financial Relationships with Any Commercial Interests 2 How did we get here? Good intentions leading to unintended consequences Confluence of factors, beginning in the 1990 s JCAHO standard for pain assessment (2001) and other organizations (VA) categorization of pain as the 5 th vital sign (1990 s) Launch of Oxycontin in 1996, becoming the #1 selling narcotic pain reliever in 2001 Hospital Consumer Survey of Health Care Providers and Systems (HCAHPS) in 2006 had 3 pain questions HCAHPS Optional in 2006.Mandatory in 2010 (ACA) CMS tied responses to reimbursement 3 1

2 Opioid Use Disorder Epidemic NESARC III NIAAA (NIH) Opioid use: 1.8% (2002) vs 4.1% (2013) Opioid use:10,000,000 adults (4.1%) of US population NMU of Rx Opioids more than doubled among US adults NMU (lifetime): 4.7% (2002) vs 11% (2013) Adults w/ NMP Opioid Use D/O: 2.1 million (0.9%) 4 Oxycodone and Hydrocodone Prescriptions ( ) 5 Who s Writing these Prescriptions? 6 2

3 7 8 US Opioid Overdose Deaths 9 3

4 The rise of Synthetic opioids 10 Opioid Use Disorder Epidemic 11 Opioid Use Disorder Epidemic Opioid Poisoning Deaths ( ) Quadrupled 12 4

5 Opioid Use Disorder Epidemic 13 Opioid Use Disorder Epidemic 14 3,383 Overdose Deaths in Pennsylvania in

6 2015 PA OD Deaths by County 16 4,652 PA OD Deaths in PA OD Deaths by County 17 Opioid Use Disorder Epidemic 18 6

7 Chronic Pain is Overmedicated 259,000,000 opioid prescriptions were written in U.S. = 4.6 percent of the world's population consumes 80% of its opioids and 99% of its hydrocodone. 19 Opioid Use Disorder Epidemic What now? 20 CDC Guideline MMWR CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016 Recommendations and Reports / March 18, 2016 / 65(1);

8 Summary of evidence used in determining the recent CDC Opioid prescribing guidelines No evidence shows a long-term benefit of opioids in pain and function versus no opioids for chronic pain with outcomes examined at least 1 year later (with most placebo-controlled randomized trials 6 weeks in duration). Extensive evidence shows the possible harms of opioids (including opioid use disorder, overdose, and motor vehicle injury). Extensive evidence suggests some benefits of nonpharmacologic and nonopioid pharmacologic treatments compared with long-term opioid therapy, with less harm 22 As pain becomes chronic, it is represented in different regions of the brain Subacute Back Pain [~2 mos.] anterior to mid-insula, thalamus, striatum, orbitofrontal and inferior cortex, anterior cingulate cortex. Chronic Back Pain [>10 yrs) anterior cingulate cortex, medial prefrontal cortex and parts of the amygdala. Chronic somatic pain becomes emotional pain! 23 A: Address the unpleasant experience. Q: How can we treat pain appropriately? Biological component Nociceptive Neuropathic Other central pain syndromes, migraine, cancer pain, fibromyalgia 24 8

9 The Psychological Component Pain the unpleasant experience Distraction Focused attention Inability to concentrate Sleep disturbance 25 The Sociologic Component Pain the unpleasant experience Homebound Loneliness Diminished sense of usefulness Dependence on others 26 The Spiritual Component Suffering Pain the unpleasant experience Isolation Resistance Feeling threatened Giving up 27 9

10 CDC guideline excerpts Because pain management in patients with substance use disorder can be complex, clinicians should consider consulting substance use disorder specialists and pain specialists regarding pain management for persons with active or recent past history of substance abuse. 28 Opioid prescribing decreased between 2010 and 2015 Some characteristics of counties with higher opioid prescribing: Small cities or large towns Higher percent of white residents More dentists and primary care physicians More people who are uninsured or unemployed More people who have diabetes, arthritis, or disability 29 Medication Assisted Treatment (MAT) Evidence based approach to treating opioid use disorders Decrease craving Reduce risk of relapse/od Harm reduction (decreased criminal behavior and decreased communicable diseases) 30 10

11 MAT Methadone Maintenance (Agonist) Buprenorphine Maintenance (Partial Agonist) Depot Naltrexone (Vivitrol) (Antagonist) 31 MAT action on mu opioid receptors Methadone Suboxone Vivitrol 32 Co prescribing with Naloxone Naloxone auto injection for suspected opioid overdose 33 11

12 Co prescribing with Naloxone Intranasal Naloxone 34 Naloxone Intranasal 35 Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors

13 Summary Addiction is a chronic brain disease it is not a lack of willpower or moral failing We need to treat addiction as a chronic disease Addiction affects all areas of a person s life Addiction is a family disease Addiction requires a comprehensive solution Body (MAT), mind, spirit Treatment works and the brain heals Recovery is a lifelong process 37 References 1. CDC. Vital signs: overdoses of prescription opioid pain relievers United States, MMWR. 2011;60: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision). Washington, DC: American Psychiatric Association; 2000: National Institute on Drug Abuse. Prescription Drugs: Abuse and Addiction. NIH Pub No Revised October Accessed December 30, National Institute on Drug Abuse. Prescription Drug Abuse May 2011: A Research Update from the National Institute on Drug Abuse. Washington, DC: Public Information and Liaison Branch: Office of Science Policy and Communications; Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, Accessed December 30, National Institute on Drug Abuse. Drugs, Brains and Behavior: The Science of Addiction. NIH Pub No Revised August Accessed January 12, Doering PL. Substance related disorders: overview and depressants, stimulants, and hallucinogens. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York, NY: McGraw Hill Medical; 2011: Trescot AM, Boswell MV, Atluri SL, et al. Opioid guidelines in the management of chronic non cancer pain. Pain Physician. 2006;9: Amass L, Ling W, Freese TE, et al. Bringing buprenorphine naloxone detoxification to community treatment providers: the NIDA Clinical Trials Network field experience. Am J Addict. 2004;13:S42 S Office of Diversion Control. Section : administering or dispensing of narcotic drugs. Updated June Accessed January 3, References 11. Fiellin DA, O Connor PG. Office based treatment of opioid dependent patients. N Engl J Med. 2002;347: Dolophine (methadone hydrochloride) prescribing information. Columbus, OH: Roxane Laboratories, Inc; October Gold MS, Pottash AC, Sweeney DR, Kleber HD. Opiate withdrawal using clonidine. A safe, effective, and rapid nonopiate treatment. JAMA. 1980;243: Gouldin WM, Kennedy DT, Small RE. American Pain Society. Methadone: history and recommendations for use in analgesia. APS Bulletin. 2000;10. Accessed January 8, DuPont RL, Dormer RA, Nightingale SL. Treatment of narcotics addiction with narcotic drugs. JAMA. 1976;235: DEA announces restrictions on distribution of methadone. AAFP News Now. now/clinical care research/ methadone.html. Accessed January 20, Code of Federal Regulations Title 42: Public Health. Part 8 certification of opioid treatment programs. Accessed January 31, Nicholls L, Bragaw L, Ruetsch C. Opioid dependence treatment and guidelines. J Manag Care Pharm. 2010;16(1 suppl B):S14 S Data brief 81: Drug poisoning deaths in the United States, CDC/NCHS, National Vital Statistics System. Accessed January 26, Hashmi, J.A. et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain 136, (2013)