Follow-Up Q & A Webinar: Opioid Use Disorders: The Female Experience. Ashley Braun-Gabelman, Ph.D. University Hospitals Case Medical Center

Transcription

1 Follow-Up Q & A Webinar: Opioid Use Disorders: The Female Experience Ashley Braun-Gabelman, Ph.D. University Hospitals Case Medical Center 1

2 Ashley Braun-Gabelman, Disclosures No disclosures 2

3 Planning Committee, Disclosures AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below: The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this webinar to disclose: AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, and Justina Andonian. All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. The content of this CME activity has been reviewed and the committee determined the presentation is balanced, independent, and free of any commercial bias. Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products. 3

4 Target Audience The overarching goal of PCSS-O is to offer evidence-based trainings on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction. Our focus is to reach providers and/or providers-in-training from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators. 4

5 Educational Objectives At the conclusion of this activity participants should be able to: Identify changing demographics of heroin and opioid use disorders Recognize barriers to treatment Discuss gender-related treatment issues Describe co-occurring disorders Identify treatment options for pregnant women 5

6 Outline Changing demographics of OUD Course of illness Treatment issues Barriers to treatment Co-occurring disorders Pregnancy 6

7 Case Vignette #1: Kelly Caucasian, 45 y/o presents with Heroin Use Disorder, severe Childhood sexual abuse, incest, poverty, neglect Strong family h/o addiction First given tramadol by brother Mother s little helper 7

8 Case Vignette #1: Kelly Now self-described Soccer Mom Married mother of 2 teenage daughters Manager at work I needed to use to be able to get everything done. 8

9 Case Vignette #2: Jessica 36 y/o, Caucasian, single mother of 3 y/o son and 8 y/o daughter Works as RN Nominated for Nurse of the Year Award Diverting Oxycodone from work Mother recovering alcoholic The pills made me feel competent, energetic. 9

10 Changing Demographics of Opiate Users Currently, about 1/3 of those with opioid dependence are women of child-bearing age (Unger et al. 2010) January 17, 2016 NY Times: The death rates of Caucasians, especially women, are rising (death rates for black and Hispanics continue to fall) Drug overdose New users predominantly white, living in nonurban areas 75% current heroin users began with Rx opioids first 10

11 Epidemiology The demographics of those who abuse heroin and other opiates has changed in recent years (Cicero, 2014) 1960s: mostly men abusing heroin Now: men and women Cicero, Ellis, Surratt, Kurtz (2014) 11

12 Prescription Opioids Mixed findings Several large scale studies found women more likely to use and abuse prescription opioids (CDC, 2016; Green et al., 2009, Rosenblum et al., 2007; Simoni-Wastila et al., 2000,2004, c.f. Back et al., 2010 In contrast, 2013 and 2014 NSDUH nonmedical use of pain medication still higher among men Rx misuse and overdose among women rapidly rising 12

13 Rx Opioids In the past two decades, opioid prescriptions have increased overall Women tend to be prescribed medication with abuse potential more often than men (Isacson and Bingefors, 2002; Simoni- Wastila, 2004) Women prescribed opiates more often than men (Anthony, 2008; Gu, 2010; McCabe et al., 2005; Parsells, 2008; Roe, 2003; Zhong 2013) More chronic pain (Wiesenfeld-Hallin, 2005) Lower pain tolerance (Berkley, 1997; Dixon et al., 2004) 13

14 Heroin Men still more likely to use heroin but women s use rapidly rising o Men and women equally likely to inject 14

15 Injection Drug Use Injection drug use in particular related to partner drug use (Powis et al. 1996) Women who inject heroin often have partner who also injects Women more likely to be introduced to injection by male partner Women more likely to share needles, leading to higher risk of infection (Maher et al. 2006) 15

16 Telescoping A faster course from commencing substance use to SUD and treatment onset More rapid progression of the disease more drug-related problems, sooner Several studies indicate a telescoping course for women with OUD 16

17 Treatment Women less likely to go to treatment compared to men Gender not predictive of LOS or outcome (Greenfield et al., 2007) 17

18 Children: Barrier to Treatment Women more likely to have children to care for (Bawor et al., 2015) Barriers to treatment Who will care for children while mother is in treatment? Many worry about custody issues (Greenfield et al., 2010) Mothers who are primary caretakers of the children may leave treatment early or not go at all due to childcare restraints (Castillo & Waldorf, 2008) 18

19 Children: Motivator for Treatment Evidence that women who live with their children more likely to go to treatment (Greenfield et al., 2010) Women who are able to have children with them in treatment or maintain custody, more likely to stay in treatment (Greenfield et al., 2010) 19

20 Other Barriers Women often caretakers, both at home and in caretaking professional roles (nurses, social services, etc.) Women in leadership roles at home and at work It can be a difficult role-shift to ask for help, accept help Shame Associated with relapse among women (Wiechelt & Sales, 2001) 20

21 Question How to motivate women to seek and sustain treatment? Whenever possible, reducing practical barriers including childcare Motivation to seek treatment: Often from primary care, welfare and other community agencies A non-judgmental approach allows women to be more open, reduce shame and stigma 21

22 Question Motivation to sustain treatment Motivational Interviewing Strengthen patient s own motivation to change Elicit and encourage change talk OARS Non-confrontational, compassionate, collaborative 22

23 Question When should children be removed from home/parent? Safety of child Move to a safe family member if possible Consult with experts in social work and/or law 23

24 Case Example 32 y/o single mother of 5 y/o boy and 3 y/o girl Father of children is in prison Patient is charged with attempting to sell drugs from her car while children are in the backseat Patient is mandated to treatment Children to live with patient s mother Patient s mother becomes legal guardian At least 6 months sobriety required to reassess 24

25 Medication Treatment Medication: Methadone, Buprenorphine, Naltrexone Consider gender-specific issues Different opioid binding capacity Hormone levels 25

26 Psychosocial Treatment In early recovery: Coping skills, problem-solving Meditation and breathing techniques Psychoeducation Motivational Interviewing Cognitive Behavioral Therapy Relapse Prevention Couples and Family 26

27 Question Are there structured support groups for recovering women? AA/NA women s groups Women s groups at specific treatment centers 27

28 Co-occurring Conditions Compared to men, women with OUD more likely to have: More physical health problems Family history of psychiatric illness Co-occurring psychological distress compared to men (Back, 2010; Green et al., 2009) 28

29 Psychiatric Comorbidity Anxiety Disorders PTSD, OCD Mood Disorders Major depression Dysthymia Manic Disorder (Grella et al., 2009) Eating Disorders Bulimia Disordered eating Borderline Personality Disorder 29

30 Co-Occurring Disorders Treatment Many symptoms of acute and post-acute withdrawal are also common to other mental health conditions: Anxiety, nervousness Insomnia Depressed mood Difficulty concentrating Important for treating clinician to differentiate and treat appropriately 30

31 Maternal Opioid Use is Increasing Opiate use among pregnant women 1.19 (2000) to 5.63 (2009) per 1000 hospital births per year Neonatal Abstinence Syndrome 1.20 (2000) to 3.39 (2009) per 1000 hospital births per year (Patrick et al., 2012) 31

32 Heroin During Pregnancy Heroin use during pregnancy associated with many adverse effects on fetus Short half-life, effects may be due to repeated withdrawal in the fetus Take into account lifestyle effects of some women actively using heroin Prostitution, theft, violence, STI s 32

33 Treatment of Pregnant Women Opioid withdrawal should be avoided in pregnant women Goals of MAT in pregnant women: Reduce risks of illicit opioid use and withdrawal Encourage prenatal care and treatment Reduce criminal activity Avoid associated risks 33

34 MOTHER Study Jones et al Methadone vs. buprenorphine in pregnant women Outcomes: Buprenorphine has similar maternal outcomes to methadone Buprenorphine resulted in less severe neonatal abstinence syndrome 34

35 Opioid Rx in Pregnant Women If an opioid dependent pregnant woman is Stable on single agent buprenorphine Remain on single agent buprenorphine Stable on Suboxone Switch to single agent buprenorphine Stable on methadone Remain on methadone* Naïve to agonist therapy Consider buprenorphine due to lower NAS severity *unless reason to switch to buprenorphine, e.g., moving to location without access to methadone clinic Risk of precipitated withdrawal, vulnerability to illicit drug use 35

36 Opioid Rx in Pregnant Women Always consider full medical and psychological history Assess dosage throughout pregnancy and adjust as necessary Inadequate dose may lead to withdrawal symptoms, fetal distress, vulnerability to use illicit drugs 36

37 Question Please discuss the connection between opiate medication combined with the epidural during childbirth and previous and/or future addiction. 37

38 Analgesia During Labor Women on methadone or buprenorphine should be offered analgesia options (epidural/spinal anesthesia) Maintenance dose not adequate for pain relief Avoid agonist-antagonist may precipitate withdrawal Women taking methadone should not be given buprenorphine 38

39 Analgesia During Labor Higher dose often needed for women on maintenance medication Continue regular daily dose of maintenance medication to prevent withdrawal Breastfeeding safe and encouraged Minimal levels of methadone and buprenorphine in breast milk 39

40 Question: OUD and Pain OUD and chronic pain commonly co-occur Women have: More chronic pain (Wiesenfeld-Hallin, 2005) Lower pain tolerance (Berkley, 1997; Dixon et al., 2004) Opiate pain medication should be avoided For individuals on maintenance medication, in the case of surgery, medical team should be notified and plan formulated 40

41 OUD and Pain Effective, non-pharmacological treatments for pain Psychoeducation Mindfulness exercises CBT cognitive restructuring activity pacing Grounding 41

42 Summary Women progress from first use to problem use faster than men Women more likely to have co-occurring physical or mental health condition Despite faster course, faster time to develop problems associated with opioid use, and more co-occurring disorders, women less likely to enter treatment compared to men Gender is not predictive of LOS or outcome 42

43 Summary Must take into account co-occurring disorders Special considerations for pregnant women 43

44 Additional Questions Could you address using while on methadone? Different treatment programs address this differently Total abstinence vs. harm reduction May indicate need for higher LOC 44

45 Additional Questions Info on changing standards for prescribing opioids. CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016 Recommendations and Reports / March 18, 2016 / 65(1); e1.htm 45

46 Additional Questions What are the studies identifying about the relapse statistics after a methadone maintenance program? According to California Society of Addiction Medicine, methadone maintenance success rates range from 60-90% Longer time in treatment, better outcomes Best outcomes when combine medication with psychosocial treatment 46

47 References Anthony M, Lee KY, Bertram CT, Abarca J, Rehfeld RA, Malone DC,... Woosley RL (2008). Gender and age differences in medications dispensed from a national chain drugstore. Journal of Women's Health, 17(5): Back SE, Lawson KM, Singleton LM, Brady KT (2011). Characteristics and correlates of men and women with prescription opioid dependence. Addictive Behaviors, 36: Back S., Payne RL, Wahlquist AH, Carter RE, Stroud Z, Haynes L.,... Lin W (2011). Comparative profiles of men and women with opioid dependence: results from a national multisite effectiveness trial.the American journal of drug and alcohol abuse, 37(5): Bawor M., Dennis BB, Varenbut M, Daiter J, Marsh DC, Plater C,... Desai D. (2015). Sex differences in substance use, health, and social functioning among opioid users receiving methadone treatment: a multicenter cohort study. Biology of sex differences, 6(1): Berkley KJ.(1997). Sex differences in pain. Behavioral and Brain Sciences, 20: Bernstein J, Derrington TM, Belanoff C, Cabral HJ, Babakhanlou-Chase H, Diop H,... Kotelchuck M (2015). Treatment outcomes for substance use disorder among women of reproductive age in Massachusetts: A populationbased approach. Drug and alcohol dependence, 147: Castillo DT, Waldorf VA (2008). Ethical issues in the treatment of women with substance abuse. The book of ethics: Expert guidance for professionals who treat addiction, Centers for Disease Control and Prevention (CDC). Prescribing Data. (2016, March 16). Retrieved April 10, 2016, from Centers for Disease Control and Prevention (CDC). Prescription painkiller overdoses: a growing epidemic, especially among women (2013, July.) Retrieved April 11, 2016 from Cicero TJ, Ellis MS, Surratt HL, Kurtz, SP (2014). The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA psychiatry, 71(7): Dixon KE, Thorn BE, Ward LC (2004). An evaluation of sex differences in psychological and physiological responses to experimentally-induced pain: a path analytic description. Pain, 112(1): Green TC, Grimes Serrano JM, Licari A, Budman SH, Butler SF. (2009). Women who abuse prescription opioids: findings from the Addiction Severity Index-Multimedia Version Connect prescription opioid database. Drug and Alcohol Dependence, 102 (1-2): Greenfield SF, Back SE, Lawson K, Brady KT (2010). Substance Abuse in Women. Psychiatric Clinics of North America, 33:

48 References Greenfield SF, Brooks AJ, Gordon SM, Green CA, Kropp F, McHugh RK.,... Miele, G. M. (2007). Substance abuse treatment entry, retention, and outcome in women: A review of the literature. Drug and alcohol dependence, 86(1): Grella CE, Karno MP, Warda US, Niv N, Moore AA (2009). Gender and comorbidity among individuals with opioid use disorders in the NESARC study. Addictive behaviors, 34(6): Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug data for NCHS Data Brief. 2010:1 8. Hölscher F, Reissner V, Di Furia L, Room R, Schifano F, Stohler R,... Scherbaum N (2010). Differences between men and women in the course of opiate dependence: is there a telescoping effect?. European archives of psychiatry and clinical neuroscience, 260(3): Isacson D, Bingefors K. (2002). Epidemiology of analgesic use: a gender perspective. European Journal of Anaesthesiology, 19: Jones HE, Finnegan LP, Kaltenbach K (2012). Methadone and buprenorphine for the management of opioid dependence in pregnancy. Drugs, 72(6): Maher L, Jalaludin B, Chant KG, Jayasuriya R, Sladden T, Kaldor JM, Sargent PL (2006). Incidence and risk factors for hepatitis C seroconversion in injecting drug users in Australia. Addiction, 101(10): McCabe, S, Knight JR, Teter CJ, Wechsler H. (2005). Non medical use of prescription stimulants among US college students: Prevalence and correlates from a national survey. Addiction, 100(1): Parsells KJ, Cook SF, Kaufman DW, Anderson T, Rosenberg L, Mitchell AA. (2008) Prevalence and characteristics of opioid use in the US adult population. Pain, 138: Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. (2012). Neonatal abstinence syndrome and associated health care expenditures: United States, Jama,307(18): Peles E, Adelson M, Seligman Z, Bloch M, Potik D, Schreiber S (2014). Psychiatric comorbidity differences between women with history of childhood sexual abuse who are methadone-maintained former opiate addicts and non-addicts. Psychiatry research, 219(1): Peles E, Weinstein A, Sason A, Adelson M, Schreiber S. (2014). Stroop task among patients with obsessivecompulsive disorder (OCD) and pathological gambling (PG) in methadone maintenance treatment (MMT). CNS spectrums, 19(06): Roe CM, McNamara AM, Motheral BR. (2002). Gender- and age-related prescription drug use patterns. Annals of Pharmacotherapy, 36:

49 References Rosenblum A, Parrino M, Schnoll SH, Fong C, Maxwell C, Cleland CM,... Haddox JD (2007). Prescription opioid abuse among enrollees into methadone maintenance treatment. Drug and alcohol dependence, 90(1): Ross J, Ross J, Teesson M, Ross J, Teesson M, Darke S,... Ross J. (2005). The characteristics of heroin users entering treatment: findings from the Australian treatment outcome study (ATOS). Drug and alcohol review, 24(5): Shah NG, Lathrop SL, Reichard RR, Landen MG (2007). Unintentional drug overdose death trends in New Mexico, USA, : Combinations of heroin, cocaine, prescription opioids and alcohol. Addiction, 103: Simoni-Wastila L. (2000). The use of abusable prescription drugs: the role of gender. Journal of women's health & gender-based medicine, 9(3): Simoni-Wastila L., Ritter G., Strickler G. (2004). Gender and other factors associated with the nonmedical use of abusable prescription drugs.substance use & misuse, 39(1): Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Unger A, Jung E, Winklbaur B, Fischer, G. (2010). Gender issues in the pharmacotherapy of opioid-addicted women: buprenorphine. Journal of addictive diseases, 29(2), Wiechelt SA, Sales E. (2001). The role of shame in women's recovery from alcoholism: The impact of childhood sexual abuse. Journal of Social Work Practice in the Addictions, 1(4): Wiesenfeld-Hallin Z. (2005). Sex differences in pain perception. Gender Medicine, 2: Zhong W, Maradit-Kremers H, St. Stauver JL, Yawn BP, Ebbert JO, Roger VL (2013). Age and sex patterns of drug prescribing in a defined American population. Mayo Clinic Proceedings, 88: Zweben, J. E. (2003). Special issues in treatment: Women. Principles of addiction medicine, 3111:

50 PCSS-O Colleague Support Program and Listserv PCSS-O Colleague Support Program is designed to offer general information to health professionals seeking guidance in their clinical practice in prescribing opioid medications. PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management. Our mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties. The mentoring program is available at no cost to providers. For more information on requesting or becoming a mentor visit: Listserv: A resource that provides an Expert of the Month who will answer questions about educational content that has been presented through PCSS-O project. To join pcss-o@aaap.org. 50

51 PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and Southeast Consortium for Substance Abuse Training (SECSAT). For more information visit: For questions pcss-o@aaap.org Funding for this initiative was made possible (in part) by Providers Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department 51 of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.