Treating Opioid Use Disorders: An Update for Counselors and Other Providers

Transcription

1 Treating Opioid Use Disorders: An Update for Counselors and Other Providers Brad Shapiro, MD Medical Director Opiate Treatment Outpatient Program Zuckerberg San Francisco General

2

3 THE DOSING WINDOW

4 HISTORICAL CONTEXT

5 THE FIRST OPIOID EPIDEMIC IN AMERICA What was the key invention? Iatrogenic Addiction to Morphine Photo: Anesthesia and Intensive Care, Vol. 28, No. 1, February 2000 Patent Medicines

6 PATENT MEDICATIONS

7 PROLIFERATING INEFFECTIVE CURES

8 8

9 9

10 New York Times Photo (Brendan Hoffman 7/22/08) 10

11 11

12 SWEDISH MORTALITY DATA Drug and Alcohol Dependence 7; 1981:

13 SWEDISH DATA: MORTALITY TREATED VS UNTREATED Acta Psychiatr Scand 1990; 82:

14 Recent Trends Prescription Opioid Epidemic Buprenorphine Treatment Integration and System Changes New Roles for OTPs New Drug use patterns, practices and challenges Interventions to decrease prescribing

15 Heroin Use (NSDUH 2014) 435,000 Current heroin users 914,000 Used heroin in the past year 586,000 people with heroin use disorder (NSDUH 2014)

16

17

18 Pain Reliever Use Increased Dramatically (NSDUH, 2002)

19

20 Non-Medical Pain Reliever Use

21

22 Commonly Abused Opioids Diacetylmorphine (Heroin) Hydromorphone (Dilaudid) Oxycodone (OxyContin, Percodan, Percocet, Tylox) Meperidine (Demerol) Hydrocodone (Lortab, Vicodin)

23 Commonly Abused Opioids (continued) Morphine (MS Contin, Oramorph) Fentanyl (Sublimaze) Propoxyphene (Darvon) Methadone (Dolophine) Codeine Opium

24 Norco or Fentanyl?

25 Source: Office of the Chief Medical Examiner, San Francisco Fentanyl powder Counterfeit Xanax

26 Forearm Injection Drug Abuse Photo: C. Redis

27 Forearm Injection Drug Abuse Photo: C. Redis

28 Shoulder Abcess post incision and drainage Injection Drug Abuse Photo: C. Redis

29 Antecubital Fossa Injection Drug Abuse Photo: C. Redis

30 ADDICTION AS A CHRONIC ILLNESS Chronic relapsing condition which untreated may lead to severe complications and death.

31 ADDICTION AS CHRONIC DISEASE: IMPLICATIONS It is treatable but not curable. Adjustment to diagnosis is part of patient s task. There is a wide spectrum of severity. Retention in treatment is key. Best treatment is integrated.

32 Four questions patients ask: How is methadone better for me than heroin? What is the right dose of methadone for me? How long should I stay on methadone? What are the side effects of methadone?

33 Legal How is methadone better than heroin? Avoids needles Known amount ingested Slow onset: no rush Long acting: can maintain comfort or normal brain function Stabilized physiology, hormones, tolerance

34 Methadone Simulated 24 Hr. Dose/Response At steady-state in tolerant patient Dose Response Loaded High Normal Range Comfort Zone Subjective w/d Sick Objective w/d 0 hrs. Time 24 hrs. Opioid Agonist Treatment of Addiction - Payte

35 Four questions patients ask: How is methadone better for me than heroin? What is the right dose of methadone for me? How long should I stay on methadone? What are the side effects of methadone?

36 What is the right dose? Eliminate physical withdrawal Eliminate craving Not over-sedated Blocking dose Patient preference/harm reduction

37 What is the right dose?: Other Medical Concerns Comfort/function: usually trough is ng/ml, peak no more than twice the trough. Minimize risk of Torsade de Pointes Minimize hyperhydrosis Reduce risk of serotonin syndrome

38 38

39 Methadone Simulated 24 Hr. Dose/Response At steady-state in tolerant patient Dose Response Loaded High Normal Range Comfort Zone Subjective w/d trough Sick Objective w/d 0 hrs. Time 24 hrs. Opioid Agonist Treatment of Addiction - Payte

40 % Heroin Use Recent Heroin Use by Current Methadone Dose Methadone Dose, in mg. Ref: J. C. Ball, November 18, 1988 Slide adapted from Tom Payte

41 How Much???? Enough!!! Tom Payte, MD

42 Four questions patients ask: How is methadone better for me than heroin? What is the right dose of methadone for me? How long should I stay on methadone? What are the side effects of methadone?

43 Relapse to IV drug use after MMT 105 male patients who left treatment 100 Percent IV Users IN 1 to 3 4 to 6 7 to 9 10 to 12 Treatment Months Since Stopping Treatment Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991 Opioid Agonist Treatment of Addiction - Payte

44 How Long??? Long Enough!! Tom Payte, MD

45 Four questions patients ask: How is methadone better for me than heroin? What is the right dose of methadone for me? How long should I stay on methadone? What are the side effects of methadone?

46 Opiate effects, physical Predictable physical effects of administering opiates: Tolerance: the body becomes efficient in processing the drug and requires ever higher doses to produce the desired effect. Dependence: when the drug is discontinued there are typical withdrawal signs and symptoms.

47 Side effects of methadone: General opiate effects: Sedation/stimulation Maintained phys. dependence (stable) hypogonadism (not as severe as with heroin, may be dose dependent) Constipation Slight QTc prolongation on ECG (Martell etal) Sweating Methadone treatment tied to regulated clinic

48 Treatment Outcome Data 4-5 fold reduction in death rate reduction of drug use reduction of criminal activity engagement in socially productive roles reduced spread of HIV excellent retention (see: Joseph et al, 2000, Mt. Sinai J.Med., vol67, # 5, 6)

49 Crime among 491 patients before and during MMT at 6 programs 300 Crime Days Per Year Before TX During TX 0 A B C D E F Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991 Opioid Agonist Treatment of Addiction - Payte

50 HIV CONVERSION IN TREATMENT 35% 30% 25% 20% 15% IT OT 10% 5% 0% Base line 6 Month 12 Month 18 Month HIV infection rates by baseline treatment status. In treatment (IT) n=138, not in treatment (OT) n=88 Source: Metzger, D. et. al. J of AIDS 6:1993. p.1052 Opioid Maintenance Pharmacotherapy - A Course for Clinicians

51 Other drugs of abuse: how do they affect MMT? Stimulants: patients may have poor outcomes Alcohol: additive sedation, complicate Hep C. Benzodiazepines: synergistic sedation THC: no effect on major outcomes Opioids: usually blocked, tolerance

52 Pregnancy OAT treatment of choice for pregnant, opioid-abusing women. Both Buprenorphine and Methadone are options Efforts to avoid intra-uterine fetal withdrawal, including split dose. Neonatal withdrawal occurs within 72 hours, at least 45% need treatment. Breastfeeding recommended if not HIV positive.

53 Pain in patients on MMT Methadone is prescribed for pain treatment in twice or three times daily doses. Up to 60% of MMT patients have chronic pain (Jamison 2000, Rosenblum 2003) Split doses may be indicated.

54 Pharmacotherapy in context: correct glossary Abstinence includes pharmacotherapy Maintenance, not substituion or replacement (new term also: MAT) Tapering from maintenance, not detoxification, (also medically supervised withdrawal, or MSW) Discontinuation, not discharge Toxicology screens: pos/neg, not clean/dirty)

55 BUPRENORPHINE

56 A FEW WORDS ABOUT BUPRENORPHINE Ceiling effect and safety Displaced other opiates: withdrawal on induction Sublingual tablet Schedule 3(methadone is 2) One form combined with naloxone Office based use available

57 Comparison of Activity 100 Levels Full Agonist (e.g. methadone) % Mu Receptor Intrinsic Activity Partial Agonist (e.g. buprenorphine) 10 0 no drug low dose Antagonist (e.g. naloxone) high dose DRUG DOSE

58

59

60 Buprenorphine, Methadone, LAAM: Treatment Retention 100 Percent Retained 80 73% Hi Meth 60 58% Bup 40 53% LAAM 20 20% Lo Meth Study Week Johnson et al, 2000

61 Buprenorphine, Methadone, LAAM: Opioid Urine Results Mean % Negative All Subjects 49% 40% 39% 19% LAAM Bup Hi Meth Lo Meth Study Week

62 Effect of counseling in buprenorphine treatment (Fiellin, 2002) 1 Opioid positive urines MM MM+DC 0 Induction week 2-4 week 5-7 week 8-10

63 Retention in treatment Kakko et al, 2003, Remaining in treatment (nr) Control, 6-day detox Buprenorphine maintenance Treatment duration (days)

64 Opioid pharmacotherapy, summary: Methadone, buprenorphine and LAAM all approved by the FDA for treatment of opiate dependence. (LAAM not currently available from any drug company) Best evidence so far supports maintenance. Detoxification attempts should have maintenance as a back up in case of relapse.

65 OVERDOSE PREVENTION

66

67 Overdose Prevention

68 Overdose prevention, including prescribing or dispensing naloxone, is an essential complement to both detoxification services as well as medically supervised withdrawal

69 Outcomes of Heroin Overdose Source: Darke S, Mattick RP, Degenhardt L. The ratio of non-fatal to

70 Positive - More cautious about dosing or timing - Improved knowledg e about opioids and overdose - Reduced polysubsta nce use - Not using opioids al one Neutral I ve probably been a little more cautious. Just being careful to take the right amount, count the hours just thinking more cautiously about dosing. Source: Behar E, Rowe C, Santos G-M, Murphy S, Coffin PO. Primary Care Patient Experience with Naloxone Prescription.