Health Systems and Addiction: Provider Issues

Transcription

1 Health Systems and Addiction: Provider Issues The Emerging Roles of Primary Care Patrick G. O Connor MD, MPH Dan and Amanda Adams Professor of General Medicine Chief, General Internal Medicine Yale University School of Medicine ECRI Institute s 23 rd Annual Conference on the Use of Evidence in Policy and Practice November 16-17, 2016 National Academy of Sciences, Washington, D.C. Yale University School of Medicine, General Internal Medicine

2 Treatment for Addiction is Highly Effective Evidence-based addiction treatments: Counseling & behavioral therapies Medication therapies Combination of both Treatment is effective for: Tobacco Alcohol Other drugs

3 Evidence-based Counseling Treatments for Addiction CBT v MET v TSFT (N=1726) * Outpatients Inpatients Abstinent 19% 35% 54% 60% Non-abstinent 35% 25% Relapse (to heavy drinking) 46% 40% *1 year outcomes, Project MATCH Research Group. J Stud Alcohol 1997;58:7-29

4 Evidence Supporting the Effectiveness of Medications for Treating Alcohol Dependence Medication # of studies # of pts studied NNT Effect-size Approved for AUD Disulfiram Acamprosate Naltrexone PO Naltrexone IM Topiramate Gabapentin Holt & Tetrault, Clinics in Liver Disease,

5 Evidence-based Treatment for Opioid Use Disorder: Methadone Maintenance Decreases: Improves: Limitations: heroin and other drug use HIV and hepatitis B/C infection crime & social dysfunction obstetric and birth outcomes overall survival restrictions = limited access few programs patient acceptance Expanded treatment options needed O Connor PG. NEJM 2000: 344.

6 Evidence-based Behavorial Intervention in Drug Use Disorders: CBT4CBT trial Carroll et al., Am J Psyph, 2014

7 Despite Evidence of Treatment Effectiveness: An Addiction Treatment Gap Exists in the U. S. There continues to be a large treatment gap in this country. In million Americans - 8.4% - needed specialized treatment for addiction, however million people or only 11% those in need received treatment. [NIDA Drug Facts, December 2012] Would we tolerate this lack of access to treatment for: Cancer? Diabetes? Myocardial Infarction? No! Expanded access to addiction treatment is needed: Enhance access to current evidence-based treatments in traditional settings (e.g.: expand sites, insurance coverage) Develop new models of treatment

8 New Models: Addiction Treatment in Primary Care and Other General Medical Settings Why? Increase entry points to addiction treatment and treatment capacity Coordinate addiction treatment and medical care under one roof Approach addiction like other chronic diseases Engage patients in less stigmatizing medical settings Where? Primary care clinics and offices Other general medical settings such as: Emergency departments Inpatient medical settings

9 COCHRANE REVIEW: Brief Intervention for Heavy Drinkers in Primary Care Office based Brief Intervention : Nondependent heavy drinkers feedback & advice concerning heavy drinking provided by a general physician 5-10 minutes, within a routine office visit, 1-2x 24 randomized trials, N: >7000, drinks/w decreased mean consumption by up to 9 drinks/w, benefit most clear in men Conclusion: Overall brief interventions in primary care lowers alcohol consumption.

10 Naltrexone Works in Alcohol Dependent Patients in Primary Care Primary Outcomes CBT PC p (n=97) (n=93) Responder (n, %) 77 (79.4%) 74 (79.6%) ns Percentage of days abstinent ns Secondary Outcomes Drinks per drinking day ns No relapse to heavy drinking 60 (61.9%) 52 (55.9%) ns Continuous Abstinence (n, %) 43 (44.3%) 31 (33.3%) ns GGT end point change from baseline (mean + SD) ns OCDS total score Therapy (mean + SD) ns Arch Int Med 2003, 163:

11 How does the effectiveness of alcohol pharmacotherapy compare other drugs? Pharmacotherapy vs placebo for maintaining abstinence and/or reducing heavy drinking days? NNT = 5-12 SSRIs vs placebo for Rx of depression? NNT = 7-9 for a significant reduction in depression Statin vs placebo for primary prevention of one nonfatal MI? NNT = 104 DVT prophylaxis vs no treatment to prevent one nonfatal PE? NNT = 345 Barth, BJ Psychiatry, 2016 Ray et al, Arch of Int Med, 2010 Lederle, Ann of Int Med, 2011

12 Primary Care Buprenorphine Maintenance for Opioid Dependence: First Randomized Clinical Trial Am J Med. 1998;105(2):100-5.

13 The Birth of Office-based tx of Opioid Dependence: Drug Addiction Treatment Act (DATA) 2000 Amended 1970 CSA: allow office-based treatment of opioid dependence. Physicians may qualify for DEA approval by: Board Certification as addiction specialist, or... Training: 8 hour course, classroom or online But only DEA Schedule III-V drugs can be used & none were available in 2000, until : Buprenorphine/naloxone was approved by the FDA.

14 Intensity of Counseling: Does adding Cognitive Behavioral Therapy (CBT) help? American J Med, 2013; 126, 74.e11-74.e17

15 Percent opioid negative Primary Care Buprenorphine: More Effective in Prescription Opioid Abuse? Heroin only Heroin & Prescription Prescription only American J Med, 2013; 126, 74.e11-74.e17

16 Primary Care Buprenorphine: Prescription Drug Abuse Taper vs Maintenance Fiellin D et al. N Engl J Med 2006;355: JAMA Intern Med. 2014;174:1947

17 Primary Care Buprenorphine: Long Term Outcomes (2-5 years) Am J Addict, 2008; 17:

18 Emergency Department Initiated Buprenorphine: 30-Day Outcomes Days of Opioid Use Treatment Engagement Past Week Illicit Opioid Use 100% 6 90% 80% 70% P< SRT Referral 60% 50% 40% 30% 20% 10% SBIRTBI+Re f SBIRT+BupP Bup+PC C 0% Referral Brief Intervention +Referral Bup+PC Enrollment 30-Day JAMA 2015; 313:

19 Impact of Office-based Treatment since DATA 2000: Methadone and Buprenorphine Treated Patients , Methadone Methadone 0 0 Buprenorphine Buprenorphine

20 Impact of Office-based Treatment since DATA 2000: Methadone and Buprenorphine Treated Patients , , Methadone Methadone Buprenorphine Buprenorphine

21 DATA 2000: Sixteen Years Later August 8, 2016: DHSS final rule increased buprenorphine patient limit from 100 to 275, eligibility criteria: Have current waiver to treat 100 patients Board certification in Addiction Medicine or Addiction Psychiatry Practice in a qualified setting : 24/7 service, accepts 3 rd party payments access to case-management & services health IT compliant PDMP registration

22 Comprehensive Addiction Recovery Act CARA 2016 Improve access to opioid overdose treatment Expand Medication-Assisted Treatment (MAT) for opioid use disorder: Expand prescribing privileges to NPs and PAs: 24 hours of training required, details to come soon State-by-state variability in prescribing laws apply Exclude patient limit when medication is directly administered Grants to expand the availability of MAT Improve treatment for pregnant and post-partum women

23 The Physician s Role in Preventing Addiction: Opioid Sales, Deaths, and Treatment Admissions

24 Improving Addiction Medicine Education in Medical School and Residency Training Ann Intern Med, 2011; 154:56-59

25 Addiction Medicine: New Subspecialty Approved by ABMS in October 2015

26 Health Systems and Addiction: Provider Issues The Emerging Roles of Primary Care Evidence-based treatments for addiction are well established: Counseling & behavioral therapy Medications Access to these treatments is poor Along with improving access to traditional settings, new models are needed to expand access to evidence-based treatment Primary care and other general medical settings can effectively help to fill this need