John Murphy DO, MS Lynx Healthcare

Transcription

1 Addiction to Pain Medication and Treatment John Murphy DO, MS Lynx Healthcare

2 No Disclosures

3 Objectives 1 Understand basic neurobiology and learning theory around opioid addiction 2 Identify aberrant behavior and relationship to addiction 3 Identify and describe 3 treatments for MAT (medication assisted treatment) 4 Describe HUB and SPOKE concept 5 Understand pseudoaddiction

4 HUB and Spoke Designated all OTP methadone programs as HUBS 5 HUBS-Chittenden, Central, Northeast, Southeast, and Southwest. Due to continued need, adding a 6 th Hub in Northwest region, opening 1/17 Opened HUBS in all regions of the State to serve all counties by end of 2014 (leveraged ACA 90/10 funding to support enhancements over 8 quarters)

5 HUB and Spoke

6 HUB SERVICES Buprenorphine could be prescribed just like methadone within the HUBS More flexibility with take homes offered every other day or every third day dosing Introduced the use of Med-o-wheels for securing take homes of buprenorphine tablets Required all patients to FULLY DISSOLVE and ABSORB sublingually both forms of buprenorphine-films and tablets- in a 5 minute observation period Prior Authorization process put in place by Medicaid for mono buprenorphine and all doses over 16 mg

7 HUB Process 1 Patient called in the early morning for a same-day intake 3 Patient stopped opiates for a designated period of time, Office induction followed by dosing 2 Within 1 business week patient reported for intake history and physical 4 Patient seen one week later for possible dose adjustment

8 HUB SERVICES Intake/Physical exams Screening for STDs, TB, HIV, Hep A, B, C, and education and referral Onsite urine screening and breathalyzer Medical and psychological evaluation and screening Pregnancy screening and birth control information

9 HUB Process Daily dosing of Suboxone Weekly MAT groups Monthly individual counseling Level of care decided by the counselor Callbacks: Patients chosen randomly. Patient called and given 24 hours to report for urine sample and film count. Each film has a serial number to ensure compliance

10 Outcomes 20% 50% 75% 75% Patient population: 75 percent with psychiatric comorbidity including PTSD, bipolar disorder, major depression, borderline About 50 percent retention at 6 months 20 percent achieved take homes often after one year Roughly 75 percent of urine drug screens drug-free after 6 months personality

11 Washington HUB and SPOKE Available in 12 of the State s 39 counties No daily dosing as yet HUB serves as MAT program Serving 1600 patients

12 Mechanism of Addiction Addiction is the result of a complex interaction of the physiological effects of drugs on brain areas associated with motivation and emotion Mesolimbic dopamine systems

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14 Mesolimbic Pathways

15 Neuronal Transmission

16 Pavlovian Classical Conditioning Learning theory applied to addiction

17 Examples Venopuncture for labs can trigger cravings for heroin via classical conditioning

18 Learning Theory

19 Even an image of cocaine use produces a response

20 Prescription to addiction n=2507 patients average exposure to COAT (Chronic Opioid Analgesic Therapy) 26 mos. 11.5% 5.8% 80% 80% of opioid addicted patients started with a prescription Aberrant drug related behaviors 11.5% Abuse/addiction 5.8%

21 Aberrant Behaviors (Continue to Monitor) Admitted to wanting opioids for anxiety* Abnormal urine/blood screen** Solicited opioids from other providers Unauthorized ER Visits Unauthorized dose escalation** * Consider referral to mental health ** Refer if recurrent ***?Pseudoaddiction **** Refer if more than once Resisted therapy changes/alternative therapy Canceled clinic visit Requested early refills, recurrent?**** Requested refills instead of clinic visit No show or no follow-up

22 Aberrant Behaviors (Refer to Addictionology) Admits to using opioids for euphoria Used additional opioids than those prescribed, more than once Forged prescription Sold prescription Overdose Injected drug (or intranasal use) Abnormal urine/blood screen positive for 2 or more substances Concurrent abuse of alcohol (recurrent ethyl glucuronide in UDS despite warning. S of prior alcohol.? cough medicine) Reported lost or stolen prescriptions, recurrent? Abused prescribed drug Third party required to manage patient s medication Was discharged from practice (dependent upon reason for discharge)

23 Pseudoaddiction Definition: Iatrogenic disease resulting from withholding opioids for pain that can be diagnosed, prevented, and treated with more aggressive opioid treatment. Three phases: Pain onset: Patient receives inadequate analgesia and requests more RX Escalation: Patient realizes that to receive additional medication, he/she has to convince the provider of the legitimacy of the pain

24 Pseudoaddiction (cont) In crisis, culminating when unrelieved pain continues, the patient engages in increasingly bizarre drug seeking behaviors. When the pain is adequately treated, the behavior returns to normal. My story: R knee OA with increased pain with driving and trying to sleep. The PA prescribed tramadol pending arthroscopic meniscectomy. When I ran out I called the orthopedic surgeon.

25 Pseudoaddiction Fact or Fiction? Pseudoaddiction discussed in 224 articles 12 articles were proponents of pseudoaddiction (4 with pharmaceutical funding) None empirically tested or confirmed 1989 single case report of a 17 year old male with leukemia admitted for pneumonia and chest wall pain given morphine 5 mg IV. Given additional pain meds. Over 3 days progressively exhibiting addiction behaviors like seeking his dose too early, requesting specific opioids, and engaging in pain behaviors including crying and moaning

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27 Case Study 1 62 year old male with back and knee pain,osa,htn OA. Started tx in July with oxycodone. Dose adjusted to 6 tablets daily. Over time dose reduced to 4 daily. Addiction History: Alcohol 15 years of abuse ending in Cocaine for years DC in the 90s. When the dose was reduced suffered increased anxiety an panic attacks. Bought oxycodone on the internet. He was embarrassed by this behavior. What would be the best plan to provide good patient care? a. Discharge the patient with a short taper. Continue treatment as high risk with no opiates. b,. Discontinue opiates and refer to mental health. c. Refer to addictionology.

28 Case 1 cont. Referred to addiction. Opiates discontinued. Panic got worse, seen in ER and returned the next day. COWS score of 11 (high) Panic attack observed in the office. Induced on Suboxone. Reported sleep disturbance, nightmares and extreme anxiety. Reports that anxiety was better on higher doses of opiates.?ptsd Patient recalled trauma at age 19 when he was lost in the woods for 4 days. Low dose gabapentin for anxiety. Over the next few weeks withdrawal well controlled but reported pain of 8/10. Reduced by 50% when suboxone was titrated to 8 mg TID. Referral to mental health pending. Difficult to find provider who accepts medicaire. Gabapentin increased to 1200mg daily with total relief from panic attacks and some relief from anxiety (some concern over abuse potential and respiratory depression) Working diagnosis Substance Use Disorder, GAD,?PTSD

29 Case Study 2 42 year old female treated with oxycodone for the past 6 months with no aberrant behavior. Two weeks ago +UDS for cocaine which she admitted. Next step a. Discharge the patient with a quick taper b. Discharge With no taper c. Refer to addictionoology

30 Case Study 2 cont Patient referred to addiction. Admitted a remote history of cocaine use. Went to a party, drank too much. Judgement was affected by alcohol and snorted cocaine. Appeared motivated to comply with the program. Strong warning against the use of alcohol. Resumed treatment with high risk precautions. Any illicit drug use will lead to discharge

31 Case study 3 43 year old female hairdresser treated for neck pain with oxycodone 10 mg QID. Taking one extra pill daily every month over the past 3 months despite a warning. Unable to work full time without the additional dose. Plans to transfer to management in the next few years. Plan a Discharge the patient with a taper b Discharge with no taper c addictionology consult

32 Case study 3 cont Addiction consulted. Difficult case. No DSM 5 criteria except using additional medication. Recommend dose change. Possible pseudoaddiction.? No more aberrant behavior. Complicated by regulatory constraints

33 The higher the ACE score is, the more likely a person is to experience an increased risk for the following health problems and diseases: Alcoholism & Alcohol Abuse Illicit Drug Use Early Initiation of Smoking Smoking Early Initiation of Sexual Activity Adolescent Pregnancy Multiple Sexual Partners Sexually Transmitted Diseases (STDs) HIV Unintended Pregnancies Fetal Death Risk for Intimate Partner Violence Depression Suicide Attempts Health-Related Quality of Life Chronic Obstructive Pulmonary Disease (COPD) Ischemic Heart Disease (IHD) Liver Disease

34 ACE score 40% ACE score > 4 correlates with 2-4 x more likelihood of drug or alcohol abuse Relief of anxiety and depression 40% of addiction is related to heredity

35 ACE

36 Residential Most studied population emerging adults age admission for prescription opioid dependence increase by 350 percent in this population 2014 study n=290, 30 day residential treatment program including motivational enhancement, cognitive behavioral therapy, and family based therapy At 12 months, 29 percent were drug-free, including those that had decided to discontinue MAT

37 Medication Assisted Treatment Buprenorphine prescribing alone does not constitute a recovery program Medication assisted recovery emphasizes the need for treatment including therapy and substance abuse counseling

38 ACE score 2009 n=121 Baltimore primary care setting 56% 64% 47% After 12 months, 56% remaining in treatment and 64% of their months were opioid negative drug screens 47% were opioid negative for 6 months or more

39 Methadone Started in 1964 in New York City Outcomes are very similar to buprenorphine except retention is considerably better in methadone clinics More structure than buprenorphine using daily dosing and limited take-home opportunity

40 Antagonist Treatment Naltrexone is an opiate antagonist at the mu receptor Disadvantages: To avoid precipitous withdrawal the patient needs to be drug-free for short acting opiates at least 48 hours but as long as one week for longacting opiates like methadone Painful at the injection site Compliance difficult with by mouth medication

41 Outcomes with Naltrexone Treatment 2016 N equals 308 Received monthly injections of 380 mg of naltrexone 43% 64% Relapse defined as use of opiates for 10 days out of 28 days No overdoses were seen in the study 43% relapse rate in the study group versus 64% and the control

42 Questions?