Evidence-Based Practices for the Treatment of Opioid Use Disorder. Zach Ludwig, LPC Corporate Director Clinical Programs Bradford Health Services

Transcription

1 Evidence-Based Practices for the Treatment of Opioid Use Disorder Zach Ludwig, LPC Corporate Director Clinical Programs Bradford Health Services

2 Objectives Review the scope of the opioid epidemic Discuss clinical challenges working with opioid use disorder Identify treatment considerations including definition of best practices and integration along a continuum of care.

3 The more we learn about the treatment of addiction, the more we realize that one size does not fit all. -Petros Levounis, St. Luke s-roosevelt Hospital, quoted by The NY Times, 7/10/2011

4 Pre-Test Which of the following items best describes the difference between opioids and opiates? Opiates are natural substances; opioids are synthetic or semi-synthetic substances Opiates are always illegal; opioids are always prescribed by a physician Opiates are used in medication assisted treatment; opioids are not used in medication assisted treatment Opioids can be fatal; opiates are safe

5 Which of the following items is not true about opiate abstinence syndrome? It can last up to 14 days It starts within 4-6 hours of last use It typically results in death It includes flu-like symptoms

6 Which of the following scenarios does not increase the risk of an opioid overdose? Using heroin laced with fentanyl Using a combination of heroin and benzodiazepines Taking opioid medication as prescribed following a surgery Returning to a previous dose of heroin immediately after detoxification from opioids

7 Which of the following medications can reverse an opioid overdose? Naloxone Suboxone Methadone Benzodiazepine

8 Which of the following medications is a buprenorphine product? Methadone Suboxone Vivitrol Kratom

9 The Medication Assisted Treatment of choice for opioid dependent pregnant women is? Methadone Naloxone Vivitrol Methamphetamine

10 Which of the following counseling modalities are recommended with Medication Assisted Treatment? Interpersonal-process Psycho-educational Cognitive-behavioral All of the above

11 Scope of Problem Lifetime non-medical use of prescription pain relievers has increased three-fold over the last decade. Despite the fact that opioid overdose is now the leading cause of accidental death in the U.S., nearly 80 percent of individuals with an opioid use disorder do not receive treatment (2016).

12 Opioids Opioids are a class of drugs that include the illicit drug heroin as well as the licit prescription pain relievers oxycodone, hydrocodone, codeine, morphine, fentanyl and others. Opioids are chemically related and interact with opioid receptors on nerve cells in the brain and nervous system to produce pleasurable effects and relieve pain.

13 Nationally Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled. Deaths from prescription opioids drugs like oxycodone, hydrocodone, and methadone have also quadrupled since In 2014, overdoses from opiates (heroin and prescription medications) surpassed car accidents as the leading cause of injury-related death in America.

14 Opioid Overdose Deaths (Total US)

15 2017 (Provisional) Overdose Comparison of All-Types Overdoses 49,060 Opioid Overdose Deaths 72,287 All-Type Overdose Deaths 68% of overdose deaths were opioidrelated

16 Opioid Overdose Deaths by State,

17 Relationship between Opioid Use and Heroin Use 4 in 5 new heroin users started out misusing prescription painkillers. In a 2014 survey, 94% of respondents said they chose to use heroin because prescription opioids were (comparatively) too expense and harder to obtain % of those who abuse prescription opioids move on to inject either opioids or heroin marked the first time in two decades that number of HIV diagnoses attributed to injection drug use (IDU) increased.

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19 Access to Medications The CDC reported that southern states (particularly Alabama, Tennessee, and West Virginia) had the most painkiller prescriptions per person. Nationally, in 2012, providers wrote 259 million prescriptions for painkillers In Alabama, in 2012, doctors wrote 143 prescriptions for every 100 people. States with higher sales per person and more nonmedical use of prescription painkillers tend to have more deaths from drug overdoses. CDC,2014

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21 Diversion of Medications in Alabama Hydrocodone drugs (such as Vicodin) have the highest incidence of diversion. Diversion typically occurs through three main streams: Direct illegal distribution and sale of prescription drugs by health care professionals and workers in the healthcare arena Doctor Shopping (going to different doctors to obtain multiple prescriptions) Fraudulent Internet purchase

22 Prescription Monitoring Programs The CDC recommends the national implementation of state-run Prescription Drug Monitoring Programs (PDMPs). Thirty-five states have operational programs. Alabama s PDMP was established in 2006 and currently monitors controlled substances with schedules II-V.

23 A Brief History of Opioids Civil War-era: Morphine, Laudenum, and Paregoric widely available could even be purchased in Sears catalogue 1874: Heroin invented the new drug was advertised as a safe, non-addictive substitute for morphine (marketed by Bayer in 1895) 1920: U.S. passes Dangerous Drug Act that makes OTC sale of opiate-derivates illegal

24 Fast Forward 1990s: OxyContin advertised in a big push as a low addiction risk pain management alternative to other drugs Early 2000s: Pain is added as the Fifth Vital Sign for medical practitioners to assess and pressure was on to treat the reported pain And doctors feared consequences if they did not meet these apparent needs While prescribing rates are on the decrease, federal officials still say that rates are too high.

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26 Overdose Quantity Comparison

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28 Opioid Overdose Deaths by Opioid Type,

29 Overdose Deaths in U.S. by Synthetic Opioids (other than Methadone) Deaths A 639% increase since

30 Patient Characteristics (Non-Elderly Adults with Opioid Use Disorder) Nearly 2 million people addicted to prescription opioids, 591,000 people addicted to heroin (2015) Predominantly white, male, young More likely living in rural areas Slightly more likely to be employed than not, but many have low incomes 38% (in 2016) were covered by Medicaid 441,000 were uninsured (2015) Overall receipt of treatment is low (less than 30%) Those with Medicaid are significantly more likely than those with private insurance or the uninsured to receive treatment

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32 Opioid Overdose Deaths by Gender,

33 Opioid Overdose Deaths by Race/Ethnicity,

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35 Aging Face of Opioid Users 60% of long-term opioid users are between 40 and 64 years old 98% said they use opioids to relieve pain 40% started use due to pain 25% started because of pain after surgery 25% started because of pain after an accident/injury 70% said they have debilitating disability or chronic disease Less than 25% worked full time 33% were on disability or retired (20%) 97% received medication from a physician

36 In 2016, a third of the more than 40 million Americans enrolled in Medicare Part D received prescription opioids and a substantial number received higher doses than recommended for prolonged periods of time, putting them at increased risk of misuse. Between 2005 and 2014, the rate of opioidrelated hospitalizations increased fastest among patients aged 65 years and older compared with all other age groups

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39 Opioid Overdose Deaths by Age Group,

40 Recovery A return to a normal state of health, mind, or strength. The action or process of regaining possession or control of something stolen or lost.

41 Realities about Treatment Success Rates of opiate dependent individuals leaving detoxification against medical advice (AMA) are high Relapse following detoxification is often rapid Overall rates of relapse are high Likelihood of entrance into and completion of abstinence-based residential treatment is low

42 Treatment Challenges Addiction Primary and Immediate A family pattern often a pediatric condition Chronic Terminal Transferable to other addictions Characterized by denial and defensiveness A Disease Reinforced by social factors, habitual behavior patterns, employment/financial status, and mental status Cannot be seperated from emotional, behaivoral, cognitive, or spiritual functioning of the person

43 Retention Longer retention is the most consistent predictor of favorable treatment outcomes. Pretreatment motivation related to higher engagement. More positive therapeutic relationships led to lower levels of during-treatment drug use, better session attendance, and longer retention. Lower during-treatment drug use was related to longer retention.

44 Retention Who remained in treatment longer? Patients who perceive their addiction as serious Have higher expectations of improvement And with greater confidence that they would attain the treatment goals

45 Risk Factors for Unplanned Discharge Age: younger age has been correlated as a retention barrier Socioeconomic status: having money has been correlated with sustaining drug treatment; inability to stop working may make treatment difficult; consider other factors associated child care, out-of-pocket costs Conversely, unemployment has been shown to be correlated with treatment abandonment (likely for same associated reasons as above) Gender/Ethnicity: inconsistent predictors

46 Risk Factors for Unplanned Discharge Lower education level History of arrests (though legal coercion is associated with reduced risk of drop-out and better long-term outcomes for short-term resid., long-term resid., and outpt tx) Earlier onset of substance use (i.e. longer drug histories) Greater previous treatments Polysubstance use Impaired coping skills Lower perception of treatment benefits Depression and avoidance coping (self-medication) Lower motivation Limited social support

47 Treatment Options for OUD Behavioral treatments educate patients about the conditioning process and teach recovery management strategies. Medications such as methadone and suboxone operate on the opioid receptors to relieve cravings. Medications such as naltrexone block opioid receptor sites. Combining the two types of treatment enables patients to stop using opioids and return to more stable and productive lives.

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49 Abstinence [Minnesota Model] Bio-psycho-social holistic in approach Brief detoxification, typically 1-2 weeks Counsels patient to remain abstinent from ALL mood altering drugs for the rest of their life (high bar, but addiction is chronic and transferable substance-to-substance) Heavily dependent on mutual support groups and 12 step foundation Origin in alcohol treatment

50 Clinical Interventions Motivational Interviewing Since most patients are Pre-Contemplation, this modality is very effective with individuals early in treatment. Cognitive Behavioral Therapy (CBT) Once individuals enter the Contemplation, Action or Maintenance Stage, most effective. Contingency Management Based on principles of operant conditioning Uses reinforcement (e.g., vouchers) of positive behaviors in order to facilitate change

51 Medication-Assisted Treatment (MAT) Specific to opioid and alcohol use disorders Also called replacement therapy; a harmreduction model Methadone Buprenorphine Naloxone Naltrexone/Vivitrol

52 Purpose of Medication-Assisted Treatment Manage physical withdrawal symptoms Reduce risk of drug overdose Block any euphoric effect Facilitate therapeutic engagement Achieve long-term changes and prevent return to use

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54 Methadone An agonist, the most widely used maintenance agent The mainstay of treatment therapy for many years contributing vastly to harm reduction and prevention policies Disadvantages: May produce dependence resulting in increased doses with time Subsequent detoxification may be more difficult than from heroin Methadone is a full agonist at mu-opioid receptors and can therefore lead to severe respiratory depression. Dispensed in special clinics where frequent visits are required

55 Buprenorphine A partial agonist at the opioid mu-receptor: Functions on the same brain receptors as morphine but does not produce high, dependence, or withdrawal syndrome Prevents morphine from binding to opiate receptors, thus blocking its pleasurable effects Blocks withdrawal discomfort by keeping the receptors occupied Maximal effects are less than those of full agonists like heroin and methadone, i.e. a ceiling effect Lower risk of abuse, dependence and side effects compared to full agonists. Overdose is rare except when combined with benzodiazepines Purpose of prescription is to reduce harm minimize withdrawal symptoms thereby decrease need for continued illicit acquisition.

56 Advantages of Buprenorphine vs. Methadone: Low level of dependence results from repeated use Produces lower subjective euphoric A ceiling effect exists for respiratory depressive effects; some reports of reduction in mortality by 10-fold More applicable for patients with heart or metabolic illness Cited as suitable for home use, can be more easily implemented by outpatient facilities Easier termination of medication Withdrawal symptoms are milder compared to methadone

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58 Subutex / Suboxone Subutex (buprenorphine) Suboxone (buprenorphine plus naloxone) When Suboxone is injected intravenously, naloxone is intended to precipitate withdrawal effects in opioid-dependent users to attenuate feelings of drug liking, and to provide a generally unpleasant experience. Buprenorphine and buprenorphine in combination with naloxone both have higher efficacy in study (2003) than placebo.

59 Naloxone Designed to rapidly reverse opioid overdose. It is an opioid antagonist it binds to opioid receptors and can reverse and block the effects of other opioids. It can very quickly restore normal respiration to a person whose breathing has slowed or stopped as a result of overdosing with heroin or prescription opioid pain medications. EVZIO is a prefilled auto-injection device that makes it easy for families or emergency personnel to inject naloxone quickly into the outer thigh. Once activated, the device provides verbal instruction to the user describing how to deliver the medication, similar to automated defibrillators. NARCAN Nasal Spray is a prefilled, needle-free device that requires no assembly and is sprayed into one nostril while patients lay on their back.

60 Detox and Buprenorphine Buprenorphine, in some studies, has been shown to be more effective than Clonidine to reduce signs and symptoms of heroin withdrawal Gradual dose tapering (28-36 days) appears to be associated with the best outcomes Just following detox, a patient is prone to risk for relapse If transferring from methadone, switch to naltrexone is often delayed for up to 14 days due to potential for precipitated withdrawal problems If transferring from buprenorphine, switch to naltrexone can be well tolerated in significantly less time

61 Naltrexone Opioid receptor antagonist Non-addictive Non-mood altering drug that blocks euphoria from the use of opiates; it has no agonist effects no opioid subjective effects Potential impairment of neuroendocrine function could be assumed with long-term use; however, remarkably few negative effects have been noted in patients taking naltrexone daily for years Has also been cited to reduce alcohol cravings Injection form (Vivitrol) lasts 28 days; also available in pill form that lasts 24

62 Detoxification The process which eventually leads to the addict achieving a drug-free state through the gradual or abrupt withdrawal of the illicit or prescribed drug. Detox schedules are: Labor intensive Require many resources and support for success Once detoxed, administration of opioid antagonist (naltrexone) can be used to block the effects of any subsequent opiate use

63 Detoxification Research Detoxification alone has limited long-term effectiveness Short-term treatment and detoxification success has been negatively correlated with individuals with extensive opioid abuse history, previous treatment attempt(s), and criminal justice history. Limited-duration pharmacotherapy has, per research, been shown to be successful with individuals who have stable social support, have some period of abstinence at baseline, and report no IV use.

64 Conflicting Modalities An abstinence-based approach and medication-assisted therapies have historically existed separately. Meanwhile, overdose deaths climb. Each approach has challenges: Abstinence: drop out rates (AMAs) tend to be high since cravings/medical needs are not adequately addressed. MAT: often very limited help and support with the mental, emotional, social and spiritual aspects of addiction

65 Hazelden s Comprehensive Opioid Recovery (COR-12)

66 Hazelden s Comprehensive Opioid Recovery (COR-12) Treatment Modality developed by Hazelden for individuals with OUD After initial stabilization, based on individual situations, Treatment Team recommends one of three options for patients. If necessary a person in any of the tracks will receive Buprenorphine / Naloxone for detoxification. All tracks receive the same comprehensive treatment services.

67 MAT Considerations Diagnosis of moderate to severe opioid use disorder Patient preference, autonomy Current intoxication/withdrawals/imminent withdrawal, including severity Need for additional resources/education Polysubstance use, concerns about interactions (esp benzo) Medical condition, concerns about interactions (esp pregnancy) Environmental impact on ability to comply Prior history of MAT (pro/con) Pre-treatment motivation level, likelihood of compliance

68 Collaborative Approach Each treatment camp has concerns: substituting one drug for another; disregard for advancements in neurological science. Goal should be to combine strengths of each approach: MAT to control cravings and manage physical dependence Biopsychosocial (person-centered) focus to address underlying factors of addiction

69 Challenges to Collaboration Currently, there is inconsistency among MAT providers emphasizing other types of treatment Especially when working in high-volume settings If addressed is discussed more as recommendation than requirement Emphasizes a lower-intensity (monthly) approach than may be required Lack of controls of content

70 and-in-hand MAT buys the newly-abstinent person time Time to get traction in recovery Time to change playgrounds and playmates Time to create and maintain self-serving thinking habits. Time to repair relationship damage Time to work on the basics: Housing security Financial security Vocational and educational advancement A user who does not aggressively address these crucial aspects of his/her addiction during MAT often ends up at the end of MAT with little change having occurred and at risk. Duration of MAT is far less important than what you do with the period of normalcy it creates for you.

71 oving Forward MAT professionals must recognize that recovery is not just addressing physical dependence. Must address the bio-psych-social for abstinence to be sustainable Abstinence approach caregivers must recognize that MAT provides a valuable part of the solution Managing physical cravings that often create insurmountable barriers to treatment Both must do everything in their power to increase retention Longevity of engagement is the greatest predictor of success Until you get physical dependence under control,

72 he more we learn about the eatment of addiction, the ore we realize that one size oes not fit all. -Petros Levounis, St. Luke s-roosevelt Hospital, quoted by The NY Times, 7/10/2011