Pennsylvania Coordinated Medication Assisted Treatment: A Penn State and Pennsylvania Psychiatric Institute Story

Transcription

1 Pennsylvania Coordinated Medication Assisted Treatment: A Penn State and Pennsylvania Psychiatric Institute Story Sarah Sharfstein Kawasaki, MD Director of Addictions Services, Pennsylvania Psychiatric Institute Assistant Professor of Psychiatry and Internal Medicine, Penn State Hershey Medical Center

2 Disclosures: I have nothing to disclose

3 Learning Objectives: 1. What is Addiction? What is Dependence? 2. What is the problem, and how did we get here? 3. Treatment Options: what the evidence tells us 4. Challenges: the stigma of Opioid Use Disorder and its treatment 5. Penn State and PPI s approach

4 Thought Exercise: If you were diagnosed with stage III colon cancer, which treatment would you pick? A. Survival rate: 76% at 6 months B. Survival rate: 53% at 6 months C. Survival rate: <10% at 6 months D. Unknown survival rate

5 Definitions 1. Addiction: Strong desire to use, inability to control use, continued use despite obligations, social functioning, impaired health, spending a lot of time obtaining and using opioids 2. Physiologic Dependence: withdrawal symptoms after stopping or reducing use

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7 Why is it bad? 1. Mortality a. Death rates from overdoses: 3,785 in 2000 to 72,000 in 2017 b. US non Hispanic white population deaths are up mostly to poisonings, suicide: Case and Deaton, Proc Nat Acad Sci 2015 comparable to lives lost in the US AIDS epidemic

8 Why is it bad? 2. Morbidity: infection with HIV, Hepatitis C, hospitalizations for heart, bone, skin infections Causes of HCV infection March 2015: An HIV outbreak in Southern Indiana caused Gov. Mike Pence to declare a health emergency on Thursday and authorize a needle-exchange program Chicago Tribune

9 How bad is it? Past Month and Past Year Heroin Use Among Persons Aged 12 or Older: Source: SAMHSA, 2014 National Survey on Drug Use and Health, 2015 Source: National Survey on Drug Use and Health: Summary of National Findings, 2012.

10 How bad is it? Slide courtesy of Nora Volkow, Director of NIDA, ASAM plenary, 2016

11 How bad is it? Slide courtesy of Nora Volkow, Director of NIDA, ASAM plenary, 2016

12 How did we get here? Big Pharma: Purdue spreading misinformation Medical Culture: Pain as the fifth vital sign DEA lapses: failure to go after distributors diverting drugs, New lack of access from doctors not prescribing HEROIN + + =

13 What are the treatment options? 1. Methadone 2. Buprenorphine 3. Naltrexone: Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication no. (SMA) Rockville, MD: US Substance Abuse and Mental Health Services Administration, bv.fcgi?rid=hstat5.chapter.72248

14 What does the evidence say? Definitions: How do we measure success? a. Reduction in overdoses/deaths b. Retention in treatment c. Reduced recidivism d. Reduced disease transmission

15 What does the evidence say? Methadone a. Reduction in death rates: Gronbladh et al, MMT vs 115 controls over 8 years 34 VD vs 53 NVD vs 115 controls

16 What does the evidence say? Methadone b. Retention in Treatment: Newman et al, Lancet 1979: 100 heroin addicts randomized: Detox/placebo Maintenance 76% retention rate at 32 weeks in MMT 10% in placebo 56% retention rate at 3 years 2% in placebo

17 What does the evidence say? Methadone c. Reduction in recidivism rates: Dole et al, NEJM 1969

18 What does the evidence say? Methadone d. Reduced Disease transmission: Gowing et al, JGIM 2005: 28 studies 7900 methadone patients Results: methadone significantly reduces the high risk behaviors of HIV transmission (eg, IVDU, high risk sex) and seroconversion

19 What does the evidence say? Buprenorphine a. Reduction in death rates

20 What does the evidence say? Buprenorphine b. Retention in Treatment: 255 patients 56% retained at 1 year Those with polysubstance use were more likely to adhere to treatment 64% were opioid negative in tox screens for >6 months Soeffing et al, JSAT 2009

21 What does the evidence say? Buprenorphine c. Reduction in recidivism rates: Criminal charges compared between methadone maintenance and office-based buprenorphine 2 years prior to treatment vs 2 years after initiating treatment Significant reductions in the methadone group in all charges and drug charges No significant reductions in the buprenorphine group Rastegar, Kawasaki et al, Substance use and misuse 2016

22 What does the evidence say? Buprenorphine d. Reduced Disease transmission: Compares two methods: 15 day detox (2x) and 21 therapy sessions with Bup/naloxone Every 3 day dosing of Bup/naloxone for 48 weeks with 21 therapy sessions In 4 high risk communities in Thailand and China Followed for 52 weeks after treatment Long Term (LT) buprenorphine rx associated with less heroin and injection drug use by nearly 3x as much as short term detox Dramatically reduced rates of HIV-risk behavior Metzger et al, 2015 J Acquir Immune Defic Syndr

23 What does the evidence say? Naltrexone a. Reduction in death rates *Note: These patients VOLUNTARILY wanted naltrexone *abstinent at start of trial *Note: No patient continued injections after 24 week trial

24 What does the evidence say? Naltrexone b. Retention in Treatment: SJ Cousins et al. JSAT, 2016 Those who identified as homeless, injected heroin or having mental illness were less likely to stay in treatment

25 What does the evidence say? Naltrexone c. Reduction in recidivism rates: Gordon, et al. Journal of substance abuse treatment April 2015 One small study Non randomized 27 incarcerated individuals with OUD in the year prior to incarceration Received 1 injection prior to release and 6 injections in the community 10(37%) retained in treatment Those completing treatment less likely to test positive for opiates Those who didn t were more likely to be re-arrested Did not reach level of statistical significance.

26 What does the evidence say? Naltrexone d. Reduced Disease transmission: Has not been studied specifically. We do know it is more effective at producing negative urine drug screens than placebo

27 What does the evidence say? Comparison Studies Treatment retention Mattick et al, 2014, Cochrane Review: buprenorphine vs methadone vs placebo 31 studies, ~5500 participants Methadone better at retention in treatment (52 weeks) (RR 1.12) vs buprenorphine Buprenorphine much better than placebo for 52 week retention (16mg)(RR 1.88)

28 What does the evidence say? Naltrexone b. Buprenorphine vs Naltrexone: Lee et al. Lancet, 2018

29 What does the evidence say? Naltrexone b. Buprenorphine vs Naltrexone: Tanum et al, Jama Psychiatry 2017

30 How are people receiving treatment?

31 Challenges: STIGMA Doctors not treating with buprenorphine Doctors not mandating counseling along with buprenorphine Lack of shared treatment planning I know what s best for you Lack of understanding No fly lists at local hospitals

32 Challenges: STIGMA Perception from 12 step (and patients themselves) that patients aren t drug free Clean vs dirty Concern that bad behavior gets rewarded Concern for diversion outweighs concern for treatment

33 McClellan et al, JAMA 2000 Addiction like an acute condition (rehab, detox) But, more like type 2 diabetes, HTN and asthma Easily, reliably diagnosed Heritability (twin studies): HTN 25-50%, 35% heroin Type 2 diabetes 80%, Asthma 36-70% 55% alcohol 52% THC 61% nicotine Behavioral modifiers: (salt/carb intake,smoking) Treatment works, medication works Adherence: <40% 50-70% recurrence needing medical care

34 McClellan et al, JAMA 2000 Addiction: Little evidence for detox alone Problems medication adherence Poverty Lack of family support Psychiatric comorbidities We discharge as in for a knee replacement Do we do this for HTN? Relapse = need for maintenance Relapse for SUD = treatment failure.

35 Challenges: STIGMA From a criminal justice problem public health problem Is it a disease or a sin?? vs

36 MAT Treatment Cascade Williams, Nunes and Olfson, Health Affairs Blog March 2017

37 Regional ERs: Inpatient units: Rural clinics unaffiliated with hospitals Drug free counseling facilities Community Health clinics, mental health clinics: MDs, NPs, PAs Opioid Treatment Program,PPI Methadone induction & Buprenorphine maintenance ER naltrexone Counseling Safety net primary care ΨΨΨ Legal Services Pain management clinics Inpatient detox treatment induction facilities Probation/Parole Drug Courts

38 Thought Exercise: If you were diagnosed with stage III colon cancer, which treatment would you pick? A. Survival rate: 76% at 6 months B. Survival rate: 53% at 6 months C. Survival rate: <10% at 6 months D. Unknown survival rate

39 Thought Exercise: If you were diagnosed with opioid use disorder, which treatment would you pick? A. Methadone (76%) B. Buprenorphine (53%) C. Drug-Free (<10%) D. Extended release Naltrexone (??)

40 Thank you