Medication Supported Recovery- A Review of Evidence-Based Practice

Transcription

1 Medication Supported Recovery- A Review of Evidence-Based Practice Andrew B. Mendenhall, MD, DABAM, DABFM, Senior Medical Director, Substance Use Disorder Services, Central City Concern 1

2 Objectives 1. Discuss the science and best-practices for the treatment of opioid use and alcohol use disorders. 2. Discuss historical barriers that exist within the treatment and recovery culture. 3. Review the stages of change and challenges in managing more of the SUD population. 4. Discuss the ideal model of care-integration to meet the needs of more of the SUDS population. 2

3 The Medical Literature 1. Supports the use of medication to help patients improve their probability of abstinence. Data has been around for nearly 50 years. Alcohol Use Disorders Opioid Use Disorders 2. Supports the attendance of fellowship groups as increasing the probability of sustained abstinence. Less than 15% of patients who attend 12-step meetings will continue to be active at 12 months. 90 meetings in 90 days is as effective as a 28 day residential treatment. Very poor outcomes data-self reported success rates of 80% or more 3

4 Oral Naltrexone and Alcohol Use Disorder

5 The Medical Literature 3. Demonstrates that treatment of Depressive Disorders markedly reduces substance use but have a minimal effect on the probability of total abstinence. 4. Informs clinicians that the disease of addiction is a chronic relapsing brain disease. Spectrum Disease- Mild, Moderate, Severe Vastly less expensive to treat than it is to ignore or to provide less effective treatment modalities. Edward V. Nunes, MD; Frances R. Levin, MD JAMA. 2004;291(15): doi: /jama

6 Slide from Dr. Darryl Inaba Pharm.D. CADC III

7 CEREBRAL ACTIVATION AND OPIOID CRAVNG Images Showing Differences in Activation of the Left Medial Prefrontal and Anterior Cingulate Cortex Between Response to a Drug-Related Audio-taped Script and to a Neutral Audio-taped Script in 12 Abstinent Opiate-Dependent Subjects Am J Psychiatry 158:10, Oct. 2001

8 CEREBRAL ACTIVATION AND OPIOID CRAVING Images Showing Activation in the Left Orbitofrontal Cortex Correlated With Scores on a Composite Crave/Urge Visual Analogue Scale for Eight Abstinent Opiate-Dependent Subjects. Am J Psychiatry 158:10, Oct. 2001

9 The History and Culture of Addiction Treatment 12-Step Fellowship has defined most of the culture of recovery for the past 80+ years Bill W. and Dr. Bob. AA, NA, HA, MA, OA, SAA Guiding principle of a spiritual transformation that occurs through fellowship and step-work. MILLIONS OF LIVES SAVED through this practice and culture. The Minnesota Model refers to the Hazelden-BettyFord Residential experience developed during the 1950s-1970s. Historically, the concept of taking any medication for any reason has been associated with not being abstinent. False belief that medication somehow impairs the possibility of spiritual transformation. 9

10 The History and Culture of Addiction Treatment 1969 The first Methadone programs opened in San Francisco, New York, Baltimore. Operated in relative silence and obscurity from the establishment form of drug and alcohol treatment s-1980 s Scientific Advances in understanding brain structure and function lead to clinical advances in treatment. Buprenorphine treatment access in the 1980 s in Europe s Addiction is Stigmatized: Crack Cocaine Epidemic Racial Injustice Industrialized, for-profit prisons 10

11 The History and Culture of Addiction Treatment DATA 2000/2004 Buprenorphine Access in the United States. Early 2000 s the Opioid Epidemic begins to declare itself Mental Health And Addiction Parity Act Clinical Access Deficiency to Evidence-Based Treatment Epidemic levels of Overdose and Death Criminal Justice systems practicing medicine. Persistent philosophical divide surrounding what works vs. what is best. 11

12 Patients Maintained with OAT Demonstrate VASTLY Less Relapse with Opioids. (OAT = Opioid Agonist Treatment)

13 What are the costs of caring for patients? (OAT = Opioid Agonist Treatment)

14 VAST Chasm between NEED and ACCESS Jones et. al. American Journal of Public Health, June 11 th,2015 Electronic Publication-Peer Reviewed. Jones et. al. American Journal of Public Health, June 11 th,2015 Electronic Publication-Peer Reviewed.

15 State-by-State Access Regression Analysis Jones et. al. American Journal of Public Health, June 11 th,2015 Jones et. Electronic al. American Publication-Peer Journal of Public Reviewed. Health, June 11 th,2015 Electronic Publication-Peer Reviewed.

16 Additional Challenges Low-quality MAT programs that do not hold patients accountable. Cash for buprenorphine programs. No Urine Monitoring Infrequent follow-up visits High-quality MAT programs that provide access to medication support in exchange for rigid standards around total abstinence. Stage-of-change mismatch Highest level of care first, then step-down Barriers to real-world engagement- like employment. Often abandon patients who are not successful. Blaming the patient who is not ready.

17 Additional Challenges Ok- I am a prescriber but I don t just want to prescribe. The patient needs treatment and Some Treatment Programs don t want MAT in their milieu Not Recovery Not Abstinence Vivitrol or Naltrexone is OK but Not Buprenorphine or Methadone Some Supportive Housing Environments don t want MAT in their milieu Same Allegations

18 Who to Care for and How to care for them? What segment of the SUD population are you capable of helping? Who can help you help more of the population? Who doesn t want to do anything differently? How can you work together to collaboratively care for more patients?

19 Severe SUD Patient Experience Crime Law Enforcement Employer Insurance Payer CJ/Restitution STOP Courts (MSR?) Sober Living (MSR?) Family Residential (MSR?) Drug Using Community Patient Outpatient Tx. (+/- MAT) ER/IC for Pills ER/IC for O.D. Deliver NAS Baby DETOX CTR Buprenorphine/V ivitrol Outpatient Admission to Hosp. Medical Admission for Psych. DEATH Methadone OTP

20 Medication support allows more patients to enter treatment: SUD= Substance use disorder -Treat earlier = Less Severe -Less impact on work and family -More outpatient, less inpatient

21 Defining Treatment Phases/Programming Stabilization for 3-6 months Maintenance for 6+ months Opioid positive Opioid negative + Impairment from other substances Opioid negative Early Recovery Use of substances without impairment Opioid negative With Rare use of ETOH or Cannabis Opioid negative And totally clean and sober It is critical to consider clinical stage of change and your program s threshold for management of a precontemplative patient population. This is particularly important considering cannabis and/or episodic alcohol use. It is ALSO critical to have an expedited pathway for clinical non-responders to Medication Support

22 A Fully Integrated Medical Home for Recovery A FULLY DEVELOPED SYSTEM: Accountable Care Organization Sober Housing ER Inpatient Day Tx Restitution Center (CJ) IC Clinic Medication Support from a Medical Clinic IOP OP OTP (methadone) and/or Suboxone Case Management/Recovery Management

23 Concluding Thoughts 1. What can you do to provide increased access to evidence-based practices for the treatment of substance use disorders? 2. What are the barriers that exist for you to successfully achieve the above? 3. Who can you ask for support and development of these services within your regional continuum? 23

24 THANK YOU Andy Mendenhall M.D. 24