Opioid Use Disorder Treatment Initiation in Diverse Settings

Transcription

1 Opioid Use Disorder Treatment Initiation in Diverse Settings Sarah Wakeman, MD, FASAM Medical Director, Mass General Substance Use Disorder Initiative Assistant Professor, Harvard Medical School

2 Disclosures Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.

3

4 Ongoing Death Toll Due to Heroin/Fentanyl Dowell D. Underlying Factors in Drug Overdose Deaths JAMA. Published online October 11, doi: /jama Copyright 2017 American Medical Association. All Rights Reserved.

5 Learning from other epidemics: HIV/AIDS

6 Medication Saves Lives

7 Medication Saves Lives Maryland: 50% reduction in overdose death with opioid agonist treatment France: 79% reduction in overdose death opioid agonist treatment

8 Long-term Outcomes: Most Patients Get Well Weiss et al. Drug Alc Depend. 2015;150:112-9.

9 Systems Failures, Not Patient Failures Patient admitted to the hospital with heart attack Told it s her fault because of diet, high stress job, and history of tobacco use Advised to call a list of cardiologists/cath labs Told she can t get aspirin or cholesterol medication until she sees a nutritionist first Sent home with a stern reminder to not have another heart attack

10 Systems Failures, Not Patient Failures Patient admitted to the hospital with endocarditis Told it s her fault because of her substance use disorder Advised to call a list of treatment programs Told she can t get addiction medication until she sees a counselor first Sent home with a stern reminder to not use drugs

11 OD deaths per 100 pys Being Wait-listed For Treatment is Deadly 2.5 Methadone in Norway: Clausen et al. Addiction Treatment waitlist During treatment Off treatment

12 Rate per 1000 person years Deaths Increase When Medication Stopped Overdose Mortality In Treatment Out of Treatment Overdose Mortality N= people treated with buprenorphine over years (Sordo BMJ Apr 26;357:j1550.)

13 Relapse & Cost Reduced with Methadone or Buprenorphine Relapse reduced by 50% Costs $153 to $223 lower per month Clark RE et al. J Subst Abuse Treat Oct;57:75-80

14 What is Effective Treatment? Pharmacotherapy Full opioid agonist: methadone Partial opioid agonist: buprenorphine Opioid antagonist: naltrexone Recovery Supports AA, NA, SMART recovery Recovery coaches Psychosocial Interventions CBT, MI/MET, CM, TSF

15 Goal of Medications for Addiction Treatment Relieve withdrawal symptoms Block effects of other opioids Reduce cravings Restore normal reward pathway

16 Hospitalized patients Initiating methadone in hospital: 82% present for follow-up addiction care Initiating buprenorphine vs detox: Bupe: 72.2% enter into treatment after discharge Detox : 11.9% enter treatment after discharge J Gen Intern Med. Aug 2010; 25(8): ; JAMA Intern Med 2014 Aug;174(8): )

17 Treatment in the ER 78% vs 37% engaged in buprenorphine treatment Fewer days of self-reported opioid use D'Onofrio et al. JAMA 2015 Apr 28;313(16):

18 Treatment in Primary Care No difference in self reported opioid use, opioid abstinence, study completion, or cocaine abstinence between the 2 groups Fiellin DA et al. Am J Med 126:1 2013

19 Treatment in Correctional Facilities 21 studies: 6 experimental, 15 observational Treatment during incarceration reduced heroin use, injection, and syringe sharing during incarceration Pre-release opioid agonist therapy increased treatment entry, retention, & reduced post-release heroin use (4/5 studies)

20 Treatment in Harm Reduction Settings Buprenorphine harm reduction pilot Patients retention similar to standard buprenorphine 68%, 63%, 56%, 42% retained at 3, 6, 9, 12 months Stancliff et al. J Addict Dis 2012;31(3):

21 Mobile Treatment Mobile treatment enrolled a greater proportion of African-American, homeless, and uninsured individuals than the fixedsite methadone clinics More likely to be using daily & injecting Less likely to have a recent history of treatment Suggest mobile treatment may increase entry for most vulnerable patients J Subst Abuse Treat Apr;46(4):511-5

22 1 Among patients with SUD Dx code on floors where ACT available; Controlled for type of substance, gender, age 2 remained statistically significant in intention-to-treat analysis and after controlling for age, gender, employment status, smoking status, and baseline days abstinent (p=0.02) Hospital Addiction Consultation Associated with Lower Readmission Rates, Increased Abstinence ACT Consults: 4235 consults 32% involve opioids 70% male, mean age Change in Days Abstinent 2 Intervention Patients seen by ACT have 25% lower 30-day readmission Initial 30 Day Follow-Up

23 Bridge Clinic & Integrated Outpatient Care Provides SUD Treatment Across MGH Bridge Clinic Bridge Clinic provided On Demand Visits for 596 Patients 50% of visits not scheduled ahead Mean LOS 76 days, median 25.5 For recent inpatients, 10.4% readmitted within 30 days Integrated SUD Treatment in Primary Care Multidisciplinary primary care teams In CHCs alone: 38 physicians waivered to prescribe buprenorphine treating 546 patients 10 recovery coaches have had 11,556 contacts with 1,233 patients Linkage to a recovery coach associated with 25% fewer inpatient admissions & 44% more outpatient appointments

24 You Need a Pulse to Get Into Recovery!

25 Big Picture: Addressing the Overdose Crisis Prevention Treatment Harm Reduction Judicious opioid prescribing Address risk factors for development of OUD Immediate access to opioid agonist therapy Reduce stigma Naloxone Syringe exchange Safe consumption sites

26 Thank