Opioid Use Disorders as a Brain Disease Why MAT is so important Ron Jackson, M.S.W., L.I.C.S.W. Affiliate Professor School of Social Work University of Washington
Organization Name: CareOregon Course Title: Opioid & Substance Use Summit Location: Seaside, OR Date: April 24, 2018 Disclosure: It is the policy of the Oregon Medical Association (OMA) to ensure balance, independence, objectivity, and scientific rigor in its CME activities. To comply with the Standards for Commercial Support of the Accreditation Council for Continuing Medical Education (ACCME), the OMA requires members of the planning committee, applicable staff and faculty to disclose the existence of those commercial interests which produce, market, re-sell, or distribute health care goods or services consumed by, or used on patients with which he/she or their spouse/partner either: a) have a relevant financial relationship now, or b) have had a relevant financial relationship during the past 12 months. Non-profit companies, non-health care related companies and government organizations do not need to be included. The members of the faculty and planning committee and applicable staff for this conference have indicated that they have no financial relationships to disclose. Faculty members have declared that they will uphold the OMA s standards regarding CME activities and that any clinical recommendations are based on the best available evidence or are consistent with generally accepted medical practice. Please indicate in the comments section of the evaluation form whether you detect any instances of bias toward products manufactured by commercial interests. CME Credit: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint providership of the Oregon Medical Association and Columbia Pacific CCO. The Oregon Medical Association (OMA) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Oregon Medical Association designates this live activity for a maximum of 8 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity.
U.S. Opioid Epidemic
U.S. Opioid Epidemic
U.S. Drug Overdose Death Rates 1999-2016 Source: NCHS, National Vital Statistics System, Mortality
U.S. Drug Overdose Death Rates by Age Group 1999-2016 Source: NCHS, National Vital Statistics System, Mortality
U.S. Drug Overdose Death Rates 2016 Source: NCHS, National Vital Statistics System, Mortality
Rate per 100,000 Opioid-Related Drug Deaths 1999-2016 15 10 5 0 1999 2001 2003 2005 2007 2009 2011 2013 2015 Washington Oregon Alaska Idaho Centers for Disease Control and Prevention, National Center for Health Statistics; 1999-2016 on CDC WONDER Online Database
Opioid-related drug deaths - WA
Drug-Drug Interactions CNS DEPRESSANTS SEDATIVE-HYPNOTICS ETHANOL, BARBITURATES, BENZODIAZEPINES OPIOID ANALGESICS MORPHINE, HEROIN, METHADONE, CODEINE, OXYCODONE, DEMEROL, FENTANYL
Opioids Dates to 4,000 BC Mimics endorphin activity Natural - Opium, morphine, codeine Semi-synthetic- Heroin, Dilaudid Synthetics - Darvon, Demerol, Fentanyl, Oxycontin (oxycodone)
HEROIN & OTHER OPIOIDS ACUTE USE SYMPTOMS DECREASED HEART RATE, BLOOD PRESSURE AND RESPIRATION RATE CONSTRICTED PUPILS DROOPING EYELIDS AND SLURRED SPEECH SLEEPINESS / SEDATION NAUSEA RELIEF OF PHYSICAL / EMOTIONAL PAIN (ANALGESIA)
HEROIN & OTHER OPIOIDS CHRONIC USE SYMPTOMS Constipation Decreased Sexual Interest Tolerance Hyperalgesia Heroin & Illicit Prescription Opioids: Criminal lifestyle to support habit Lifestyle changes Hepatitis and HIV infection through needle sharing and other hiv high risk acts
Opioid Withdrawal Syndrome Acute Symptoms FLU-LIKE SYMPTOMS RUNNY NOSE WATERY EYES DILATED PUPILS GOOSE FLESH STOMACH CRAMPS & DIARRHEA INCREASED HEART RATE & BLOOD PRESSURE INTENSE DISCOMFORT 4-7 days (short-acting opioids) 10-21 days (methadone, if on long term)
Opioid Withdrawal Syndrome Protracted Symptoms Deep muscle aches and pains Insomnia, disturbed sleep Poor appetite Reduced libido, impotence, anorgasmia Depressed mood, anhedonia Drug craving and obsession
ADDICTION INVOLVES MULTIPLE FACTORS Biology/Genes Environment DRUG Brain Mechanisms Addiction
Drug Dependence: A Chronic Medical Illness Genetic Heritability twin studies Hypertension 25-50% Diabetes Type 1: 30-55%; Type 2: 80% Asthma 36-70% Nicotine 61% (both sexes) Alcohol 55% (males) Marijuana 52% (females) Heroin 34% (males) Voluntary Choice shaped by personality and environment Pathophysiology neurochemical adaptations Treatment Response Medications effectiveness and compliance Behavioral interventions McLellan, A.T., et.al., Drug Dependence, a Chronic Medical Illness Journal of the American Medical Association 284:1689-1695, 2000.
If addiction is a chronic disease: Addiction treatment doesn t cure the disease. The goal of treatment is to: Provide patients the tools to help them manage their addiction and medications are among those tools Teach them how to use those tools to achieve and maintain recovery
Psychological and Social Problems X Counseling & social supports Addiction Opioid addiction treatment medicines X Brain changes and Dependence
Medications for the Treatment of Opioid Use Disorders Research clearly and consistently shows that medication assisted treatment for opioid use disorder saves lives and money. mortality rates were 75 percent higher among those receiving drug-free treatment compared to those receiving buprenorphine (or methadone) Health Affairs, August 2011 vol. 30 no. 8 1425-1433
How do Medications for Opioid Addiction Work? There are three types of medications that can block the high : Agonists produce opioid effects Partial Agonists produce moderate opioid effects Antagonists block opioid effects
How do Medications for Opioid Addiction Work? Opioid Effect Full Agonist (e.g., methadone) Dose of Opioid Partial Agonist (e.g. buprenorphine) Antagonist (e.g. Naloxone)
How does methadone work? Methadone binds to the same receptor sites as other opioids. Orally effective Slow onset of action Long duration of action Slow offset of action
Treatment Outcome Data: Methadone 8-10 fold reduction in death rate Reduction of drug use Reduction of criminal activity Engagement in socially productive roles; improved family and social function Improved physical and mental health Reduced spread of HIV Excellent retention
Methadone Treatment For Opiate Addiction Lowers Health Care Costs Source: State of Washington, DSHS, Research & Data Analysis Division, Report 4.49fs, June, 2004
Buprenorphine Buprenorphine/ Naloxone
Formulations of Buprenorphine Buprenorphine is currently marketed for opioid treatment under the trade names: Subutex (buprenorphine) Zubsolv (buprenorphine/naloxone) (1 Mo. Inj.) Suboxone (buprenorphine/naloxone) Suboxone Sublingual Film (buprenorphine/naloxone) Sublocade 5.7 mg. bup./1.4 mg. nalox. 1.4 mg. bup./0.36 mg. nalox. Probuphine - 6 months implant requires surgical procedure 32
The Role of Buprenorphine in Opioid Treatment Partial Opioid Agonist Produces a ceiling effect at higher doses Has effects of typical opioid agonists these effects are dose dependent up to a limit Binds strongly to opiate receptor and is long-acting Safe and effective therapy for opioid maintenance and detoxification
Drug Addiction Treatment Act of 2000 (DATA 2000) Expanded treatment options to include both the general health care system and opioid treatment programs. Expanded the number of available treatment slots Allows opioid treatment in office settings Sets physician qualifications for prescribing the medication Comprehensive Addiction and Recovery Act (2016) Gives nurse practitioners and physician assistants the ability to prescribe buprenorphine in states where those medical professionals have full practice authority.
Physicians must: DATA 2000: Prescriber Qualifications Be licensed to practice by his/her state Have the capacity to refer patients for psychosocial treatment Originally limited to 30 patients later expanded to allow for 100 patients after the first year of experience; after two years can increase to 275 patients with some additional reporting requirements. Be qualified to provide buprenorphine (complete an 8 hour training) and receive a license waiver ARNPs and PA-Cs must: complete 24 hours of training. HHS plans to start issuing waivers to these professionals in Feb. 2017.
The Prescription Opioid Addiction Treatment Study (POATS) Largest study ever conducted for prescription opioid dependence 653 participants enrolled Compared treatments for prescription opioid dependence, using buprenorphine-naloxone and counseling Conducted as part of NIDA Clinical Trials Network (CTN) at 10 participating sites across U.S. Examined detoxification as initial treatment strategy, and for those who were unsuccessful, how well buprenorphine stabilization worked 37
Take Home Messages News from the 42 month Follow-up Results revealed significant improvements at 42 months: 31.7% were abstinent from opioids and not on agonist therapy; 29.4% were receiving opioid agonist therapy but met no symptom criteria for current opioid dependence; 7.5% were using illicit opioids while on agonist therapy; 31.4% were using opioids without agonist therapy Weiss RD, et al. Long-Term Outcomes from the National Drug Abuse Treatment Clinical Trial Network Prescription Opioid Study. Drug and Alcohol Dependence 2015 (in press) 38
Opioid Antagonists Naltrexone Naltrexone for Extended- Release Injectable Suspension Revia or Depade Vivitrol
How Does Naltrexone Work? Naltrexone is an opioid receptor antagonist and blocks opioid receptors. This prevents the effects of selfadministered opioids. Naltrexone
What Does the Research Say? Naltrexone is effective for opioid and alcohol addiction: Reduces risk of re-imprisonment Lowers risk of opioid use, with or without psychological support Extended-release naltrexone addresses the issue of patient compliance
Naltrexone Hydrocholoride Marketed As: ReVia and Depade Indication Used in the treatment of alcohol or opioid dependence and for the blockade of the effects of exogenous administered opioids and/or decreasing the pleasurable effects experienced by consuming alcohol. Has not been found to be addictive or produce withdrawal symptoms when the medication is ceased. Administering naltrexone will invoke opioid withdrawal symptoms in patients who are physically dependent on opioids.
Extended-Release Naltrexone One 380mg injection deep muscle in the buttock, : every 4 weeks Dosing: Must be administered by a healthcare professional and should alternate buttocks each month. Blocks opioid receptors for one entire month compared to approximately 28 doses of oral naltrexone. It is not possible to remove it from the body once extended-release naltrexone has been injected. Pricing: $800 1200 per month (one injection)
Induction Burden Abstinence requirements: must be taken at least 7-10 days after last consumption of opioids
Heroin Overdose Prevention Studies have shown that heroin overdose is a preventable manner of death. Methods for overdose prevent include the following: Education of heroin users about dangerous drug interactions Education about rescue breathing and Good Samaritan laws Naloxone (Narcan ) distribution and education about its use. http://stopoverdose.org/
Local Resources Treatment access Washington Recovery Help Line https://www.warecoveryhelpline.org/ 866.789.1511 State and local drug trends Alcohol and Drug Abuse Institute (ADAI) at UW http://adai.washington.edu/
National Resources Drug information and research findings National Institute on Drug Abuse (NIDA) https://www.drugabuse.gov/ Information and treatment locator Substance Abuse & Mental Health Services Administration https://www.samhsa.gov/
Clinical Guidance for Treating Pregnant and Parenting Women with OUD: https://store.samhsa.gov/shin/conte nt//sma18-5054/sma18-5054.pdf